Spinal Manipulation Therapy for Non-Specific Lower Back Pain- a literature review.INTRODUCTIONLower Back Pain (LBP) is defined as pain or discomfort below the costal margin and above the inferior gluteal folds, with or without referred leg pain. LBP may be caused by multiple factors. However, bio-mechanical and neurophysiological factors have been considered as the key underlying mechanisms of LBP and its chronicity. Approximately 90% of all LBP cases are nonspecific in nature. The Non-Specific Lower Back Pain (NSLBP) is defined as the pain which cannot be attributed to any specific pathology of the spine. In contrast, about 5% of LBP cases present as pain that follows a specific nerve root distribution from a compression, a prolapsed lumbar disk, spinal stenosis, or surgical scarring. NSLBP (here onwards, abbreviated as LBP only) can be further subdivided into the following: (1) acute, defined as pain that restricts daily activities and lasting from 1 day to 12 weeks (0-3 months); and (2) chronic or persistent, defined as pain that restricts daily activities longer than 12 weeks (>3 months). LBP is often considered as one of the most substantial health care challenges affecting modern society and is one the leading causes of disability worldwide. LBP is the most common cause for chronic or permanent impairment in the United States among adults younger than age 65. LBP imposes a large financial burden on society and results in significant physical, psychological, and social burden. A person with LBP, in addition to being physically limited, also tends to have a higher proportion of functional disability, dysfunctional family relationships, depression, social isolation, work absence and poor work productivity. This leads them to have a lower socioeconomic status and a lower quality of life. Chronic LBP can also be associated with significant comorbidities such as coronary heart disease, diabetes and depression.Despite the fact that thousands of studies and trials have been conducted on the management of LBP, the most effective approach still remains unclear. Non-steroidal anti-inflammatory drugs, opioid and neurotropic medications or steroid injections and surgery have had been the main tools for many physicians in the past. But, due to the potential or apparent risks associated with these tools, many patients seek out complementary and alternative medicine approaches that are thought to have minimal adverse events, to care this enigmatic condition. These approaches include- Spinal Manipulation Therapy (SMT), Behavioral Therapy, Exercise Therapy, Transcutaneous electrical nerve stimulation, Inferential currents, Low-level laser therapy and Yoga. Massage, Acupuncture and superficial heat therapy (e.g.electric heating pads, hot water bottles, heated packs filled with grain, hot towels) can also be included as other therapies for managing LBP. Varying levels of evidence (mostly moderate quality) exist for these treatments as recently described by Chou et al. According to new clinical practical guidelines for American College of Physicians, manual therapy has become a recommended treatment option to manage LBP. Thus, the use of Spinal Manipulation Therapy(SMT) for management of LBP was the main focus for this review.This review aims to discuss the following questions regarding Spinal Manipulative Treatment(SMT) for LBP-What is Spinal Manipulative Treatment and its mechanism? How effective SMT really is in patients with Low Back Pain? Is it better if we use SMT with combination of other treatments (like Acupuncture, Pharmaceutical Treatments, exercise etc) to manage and treat LBP?How can we offer to improve the effectiveness of SMT for treating LBP in the future? What is Spinal Manipulative Treatment and its mechanism?SMT includes the application of high-velocity, low-amplitude manual thrusts to the spinal joints slightly beyond the passive range of joint motion and aims to correct misalignments or so called subluxations of the joints- both spinal and peripheral. Although its unproven safety, debatable effectiveness and cost- effectiveness, SMT is still widely used for a range of pain related conditions like Low Back Pain, Neck Pain and Headaches. Despite the non-specific characteristic in most cases of LBP, several studies suggest that LBP is characterized by central sensitization. A hypersentivity to pain may be indicative of a centrally mediated mechanism and neuroplastic changes in subjects with chronic LBP. As proposed by several authors, spinal manipulation can inhibit neuroplastic changes in pain perception at the dorsal horn of the spinal cord. This, in turn, alters central sensitization and results in effective treatment of individuals with chronic LBP. According to Bialosky et al (2014), they have interpreted their findings to reveal a mechanism of SMT related to modulation of dorsal horn excitability. Thereby, lessening of central sensitization as indicated by changes in suprathreshold heat response, their trial suggests a treatment target with potential relevance to clinical pain conditions. How effective SMT really is in patients with Low Back Pain?Although the mechanical, physiological, and neurological effects produced by Lumbar Spine Manipulations have been investigated by a number of studies, a considerable controversy regarding the efficacy of spinal manipulation for patients with chronic LBP still exists. Some reviews conclude that it has positive effects whereas others do not, creating debatable results on its effects on patients with LBP. Evans et al (1978) noted that, although the pain results suggested the SMT group experienced almost no change in pain compared with the no treatment group, more patients in the SMT group believed they benefited from the treatment. Previous systematic reviews by Assendelft et al (1996) and Koes et al (1996) found no clear evidence on the effectiveness of SMT for LBP, whereas Van Tulder et al (1997a) reported results that supported the effectiveness of this intervention for LBP. The early systematic review of Furlan et al (2001), used a qualitative approach for synthesizing trial findings, but it had considered only the number of trials favoring the experimental or control group to synthesize the findings; thus leaving the question of the size of the effect unanswered. The Randomized Controlled Trial (RCT) conducted by Ferreira et al (2002) concluded that spinal manipulative therapy does not produce a clinically significant reduction in pain when compared with sham treatment, nor a significant improvement in disability when compared with NSAIDs in patients with chronic low back pain. Later, Rubinstein et al (2011) conducted a systematic review of twenty-six RCTs to assess the Spinal Manipulative Therapy for Chronic Low Back Pain, and concluded that sound evidence emerged supporting that SMT has a small, statistically significant, but not clinically significant, short-term effect on pain and function when compared to other treatments. However, high quality evidence in their review suggested that there was no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic LBP. Nonetheless, he also mentions that among the total of twenty-six RCTs assessed in the review, only nine RCTs were of high quality. Thereby, making the results of this RCT rather unclear. The study conducted by Yagci et. al(2011) also concluded that SMT is an effective approach to reduce pain and disability level, and to improve endurance in patients with LBP. However, the sample recruited was only among 216 patients suffering from chronic non-specific LBP randomly with a mean of pain duration of 62.93 month.Hence, further researches are liable to have an important effect on the estimation of the of relationship between Spinal Manipulative Treatment and LBP, and the data related to recovery.Is it better if we use SMT with combination of other treatments (like Acupuncture, Pharmaceutical Treatments, exercise etc) to manage and treat LBP?We have discussed various studies and findings regarding the effectiveness of Spinal Manipulative Therapy (SMT) for patients with LBP as the only intervention method. But, in reality, rather than using SMT in isolation, physical therapists and clinicians normally use a multimodal approach in their treatment for LBP. In fact, clinical guidelines have suggested that outcomes in patients with LBP are improved with combination of manual physical therapy (including joint mobilization and manipulation) and exercise (Koes et al 2010, Dagenais et al 2010). According to Van Tulder et al (2001a, 2001b, 20001c), exercise, back school, multidisciplinary rehabilitation and cognitive treatment are other evidence-based physiotherapy management options for chronic LBP. The RCT conducted to determine the effectiveness of acupuncture and SMT, either alone or in combination revealed that acupuncture and SMT, either alone or in combination, were effective in the treatment of LBP (Kizhakkeveettil et al 2017). The study suggested that combining SMT and acupuncture might lead to better outcomes for LBP than either therapy alone. In addition, their findings proposed that acupuncture and SMT combined, can help mitigate some of the damaging effects LBP has on society, including direct (e.g. pharmaceutical) and indirect costs (e.g. absenteeism). However, as it was a feasibility study assessing a small sample size (n=101), so it is unclear that the results obtained can be generalized to other populations with LBP.In the study by Bussières et al (2018) which aimed to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults, the results have recommended that- (i) for patients with acute (0-3 months) back pain, offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care has been suggested to improve pain and disability. (ii) for patients with chronic (>3 months) back pain, offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial) has been suggested. (iii) for patients with chronic back-related leg pain, a suggestion of offering advice and education along with SMT and home exercise (positioning and stabilization exercises) is put forward.How can we offer to improve the effectiveness of SMT for treating LBP in the future? Researches on the effectiveness of SMT for treating LBP is often at times difficult to interpret, mostly due to poor reporting and high heterogeneity of various randomized controlled trials (patients, settings, treatments, outcomes) and their reviews. Therefore, improvement in the comparability of studies, facilitating pooling of data from multiple sources and the ability to define phenotype among patients with LBP is required.Spinal manipulative care is not inherently resource intensive. Various factors such as training, practice patterns and legal scope of practice may influence a single regulated professional’s ability to deliver treatment, thereby limiting health care access inequalities. SMT is not only practiced by general physicians, but also by some chiropractors, physical therapists, and osteopathic physicians. Considering the skills required to deliver manual therapy and other forms of therapies (e.g. exercise prescription) and based on individual patient preference, lumbar SMT as part of multimodal care should be delivered by properly trained licensed professionals. The level of knowledge about the extent of evidence supporting the SMT is ubiquitously low among health care professionals (physicians, physiotherapists) and students (medical, nurse practitioners, physician assistants). As most professionals develop their practical skills and opinions of treatment during or after medical school, proper guidance and education should be implemented during training. Professional barriers such as lack of knowledge, skills, self-capacity, misperceptions about evidences available, lack of time along with organizational/contextual barriers like leadership, organizational culture, years involved in quality improvement, data infrastructure/information systems and resources impede the uptake of guideline recommendations in clinical practice. The field of knowledge translation has produced a plethora of tools and methods to address these barriers and enhance the uptake of guidelines by clinicians. Knowledge translation should be focused on closing the gap between what is known to work best and what is routinely done in practice.The closure of this gap can be achieved by developing and implementing knowledge translation strategies targeting care providers, patients, and wider health care organizations. The preferences of people with LBP should also be taken into consideration while planning a treatment strategy by the care provider, as this leads to more active participation of the patients in their therapy, thereby leading to better outcomes. More importantly, as concluded in the systematic review and meta-anaylsis of LBP by (Steffens et al 2016), we should spread awareness about the importance of exercise and education in our daily life among people, as it helps in reducing the subsequent occurrence of LBP by approximately 30% .DISCUSSION AND CONCLUSIONAlthough numerous studies showing varying results have been performed on the effectiveness of SMT for patients with LBP in the past, current evidences published on the effectiveness, lower risks of adverse events and equivalent costs are more suggestive that non-pharmacological therapies including SMT should be the first line of treatment for acute and chronic LBP. Based on patient preference and resources available, a mixed multimodal approach including manual therapy, advice on self-management, and exercise (supervised/unsupervised or at home) may be an effective treatment strategy for acute and chronic LBP. Progress, particularly with respect to pain alleviation and reduction of disability, should be regularly monitored for evidence of benefit.REFERENCE:Assendelft WJJ, Koes BW, Van der Heijden GJ and Bouter LM (1996): The effectiveness of chiropractic for treatment of low back pain: an update and attempt at statistical pooling. Journal of Manipulative and Physiological Therapeutics 19: 499-506.Evans DP, Burke MS, Lloyd KN, Roberts EE and Roberts GM (1978): Lumbar spinal manipulation on trial. Part I -clinical assessment. Rheumatology and Rehabilitation 17: 46-53.Koes BW, Assendelft WJJ, van der Heijden and Bouter LM (1996): Spinal manipulation for low back pain – an updated systematic review of randomised clinical trials. Spine 21: 2860-2873.Furlan AD, Clarke J, Esmail R, Sinclair S and Irvin E (2001): A critical review of reviews on the treatment of chronic low back pain. Spine 26: E155-E163.Ferreira PH, Ferreira ML, Maher C, Latimer J, Herbert R and Refshauge K (2002): Effect of applying different “levels of evidence” criteria on conclusions of Cochrane reviews of interventions for low back pain. Journal of Clinical Epidemiology 55: 1111-1114.Van Tulder MW, Koes BW and Bouter LM (1997a): Conservative treatment of acute and chronic non-specific low back pain. Spine 22: 2128-2136.Van Tulder M, Assendelft WJJ, Koes BW and Bouter LM (1997b): Method guidelines for systematic reviews in the Cochrane Collaboration back review group for spinal disorders. Spine 22: 2323-2330.Van Tulder MW, Esmail R, Bombardier C and Koes BW (2001a): Back schools for non-specific low back pain. The Cochrane Library, Issue 4. Oxford: Update Software.Van Tulder MW, Malmivaara A, Esmail R and Koes BW (2001b): Exercise therapy for low back pain. The Cochrane Library, Issue 4. Oxford: Update Software.Van Tulder MW, Ostelo RWJG, Vlaeyen JWS, Linton SJ, Morley SJ and Assendelft WJJ (2001c): Behavioural treatment for chronic low back pain. The Cochrane Library, Issue 4. Oxford: Update Software.Steffens D, Maher CG, Pereira LS, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199-208.Anupama Kizhakkeveettil et al. Integrative Acupuncture and Spinal Manipulative Therapy Versus Either Alone for Low Back Pain: A Randomized Controlled Trial Feasibility Study in the Journal of Manipulative and Physiological Therapeutics, March/April 2017.Joel E. Bialosky, Steven Z. George et al. Spinal Manipulative Therapy–Specific Changes in Pain Sensitivity in Individuals With Low Back Pain (NCT01168999) in the The Journal of Pain, Vol 15, No 2 (February), 2014: pp 136-148. Available online at www.jpain.org and www.sciencedirect.com.Rubinstein SM et al.Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev 2011; 2: CD008112.Yagci et al. POSTER SESSIONS / European Journal of Pain Supplements 5 (2011) 15–295.I.D. Coulter et al. / The Spine Journal 18 (2018) 866–879. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis.André E. Bussières et al. Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative in Journal of Manipulative and Physiological Therapeutics May 2018.