Evidence regarding the use of manipulation in general -2010


Findings and conclusions generally relate to the effectiveness of spinal manipulation, or manipulative therapies in general. Independent or 'stand alone' findings on Osteopathy are rarely available.

Because of the methodological deficit, findings of effectiveness tend to be rather tenuously put forward. Many publications, however, do report distinct indications that manipulation therapy is effective in the treatment of low back pain, and the best of these are mentioned and referenced in this document. For example, Koes et al (1996) found that, in terms of methodological quality, 36 randomised control trials studied were "mostly poor".
However, they did find that "there certainly are indications that manipulation might be effective in some sub-groups of patients with low back pain". The full reference is: Koes BW. Assendelft WJ van der Heijden GJ. Bouter LM. (1996) Spinal manipulation for low back pain. An updated systematic review of randomised clinical trials. Spine. 21(24):2860-71
Similarly, Assendelft et al (1995) found that, in a review of reviews, methodological quality was in general poor. They also found, however, that "nine out of the ten methodologically best reviews were positive" (in terms of the effectiveness of spinal manipulation for low back pain). Their conclusion stated that "The majority of the reviews concluded that spinal manipulation is an effective treatment for low back pain". The full reference is: Assendelft WJ, Koes BW, Knipschild PG, Bouter LM, (1995).
The relationship between methodological quality and conclusions in reviews of spinal manipulation. JAMA. 274(24):1942-8, 1995 The paper says that there is as yet no conclusive evidence for the long-term efficacy of spinal manipulation for any type of low back pain. The full reference is: Bronfort G. (1999) Spinal manipulation: current state of research and its indications. Neurological Clinics. 17(1):91-111, 1999 Feb.
Specific evidence for manipulation reviewed by RCGP in 1999
  • 36 randomised controlled trials, 19 of which report positive results and 5 more positive sub group results.
  • Little new evidence regarding the treatment of lower extremity symptoms by manipulation.
  • In acute and sub acute low back pain manipulation better than other modalities.
  • No firm evidence as to which patients respond to which type of manipulation.
  • The optimum timing of manipulative intervention remains unclear.
  • Risks of manipulation are very low provided patients are selected and assessed properly and treatment carried out by a trained practitioner Haldeman and Reubenstein Spine 17 1992.
  • Recommendation - consider manipulation for patients who needed initial help with pain relief or failing to return to normal activities.

Liverpool Centre for Health. Interim Evaluation Report.
January 1994
Research into the efficiency and effectiveness of a Multidisciplinary Complementary Health Centre provided by Liverpool Health Authority. Uses audit of various areas including characteristics of patients referred by GP's referral patterns, effect on GP prescribing, effect on referral elsewhere, patients' quality of life. It also reviews comments of patients, practitioners and GP's and uses case studies. Conclusions highlighted that a high level of need was being met, with both patients and GP's reporting high satisfaction. Quality of life questionnaires showed significant improvement.

Clinical Standards Advisory Group Report Back Pain
(1994) HMSO.ISBN.0113218877
Recommends increased support for the management of back pain in primary care and improved access to physical therapy which may be delivered by physiotherapists, osteopaths or chiropractors. The government response 6.4 supports this.

Clinical Standards Advisory Group. Epidemiology Review
The Epidemiology and Cost of Back Pain. HMSO (1994) ISBN 001 3218893

Di-Fabio (1992) Efficacy of Manual Therapy
Physical therapy, 71 (12) 834-864 General (1993) Which? Way to Health, Osteopathy 173-175

Hsieh C Phillips R Adams A et al 1991
Functional Outcomes of Low Back Pain, Comparison of Four Treatment Groups in a Randomised Controlled Trial
Journal of Manipulative and Physiological Therapeutics, Vol. 15, No1,4-9

Kinalski R, Kuwil W, Pietrzak D 1989
The Comparison of the Results of Manual Therapy Versus Physiotherapy Methods used in Treatment of Patients with Low Back Pain Syndromes
Journal of Manual Medicine Vol 4, 44-46

Peters, Davies & Pietroni (1994)
Musculoskeletal Clinic in General Practice, Study on One Year's Referrals
British Journal of General Practice, 25-28

Stodolny J (1989)
Manual Therapy in the Treatment of Patients with Cervical Migraine
Manual Medicine 4(2), 49-51

Zigenfus et al 2000
Early Physical Therapy Helps Work-Related Back Injuries
Journal of Occupational and Environmental Medicine 42:35-39

Bergmann Jongeward 1998
Manipulative Therapy in Lower Back Pain and Neurological Deficit
Journal of Manipulative and Physiological Therapeutics Vol 21, 4, May 1998

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