Intervention Review

Spinal manipulative therapy for chronic low-back pain

  1. Sidney M Rubinstein1,*,
  2. Marienke van Middelkoop2,
  3. Willem JJ Assendelft3,4,
  4. Michiel R de Boer5,
  5. Maurits W van Tulder5

Editorial Group: Cochrane Back Group

Published Online: 16 FEB 2011

Assessed as up-to-date: 5 DEC 2009

DOI: 10.1002/14651858.CD008112.pub2


How to Cite

Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD008112. DOI: 10.1002/14651858.CD008112.pub2.

Author Information

  1. 1

    VU University Medical Center, Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, Amsterdam, Netherlands

  2. 2

    Erasmus Medical Center, Department of General Practice, Rotterdam, Netherlands

  3. 3

    Leiden University Medical Center, Department of Public Health and Primary Care, Leiden, Netherlands

  4. 4

    Radboud University Medical Center, Department of Primary and Community Care, Nijmegen, Netherlands

  5. 5

    VU University, Department of Health Sciences, Faculty of Earth and Life Sciences, Amsterdam, Netherlands

*Sidney M Rubinstein, Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, PO Box 7057, Room D518, Amsterdam, 1007 MB, Netherlands. sm.rubinstein@vumc.nl.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 16 FEB 2011

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. アブストラクト
  5. 摘要
  6. 淺顯易懂的口語結論

Background

Many therapies exist for the treatment of low-back pain including spinal manipulative therapy (SMT), which is a worldwide, extensively practiced intervention.

Objectives

To assess the effects of SMT for chronic low-back pain.

Search methods

An updated search was conducted by an experienced librarian to June 2009 for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2009, issue 2), MEDLINE, EMBASE, CINAHL, PEDro, and the Index to Chiropractic Literature.  

Selection criteria

RCTs which examined the effectiveness of spinal manipulation or mobilisation in adults with chronic low-back pain were included. No restrictions were placed on the setting or type of pain; studies which exclusively examined sciatica were excluded. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life.

Data collection and analysis

Two review authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the quality of the evidence. Sensitivity analyses and investigation of heterogeneity were performed, where possible, for the meta-analyses.

Main results

We included 26 RCTs (total participants = 6070), nine of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. In general, there is high quality evidence that SMT has a small, statistically significant but not clinically relevant, short-term effect on pain relief (MD: -4.16, 95% CI -6.97 to -1.36) and functional status (SMD: -0.22, 95% CI -0.36 to -0.07) compared to other interventions. Sensitivity analyses confirmed the robustness of these findings. There is varying quality of evidence (ranging from low to high) that SMT has a statistically significant short-term effect on pain relief and functional status when added to another intervention. There is very low quality evidence that SMT is not statistically significantly more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.

Authors' conclusions

High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT, and data related to recovery.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. アブストラクト
  5. 摘要
  6. 淺顯易懂的口語結論

Spinal manipulative therapy for chronic low-back pain

Spinal manipulative therapy (SMT) is an intervention that is widely practiced by a variety of health care professionals worldwide. The effectiveness of this form of therapy for the management of chronic low-back pain has come under dispute.

Low-back pain is a common and disabling disorder, which represents a great burden to the individual and society. It often results in reduced quality of life, time lost from work and substantial medical expense. In this review, chronic low-back pain is defined as low-back pain lasting longer than 12 weeks. For this review, we only included cases of low-back pain that were not caused by known underlying conditions, for example, infection, tumour, or fracture. We also included patients whose pain was predominantly in the lower back, but may also have radiated (spread) into the buttocks and legs.

SMT is known as a "hands-on" treatment of the spine, which includes both manipulation and mobilisation. In manual mobilisations, the therapist moves the patient’s spine within their range of motion. They use slow, passive movements, starting with a small range and gradually increasing to a larger range of motion. Manipulation is a passive technique where the therapist applies a specifically directed manual impulse, or thrust, to a joint, at or near the end of the passive (or physiological) range of motion. This is often accompanied by an audible ‘crack’.

In this updated review, we identified 26 randomised controlled trials (represented by 6070 participants) that assessed the effects of SMT in patients with chronic low-back pain. Treatment was delivered by a variety of practitioners, including chiropractors, manual therapists and osteopaths. Only nine trials were considered to have a low risk of bias. In other words, results in which we could put some confidence.

The results of this review demonstrate that SMT appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy. However, it is less clear how it compares to inert interventions or sham (placebo) treatment because there are only a few studies, typically with a high risk of bias, which investigated these factors. Approximately two-thirds of the studies had a high risk of bias, which means we cannot be completely confident with their results. Furthermore, no serious complications were observed with SMT.

In summary, SMT appears to be no better or worse than other existing therapies for patients with chronic low-back pain.

 

アブストラクト

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. アブストラクト
  5. 摘要
  6. 淺顯易懂的口語結論

慢性腰痛に対する脊椎手技療法

背景

腰痛には多くの治療法が存在するが、脊椎手技療法(SMT)は世界で広く実施されている介入である。

目的

慢性腰痛に対するSMTの効果を評価すること。

検索戦略

経験豊富な司書がCENTRAL(コクラン・ライブラリ 2009年、Issue 2)、MEDLINE、EMBASE、CINAHL、PEDro、およびIndex to Chiropractic Literatureのランダム化比較試験(RCT)の検索を2009年6月まで更新した。

選択基準

慢性腰痛のある成人を対象に脊椎マニピュレーションまたはモビライゼーションの有効性を評価したRCTを選択した。疼痛の状況や種類に制約はかけず、また、坐骨神経痛のみを対象とした研究は除外した。主要アウトカムは疼痛、機能状態、および自覚的回復度で、副次アウトカムは職場復帰および生活の質であった。

データ収集と分析

2名のレビューアが別々に研究の選択、バイアスのリスク評価、およびデータの抽出を実施した。エビデンスの質の評価には、GRADEシステムを用いた。可能な場合、メタアナリシスについて感度解析および異質性の調査を実施した。

主な結果

26例のRCTを選択した(合計参加者6,070例)、そのうち9例はバイアスのリスクが低かった。選択した研究の約3分の2(18例)は前回のレビューで評価されていなかった。概して、SMTはその他の介入と比較して、疼痛軽減(MD -4.16、95%CI -6.97~-1.36)および機能状態(SMD -0.22、95%CI -0.36~-0.07)について、統計学的に有意ではあるが臨床的な関連性のない、短期的かつ小さな効果があるという質の高いエビデンスがある。感度解析により、これらの結果の頑強性が確認された。SMTをその他の介入に追加した場合、疼痛軽減および機能状態について、統計学的に有意な、短期的効果があるというエビデンスは、質にばらつきがある(低から高に及ぶ)。SMTは不活性の介入または偽SMTと比較して、短期的疼痛軽減または機能状態について、統計学的に有意な有効性はないという非常に質の低いエビデンスがある。回復、職場復帰、生活の質、および介護費用に関するデータは特にわずかであった。SMTでは重篤な合併症は認められなかった。

著者の結論

質の高いエビデンスにより、SMTとその他の介入では、慢性腰痛患者における疼痛軽減および機能改善について、臨床的に関連性のある差はないことが示唆されている。介護の費用対効果の判定が最優先である。今後の研究は、不活性の介入、偽SMT、および回復に関するデータに関して、我々が確信している効果の推定値に重要な影響を及ぼすと考えられる。

訳注

監  訳: 内藤 徹,2011.10.4

実施組織: 厚生労働省委託事業によりMindsが実施した。

ご注意 : この日本語訳は、臨床医、疫学研究者などによる翻訳のチェックを受けて公開していますが、訳語の間違いなどお気づきの点がございましたら、Minds事務局までご連絡ください。Mindsでは最新版の日本語訳を掲載するよう努めておりますが、編集作業に伴うタイム・ラグが生じている場合もあります。ご利用に際しては、最新版(英語版)の内容をご確認ください。

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. アブストラクト
  5. 摘要
  6. 淺顯易懂的口語結論

慢性下背痛的脊椎徒手推拿治療

背景

可用於治療下背痛的療法很多,包括脊椎徒手推拿治療(spinal manipulative therapy, SMT),此療法已在全球廣泛使用。

目的

評估脊椎徒手推拿治療對慢性下背痛的效果。

搜尋策略

由一位有經驗的圖書館員在CENTRAL (The Cochrane Library2009,第2期)、MEDLINE、EMBASE、CINAHL、PEDro與脊骨神經醫學文獻索引(the Index to Chiropractic Literature)

選擇標準

納入檢視整脊術徒手推拿(spinal manipulation)與脊椎活動手法(spinal mobilization)對成人慢性下背痛之有效性的隨機分組對照試驗(RCT)。未針對醫療機構或疼痛類型設限;僅檢視坐骨神經痛的試驗則予以排除。主要評估指標為疼痛、功能狀態與自覺復原。次要評估指標為恢復工作與生活品質。

資料收集與分析

由兩位回顧文獻作者分別獨立地進行試驗選擇、偏差風險評估與資料萃取。使用GRADE對證據品質進行評估。對於綜合分析,皆盡可能進行靈敏度分析與異質性檢測。

主要結果

總共納入26項隨機分組對照試驗(受試者總數= 6070),其中9項具有低偏差風險。所納入的試驗中約有三分之二(N = 18)尚未在先前的文獻回顧中進行評估。一般而言,高品質的證據顯示,相較於其他療法,脊椎徒手推拿治療對於疼痛紓解(MD:-4.16,95%信賴區間:-6.97至-1.36)與功能狀態(SMD:-0.22,95%信賴區間:-0.36至-0.07)具有統計顯著性但不具臨床相關性的小幅短期療效。靈敏度分析證實這些發現的可信度高。有各種品質的證據(低至高品質)顯示,在另一種療法以外再給予脊椎徒手推拿治療時,對於疼痛紓解與功能狀態具有統計顯著性的短期效果。有低品質的證據顯示,根據統計,就短期疼痛紓解或功能狀態而言,相較於無效療法(inert interventions)或虛擬脊椎徒手推拿治療(sham SMT),脊椎手法治療的效果並未顯著較高。復原、恢復工作、生活品質與照護費用方面的資料極少。脊椎手法治療不會造成嚴重的併發症。

作者結論

高品質證據顯示,對於慢性下背痛患者的疼痛紓解與功能改善,脊椎徒手推拿治療與其他介入療法之間並無具臨床重要性的差異存在。照護方法的成本效益研究為應優先進行的研究。更深入的研究,可能極有助於我們對此療法相較於無效療法或虛擬脊椎徒手推拿治療的療效評估以及復原之相關資料的可靠性更具信心。

 

淺顯易懂的口語結論

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. アブストラクト
  5. 摘要
  6. 淺顯易懂的口語結論

慢性下背痛的脊椎徒手推拿治療

脊椎徒手推拿治療(spinal manipulative therapy, SMT)已獲全球許多醫療照護專業人員廣泛使用。惟此種療法對於治療慢性下背痛的有效性仍有爭議。

下背痛是可能造成失能的一種常見疾患,對個人及社會皆可造成極大的負擔,常導致患者生活品質降低、工作時間損失、以及極高的醫療費用。在本文獻回顧中,慢性下背痛的定義為持續超過12週的下背疼痛。在本文獻回顧中,我們僅納入非由已知之既有狀況(例如感染、腫瘤或骨折)所引發的下背痛病例。我們亦納入疼痛主要發生在下背部但亦可能擴散至臀部與腿部的病患。

脊椎徒手推拿治療(SMT)亦即脊椎的「徒手」(hands-on)治療,包括整脊術推拿(manipulation)與脊椎活動手法(mobilisation)。在以雙手進行脊椎鬆動術時,治療師將病患的脊椎在其可動範圍內移動。他們以緩慢被動的動作,從較小範圍開始移動,再逐漸增加移動幅度。推拿術是一種被動的技術,在被動(生理)移動範圍的極限或接近極限時,治療師以手對關節施加特定方向的推力,常可聽到「劈啪聲」(crack)。

在本項更新的文獻回顧中,我們搜尋到26項針對慢性下背痛患者評估脊椎徒手推拿治療之功效的隨機分組對照試驗(6070名受試者)。提供治療服務者包括脊骨神經醫師、徒手治療師與整骨醫師。僅9項試驗經判定具有低偏差風險,亦即我們可以對其研究結果具有一些信心。

本文獻回顧工作的結果顯示,脊椎徒手推拿治療與其他常用於治療慢性下背痛的療法(例如,運動療法、標準醫療照護或物理治療)一樣有效。不過,因為僅有一些探討這些方法的試驗(且普遍具有高偏差風險),因此對於其相較於無效療法或虛擬(安慰劑)療法的效果如何,目前尚不清楚。大約三分之二的試驗具有高偏差風險,亦即我們無法完全信任其結果。此外,脊椎徒手推拿治療並未造成嚴重的併發症。

總結而言,脊椎徒手推拿治療的療效,與現有的其他慢性下背痛療法不相上下。

譯註

翻譯: East Asian Cochrane Alliance
翻譯補助: 此翻譯計畫由臺灣行政院衛生福利部經費補助,臺北醫學大學實證醫學研究中心統籌。

翻譯線上出版: 2013/1/31