People with LBP who do not improve with self-managed care may receive a short-course of manual therapy (e.g. 2-4 week trial) as an adjunct to their self-managed care.
NHMRC Australian Acute Musculoskeletal Pain Guidelines Group 2003. Evidence-based Management of Acute Musculoskeletal Pain. Available at: https://www.nhmrc.gov.au/
There is conflicting evidence that spinal manipulation provides pain relief compared to placebo in the first two to four weeks of acute low back pain.
There are no controlled studies of massage therapy in acute low back pain.
Massage is superior to placebo (sham laser) and acupuncture in mixed populations with low back pain.
There is conflicting evidence of the effect of massage compared to manipulation and education in mixed populations with low back pain.
There is insufficient evidence that spinal manipulation is more or less effective than other conservative treatments for acute low back pain.
Adverse effects of spinal manipulation are rare but serious.
Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012.
Spinal manipulative therapy should be considered in the early intervention of low back pain.
TOP 2015. Toward Optimised Practice - Evidence-Informed Primary Care Management of Low Back Pain: Clinical Practice Guidelines. 3rd Edition. December 2015. Institute of Health Economics, Alberta, Canada.
Recommend massage therapy as an adjunct to a broader active rehabilitation program.
Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, et al. Clinical Practice Guideline: Chiropractic Care for Low Back Pain. J Manipulative Physiol Ther 2016;39:1-22
Currently, the most robust literature regarding manual therapy for LBP is based primarily on high-velocity, low-amplitude (HVLA) techniques, and mobilization (such as flexion-distraction). Therefore, in the absence of contraindications, these methods are generally recommended.
Low Back Pain: Medical Treatment Guidelines. July 2007. Department of Labor and Employment, State of Colorado, USA.
Manipulative treatment (not therapy) is defined as the therapeutic application of manually guided forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury or occupational disease and has associated clinical significance. For acute low back pain, there is good evidence that manipulation does not have a clinically greater therapeutic effect on acute , 6 weeks or less, nonspecific low back pain than other interventions including physical therapy.
Massage – Manual or Mechanical: Massage is manipulation of soft tissue with broad ranging relaxation and circulatory benefits. This may include stimulation of acupuncture points and acupuncture channels (acupressure), application of suction cups, and techniques that include pressing, lifting, rubbing, pinching of soft tissues by or with the practitioners’ hands. Indications include edema (peripheral or hard and non-pliable edema), muscle spasm, adhesions, the need to improve peripheral circulation and ROM, or the need to increase muscle relaxation and flexibility prior to exercise. There is good evidence that massage therapy in combination with exercise reduces pain and improves function short-term for patients with sub-acute low back pain.
Mobilization (Joint): Mobilization is a passive movement involving oscillatory motions to the vertebral segment(s). The passive mobility is performed in a graded manner (I, II, III, IV, or V), which depicts the speed and depth of joint motion during the maneuver. For acute low back pain, there is good evidence that manipulation does not have a clinically greater therapeutic effect on acute, 6 weeks or less, nonspecific low back pain than other interventions including physical therapy.
Mobilization (Soft Tissue): A generally well-accepted treatment. Mobilization of soft tissue is the skilled application of muscle energy, strain/counter strain, myofascial release, manual trigger point release, and manual therapy techniques designed to improve or normalize movement patterns through the reduction of soft tissue pain and restrictions. These can be interactive with the patient participating or can be with the patient relaxing and letting the practitioner move the body tissues. Indications include muscle spasm around a joint, trigger points, adhesions, and neural compression. Best practice suggests that mobilization should be accompanied by active therapy.
Agency for Healthcare Research and Quality / National Guidelines Clearinghouse 2012. Low back pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Available at: http://www.guideline.gov/
INTERVENTIONS – MANUAL THERAPY: Clinicians should consider utilizing thrust manipulative procedures to reduce pain and disability in patients with mobility deficits and acute low back and back-related buttock or thigh pain. Thrust manipulative and nonthrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with subacute and chronic low back and back-related lower extremity pain.
Massage provides similar effect to back schools (involving exercise and education), corsets and TENS in mixed (acute/chronic) populations with low back pain.
NICE 2016. Low back pain and sciatica in over 16s: assessment and management. NICE Guideline [NG59] November 2016. Available at: https://www.nice.org.uk/guidance/NG59
Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.
Spinal Manipulation — There is conflicting evidence that spinal manipulation provides pain relief compared to placebo in the first two to four weeks of acute low back pain. There is insufficient evidence that spinal manipulation is more or less effective than other conservative treatments for acute low back pain. Adverse effects of spinal manipulation are rare but potentially serious.
An initial course of chiropractic treatment typically includes 1 or more “passive” (i.e., non-exercise) manual therapeutic procedures (i.e., spinal manipulation or mobilization) and physiotherapeutic modalities for pain reduction, in addition to patient education designed to reassure and instil optimal strategies for independent management.
Qaseem A, Wilt TJ, McLean RM, Forciea MA.Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166:514-530. doi:10.7326/M16-2367
Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)
Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture,
mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)
Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M etal. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2017 Apr 20. doi: 10.1007/s00586-017-5099-2. [Epub ahead of print]
Consider offering patients with recent onset LBP spinal manual therapy in addition to usual care
Consider offering spinal manual therapy to patients with recent onset lumbar nerve root compression as an add-on to the usual treatment
Consider recommending supervised exercise therapy or manual therapy to patients with recent onset lumbar nerve root compression. There is no documentation of a clinically relevant difference between the two interventions.
Do only offer patients with recent onset LBP acupuncture in addition to usual care after careful consideration, as the effect is uncertain.
It is not good practice to offer acupuncture on a routine basis to patients with recent onset lumbar nerve root compression
Van Wambeke P, Desomer A, Ailiet L, et al. Low back pain and radicular pain: assessment and management. KCE Report 2017;287