Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review

Peter Kent, Hanne L Mjøsund, Ditte H D Petersen, Peter Kent, Hanne L Mjøsund, Ditte H D Petersen

Abstract

Background: A central element in the current debate about best practice management of non-specific low back pain (NSLBP) is the efficacy of targeted versus generic (non-targeted) treatment. Many clinicians and researchers believe that tailoring treatment to NSLBP subgroups positively impacts on patient outcomes. Despite this, there are no systematic reviews comparing the efficacy of targeted versus non-targeted manual therapy and/or exercise. This systematic review was undertaken in order to determine the efficacy of such targeted treatment in adults with NSLBP.

Method: MEDLINE, EMBASE, Current Contents, AMED and the Cochrane Central Register of Controlled Trials were electronically searched, reference lists were examined and citation tracking performed. Inclusion criteria were randomized controlled trials of targeted manual therapy and/or exercise for NSLPB that used trial designs capable of providing robust information on targeted treatment (treatment effect modification) for the outcomes of activity limitation and pain. Included trials needed to be hypothesis-testing studies published in English, Danish or Norwegian. Method quality was assessed using the criteria recommended by the Cochrane Back Review Group.

Results: Four high-quality randomized controlled trials of targeted manual therapy and/or exercise for NSLBP met the inclusion criteria. One study showed statistically significant effects for short-term outcomes using McKenzie directional preference-based exercise. Research into subgroups requires much larger sample sizes than traditional two-group trials and other included studies showed effects that might be clinically important in size but were not statistically significant with their samples sizes.

Conclusions: The clinical implications of these results are that they provide very cautious evidence supporting the notion that treatment targeted to subgroups of patients with NSLBP may improve patient outcomes. The results of the studies included in this review are too patchy, inconsistent and the samples investigated are too small for any recommendation of any treatment in routine clinical practice to be based on these findings. The research shows that adequately powered controlled trials using designs capable of providing robust information on treatment effect modification are uncommon. Considering how central the notion of targeted treatment is to manual therapy principles, further studies using this research method should be a priority for the clinical and research communities.

Figures

Figure 1
Figure 1
Diagrammatic illustration of how treatment effect modifier size is isolated from prognostic effects using the 'Hancock formula'.
Figure 2
Figure 2
Review flow chart.
Figure 3
Figure 3
Improvement in patient outcomes (clinical course) for the targeted treatment group as a proportion of their baseline score. Evidence of matched treatment effect modification from multi-arm subgroup system randomized controlled trials.
Figure 4
Figure 4
Improvement in patient outcomes (clinical course) for the targeted treatment group as a proportion of their baseline score. Evidence of treatment effect modification from two-group plus subgroup covariate randomized controlled trials.

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