Elsevier

The Spine Journal

Volume 8, Issue 1, January–February 2008, Pages 142-149
The Spine Journal

Intervention Review Article
Evidence-informed management of chronic low back pain with medicine-assisted manipulation

https://doi.org/10.1016/j.spinee.2007.09.010Get rights and content

Abstract

Editors' preface

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence Informed Management of Chronic Low Back Pain Without Surgery. Articles in this supplement were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Section snippets

Terminology

Medicine-assisted manipulation (MAM) is a broad term used to define manipulation of the spine after any type of anesthesia or analgesia, whether facilitated by injections or oral pharmaceuticals. It is often used interchangeably with the term manipulation under anesthesia (MUA), which is the most commonly used form of MAM.

History

Various forms of MAM have been used since the 1930s and several studies were published on MUA in the 1940s and 1950s when it was practiced by orthopedic surgeons and

Mechanism of action

The use of MUA grew from clinical observation and experience that the combined effects of anesthesia/analgesia and SMT were more beneficial than when each was administered separately [1]. The mechanism of action offered to explain these observations is that anesthesia/analgesia decreases regional pain, spasm, or muscle guarding that could interfere with effective delivery of manual therapies such as SMT, mobilization, traction, and stretching. The relaxation brought about by MUA is postulated

Review methods

A search of the electronic databases Medline, Embase, and CINAHL was conducted in May 2007 using a search strategy recommended by the Cochrane Back Review Group (CBRG) to identify clinical trials related to LBP [14]. The following terms related to MUA, MUJA, and MUESI were added to the (CBRG) strategy: MUJA.tw. or MUJA.mp., (MUA adj20 (spin$ or back$)).tw., (manipulati$ adj3 anesthe$).tw., (manipulati$ adj5 inject$).tw., or/1-4, exp Manipulation, Spinal/, exp Manipulation, Chiropractic/, exp

Harms

Although older forms of MUA using more forceful long-lever techniques were associated with adverse events (AEs) such as cauda equina syndrome, paralysis, and fracture, more recent studies have not reported any serious AEs [1]. If malpractice insurance premiums may be used as a proxy for the safety of a procedure, it should be noted that two large chiropractic insurers provide MUA coverage at no additional charge to their members [2]. Temporary flare-ups in lumbosacral pain have been reported

Summary

As noted in previous studies, generalizing prior MUA literature is very challenging—perhaps even inappropriate—because of participant heterogeneity and differences in treatment procedures used several decades ago and those used today [1], [16]. Overall, the methodological quality of the studies uncovered related to MUA, MUESI, and MUJA is weak and evidence consists mainly of observational studies. None of the MAM procedures have been subjected to a RCT and the absence of a rigorous, comparable

References (21)

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    As with other manual therapies, it is challenging to conduct quality research in this area. Eligibility for MUA often includes a requirement for prior failed SMT, making SMT alone a poor control group because those proceeding to MUA already would have been identified as not responding to SMT.24 Furthermore, it would not be ethically justifiable not to treat these infants as the time frame for obtaining best results is limited.

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    The audible separation of these joints is associated with release of tissue adhesions, stimulation of the afferent nerve to the Z-joint and spinal muscles, and reflex neurologic and possibly immunologic sequelae and inflammatory chemical down-regulation.10-14 There are a percentage of patients in whom cavitation of the spinal facet joint is not possible because of spasm, guarding, and inhibitory mechanisms15-17 despite meeting clinical criteria for its use.18-20 Manipulation under anesthesia (MUA) is a pain management procedure using passive stretches combined with spinal manipulation under conscious sedation or general anesthesia with the goal of relieving musculoskeletal pain.

  • The Role of Manual Therapies in Equine Pain Management

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    The risks of manipulation under sedation or general anesthesia include the inability of patients to provide verbal feedback on pain or to resist overzealous manipulation because intrinsic guarding mechanisms associated with voluntary muscle contraction are absent, which can produce an increased risk of iatrogenic injuries.113 There is currently insufficient evidence to make any recommendations regarding the use of manipulation under anesthesia for chronic low back pain in humans.112 Spinal manipulation under sedation and anesthesia has been used in horses to address reduced joint mobility; however, controlled studies are lacking.101,114,115

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