Stefan Blomberg

Manipulation Does Not Alter the Position of the Sacroiliac Joint: A Roentgen Stereophotogrammetric Analysis

Study Design. A roentgen stereophotogrammetric analysis study of patients with sacroiliac joint dysfunction. Objectives. To investigate whether manipulation can influence the position between the ilium and the sacrum, and whether positional tests for the sacroiliac joint are valid. Summary of Background Data. Sacroiliac joint dysfunction is a subject of controversy. The validity of different sacroiliac joint tests is unknown. Long‐standing therapeutic tradition is to manipulate supposed dysfunctions of the sacroiliac joint. Many manual therapists claim that their good clinical results are a consequence of a reduction of subluxation. Methods. Ten patients with symptoms and sacroiliac joint tests results indicating unilateral sacroiliac joint dysfunction were recruited. Twelve sacroiliac joint tests were chosen. The results of most of these tests were required to be positive before manipulation and normalized after manipulation. Roentgen stereophotogrammetric analysis was performed with the patient in the standing position, before and after treatment. Results. In none of the 10 patients did manipulation alter the position of the sacrum in relation to the ilium, defined by roentgen stereophotogrammetric analysis. Positional test results changed from positive before manipulation to normal after. Conclusions. Manipulation of the sacroiliac joint normalized different types of clinical test results but was not accompanied by altered position of the sacroiliac joint, according to roentgen stereophotogrammetric analysis. Therefore, the positional test results were not valid. However, the current results neither disprove nor prove possible beneficial clinical effects achieved by manipulation of the sacroiliac joint. Because the supposed positive effects are not a result of a reduction of subluxation, further studies of the effects of manipulation should focus on the soft tissue response.

Traction for low back pain with or without sciatica: an updated systematic review within the framework of the Cochrane collaboration

Study Design. Systematic review. Objective. To determine if traction is more effective than reference treatments, placebo/sham traction, or no treatment for low back pain (LBP). Summary of Background Data. Various types of traction are used in the treatment of LBP, often in conjunction with other treatments. Methods. We searched MEDLINE, EMBASE, and CINAHL to November 2004, and screened the latest issue of the Cochrane Library (2004, issue 4) and references in relevant reviews and our personal files. We selected randomized controlled trials (RCTs) involving any type of traction for the treatment of acute (less than 4 weeks duration), subacute (4–12 weeks), or chronic (more than 12 weeks) nonspecific LBP with or without sciatica. Sets of 2 reviewers independently performed study selection, methodological quality assessment, and data extraction. Because available studies did not provide sufficient data for statistical pooling, we performed a qualitative “levels of evidence” analysis, systematically estimating the strength of the cumulative evidence on the difference/lack of difference observed in trial outcomes. Results. A total of 24 RCTs (2177 patients) were included. There were 5 trials considered high quality. For mixed groups of patients with LBP with and without sciatica, we found: (1) strong evidence that there is no statistically significant difference in short or long-term outcomes between traction as a single treatment, (continuous or intermittent) and placebo, sham, or no treatment; (2) moderate evidence that traction as a single treatment is no more effective than other treatments; and (3) limited evidence that adding traction to a standard physiotherapy program does not result in significantly different outcomes. For LBP with sciatica, we found conflicting evidence in several of the comparisons: autotraction compared to placebo, sham, or no treatment; other forms of traction compared to other treatments; and different forms of traction. In the remaining comparisons, there were no statistically significant differences; level of evidence is moderate regarding continuous or intermittent traction compared to placebo, sham, or no treatment, and is limited regarding different forms of traction. Conclusion. Based on the current evidence, intermittent or continuous traction as a single treatment for LBP cannot be recommended for mixed groups of patients with LBP with and without sciatica. Neither can traction be recommended for patients with sciatica because of inconsistent results and methodological problems in most of the studies involved. However, because high-quality studies within the field are scarce, because many are underpowered, and because traction often is supplied in combination with other treatment modalities, the literature allows no firm negative conclusion that traction, in a generalized sense, is not an effective treatment for patients with LBP.

Sick leave reductions from a comprehensive manual therapy programme for low back pain: the Gotland Low Back Pain Study

Objective: To evaluate if a comprehensive manual therapy programme reduces sick leave due low back pain and facilitates return to work more than the conventional optimized activating care. Design: A randomized controlled trial over a 10-week period with a two-year follow-up. Setting: Primary health care and Visby Hospital, Municipality of Gotland, Sweden. Subjects: One hundred and sixty patients (70 women, 90 men, ages 20—55 years) with acute or subacute low back pain with or without pain radiation into the legs. Interventions: Standardized optimized activating care (n = 71) versus a comprehensive pragmatic manual therapy programme including specific corticosteroid injections (n = 89). Main measures: Sick leave measured as net sick leave volume, point prevalence and return to work. Results: After 10 weeks, significantly more manual therapy patients than reference patients had returned to work (hazards ratio 1.62, 95% confidence interval (CI) 1.006—2.60, P<0.05), and among those on sick leave at baseline, significantly fewer were still on sick leave (8/58 versus 13/40, ratio 0.35, 95% CI 0.13—0.97, P<0.05). For all other measures there were inconclusive differences in favour of the manual therapy group. No significant differences remained after two years. Conclusions: The manual therapy programme used in this study decreased sick leave and increased return to work more than the standardized optimized activating care only up to 10 weeks but not up to two years.

A randomized controlled trial of the effects of muscle stretching, manual therapy and steroid injections in addition to ‘stay active’ care on health-related quality of life in acute or subacute low back pain

Objective: To evaluate the health-related quality of life effects of muscle stretching, manual therapy and steroid injections in addition to ‘stay active’ care in acute or subacute low back pain patients. Study design: A randomized, controlled trial during 10 weeks with four treatment groups. Setting: Nine primary health care and one outpatient orthopaedic hospital department. Subjects: One hundred and sixty patients with acute or subacute low back pain. Interventions: Ten weeks of ‘stay active’ care only (group 1), or ‘stay active’ and muscle stretching (group 2), or ‘stay active’, muscle stretching and manual therapy (group 3), or ‘stay active’, muscle stretching, manual therapy and steroid injections (group 4). Main measures: The Gothenburg Quality of Life instrument subscales Well-being score and Complaint score. Results: In a multivariate analysis adjusted for possible outcome affecting variables other than the treatment given Well-being score was 68.4 (12.5), 72.1 (12.4), 72,3 (12.4) and 72.7 (12.5) in groups 1–4, respectively (P for trend <0.05). There were significant trends for the well-being components patience (P < 0.005), energy (P < 0.05), mood (P < 0.05) and family situation (P < 0.05). The remaining two components and Complaint score showed a non-significant trend towards improvement. Conclusion: The effects on health-related quality of life were greater the larger the number of treatment modalities available. The ‘stay active’ treatment group, with the most restricted number of modalities, had the most modest health-related quality of life improvement, while group 4 with the most generous choice of treatment modalities, had the greatest improvement.

A controlled, multicentre trial of manual therapy with steroid injections in low-back pain: functional variables, side effects and complications during four months follow-up

Outpatients with acute or subacute low-back pain were randomly allocated to one of two treatment groups. One group (n = 53) was given standardized but optimized conventional activating treatment by primary health care teams. The other group (n = 48) received specific manual treatment such as manipulation, specific mobilization, muscle stretching, autotraction and cortisone injections. There were significant differences on 15 disability rating scores and complaints in everyday life due to low-back problems in favour of the group receiving manual treatment, indicating that this treatment was superior to conventional treatment. The patients given manual treatment had a more positive view of treatment than those in the conventionally treated group. The experimental treatment was more painful than the conventional treatment, due to injections and muscle stretching. Only a few patients experienced manipulation and specific mobilization as painful. No persisting deterioration or complications were reported due to the experimental treatment.

Diagnostic Differences Between General Practitioners and Orthopaedic Surgeons in Low Back Pain Patients

Background. There is a growing consensus on low back pain treatment. However, whether this extends to diagnostic labelling is still largely unknown. The aim of this report was to compare the diagnostic assessment of low back pain patients between general practitioners trained in manual therapy and orthopaedic surgeons. Methods. Population-based randomized controlled trial in which 160 patients with acute or sub-acute low back pain were assessed and treated by general practitioners or orthopaedic surgeons. Information on diagnoses and use of diagnostic imaging was obtained from medical records and physician questionnaires covering the ten-week treatment period. The Quebec Task Force classification and free text analysis were used to group diagnostic labels. Results: At baseline there were no significant differences in medical history, findings at physical examination and distribution of the Quebec Task Force diagnostic classification between the patient groups, indicating that they were similar. However, there were significant differences in physicians’ use of diagnostic labels for local pain and their characterisation of radiating pain. General practitioners used more terms from manual medicine and reported more pseudoradicular pain than orthopaedic surgeons, who used non-specific pain labels, reported more true radicular pain and used more x-ray examinations. Differences were found at all times from first visit to ten week follow-up. Conclusions: There were significant differences in diagnostic assessment and use of diagnostic radiology between general practitioners and orthopaedic surgeons.

A Controlled, Multicentre Trial of Manual Therapy in Low Back Pain: Initial Status, Sick Leave and Pain Score during Follow-up

One hundred and one outpatients with acute or subacute low back pain were randomly allocated to one of two treatment groups. One group was given standardised conventional but optimal activating treatment by primary health care teams. The other group received manual treatment such as manipulation, specific mobilisation, muscle stretching, auto-traction, and cortisone injections. The two groups were similar in most of the pre-trial variables, including age, sex, previous low back pain problems, sick leave, previous treatment, findings at the physical examination, quality of life score, disability rating, and pain score.After one month in the study, the proportion of patients on sick leave was 6 times larger in the conventionally treated group than in the group receiving the specific manual treatment. The difference diminished over time, but was still significant after 8 months. Two slightly different pain scores (“pain at the moment” and “pain during the last weeks”), initially similar in the two groups, di...

Supplement for the International Federation of Manual / Musculoskeletal Medicine: The Rationale for Invasive Treatments in Manual / Musculoskeletal Medicine

Introduction In the treatment of locomotor pain, many conditions can be treated by manual methods alone, but invasive treatments are often used in combination with manual treatments, or are used on their own. This paper looks at the rationale for these invasive treatments and for evidence for or against their efficacy. The special skills of the doctor practising manual/musculoskeletal medicine (MMSM) are complemented by the general skills of a doctor treating general medical conditions, as many systemic conditions will influence or cause locomotor pain or dysfunction. The wide range of locomotor disorders can be divided, for the purpose of this paper, into conditions with structural disease causing pathomorphological change, and those with dysfunction (where there is a potentially reversible change of function). Certainly structural disease is itself likely to cause dysfunction as Lewit continues to remind us (39). A concern in treating locomotor pain is that delay in correcting dysfunction might result in non-reversible, structural change: since it was shown that results of treatment can be improved by avoidance of delay (40) and that good results can be obtained by combinations of manual and invasive treatments (4), there has been great interest in the efficacy of invasive treatments. In analysing the rationale for treatment, structural disease and dysfunction will be considered separately.

Manipulatie brengt geen verandering teweeg van de stand van het sacro-iliacale gewricht: een röntgen-stereofotogrammetrische analyse

Rontgen-stereofotogrammetrische analyse (rsa) volgens Selvik (1989) van patienten met sacro-iliacale gewrichtsdysfunctie.