Ländryggsmanipulation vid ländryggsbesvär: en systematisk litteraturgenomgång med meta-analys : Jämförelse av evidens för ländryggsmanipulation gentemot träning och akupunktur

Background Non-specific Low Back Pain (LBP) is a common cause for pain experienced in the lower back. Three common methods for treating LBP are Spinal Manipulative Therapy (SMT), physical exercise and acupuncture. Objectives This systematic review and meta-analysis aimed to compare SMT to acupuncture and physical exercise for patients with non-specific LBP. By comparing the effects of the different treatments the authors hoped to present a clearer view of the current state of evidence.Search methods The databases CENTRAL, MedLine, EMBASE, PubMed, PEDro, SCOPUS, Web of Science, CINAHL and Amed were searched in September 2011. The search produced 3829 hits out of which six studies between the years 2002 - 2011 were included in the review and three in the meta-analysis. Selection criteria The authors included only RCT studies comparing SMT vs exercise or acupuncture for patients suffering from acute, subacute and chronic LBP. Data collection and analysis The extraction and analysis of data were done by both authors using a standardized method. The extraction included characteristics of participants, method specifics, result specifics, sponsorship and Risk of Bias (RoB) specifics. GRADE (Grading of Recommendations Assessment, Development and Evaluation) was used to determine the quality of evidence and the assessment of bias was done using a twelve-question protocol provided by The Cochrane Back Group. The results were pooled in a meta-analysis using either Weighted Mean Difference (WMD) or Standardized Mean Difference (SMD). All calculations were done in Review Manager 5.1. Results Six studies with low risk of bias were included in the review with a total of 1276 participants. In terms of pain and disability, there was moderate evidence suggesting that SMT and exercise therapy were equally effective in treating patients with LBP. The meta-analysis presented small clinically relevant and no statistically relevant results favoring SMT in the short- (MD -0.45; 95% CI 1.81 to 0.91), medium- (MD -0.23; 95% CI -1.16 to 0.70) and long-term follow-up (MD -0.36; 95% CI -1.74 to 1.02) for treating pain. Regarding the secondary outcome, disability, the meta-analysis presented small clinically relevant and no statistically relevant results favoring SMT at short- (SMD -0.19; 95% CI -0.76 to 0.39), medium- (SMD -0.21; 95% CI -0.73 to 0.30) and long-term follow-up (SMD -0.13; 95% CI -0.72 to 0.46). There were not enough studies regarding acupuncture to draw any conclusions other than the need for more studies on the area.Authors' conclusions There is moderate quality of evidence suggesting that there is no difference in effect between the interventions SMT and physical exercise for the outcome pain in individuals with non-specific LBP without neurological symptoms. The improvement of the experimental intervention compared to the control was of small clinical relevance and no statistical relevance.Validerat; 20120116 (anonymous