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Three Part Question

IN [adults presenting with acute lumbar disc prolapse] IS [manual therapy better than advice on back care & the stay active concept] AT [reducing pain & improving time to return to work & normal activity].

Clinical Scenario

"A 35 year old male presents to the physiotherapy department two weeks after an acute episode of low back pain with referred leg pain. You make a clinical diagnosis of acute lumbar disc prolpase. Evidence based national guidelines suggest it is effacious to give advice on back care education & the stay active concept, but you want to add in manual therapy as you feel this will further speed up his improvement.You decide to see if there is any evidence to support this."

Search Strategy

AMED on OVID interface 1985 - August 2006;PEDRO 1985 - August 2006: CINHAL on OVID interface 1982 - August 2006;
EMBASE 1974 - August 2006; COCHRANE via NELH; McKenzie Institute website; Eight other articles sourced from article references.
[Prolapse$. mp and lumbar.mp and intervertebral. mp. and disk.mp) or (lumbar.mp. and disk. mp. and {bulg$.mp. or burs$.mp. or extrus$.mp. or hernia$.mp. or sequest$.mp}) or (exp Radiculopathy/ and lumbar. mp.)] and [exp physical therapy modalities/ or exp exercise therapy/ or Mckenzie.mp. or physiotherapy$.mp. or manual thaerap$.mp. or physical therap$.mp. or manipulate$ therap$. mp. or exp bed rest/} limit to humans and English language

Search Outcome

Altogether 32 papers were found, of which 29 were irrelevant to the study question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Grunnesjo et al 2004 Sweden	160 patients with acute or subacute LBP. Group 1- stay active concept & in some cases muscle stretching (5.6% had verified disc prolapse) Group 2 - Experimental group receiving manual therapy & in some cases steroid injections as well as the stay active concept (11.2% had verified disc prolapse)	RCT	Pain score with VAS	Faster rate of decrease of pain in Group 2 after 5 weeks ( p=<0.05) NSS between groups at 10 weeks	Use of multiple treatment approaches limits evaluation of a specific modality and makes the study difficult to replicate. Treatment was provided individually or in groups giving patients differing experiences for conditions with similar causes, having a detrimental effect on validity, reliability, & reproducibility.
			15 item disability rating score	Group 2 had consistently lower disability levels than Group 1 for all variables at 5 & 10 weeks (p=<0.05)
			Use of painkillers or NSAIDs	NSS between groups
Cherkin D. et al 1998 USA	321 patients with LBP > seven days duration. Group 1 Physical Therapy Group where 92% were given a diagnosis of derangement. Group 2 Chiropractic treatment Group 3 minimal intervention (educational booklet)	RCT	Bothersomeness of symptoms at 4 & 12 weeks, & 12 months	NSS between groups	Patients with sciatica were excluded Only used the McKenzie approach in Physical Therapy Group and didn't consider other manual therapy techniques Not all subjects accounted for (8 missing) Use of single health care system therefore generalizability limited
			Roland Disability Scale at 4 & 12 weeks & 12 months	NSS between groups
			Number of days of back related disability at 12 months	NSS between groups
			Reported recurrence of symptoms 2 years after initial treatment	NSS between groups
			Patient satisfaction at 1 & 4 weeks	75% of subjects in Groups 1 & 2 rated their treatment as
Fritz J. et al 2003 USA	78 patients with work related LBP < three weeks duration & of sufficient severity to necessitate modification of work, randomised to specific therapy groups. Group 1 - 37 patients following clinical guidelines (minimal intervention) Group 2 - Classification group (defined by Delitto)	RCT	Modified Oswestry	Group 2 better than Group 1 at 4 weeks (Oswestry 21.4 v 32.4) p= 0.023. NSS between groups at 12 months.	Design of trial does not allow conclusions to be drawn over individual treatment effectiveness. Therapists gave the same number of appointments to both groups & this is not necessary according to clinical guidelines where Group 1 should receive minimal intervention, therefore potential for therapist influence cannot be discounted. Subgroups fit into a derangement pattern, but exact numbers of participants in these subgroups unclear. Up to 42% could potentially be drawn out as fitting into this category. Small sample size with no sample size estimate. Potential for therapist bias - same therapist trained in both methods & delivered both treatments. Examined only one patient population. Not all outcome measures reported on.
			SF36 PCS	Group 2 better than Group 1 at 4 weeks. PCS 36.8 v 43.0 p =0.029. NSS between groups at 12 months.
			SF36 MCS	NSS between groups at 4 weeks & 12 months
			Total medical costs over study period	Group 1 $616, Group 2 $465.70
			Work status	At 4 weeks 21 in Group 1 & 34 in Group 2 had no work restrictions.
			Additional days off work over 1 year	Group 1 11 days, Group 2 6 days
			Patient satisfaction (15 point scale)	Group 2 higher median satisfaction than Group 1 p=0.006
			Physical impairment	NSS between groups at 4 weeks & 12 months

Comment(s)

There is some support for short-term benefits from the use of manual therapy in acute low back pain, notably in reduction of pain score, lower disability rating, & quicker return to work. In the papers reviewed it was difficult to identify patients with a specific diagnosis of acute lumbar disc prolapse. No papers were identified that answered the specific clinical question.

Clinical Bottom Line

At present there is no published research that provides conclusive evidence that manual therapy is more effective than back care advice, & the stay active concept in the treatment of patients with acute lumbar disc prolapse.

References

1. Grunnesjo M. A randomized controlled clinical trial of stay active care versus manual therapy in addition to stay active care: functional variables and pain Journal of Manipulative & Physiologiacl Therapeutics Volume 27 Number 7 pp431-441 2004
2. Cherkin D. A comparison of physical therapy, chiropractic manipulation, & provision of an educational booklet for the treatment of patients with low back pain New England Journal of Medicine Volume 339 pp 1021 - 1028 1998
3. Fritz J. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain Spine Volume 28 Number 13 pp 1363 - 1372 2003