Research Review By Dr. Brynne Stainsby©

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Date Posted:

May 2020

Study Title:

Effects of manual therapies on stability in people with musculoskeletal pain: a systematic review

Authors:

Kendall JC, Vindigni D, Polus BI, Azari MF & Harman SC

Author's Affiliations:

Chiropractic, School of Health and Biomedical Sciences, RMIT University; Engineering, RMIT University, Bundoora, Australia.

Publication Information:

Chiropractic & Manual Therapies 2020: 28(13). https://doi.org/10.1186/s12998-020-0300-9

Background Information:

The global population is aging – it is estimated that by 2060, 28% of the population will be over the age of 65 (1). With this comes and an increased risk of escalating morbidity (people living longer in poor health) (2). Due to less coordinated gait, poor balance and decreased muscle strength, fall risk is a major health concern in the older population (3-5). Chronic musculoskeletal (MSK) pain in older adults has also been associated with a previous history of falls and an increased occurrence of future falls (6, 7). The severity and frequency of chronic MSK pain sites have been associated with reduced balance performance and increased fall risk (8). Manual therapy is commonly used for MSK pain and two prior systematic reviews have demonstrated evidence that manual therapy may also improve balance associated with reduction in pain intensity in symptomatic subjects (9, 10). The term stability has been used to denote how balance is controlled via a complex integration of information from multiple body systems. Put simply, deficits in balance control are associated with decreased stability. Clinical tests of stability such as sit-to-stand or single-leg stance can test the neurophysiological mechanisms that maintain balance and give us an idea of a particular patient’s capacity in this sense.

The objective of this systematic review was to examine the effectiveness of manual therapies for MSK pain on stability (defined for this review as experiencing a fall, self-reported fear of falling, and reduced performance on objective measures of mobility and balance). Further, the authors intend the results of this review to provide important information for future trials of manual therapy on MSK pain using clinical or objective stability measures.

Pertinent Results:

Literature Search and Included Studies:
  • A total of 2509 titles and abstracts were screened for eligibility, 150 potentially relevant articles were identified for full-text screening, and 26 were included in the study (11-36).
  • The MSK diagnoses included knee osteoarthritis (OA), knee/hip OA, low back pain (LBP), neck pain, fibromyalgia, ankle arthropathy and post-vertebral fracture.
  • Manual therapies included manipulation (13, 23, 24, 29, 30, 32, 36), mobilization (15, 21, 23, 24, 30, 32, 36) and massage (11-15, 19, 21, 22, 26, 30-33, 35).
  • Exercise was the most commonly compared intervention, prescribed as part of a supervised program, home exercise program or in combination. Comparison interventions also included no treatment, usual care or sham.
  • Outcome measures included clinical balance measures (gait speed, timed up-and-go [TUG], sit-to-stand, step test) and balance performance (static posture, force plate centre of pressure). No studies that met inclusion criteria were found that measured the number of falls or psychological concerns of falling.
  • Studies included in the meta-analysis included outcomes of gait speed, TUG test, step test and sit-to-stand test. There was a high level of heterogeneity, so results of the meta-analysis should be interpreted with caution.
  • Overall, the risk of bias analysis determined included studies were of low or unclear level of bias. It should be noted that performance bias (blinding of providers) was assessed to be high in all but one of the included studies.
Literature Summary:
  • Manual therapy significantly improved gait speed and TUG test performance compared to other interventions in the short-term only. Gait speed improved by 0.09 m/s (95% CI: 0.04, 0.13) while the TUG test scores significantly improved -0.53s (95% CI: -0.99, -0.07) in the short-term only.
  • Five out of eight of the studies using objective balance measures noted an improvement in balance.

Clinical Application & Conclusions:

This review identifies the possible effects of manual therapy on measures of balance and stability in people with MSK pain. Improvements have been identified in gait speed and timed up-and-go (TUG) performance following manual therapy, as well as improvement in objective balance measures. It is interesting to note that the most common presenting complaints in the included studies included lower limb and LBP. Future studies should investigate if the improvement in balance is related to body pain site, particularly if differences are observed between upper and lower limbs.

Clinically meaningful change in gait speed has previously been reported/defined as a change larger than 0.05 m/s, with a substantial change as 0.1 m/s (37). The average improvement of the included studies suggests a nearly substantial improvement in gait speed following manual therapy when compared to other interventions. It should be noted that the average improvement in the TUG test was statistically significant, but did not meet the threshold of a minimum clinically important difference. These results are preliminary and should be interpreted cautiously, however, any intervention that reduces pain intensity and may result in a decrease in falls warrants further, high-quality investigation.

Importantly, the reviewers noted that little information was provided regarding the optimal frequency and duration of the studied interventions. This highlights the need for future high-quality research regarding the effectiveness of manual therapy, the optimal dose for prescribing it, and perhaps the role of combining manual and active therapies.

Study Methods:

  • Only controlled trials published in the English language were included. To be included, participants must have been over 18 years of age with MSK pain of the spine or extremities (including multiple body sites), while studies of healthy participants or those with non-MSK pain were excluded. Studies must have included at least one component of manual therapy (manipulation, mobilisations or massage), and could have been applied in combination with other therapies. Outcome measures could include number of falls, clinical balance measures, objective balance measures and subjective measures of stability.
  • Six databases were searched in January 2018 using appropriate search terms for each database.
  • Two authors independently screened titles and abstracts for inclusion.
  • Two authors independently appraised each study using the 12-item Cochrane Risk of Bias assessment (38).
  • Data analysis was conducted by two independent authors.
  • Studies with outcome measures utilized by two or more studies were selected for meta-analysis. Short-term outcomes were classified as immediate to three-month follow-up, while long-term outcomes were classified as greater than three months. Studies that were not included in meta-analysis were included in the descriptive synthesis.

Study Strengths / Weaknesses:

Strengths:
  • Independent screening of titles and abstracts, and full texts.
  • Generally, only studies assessed to have a low risk of bias were included, though it should be noted that the authors did include studies with “unclear” risk of bias.
  • Assessment of risk of bias was performed with a validated set of criteria.
  • In addition to methodological quality, clinical relevance was also assessed.
  • Two authors independently extracted the data from the included articles.
Weaknesses:
  • The primary limitation of this study relates more to the quality of the body of evidence than the methodology of the review itself.
  • The research question and systematic search strategies were not thoroughly described.
  • Although the authors used a validated tool to assess risk of bias, the inclusion of studies with “unclear” risk of bias does require results to be interpreted with degree of caution.
  • The sample sizes of the included studies were not reported.
  • The participants and interventions were not clearly defined, which limits the external validity of the review.
  • Given the heterogeneity of the included studies, the findings of the meta-analysis should be interpreted with a great degree of caution.

Additional References:

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  3. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006; 35 Suppl 2: ii37-ii41.
  4. Patel KV, Phelan EA, Leveille SG, et al. High prevalence of falls, fear of falling, and impaired balance in older adults with pain in the United States: findings from the 2011 National Health and aging trends study. J Am Geriatr Soc 2014; 62(10): 1844–52.
  5. Tinetti ME, Kumar C. The patient who falls: “It’s always a trade-off”. JAMA 2010; 303(3): 258–66.
  6. Asai T, Misu S, Sawa R et al. Multi-chronic musculoskeletal pain is a useful clinical index to predict the risk of falls in older adults with normal motor function. Aging Clin Exp Res 2015; 27(5): 711–6.
  7. Leveille SG, Jones RN, Kiely DK et al. Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA 2009; 302(20): 2214–21.
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  11. Abbott JH, Chapple CM, Fitzgerald GK et al. The incremental effects of manual therapy or booster sessions in addition to exercise therapy for knee osteoarthritis: a randomized clinical trial. J Orthop Sports Phys Ther 2015; 45(12): 975–83.
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  20. Cuesta-Barriuso R, Gomez-Conesa A, Lopez-Pina JA. Manual therapy in the treatment of ankle hemophilic arthropathy. A randomized pilot study. Physiother Theory Pract 2014; 30(8): 534–9.
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  26. Hicks GE, Sions JM, Velasco TO et al. Trunk muscle training augmented with neuromuscular electrical stimulation appears to improve function in older adults with chronic low Back pain: a randomized preliminary trial. Clin J Pain 2016; 32(10): 898–906.
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  35. Yu SH, Sim YH, Kim MH et al. The effect of abdominal drawing-in exercise and myofascial release on pain, flexibility, and balance of elderly females. J Phys Ther Sci 2016; 28(10): 2812–5.
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