Evidence based orthopaedic manual therapy for patients with nonspecific low back pain: An integrative approach

Orthopaedic manual therapy (OMT) should be based not only on the best available evidence but also on patient values and clinician expertise. Low back pain (LBP) is a complex issue as the majority of people who suffer from LBP cannot be given a specific diagnosis based on imaging studies but kinematic analyses appear to be useful to determine dysfunctional patterns. In physical therapy, various forms of OMT are currently used to manage LBP and there is growing evidence for its use. The underlying principles of OMT are to treat neuro-musculo-skeletal disorders, the aim of which is to reduce pain, as well as improve movement and function. Manual physical therapists use a range of treatment approaches including passive techniques (``hands on'') as well as different active techniques (``hands off'') and communication skills. Systems of stratification are available for classification of people with LBP into specific sub-groups (with sub-group specific OMT intervention). This approach has been shown to be more efficient than generic treatment, although subgroups are not mutually exclusive. Various mechanisms of action are reported in the literature concerning OMT effects. These effects may be biomechanical, neurophysiological and psychological. Moreover, it is essential that the treatment, regardless of the concept of OMT, is carried out on the basis of a systematic and valid clinical examination protocol aimed to correctly classify LBP. The use of pain provocative tests during combined movement examination provides confidence that examination findings are valid and can therefore be confidently used in clinical practice to manage patient. The integrative approach presented in this article is a mix of previously developed classification systems (i.e. based on pain mechanisms, prognosis, treatment responsiveness) and new tools, as kinematic analyses for LBP, and a novel validated combined movements examinationCONCLUSION: As LBP is a complex and multidimensional problem, the integrative approach may help clinicians and researchers to better understand and then to treat patients with non-specific LBP. The efficacy of OMT treatments using an integrative approach in specific patients subgroups should be objectively analyzed according to validated kinematic analyses in future studies.