A Systematic Review and Meta-Analysis of Efficacy, Cost-Effectiveness, and Safety of Selected Complementary and Alternative Medicine for Neck and Low-Back Pain

Table 6

Summary of findings of spinal mobilization for low-back pain (only pain and functional outcomes).

Duration and cause of pain	Outcomes	GRADE*	Findings
Mobilization versus no treatment
Acute/subacute, nonspecific	Pain intensity (MPQ)	Low; Design: RCT; ROB: High; Consistency: NA (one trial); Directness: yes	In one trial [122] mobilization group had significantly lower pain intensity immediately posttreatment (𝑃=0.048). No further numerical data was provided.
Acute/subacute specific	NA	Insufficient; No trial	NA
Chronic nonspecific	Pain intensity score (VAS)	Low; Design: RCT; ROB: Medium; Consistency: NA (one trial); Directness: yes	In one trial [34] mobilization (Kaltenborn’s wedge assisted posteroanterior) was significantly superior to “no treatment.” Immediate posttreatment mean pain score values were 33.40 for mobilization versus 49.77 for “no treatment” (𝑃<0.001).
	Roland-Morris Disability score	Low; Design: RCT; ROB: Medium; Consistency: NA (one trial); Directness: yes	In one trial [34] mobilization (Kaltenborn’s wedge assisted posteroanterior) was significantly superior to “no treatment.” Immediate posttreatment mean pain score values were 7.69 for mobilization versus 10.64 for “no treatment” (𝑃<0.003).
Chronic specific	Oswestry Disability Index	Low; Design: RCT; ROB: High; Consistency: NA (one trial); Directness: yes	One trial [123] showed no difference between-groups immediately posttreatment in disability index: 5.57 (2.38) with mobilization and 2.19 (1.54) with “no treatment”.
Mixed nonspecific	Pain intensity score (VAS)	Low; Design: RCT; ROB: High; Consistency: NA (one trial); Directness: yes	In one trial [124] mobilization did not significantly differ from “no treatment” immediately after treatment. The mean difference in pain (overall %) was −24.7 with mobilization and −11.1 with no treatment (𝐹=2.63, 𝑃>0.05).
Mixed specific	NA	Insufficient; No trial	NA
Unknown (specific, nonspecific)	NA	Insufficient; No trial	NA
Mobilization versus placebo
Acute/subacute nonspecific	NA	Insufficient; No trial	NA
Acute/subacute specific	Pain intensity score (VAS)	Low; Design: RCT; ROB: High; Consistency: NA (one trial); Directness: yes	In one trial, [125, 126] of subjects with sacroiliac joint dysfunction (96% women), there was no statistically significant difference immediately posttreatment between mobilization and placebo (no numerical data was reported).
Chronic (specific, nonspecific)	NA	Insufficient; No trial	NA
Mixed nonspecific	Pain intensity score (VAS)	Low; Design: RCT; ROB: Medium; Consistency: NA (one trial); Directness: yes	In one trial, [127] mobilization did not significantly differ from placebo in reducing immediate or short-term posttreatment pain intensity. The mean (SD) pain intensity immediately posttreatment was 4.2 (2.5) with mobilization and 4.3 (2.2) with placebo (𝑃=0.8).
Mixed specific	NA	Insufficient; No trial	NA
Unknown (specific, nonspecific)	NA	Insufficient; No trial	NA
Mobilization versus physiotherapy
Acute/subacute (specific, nonspecific)	NA	Insufficient; No trial	NA
Chronic nonspecific	Pain intensity score (VAS)	Low; Design: RCT; ROB: Medium; Consistency: no; Directness: yes	The pooled estimate of 2 trials showed a significant benefit of mobilization immediately posttreatment (mean difference in VAS score: −0.50, 95% CI: −0.72, −0.28) [128–130].
	Oswestry Disability Index	Moderate; Design: RCT; ROB: Medium; Consistency: yes; Directness: yes	The pooled estimate of 2 trials [128–130] showed a significant benefit of mobilization immediately posttreatment (mean difference in disability score: −4.93, 95% CI: −5.91, −3.96).
Chronic specific	Oswestry Disability Index	Low; Design: RCT; ROB: High; Consistency: NA (one trial); Directness: yes	One trial [123] showed no difference between-groups immediately posttreatment in disability index: 5.57 (2.38) with mobilization and 2.55 (1.03) with physiotherapy (physical modalities including exercise).
Mixed nonspecific	Oswestry Disability Index	Low; Design: RCT; ROB: Medium; Consistency: NA (one trial); Directness: yes	In one trial [131] there was no difference between mobilization and physiotherapy in disability.; Mean change (95% CI) in mobilization group at immediate-, short-term, intermediate-term and long-term posttreatment were 7.0 (3.4, 10.2), 5.1 (1.7, 8.4), 9.4 (6.7, 12.1) and 8.4 (5.2, 11.6), respectively.; Mean change (95% CI) in the physiotherapy group at immediate-, short-term, intermediate-term and long-term posttreatment were 2.0 (−1.1, 5.1), 4.0 (1.3, 6.7), 4.7 (1.5, 7.9), and 4.4 (1.2, 7.6), respectively.; The between-group difference was statistically significant at intermediate and long-term posttreatment followups only.
Mixed specific	NA	Insufficient; No trial	NA
Unknown (specific, nonspecific)	NA	Insufficient; No trial	NA
Mobilization versus manipulation
Acute/subacute (nonspecific)	Roland-Morris Disability score	Low; Design: RCT; ROB: Medium; Consistency: NA (one trial); Directness: yes	In one trial, [132] the manipulation group had a significantly better disability score compared to the mobilization group immediately posttreatment. The mean (SD) disability scores were 9.1 (5.3) with manipulation and 3.9 (4.3) with mobilization (𝑃<0.04).
Acute/subacute (specific)	NA	Insufficient; No trial	NA
Chronic, mixed, unknown (specific, nonspecific)	NA	Insufficient; No trial	NA
Mobilization versus massage
Acute/subacute (specific, nonspecific)	NA	Insufficient; No trial	NA
Chronic (nonspecific)	Pain intensity score (VAS)	Low; Design: RCT; ROB: High; Consistency: NA (one trial); Directness: yes	In one trial [133], short-term posttreatment pain intensity was slightly but significantly greater in the mobilization group compared to the massage group (3.36±0.25 versus 2.48±0.25, 𝑃=0.017).
Chronic (specific)	NA	Insufficient; No trial	NA
Mixed (specific, nonspecific)	NA	Insufficient; No trial	NA
Unknown (nonspecific)	NA	Insufficient; No trial	NA
Unknown (specific)	Pain intensity score (VAS)	Low; Design: RCT; ROB: High; Consistency: NA (one trial); Directness: yes	In one trial [25] of subjects with disc protrusion, there was no statistically significant difference in posttreatment pain intensity between the groups (5.59±0.80 versus 4.71±0.52, 𝑃>0.05).
Mobilization versus exercise
Acute/subacute (specific, nonspecific)	NA	Insufficient; No trial	NA
Chronic (specific, nonspecific)	NA	Insufficient; No trial	NA
Mixed nonspecific	Pain intensity score (VAS)	Low; Design: RCT; ROB: High; Consistency: NA (one trial); Directness: yes	One trial [134] showed no significant difference between mobilization and exercise in reducing pain immediately after the end of a single treatment. The mean change (SD) was 1.7 (2.1) with mobilization and 1.2 (1.4) with exercise (no significant between-group difference).
	Oswestry Disability Index	Low; Design: RCT; ROB: Medium; Consistency: NA (one trial); Directness: yes	Mean change (95% CI) in mobilization group at immediate-, short-term, intermediate-term and long-term posttreatment were 7.0 (3.4, 10.2), 5.1 (1.7, 8.4), 9.4 (6.7, 12.1), and 8.4 (5.2, 11.6), respectively [131].; Mean change (95% CI) in the exercise group at immediate-, short-term, intermediate-term and long-term posttreatment were 3.2 (0.4, 6.1), 2.9 (−0.2, 5.9), 3.5 (0.2, 6.8), and 2.2 (−1.2, 5.7), respectively [131].; Difference between-groups was statistically significant for intermediate and long-term posttreatment followups [131].
Mixed specific	NA	Insufficient; No trial	NA
Unknown (specific, nonspecific)	NA	Insufficient; No trial	NA

*Precision in formal grading was applied only to pooled results.
VAS: visual analog scale; RMDQ: Roland-Morris disability scale; MPQ: McGill pain questionnaire; PDI: pain disability index; NPQ: neck pain questionnaire; NA: not applicable; ROB: risk of bias; RCT: randomized controlled trial.