The North American Spine Society has published a special issue of their journal on nonsurgical ways to treat chronic low back pain (CLBP). The goal was to bring us up-to-date on many types of treatments that have some clinical benefit to patients. In this article, medicine-assisted manipulation (MAM) was reviewed.

MAM refers to the use of spinal manipulation after any type of pain control has been given. The pain control may be from pills or injections. When injections are used, this treatment is called manipulation under anesthesia (MUA).

As a broad concept, MAM takes on several forms. The spinal joint can be numbed and then manipulated. Steroid injection into the epidural space can bring pain relief through anesthesia. The spine may be manipulated after epidural injection.

The patient could be under general or conscious anesthesia while the surgeon manipulates the spine. Sometimes a special X-ray called fluoroscopy is used. Fluoroscopy allows the surgeon to see inside the spine. This tool guides the surgeon's placement of the needle for injection of the steroid or anesthetic.

In all MAM procedures, manipulation takes on several forms as well. While the patient is sedated, the manual therapist (usually a physiotherapist) stretches the muscles and joints. The connective tissue is stretched or massaged to release fibrous adhesions. Various forms of traction may be used to the lumbrosacral region.

MAM has become popular in some areas of the U.S. because it seems to decrease pain, spasm, and muscle guarding. With greater relaxation of the joints and muscles, the therapist can then apply manual techniques more effectively. The end result is greater flexibility and motion with less force. The overall results seem positive.

MAM is used with patients who have loss of motion and who have not responded to other conservative methods of treatment. It is advised that four to eight weeks of soft tissue mobilization should be tried first before MAM. Patients who have had a failed back surgery or who have nerve entrapment or muscle contracture are also good candidates for this treatment.

There is not enough evidence to support or deny the value of MAM. Many of the studies done are of poor quality or too small to rely upon. Most of the studies were done back in the 1930s when this technique was first started. The methods used today are very different. There are no reported ongoing studies in this area at the present time.

There is a strong need for studies to support the theories behind MAM. Patient satisfaction and the clinician's belief that the treatment has a positive benefit is not enough in today's evidence-based medicine.

Simon Dagenais, DC, PhD, et al. Evidence-Informed Management of Chronic Low Back Pain with Medicine-Assisted Manipulation. In The Spine Journal. February 2008. Vol. 8. No. 1. Pp. 142-149.