Accepted Manuscript

Muscle energy technique for non-specific low-back pain. A Cochrane systematic

review

Helge Franke, Gary Fryer, Associate Professor, Raymond WJG. Ostelo, Steven J.
Kamper

PII: S1746-0689(16)00003-1
DOI: 10.1016/j.ijosm.2016.01.002
Reference: IJOSM 394

To appear in: International Journal of Osteopathic Medicine

Received Date: 24 November 2015

Revised Date: 5 January 2016
Accepted Date: 6 January 2016

Please cite this article as: Franke H, Fryer G, Ostelo RW, Kamper SJ, Muscle energy technique for non-
specific low-back pain. A Cochrane systematic review, International Journal of Osteopathic Medicine
(2016), doi: 10.1016/j.ijosm.2016.01.002.

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 ACCEPTED MANUSCRIPT
Muscle energy technique for non-specific low-back pain. A Cochrane systematic review.

Helge Franke1, Gary Fryer2, Raymond WJG Ostelo3, Steven J Kamper4

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1. Institute for Osteopathic Studies, Siegen, Germany. helge@franke-center.de

2. College of Health and Biomedicine, Victoria University, Melbourne, Australia.

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gary.fryer@vu.edu.au

3. Department of Health Sciences, EMGO Institute for Health and Care Research, VU

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University, Amsterdam, Netherlands. r.ostelo@vu.nl
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4. Musculoskeletal Division, The George Institute for Global Health, Sydney, Australia.
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skamper@georgeinstitute.org.au
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Corresponding Author:
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Associate Professor Gary Fryer, College of Health and Biomedicine, Victoria University, PO
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Box 14428 MCMC, Melbourne, 8001, Australia. Phone: +61 3 99191065

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Email: gary.fryer@vu.edu.au
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ABSTRACT

Background: Low back pain (LBP) is responsible for considerable personal suffering due to

pain and reduced function, as well as the societal burden due to costs of health care and lost

work productivity. Muscle energy technique (MET) is a manual therapy treatment technique

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used predominantly by osteopaths, physiotherapists and chiropractors which involves

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alternating periods of resisted muscle contractions and assisted stretching. It is unclear

whether MET is effective in reducing pain and improving function in people with LBP.

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Objectives: To examine the effectiveness of MET in the treatment of people with non-

specific LBP compared with control interventions, with particular emphasis on subjective

pain and disability outcomes.

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Methods: Eight electronic databases and two clinical trials registers were searched from
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inception to May and June 2014 together with reference checking and citation searching of

relevant systematic reviews. Randomised controlled trials assessing the effect of MET on
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pain or disability in patients with non-specific LBP were included. Two authors
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independently assessed the risk of bias and extracted the data. Meta-analysis was performed

where clinical homogeneity was sufficient. The quality of the evidence for each comparison
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was assessed with the GRADE approach.

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Results: There were 12 randomized controlled trials with 14 comparisons included in the
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review, with a total sample of 500 participants across all comparisons. Included studies were

typically very small (n = 20 to 72), all except one were assessed as being at high risk of bias,

and all reported short-term outcomes. For the purposes of pooling, studies were divided into

seven clinically homogenous comparisons according to the patient population (acute or

chronic LBP) and the nature of the control intervention. The meta-analyses and GRADE

assessment provided low-quality evidence that MET provided no additional benefit when

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either compared to, or added to, other therapies on the outcomes of pain and disability in the

short-term.

Conclusion: The quality of research related to testing the effectiveness of MET for treatment

of people with LBP is poor. Studies were generally small and at high risk of bias due to

methodological deficiencies. Studies conducted to date generally provide low-quality

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evidence that MET is not effective for patients with LBP. There is insufficient evidence to

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determine whether MET is likely to be effective in practice. Large, methodologically-sound

studies are necessary to investigate the effectiveness of MET as an intervention for treatment

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of people with LBP.

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Keywords: low back pain, systematic review, meta-analysis, isometric, muscle energy,
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musculoskeletal manipulation, osteopathic medicine
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BACKGROUND

Clinical guidelines for low back pain (LBP) developed by the National Institute for Health

and Clinical Excellence1 define nonspecific LBP as “tension, soreness and/or stiffness in the

lower back region for which it is not possible to identify a specific cause of the pain”. The

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aetiology of LBP is poorly understood and it has been estimated that 85% of patients with

isolated LBP cannot be given a precise patho-anatomical diagnosis.2 LBP is multifactorial

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and different chains of causation make it very difficult to isolate risk factors. 3 The recurrence

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rate of LBP is high and 47% to 84% of individuals who have an episode of LBP will suffer a

recurrence within one year.4

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In clinical practice, non-specific LBP which is present for less than six weeks is classified as
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'acute'. When back pain persists between six weeks and three months it is described as

'subacute', and longer than three months as 'chronic'.5 Other authors point out that patients
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with LBP typically experience changing, intermittent episodes of varying duration, and the
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'acute-subacute-chronic' classification is inadequate in classifying this episodic and

intermittent condition.6, 7
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Economic consequences of back pain are enormous. A small number of patients with chronic
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or episodic LBP account for a large proportion of the healthcare expenditure on this

condition. In addition to the economic impact of LBP on the individual and society, there is a

further personal impact on the individual, such as negative social behaviour, retreat from

activities of daily living, and reduced quality of life in people with long-term back pain.8

Description of the intervention

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Muscle energy technique (MET) is a commonly used manual treatment technique in

osteopathy9-12 and manual therapy.9-13 It was developed 50 years ago by Fred Mitchell Sr and

was then refined and partially modified by his son Fred Mitchell Jr.14, 15 MET uses the

patient’s own voluntary muscle contraction in a precisely controlled direction against an

operator applied counter-force.14, 15

PT
RI
It has been suggested that MET is indicated for lengthening shortened muscle, mobilise an

articulation with restricted mobility, strengthen a physiologically weakened muscle, and

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reduce localised oedema and passive congestion.14, 16 Authors of MET texts have described

many techniques for treating lumbar spinal joint dysfunction and lumbar, pelvic and lower

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extremity muscle dysfunction for the purpose of treating patients with mechanical non-
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specific LBP.13-18
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How the intervention might work

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The physiological mechanisms underlying the therapeutic effects of MET are unclear and
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may involve a variety of neurological and biomechanical mechanisms, including hypoalgesia,

altered proprioception, motor programming and control, and drainage of tissue fluid
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congestion.19 Clinical studies suggest MET and related post-isometric techniques reduce pain

and discomfort when applied to the spine20 or appendicular muscles.21, 22

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Why it is important to do this review

MET is a commonly used technique by osteopaths in North America,11 Australia,12 and the

United Kingdom,10 and although MET is typically used as part of a treatment package there

has been a growing number of studies examining the effectiveness of MET as a stand-alone

technique for LBP. Given that MET is a commonly applied therapeutic intervention for a

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common, relevant and expensive health problem, and that several studies have been

published supporting the effectiveness of the technique, a comprehensive systematic review

of this topic is warranted. This paper is an abridged version of the full Cochrane review.23

Objectives

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The objective of this review was to examine the effectiveness of MET in the treatment of

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non-specific LBP compared with control interventions, with particular emphasis on

subjective pain and disability outcomes.

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METHODS

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Selection criteria for inclusion of studies
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Types of studies

We included randomised controlled trials (RCTs) which were written in English, French,
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Spanish, Portuguese, Italian, Dutch or German. The studies were published or readily
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available (for example, scholarly theses). For ongoing trials, the necessary data were required

to be available on request.
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Types of participants
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We included studies of adults (older than 18 years) with non-specific LBP. Trials including a

mix of participants with acute and chronic symptoms were only included if data for the acute

and chronic participants were reported separately. Trials not reporting the duration of

participants’ symptoms were included but the impact of not clearly reporting the duration was

assessed in a subgroup analysis.

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We excluded studies which included participants with specific LBP (back pain with a specific

cause, such as compression fracture, a tumour or metastasis, ankylosing spondylitis,

infection, or where leg pain was an inclusion criterion) and studies involving pregnant

women.

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Types of interventions

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The intervention was required to be within the definition of the isometric form of MET. This

included the following:

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1. diagnosis of the restricted motion of a joint or shortened muscle, and

2. positioning of the joint or muscle to engage the end range of restricted motion or

stretch of muscle, and

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3. voluntary gentle isometric contraction of the stretched muscle, in a direction away
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from the restricted range, against the resistance of the therapist.

We included studies in which the trial authors described the intervention as a form of MET;
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however, we also considered techniques which were applied under a different name but were
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similar to the defined MET procedure. We included studies with techniques not named as

MET if the techniques met the three criteria listed above.

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We only considered studies where an effect size could be assigned to the MET intervention.
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Four types of comparisons were possible:

1. MET plus any intervention versus that same intervention alone;

2. MET versus no treatment;

3. MET versus sham MET;

4. MET versus all other therapies.

Types of outcome measures

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Primary outcomes

• Pain measured by a visual analogue scale (VAS), number rating scale (NRS) or

McGill Pain Questionnaire

• Results of functional disability questionnaires (Roland-Morris Disability

Questionnaire (RMDQ), Oswestry Disability Index (ODI), or another valid

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instrument)

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• If available, scales of general well-being (e.g., quality of life measured with the Short

Form-36 (SF-36), SF-12 or EuroQuol)

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We reported the timing of measured outcomes separately as short-term (closest to four

weeks), intermediate-term (closest to six months) and long-term (closest to one year).

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Secondary outcomes

•
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Any kind of adverse events

• Change in medication
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• Range of movement
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Search methods for identification of studies

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Electronic searches

We performed literature searches using recommended strategies24, 25 in the following

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electronic databases, from database inception:

• Cochrane Central Register of Controlled Trials (CENTRAL, which includes the Back

Review Group Trials Registry; Cochrane Library) up to May 2014

• MEDLINE (OvidSP) up to May 2014

• EMBASE (OvidSP) (1947 to 2014 week 21) up to May 2014

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• Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCO) up to

June 2014

• Physiotherapy Evidence Database (PEDro), Osteopathic Medicine Digital

Repository(OSTMED-DR), OSTEOPATHIC RESEARCHWEB, Google Scholar up

to June 2014

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These searches were supplemented by citation tracking of the identified trials and a manual

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search of the reference lists of all relevant papers not listed in the electronic database (see

Figure 1). The search strategy was not limited by language and is available in full Cochrane

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report. 23

Data collection and analysis

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Selection of studies
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Two authors independently screened titles and abstracts of the results identified by the search

strategy. Potentially eligible studies were read in full text and independently evaluated using
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the selection criteria. Disagreement between author evaluations was resolved through
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discussion or by consulting a third review author.

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Data extraction and management

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Two review authors independently extracted the study data using a pre-piloted data extraction
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form based on recommendations of the Cochrane Back Review Group.

Assessment of risk of bias in included studies

The same two review authors independently assessed the risk of bias using the updated

Cochrane risk of bias tool from the Cochrane Handbook for Systematic Reviews of

Interventions (Version 5.1, updated March 2011).24 Each criterion was scored as either 'low

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risk', 'high risk' or 'unclear'. A consensus method was used to resolve disagreements and a

third review author was consulted where disagreement persisted. If the article did not contain

sufficient information on one or more of the criteria, the trial authors were contacted for

additional information. If the authors could not be contacted, or if the information was no

longer available, the criterion was scored as 'unclear'. According to the recommendations of

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the Cochrane Back Review Group, studies were rated as having ‘low risk of bias’ when at

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least six criteria were met and the study had no serious flaws (for example, large dropout

rate).26

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Measures of treatment effect

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We evaluated clinical homogeneity between studies on the basis of similarity between
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population, treatment procedure, control group, timing of follow-up and measurement
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instruments. On the basis of these evaluations, and if the studies were clinically homogenous,

we pooled the data for outcome measures, pain, functional status and, if available, quality of
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life. Where available, analysis was made for short-, intermediate- and long-term follow-up
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measures. For pain, functional status, and quality of life, we used a standardised mean

difference (SMD) to combine studies that measured the same outcome but with different
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methods. With Review Manager 5.1 (Copenhagen: The Nordic Cochrane Centre, The
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Cochrane Collaboration, 2011), the results of each RCT were plotted as point estimates with
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corresponding 95% confidence intervals (95% CI). We reported the results in a forest plot

using a random-effects model. We did not perform a meta-analysis when the studies were

considered heterogeneous.

Where pain was scored on a 10-point scale, means and standard deviations were multiplied

by 10 to create a common metric for the pooled estimates. This enabled effect sizes to be

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expressed in units related to the most commonly used pain intensity measurement

instruments. All analyses were conducted separately for acute or subacute LBP versus

chronic LBP.

Assessment of clinical relevance

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The same two review authors independently scored the clinical relevance of the included

studies according to five items recommended by the Cochrane Back Review Group.25 Each

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item was scored positive (+) if the item was fulfilled, negative (-) if not fulfilled, and unclear

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(?) if data were not available. To assess minimal clinically important changes for LBP and

function, we used a 30% change on the VAS and NRS, two to three points (or 8%on the

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Roland-Morris Disability Questionnaire or 10 for the Oswestry Disability Index for
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function.27, 28
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For the assessment of the clinical relevance the following questions were investigated.
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1. Are the patients described in detail so that you can decide whether they are
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comparable to those that you see in your practice?

2. Are the interventions and treatment settings described well enough so that you can
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provide the same for your patients?

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3. Were all clinically relevant outcomes measured and reported?

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4. Is the size of the effect clinically important?

5. Are the likely treatment benefits worth the potential harms?

Unit of analysis issues

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In cases where three or more interventions were evaluated in a single study, we included each

pair-wise comparison separately. In this case, the total number of participants in the MET

intervention group was divided approximately evenly among the comparison groups.

Dealing with missing data

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We attempted to contact corresponding authors in cases where data were missing. Where data

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were reported in a graph and not in a table or the text, we estimated the means and standard

deviations by hand. When standard deviations were not reported, we estimated these from the

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CIs or other measures of variance, where possible.

Assessment of statistical heterogeneity

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AN
Assessment of statistical heterogeneity was undertaken using the I² statistic. We adopted the

Cochrane Handbook for Systematic Reviews of Interventions24 guidelines for interpretation of

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I² values, where: 0% to 30%, might not be important; 30% to 60%, may represent moderate
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heterogeneity; 50% to 90%, may represent substantial heterogeneity; 75% to 100%,

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considerable heterogeneity. Data from studies that were clearly heterogeneous was not

pooled.
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Data synthesis
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Regardless of whether there were sufficient data available for quantitative analyses, we

assessed the overall quality of the evidence for each outcome. To accomplish this, we used an

adapted GRADE approach, as recommended in the Cochrane Handbook for Systematic

Reviews of Interventions24 and by the updated Cochrane Back Review Group method

guidelines.25 The quality of the evidence for a specific outcome was based on the

performance against five factors: study design and risk of bias, consistency of results,

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directness (generalisability), precision (sufficient data), and reporting of the results across all

studies that measured that particular outcome.

The quality of evidence was graded down by one level for risk of bias, where studies

included in a comparison did not meet the threshold of six items on the Cochrane risk of bias

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scale. It was also graded down for consistency of results where the I² statistic was greater

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than 60% (‘substantial’ heterogeneity), and graded down for precision where there were less

than a total of 400 participants in the comparison, as recommended.29 The quality started at

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high when RCTs with a low risk of bias provided results for the outcome, and was reduced by

a level for each of the factors not met.29

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RESULTS
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Description of studies
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Results of the search

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A total of 23 studies were identified, 11 of which were excluded for a variety of reasons.23

Twelve studies with a total of 14 comparisons fulfilled the inclusion criteria (Figure 1). Six
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studies came from India,30-35 two from the USA,36, 37 two from Egypt,38, 39 and one each from

Brazil40 and South Africa.41 All trials were published in English with the exception of the
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study from Brazil,40 which was published in Portuguese and translated using computer
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software. The characteristics of included studies are provided in the full Cochrane review.23

Included studies

Overall, 500 participants were included in the trials. Study sample sizes ranged from 20 to 72

(median 40, interquartile range (IQR) 26). With the exception of one study without age

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restriction,37 and another lacking any reference to an age limit,40 all studies specified age

ranges between 18 and 65 years. Only three studies included participants older than 50

years.32, 33, 36 Five studies focused on acute non-specific LBP33, 34, 37, 40, 41 whereas the other

seven studies included participants with chronic non-specific back pain.30-32, 35, 36, 38, 39 Six

studies compared MET plus a specific intervention with other therapies plus that intervention:

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MET with moist heat versus positional release therapy with moist heat,33 MET with physical

therapy versus myofascial release with physical therapy,38 MET with physical therapy versus

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strain counterstrain with physical therapy,39 MET with specific exercises versus sham

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treatment with specific exercises,36 MET with non-specific exercises versus sham treatment

with non-specific exercises,36 MET with corrective exercises versus TENS with corrective

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exercises,31 MET with conventional therapy versus trunk muscle stabilization exercises with
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conventional therapy,32 and MET with exercises versus Maitland's mobilization with

exercises.35 One study compared MET to a sham manual treatment,37 and three studies
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compared MET to other treatments: passive mobilization;41 ultrasound, TENS and

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exercises;30 and TENS.40 Two studies compared MET plus a specific intervention with that
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intervention alone: one using interferential therapy34 and the other using exercises.35
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The average number of treatments reported in the protocol of the included studies was 6 (SD
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= 4) and the average treatment period was 13 days (SD = 11). All studies measured pain

intensity as an outcome using a VAS, with the exception of two studies that used a NRS,31, 41
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and another two studies that used the McGill Pain Questionnaire.38, 39 Eight studies reported

on pain, functional disability status and range of motion.32-36, 38, 39, 41 One study reported pain,

functional disability status and functional leg length measurement,30 whereas other studies

reported pain and functional disability status,31 pain and pain provocation testing37 and pain

and muscle length.40 Functional disability status was measured by the Oswestry-Disability

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Index,31, 35, 38, 39, 41 a modified Oswestry Disability Index,30, 32-34 or the Quebec Back Pain

Disability Scale.36

Seven studies reported that no adverse effects occurred (including additional information),30,
31, 35, 37-39, 41
whereas the remaining seven studies did not mention adverse effects.32-34, 36, 40

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Excluded studies

Ten studies were excluded for different reasons: three studies were not RCTs, 20, 42, 43 in three

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studies the intervention did not meet the operational definition of MET (use of isotonic

contractions, no isometric procedure),44-46 one study focused on specific back pain,47 and

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three studies did not report the outcomes of interest (only strength of muscle).48-50
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Risk of bias in included studies

All studies had a high risk of bias (RoB) with the exception of one study which met the
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criteria for low risk.37 A summary of study RoB is shown in Figure 2. Although all studies
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reported randomisation, only eight (57%) described an adequate randomisation procedure and

three (21%) reported adequate concealment. Owing to the nature of the interventions and the
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patient reported primary outcomes, blinding was not possible for patients or clinicians. Five
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(34%) studies reported complete outcome data, three (21%) described an intention to treat
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analysis, and only one (7%) reported adequate between group comparability at baseline.

Effects of interventions

MET plus any intervention versus other therapies plus that intervention for chronic non-

specific LBP

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Six studies31, 32, 35, 36, 38, 39 with 232 participants were found for this comparison. The studies

provided low-quality evidence (high RoB, imprecision) of no difference regarding pain (MD

0.0, 95% CI -2.97 to 2.98) and functional status (SMD -0.18, 95% CI -0.43 to 0.08) (Figures

3 and 4).

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MET versus sham MET for acute non-specific LBP

Only one small study37 (20 participants) was found to have a low risk of bias but

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demonstrated low-level evidence (downgraded due to imprecision and indirectness) of no

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clinically relevant difference in pain intensity between MET and sham MET (MD 14.20, 95%

CI -10.14 to 38.54). The mean baseline pain scores for the two groups appeared to be quite

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different, although reported as being not significantly different, and this could pose a threat to
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the internal validity of the study. Worst pain in the MET group was much higher than worst
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pain in the control group (29.3 versus 18.1), but current pain was much lower in the MET

group than current pain in the control group (18.2 versus 36.6).
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MET versus all other therapies for acute non-specific LBP

Two studies40, 41 with high risk of bias and involving 88 people were included for this
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comparison. For pain intensity there was very low-quality evidence (high RoB, inconsistency,
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imprecision) of no clinically relevant difference between MET and other therapies (MD -

10.72, 95% CI -32.57 to 11.13). For functional status, which was based only on one study41
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with 60 participants, there was low-quality evidence (high RoB, imprecision) of no difference

between MET and other therapies (MD 0.87, 95% CI -6.31 to 8.05).

MET versus all other therapies for chronic non-specific LBP

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Based upon one study30 with 30 participants, there was low-quality evidence (high RoB,

imprecision) of no clinically relevant difference between MET and other therapies regarding

pain intensity (MD -9.70, 95% CI -20.20 to 0.80) and functional status (MD -4.10, 95% CI -

9.53 to 1.33).

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MET plus any intervention versus that same intervention alone for acute non-specific LBP

Based upon one study34 with 40 participants, there was low-quality evidence (high RoB,

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imprecision) of no clinically relevant difference between MET plus any intervention versus

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that same intervention for acute non-specific LBP regarding pain intensity (MD -3, 95% CI -

11.37 to 5.37) and low-quality evidence of an effect in favour of MET for functional status

(MD -17.6, 95% CI -27.05 to -8.15).

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MET plus any intervention versus that same intervention alone for chronic non-specific

LBP
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Based upon a comparison in one study35 with 30 participants, there was low-quality evidence
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(high RoB, imprecision) of an effect in favour of MET plus any intervention versus that same

intervention for chronic non-specific LBP regarding pain intensity (MD -34.1, 95% CI -38.43
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to -29.77) and functional status (MD -22, 95% CI -27.41 to -16.59).

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AC

MET plus any intervention versus other therapies plus that intervention for acute non-

specific LBP

One small study33 (20 participants) provided low-quality evidence (high RoB, imprecision)

for no difference regarding pain intensity (MD 5.20, 95% CI -3.03 to 13.43) and functional

status (MD 6.0, 95% CI -0.49 to 12.49).

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Secondary outcomes

Seven studies reported range of motion as a secondary outcome. Mesquita32 reported a

significantly larger mean increase in lumbar flexion (P < 0.05) and extension (P < 0.05) in the

MET group compared to control. Naik et al.33 reported no difference in lumbar extension

between the MET and control groups. Another study35 reported significantly larger changes

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in flexion, medial and lateral rotation of the hip in the MET group compared to the exercise

control, but insufficient data were reported to calculate an effect size. Ellythy38 reported no

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difference in lumbar flexion and extension between MET and the control group. Two

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studies38, 41 reported there was no between-group difference in range of motion for flexion,

extension plus left and right side bending, whereas another study34 concluded that MET and

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the control intervention were equally effective in increasing side flexion, spinal flexion and
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spinal extension. Due to the different measures and regions examined for range of motion, no
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meta-analysis was conducted for this secondary outcome.

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Seven studies30, 31, 35, 37-39, 41 reported that no adverse events were observed, whereas the other
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five studies32-34, 36, 40 did not report any information on adverse events.
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Sensitivity analyses
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This review included only one study with a low RoB and 11 studies with a high RoB, so
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sensitivity analyses investigating the influence of study methodological quality were not

performed.

DISCUSSION

Summary of main results

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Twelve studies met the inclusion criteria for this review, which included a total of 500

participants across all comparisons. There was a high level of clinical heterogeneity across

studies in regard to the participant populations, duration of LBP, comparison interventions,

secondary outcomes and treatment interventions. The sample sizes in all studies were small,

ranging from 20 to 72. Furthermore, all but one study was judged to have high risk of bias.

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Only five studies reported on adverse events, and of these studies all reported that no adverse

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events occurred. Due to the number and sample sizes of the studies, insufficient data was

available for the planned sensitivity analyses.

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Due to the few studies involved and the range of comparison groups in these studies, seven

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comparisons were assessed but most of these comparisons involved few studies. One
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comparison included seven studies, one included two studies, and five comparisons included
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only one study each. The comparison group with seven studies (MET plus any intervention

versus other therapies plus that intervention for chronic non-specific LBP) demonstrated low-
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quality evidence for a non-significant effect regarding pain and functional status, and most
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estimates from other comparisons provided low-quality evidence of no difference on pain and

disability outcomes. This suggests that MET is not effective for the treatment of LBP, but,
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given the low quality of the evidence, no conclusions can be made unless larger high-quality
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studies are available.

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All studies measured pain intensity using VAS, NRS or the McGill Pain Questionnaire, but a

high level of clinical heterogeneity in the populations between studies was evident. Several

studies recruited patients with specific clinical findings such as shortened muscles or tests

purported to detect sacroiliac pain, or the detection of specific clinical aetiologies such as

sacroiliac joint dysfunction. Specific examples of clinical inclusion criteria included

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decreased lumbar range of motion,41 positive Laseque and Valsalva tests, 40 restricted lateral

flexion,34 shortened muscles,40 pain on performing pain provocation tests for sacroiliac

dysfunction,30, 31 sacroiliac joint hypomobility30 and anterior innominate rotation.37 Non-

specific LBP is not likely to be a homogeneous condition, but the populations of these studies

will likely be even less homogenous given the variability of specific clinical inclusion

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criteria.

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Although all included studies treated patients using MET, there was variation between the

SC
studies for the type of MET intervention delivered. No study appeared to use a pragmatic

MET approach typical of clinical practice where muscle and joint restrictions are addressed

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in multiple regions according to the clinical findings of the practitioner (local and remote
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from the site of pain). Instead, most studies focused on isolated clinical findings and
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treatment was limited to the specific finding or dysfunction. Although some studies allowed

treatment to be guided by the clinical physical examination findings of the practitioner,

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detection of the findings were usually limited to a particular region, specific finding, or
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muscle group. Thus some studies allowed practitioners to treat according to diagnostic

findings but limited to the pelvic region36 or a ‘diagnosed innominate dysfunction’.35 Others
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limited the treatment to specific dysfunctions, regions or muscle groups, such as treatment for

either an ‘anterior or posterior innominate rotation’,30, 31, 37 segmental side bending at L3,32
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‘fixated spinal joint’41 or for stretching erector spinal muscles,33 quadratus lumborum
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muscles34 or hip musculature.40 It is likely that many of these treatments do not represent the

therapeutic approach advocated by muscle energy authors,14, 16-18 or reflect everyday clinical

practice, and results may have been different if these approaches were used.

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Although MET is commonly used by osteopaths and other manual therapists, it is rarely

delivered as an isolated treatment. In clinical practice, MET is typically performed with other

manual and non-manual modalities in an integrated approach.10, 11 It is therefore not

surprising that few studies have examined patients with LBP using applications of this

isolated treatment modality. A number of clinical trials have examined the effect of

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osteopathic management on the treatment of LBP where MET has been a component of the

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treatment. Many of these studies have reported favourable results, but it is not possible to

determine the influence of MET in the treatment package. Several systematic reviews have

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been performed using these studies to determine the effect of osteopathic management for

LBP51-53 or musculoskeletal pain.54 The conclusions of theses reviews have differed from

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generally favourable outcomes51, 53 to inconclusive outcomes due the lack of available high-
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quality studies.52, 54
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Overall completeness and applicability of evidence

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The included studies were generally of low-quality with small sample sizes, high risk of bias,
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and lacked adequate standard treatment protocols and follow-up periods. The analysis

involved post-treatment comparisons and there was no evidence regarding the long term
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effectiveness of the interventions. For these reasons, further research is very likely to have an
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important impact on the quality of evidence, the accurate estimation of treatment effect, and
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recommendations for clinical practice.

Quality of the evidence

Overall, the methodological quality of the 12 studies was poor and all but one study37 was

found to have high risk of bias. None of the included studies provided complete information

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regarding the methods or results. This lack of information contributed to the determination of

high risk for many studies.

Assessment of blinding is an issue for studies using manual therapy because practitioners

cannot be easily blinded from the treatment intervention they deliver. Participants inevitably

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know when manual therapy is delivered and it is far more difficult to mask the applied

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manual technique compared to interventions such as pharmaceuticals. Further, testing of the

success of participant blinding was required in order for this criterion to be ranked as low

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risk. The four studies that used a sham treatment as the control36, 37 or another treatment38, 39

attempted to blind the patients to the sham nature of the intervention, but the success of the

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blinding was not tested so the procedure was assessed as unclear.
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The difficulty of blinding practitioners and participants creates a disadvantage for nearly all

manual therapy studies when assessed using the risk of bias tool. Blinding of the
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measurement assessor to treatment allocation is possible but due to inadequate methods or

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information provided, none of the studies were deemed as low risk for this criterion.
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The overall quality of the evidence was assessed using the GRADE approach. In all
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comparisons except one, the evidence was downgraded because of limitations in design
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because more than 25% of the participants came from studies with a high risk of bias. The

one comparison that was not downgraded for this reason (MET versus sham MET for acute

non-specific LBP) involved a single study with low risk of bias.37 Every comparison was

downgraded for imprecision because the total number of participants was less than 400 for

each outcome. Additionally, one comparison was downgraded due to inconsistency because

of the presence of significant statistical heterogeneity and another downgraded due to

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indirectness. The quality of evidence for the many comparisons ranged from ‘low’ to ‘very

low’.

Potential biases in the review process

The main biases in this review can be attributed to the small number of studies, the small

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sample sizes of the studies, and the high risk of bias in all but one of the studies. Given this,

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the data analysed in this review were not robust and future high-quality studies may have a

large impact on the estimate of effect sizes.

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The extensive literature search was a strength of the current review. The search strategy was

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not limited to only one language but to different languages (English, French, Spanish,
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Portuguese, Italian, Dutch and German) and was not limited to the published literature.
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CONCLUSION
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Implications for practice

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The quality of research related to testing the effectiveness of MET is poor. Studies are

generally small and at high risk of bias due to methodological deficiencies. Studies conducted
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to date generally provide low-quality evidence that MET is not effective for patients with
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non-specific LBP. There is not sufficient evidence to confidently determine whether MET is
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likely to be effective in practice and large, methodologically sound studies are necessary to

investigate this question. Given this, no implications for practice can be made at this stage.

Implications for research

There is a need for larger, higher-quality studies with more robust methodology. Studies

should clearly describe all methods, have larger sample sizes, use robust methods of

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statistical analysis, demonstrate baseline equivalence of patient characteristics between

groups, and use treatment protocols that can be generalised to clinical practice. Authors of

studies are recommended to adhere to the CONSORT guidelines55 to improve the reporting

of study methods and results.

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FIGURES

Figure 1. Flow of studies

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Figure 2. Risk of Bias summary

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Percentage of risk of bias in all included studies. Risk of bias for individual studies is

available in the full review.23

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Figure 3. Forest plot of MET plus any intervention vs. other therapies plus that intervention

for chronic non-specific LBP; pain

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Figure 4. Forest plot of MET plus any intervention vs. other therapies plus that intervention
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for chronic non-specific LBP; function

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ACKNOWLEDGEMENTS

This review is adapted from the Cochrane Review ‘Franke H, Fryer G, Ostelo RWJG,

Kamper SJ. Muscle energy technique for non-specific low-back pain. Cochrane Database

of Systematic Reviews 2015, Issue 2. Art. No.: CD009852. DOI:

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10.1002/14651858.CD009852.pub2.’. Copyright Cochrane Library, reproduced with

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permission.

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The review authors thank Ms Teresa Marin and Ms Victoria Pennick from the Cochrane Back

Review Group for their constructive advice on the protocol of this review and Ms Rachel

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Couban and Ms Shireen Harbin for their assistance with the development of the search
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strategy.
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1101 records identified 3 additional records identified

through database searching through other sources

1104 records screened 1082 records excluded

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22 full text articles assessed for 10 full text articles excluded
eligibility

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12 studies included in

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qualitative synthesis

12 studies included in
quantitative synthesis

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(meta-analysis)
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Figure 1. Flow of studies
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CONTRIBUTIONS OF AUTHORS

Helge Franke and Gary Fryer wrote the background. Helge Franke drafted the protocol with

help from the other authors. Gary Fryer and Helge Franke performed the search, study

selection and data extraction. Helge Franke and Steve Kamper performed the data analyses.

Raymond Ostelo, Steve Kamper and Helge Franke assessed the risk of bias. Steve Kamper

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performed the GRADE approach. Gary Fryer, Steve Kamper and Helge Franke wrote main

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results, discussion, conclusion, abstract and plain language summary. All authors read and

approved the final version.

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ETHICAL STATEMENT

This study was a systematic review and did not involve human or animal subjects and

therefore did not require approval from an institutional ethics committee.

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Implications for practice

The quality of research related to testing the effectiveness of MET is poor. Studies are

generally small and at high risk of bias due to methodological deficiencies. Studies conducted

to date generally provide low-quality evidence that MET is not effective for patients with

non-specific LBP. There is not sufficient evidence to reliably determine whether MET is

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likely to be effective in practice and large, methodologically-sound studies are necessary to

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investigate this question. Given this, no implications for practice can be made at this stage.

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