Spinal Manipulation Therapy for Low Back Pain Linked to Improved Pain and Function

Spinal manipulative therapy (SMT) is associated with moderate improvements in pain and function in patients with acute low back pain (LBP), according to a systematic review and meta-analysis reported in JAMA.¹

The lifetime prevalence of LBP ranges from 50% to 84% worldwide,² and studies assessing the efficacy of SMT to treat this condition have led to mixed conclusions. For example, although an earlier review determined that SMT was significantly more effective than a sham manipulation but not other therapies, a more recent review found no significant benefit of SMT vs any other treatment.^3,4 Subsequent findings show conflicting results, as indicated by a review that found SMT to be more effective than placebo, no treatment, or massage for LBP for a duration < 3 mo.⁵

Noting these inconsistent results and newer study findings,^6,7 the authors of the current study aimed to elucidate the effectiveness and risks of SMT vs nonmanipulative interventions for the treatment of acute LBP, including analgesics, physical therapy, and exercises. They analyzed studies in which adults with LBP lasting ≤6 weeks received SMT by any type of clinician in ambulatory or outpatient settings, either as an isolated intervention, or in combination with other therapies.

The primary outcomes were pain (as indicated on the 100-mm visual analog scale, the 11-point numeric rating scale, or another numeric pain scale), and functional status (per scores on the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index; range, 0-100).

The final analysis included 26 randomized controlled trials (RCTs), 12 of which were considered to be of high quality, and 14 of low quality. SMT was provided by a variety of clinicians, most commonly physical therapists, followed by chiropractors, physicians, and osteopathic physicians.

The findings demonstrate the following associations with SMT:

• Significant improvements in pain, based on 15 RCTs (n = 1711) with moderate-quality evidence (pooled mean improvement in the 100-mm visual analog pain scale, −9.95 mm; 95% CI, −15.6 to −4.3 mm)
• Significant improvements in function, based on 12 RCTs (n = 1381) with moderate-quality evidence (pooled mean effect size, −0.39; 95% CI, −0.71 to −0.07)
• No reports of serious adverse events in any RCT
• Increased pain, muscle stiffness, and other minor transient adverse events in 50% to 67% of cases, per observational studies

However, there was significant heterogeneity in results, which was not explained by clinician or SMT type, study quality, or whether SMT was an isolated intervention or combined with other therapies. “The most fruitful area for further research is likely to be assessing the role of patient selection and type of SMT on explaining heterogeneity in treatment effects,” the authors concluded.

Summary and Clinical Applicability

The current review found that spinal manipulation therapy is associated with moderate improvements in pain and function in patients with acute low back pain. 

Limitations and Disclosures

Study limitations include the significant number of low-quality studies (14 of 26), inadequate description of SMT in some studies, and the unexplained heterogeneity in results.

Dr Shekelle disclosed personal fees from ECRI Institute and UpToDate. None of the other authors reported disclosures.

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References

1. Paige NM, Miake-Lye IM, Booth MS, et al. Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain systematic review and meta-analysis. JAMA. 2017; 317(14):1451-1460. doi:10.1001/jama.2017.3086
2. Ahdhi GS, Subramanian R, Saya GK, Yamuna TV. Prevalence of low back pain and its relation to quality of life and disability among women in rural area of Puducherry, India. Indian J Pain; 2016; 30:111-115. doi:10.4103/0970-5333.18646
3. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain: a meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003; 138(11): 871-881.
4. Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low-back pain. Cochrane Database Syst Rev. 2012; (9):CD008880.  doi:10.1002/14651858.CD008880.pub2
5. Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG. Efficacy of spinal manipulative therapy for low back pain of less than three months’ duration. J Manipulative Physiol Ther. 2003; 26(9): 593-601. doi: 10.1016/j.jmpt.2003.08.010
6. Fritz JM, Magel JS, McFadden M, et al. Early physical therapy vs usual care in patients with recent-onset low back pain: a randomized clinical trial. JAMA. 2015; 314(14):1459-1467. doi: 10.1001/jama.2015.11648
7. Goertz CM, Long CR, Hondras MA, et al. Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study. Spine (Phila Pa 1976). 2013; 38 (8):627-634. doi: 10.1097/BRS.0b013e31827733e7