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 the Journal of the American Medical Association.
The lifetime prevalence of LBP ranges from 50% to 84% worldwide,and studies assessing the efficacy of SMT to treat this condition have led to mixed conclusions. For example, while 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. 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 months.
Noting these inconsistent results and newer study findings, 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, while the remaining trials were deemed low quality. SMT was provided by a variety of clinicians, most commonly physical therapists, followed by chiropractors, medical doctors, and osteopathic physicians.
The findings demonstrate the following associations with SMT:
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.
The current review found that spinal manipulation therapy is associated with moderate improvements in pain and function in patients with acute low back pain.
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.