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Meta-Analysis
. 2011 Feb 16;2011(2):CD008112.
doi: 10.1002/14651858.CD008112.pub2.

Spinal manipulative therapy for chronic low-back pain

Sidney M Rubinstein  1 , Marienke van Middelkoop, Willem Jj Assendelft, Michiel R de Boer, Maurits W van Tulder
Affiliations
Meta-Analysis

Spinal manipulative therapy for chronic low-back pain

Sidney M Rubinstein et al. Cochrane Database Syst Rev. .

Abstract

Background: Many therapies exist for the treatment of low-back pain including spinal manipulative therapy (SMT), which is a worldwide, extensively practiced intervention.

Objectives: To assess the effects of SMT for chronic low-back pain.

Search strategy: An updated search was conducted by an experienced librarian to June 2009 for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2009, issue 2), MEDLINE, EMBASE, CINAHL, PEDro, and the Index to Chiropractic Literature.

Selection criteria: RCTs which examined the effectiveness of spinal manipulation or mobilisation in adults with chronic low-back pain were included. No restrictions were placed on the setting or type of pain; studies which exclusively examined sciatica were excluded. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life.

Data collection and analysis: Two review authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the quality of the evidence. Sensitivity analyses and investigation of heterogeneity were performed, where possible, for the meta-analyses.

Main results: We included 26 RCTs (total participants = 6070), nine of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. In general, there is high quality evidence that SMT has a small, statistically significant but not clinically relevant, short-term effect on pain relief (MD: -4.16, 95% CI -6.97 to -1.36) and functional status (SMD: -0.22, 95% CI -0.36 to -0.07) compared to other interventions. Sensitivity analyses confirmed the robustness of these findings. There is varying quality of evidence (ranging from low to high) that SMT has a statistically significant short-term effect on pain relief and functional status when added to another intervention. There is very low quality evidence that SMT is not statistically significantly more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.

Authors' conclusions: High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT, and data related to recovery.

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Conflict of interest statement

None

Figures

1
1
Study flow diagram (updated July 2012)
2
2
Risk of bias summary: Summary of authors' judgement on risk of bias items within each included study.
3
3
Funnel plot of comparison: 3. SMT vs. any other intervention, outcome: 3.1 Pain. 
 Negative values favour SMT; positive values favour the control intervention.
4
4
Funnel plot of comparison: 3. SMT vs. any other intervention, outcome: 3.2 Functional status. 
 Negative values favour SMT; positive values favour the control intervention.
5
5
Forest plot of comparison: 7. SMT vs. any other intervention ‐ for studies with a low RoB only, outcome: 7.1 Pain.
6
6
Forest plot of comparison: 7. SMT vs. any other intervention ‐ for studies with a low RoB only, outcome: 7.2 Functional status.
7
7
Summary forest plot as part of the sensitivity analyses. Comparison: SMT vs. all other interventions. Outcome: Pain at one month.
8
8
Summary forest plot as part of the sensitivity analyses. Comparison: SMT vs. all other interventions. Outcome: Functional status at one month.
1.1
1.1. Analysis
Comparison 1 SMT vs. inert interventions, Outcome 1 Pain.
1.2
1.2. Analysis
Comparison 1 SMT vs. inert interventions, Outcome 2 Perceived recovery.
1.3
1.3. Analysis
Comparison 1 SMT vs. inert interventions, Outcome 3 Return to work.
2.1
2.1. Analysis
Comparison 2 SMT vs. sham SMT, Outcome 1 Pain.
2.2
2.2. Analysis
Comparison 2 SMT vs. sham SMT, Outcome 2 Functional status.
3.1
3.1. Analysis
Comparison 3 SMT vs. any other intervention, Outcome 1 Pain.
3.2
3.2. Analysis
Comparison 3 SMT vs. any other intervention, Outcome 2 Functional status.
3.3
3.3. Analysis
Comparison 3 SMT vs. any other intervention, Outcome 3 Perceived recovery.
3.4
3.4. Analysis
Comparison 3 SMT vs. any other intervention, Outcome 4 Return to work.
3.5
3.5. Analysis
Comparison 3 SMT vs. any other intervention, Outcome 5 Health‐related Quality of Life.
4.1
4.1. Analysis
Comparison 4 Subset of comparison 3. SMT vs. ineffective interventions, Outcome 1 Pain.
4.2
4.2. Analysis
Comparison 4 Subset of comparison 3. SMT vs. ineffective interventions, Outcome 2 Functional status.
4.3
4.3. Analysis
Comparison 4 Subset of comparison 3. SMT vs. ineffective interventions, Outcome 3 Perceived recovery.
4.4
4.4. Analysis
Comparison 4 Subset of comparison 3. SMT vs. ineffective interventions, Outcome 4 Return to work.
5.1
5.1. Analysis
Comparison 5 Subset of comparison 3. SMT vs. effective interventions, Outcome 1 Pain.
5.2
5.2. Analysis
Comparison 5 Subset of comparison 3. SMT vs. effective interventions, Outcome 2 Functional status.
5.3
5.3. Analysis
Comparison 5 Subset of comparison 3. SMT vs. effective interventions, Outcome 3 Perceived recovery.
5.4
5.4. Analysis
Comparison 5 Subset of comparison 3. SMT vs. effective interventions, Outcome 4 Return to work.
5.5
5.5. Analysis
Comparison 5 Subset of comparison 3. SMT vs. effective interventions, Outcome 5 Health‐related Quality of Life.
6.1
6.1. Analysis
Comparison 6 SMT + intervention vs. intervention alone, Outcome 1 Pain.
6.2
6.2. Analysis
Comparison 6 SMT + intervention vs. intervention alone, Outcome 2 Functional status.
6.3
6.3. Analysis
Comparison 6 SMT + intervention vs. intervention alone, Outcome 3 Perceived recovery.
7.1
7.1. Analysis
Comparison 7 Subset of comparison 3. SMT vs. any other intervention ‐ studies w/ low RoB only, Outcome 1 Pain.
7.2
7.2. Analysis
Comparison 7 Subset of comparison 3. SMT vs. any other intervention ‐ studies w/ low RoB only, Outcome 2 Functional status.
7.3
7.3. Analysis
Comparison 7 Subset of comparison 3. SMT vs. any other intervention ‐ studies w/ low RoB only, Outcome 3 Perceived recovery.
7.4
7.4. Analysis
Comparison 7 Subset of comparison 3. SMT vs. any other intervention ‐ studies w/ low RoB only, Outcome 4 Return to work.
7.5
7.5. Analysis
Comparison 7 Subset of comparison 3. SMT vs. any other intervention ‐ studies w/ low RoB only, Outcome 5 Health‐related Quality of Life.
8.1
8.1. Analysis
Comparison 8 Subset of comparisons 1, 2 & 3. SMT vs. ineffective/sham/inert interventions, Outcome 1 Pain.
8.2
8.2. Analysis
Comparison 8 Subset of comparisons 1, 2 & 3. SMT vs. ineffective/sham/inert interventions, Outcome 2 Functional status.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD008112

References

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Niemisto 2003/2005 {published data only}
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    1. Niemisto L, Rissanen P, Sarna S, Lahtinen‐Suopanki T, Lindgren KA, Hurri H. Cost‐effectiveness of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain: a prospective randomized trial with 2‐year follow‐up. Spine 2005;30(10):1109‐15. - PubMed
Nwuga 1982 {published data only}
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Shearar 2005 {published data only}
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Sims‐Williams 1978 {published data only}
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    1. Sims‐Williams H, Jayson MI, Young SM, Baddeley H, Collins E. Controlled trial of mobilisation and manipulation for patients with low back pain in general practice. British Medical Journal 1978;2:1338‐40. - PMC - PubMed
Skagren 1997 {published data only}
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Terrett 1984 {published data only}
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Timm 1994 {published data only}
    1. Timm KE. A randomized‐control study of active and passive treatments for chronic low back pain following L5 laminectomy. J Orthop Sports Phys Ther 1994;20:276‐86. - PubMed
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    1. Triano JJ, McGregor M, Hondras MA, Brennan PC. Manipulative therapy versus education in chronic low back pain. Spine 1995;20:948‐55. - PubMed
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References to studies awaiting assessment

Bronfort 2011 {published data only}
    1. Bronfort G, Maiers MJ, Evans RL, Schulz CA, Bracha Y, Svendsen KH, et al. Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. Spine Journal: Official Journal of the North American Spine Society 2011;11(7):585‐98. - PubMed
Cecchi 2010 {published data only}
    1. Cecchi F, Molino‐Lova R, Chiti M, Pasquini G, Paperini A, Conti AA, et al. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one‐year follow‐up. Clinical Rehabilitation 2010;24(1):26‐36. - PubMed
Petersen 2011 {published data only}
    1. Petersen T, Larsen K, Nordsteen J, Olsen S, Fournier G, Jacobsen S. The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: a randomized controlled trial. Spine 2011;36(24):1999‐2010. - PubMed

References to ongoing studies

ISRCTN47636118 {published data only}
    1. Efficacy of conventional physiotherapy and manipulative physiotherapy in the treatment of low‐back pain: A randomised controlled trial. Ongoing study January 2000; patient recruitment completed as of June 2008.
ISRCTN61808774 {published data only}
    1. A randomised controlled trial of the effect on chronic low‐back pain of a naturopathic osteopathy intervention. Ongoing study April 2000; recruitment completed; information last updated Nov. 2005.
NCT00269321 {published data only}
    1. randomised clinical trial of chiropractic manual therapy plus home exercise, supervised exercise plus home exercise and home exercises alone for individuals 65 and over with chronic mechanical low‐back painPrimary aims: to determine the relative clinical effectiveness the following treatments for LBP patients 65 years and older in both the short‐term (after 12 weeks) and long‐term (after 52 weeks), using LBP as the main outcome measure.Secondary outcomes: to estimate the short‐ and long‐term relative effectiveness of the three interventions using:Patient‐rated outcomes: low‐back disability, general health status, patient satisfaction, improvement, and medication use measured by self‐report questionnairesObjective functional performance outcomes: spinal motion, trunk strength and endurance, and functional ability measured by examiners masked to treatment group assignmentCost measures: direct and indirect costs of treatment measured by questionnaires, phone interviews, and medical records.To describe elderly LBP patients' perceptions of treatment and the issues they consider when determining their satisfaction with care using qualitative methods nested within the RCT.. Ongoing study October 2003; recruitment completed as of June 2008..
NCT00269347 {published data only}
    1. Title: Manipulation, exercise and self‐care for non‐acute low‐back painBuilding upon the principal investigators' previous collaborative research, this randomised observer‐blinded clinical trial will compare the following treatment for patients with non‐acute low‐back pain:chiropractic spinal manipulationrehabilitative exerciseself care education Theprimary aim is to examine the relative efficacy of the three interventions in terms of patient rated outcomes in the short‐term (after 12 weeks) and the long‐term (after 52 weeks) for non‐acute low‐back pain.Secondary aims include:To examine the short and long‐term relative cost effectiveness and cost utility of the three treatments.To assess if there are clinically important differences between pre‐specified subgroups of low‐back pain patients. Subgroups are based on duration and current episode and radiating leg pain.To evaluate if there treatment group differences in objective lumbar spine function (range of motion, strength and endurance) after 12 weeks of treatment and if changes in lumbar function are associated with changes in patient rated short and long‐term outcomes.To identify if baseline demographic or clinical variables can predict short or long‐term outcome.To describe patients' interpretations and perceptions of outcome measures used in clinical trials. Ongoing study January 2001; recruitment completed as of June 2008; currently in the review process..
NCT00269503 {published data only}
    1. Official title: A Pilot Study of Chiropractic Prone Distraction for Subacute Back Pain With Sciatica. Ongoing study Starting date of trial not provided. Contact author for more information.
NCT00315120 {published data only}
    1. A randomised controlled trial of osteopathic manipulative treatment and ultrasound physical therapy for chronic low‐back pain. Ongoing study August 2006; estimated study completion date: June 2010.
NCT00376350 {published data only}
    1. Dose‐response/Efficacy of manipulation for chronic low‐back pain. Ongoing study March 2007; estimated completion date March 2011.
NCT00410397 {published data only}
    1. The use of manual therapy to treat low‐back and hip pain. Ongoing study December 2006.
NCT00567333 {published data only}
    1. Individualized chiropractic and integrative care for low‐back pain. Ongoing study June 2007; recruitment completed, currently in the follow‐up phase. Estimated completion: October 2010..
NCT00632060 {published data only}
    1. The efficacy of manual and manipulative therapy for low‐back pain in military active duty personnel: A feasibility study. Ongoing study February 2008.

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References to other published versions of this review

Assendelft 2003
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