Tools for Practice


#181 Manipulating Research for Spinal Manipulative Therapy for Low Back Pain


CLINICAL QUESTION
Is spinal manipulative therapy (SMT) effective for low back pain (LBP)?

BOTTOM LINE
Research around SMT is poor, consistently inconsistent, and almost impossible to interpret. Likely no reliable effects in acute LBP, but possible small effects in chronic LBP, at best improved pain (≤0.9 points out of 10) and recovery (for one in ~11 patients at one month) but two thirds of comparisons found no effect.  


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EVIDENCE
>20 systematic reviews. The largest and highest quality presented (with pain scores out of 10): 
  • Acute LBP (<6 weeks): 20 RCTs (2,674 patients).1  
    • Pain: 3/17 comparisons statistically significant:  
      • Two based on single studies.  
      • One 0.6 points better after one month.  
    • No difference in recovery.  
  • Chronic LBP (>12 weeks): 26 RCTs (6,070 patients).2 
    • Pain: 11/29 comparisons statistically significant, pain 0.3-0.9 points better (mostly one month).  
    • Increased chance of recovery in some comparisons, best Number Needed to Treat=11 (one month).  
  • Other Findings:  
    • Functional Status: 4/18 (acute) and 9/27 (chronic) comparisons statistically significant but mostly questionable clinical significance.1,2  
    • Osteopathic SMT:3 15 RCTs (1,502 patients), pain 1.3 better.3   
    • Chiropractic SMT combined with other therapy:4 12 RCTs (2,887 patients), pain 0.5 better.4  
    • Others reviews vary from negative5,6 to supportive.7,8   
  • Multiple issues: 
    • SMT often combined with one or more interventions (exercise, education, medications, mobilization, sham, etc.) then compared to another cluster of interventions, which may not overlap at all.1,2,9 
      • Unclear which, if any, intervention is working.  
    • Large variations in outcomes, measurement scales, study duration, type of SMT, type of provider, number of providers, and number of treatments.9,10   
      • Results in multiple analyses (like 91 meta-analyses in one study).2   
    • Studies low quality (mean quality score 33%).1  
    • Reviews authored by SMT providers may be poorer quality and more positive.11 
Context: 
  • In one Saskatchewan LBP study, 29% consulted a chiropractor.12 
  • Toward Optimized Practice (TOP) guideline:13  
    • Insufficient evidence for or against SMT in preventing LBP or treating chronic LBP.  
    • If not recovering from acute LBP, SMT “may benefit.” 

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Author(s):

  • G. Michael Allan MD CCFP
  • Megan A Manning MD CCFP

1. Rubinstein SM, Terwee CB, Assendelft WJJ, et al. Cochrane Database Syst Rev. 2012; 9:CD008880.

2. Rubinstein SM, van Middelkoop M, Assendelft WJJ, et al. Cochrane Database Syst Rev. 2011; 2:CD008112.

3. Franke H, Franke JD, Fryer G. BMC Musculoskeletal Disorders. 2014; 15:286.

4. Walker BF, French SD, Grant W, et al. Cochrane Database Syst Rev. 2010; 4:CD005427.

5. Kizhakkeveettil A, Rose K, Kadar GE. Glob Adv Health Med. 2014; 3:49-64.

6. Rothberg S, Friedman BW. Am J Emerg Med. 2017; 35(1):55-61.

7. Globe G, Farabaugh RJ, Hawk C, et al. J Manipulative Physiol Ther. 2016; 39:1-22.

8. Bronfort G, Haas M, Evans R, et al. Chiropr Osteopat. 2010 Feb 25; 18:3.

9. Dagenais S, Gay RE, Tricco AC, et al. Spine J. 2010; 10:918-40.

10. Rubinstein SM, Terwee CB, Assendelft WJ, et al. Spine (Phila Pa 1976). 2013; 38:E158-77.

11. Posadzki P. Pain Med. 2012; 13:754-61.

12. Côté P, Cassidy JD, Carroll L. Med Care. 2001; 39:956-67.

13. Toward Optimized Practice. Clinical Practice Guideline. December 2015. Available at: http://www.topalbertadoctors.org/download/1885/LBPguideline.pdf?_20161121185816. Last accessed November 21, 2016.

Authors do not have any conflicts of interest to declare.