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Spinal Manipulative Therapy for Chronic Low-Back Pain: An Update of a Cochrane Review

Rubinstein, Sidney M. DC, PhD*; van Middelkoop, Marienke PhD; Assendelft, Willem J.J. MD, PhD; de Boer, Michiel R. PhD§; van Tulder, Maurits W. PhD

doi: 10.1097/BRS.0b013e3182197fe1
Cochrane Collaboration

Study Design. Systematic review of interventions.

Objective. To assess the effects of spinal manipulative therapy (SMT) for chronic low-back pain.

Summary of Background Data. SMT is one of the many therapies for the treatment of low-back pain, which is a worldwide, extensively practiced intervention.

Methods. Search methods. An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to June 2009. Selection criteria. RCTs that examined manipulation or mobilization in adults with chronic low-back pain were included. 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 authors independently conducted the study selection, risk of bias assessment, and data extraction. GRADE was used to assess the quality of the evidence.

Results. We included 26 RCTs (total participants = 6070), 9 of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. There is a high-quality evidence that SMT has a small, significant, but not clinically relevant, short-term effect on pain relief (mean difference −4.16, 95% confidence interval −6.97 to −1.36) and functional status (standardized mean difference −0.22, 95% confidence interval −0.36 to −0.07) in comparison with other interventions. There is varying quality of evidence that SMT has a significant short-term effect on pain relief and functional status when added to another intervention. There is a very low-quality evidence that SMT is not 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.

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.

An update was conducted of an existing Cochrane review on the effects of spinal manipulative therapy (SMT) for chronic low-back pain. We included 26 randomized controlled trials (N = 6070), 9 of which had a low risk of bias. Approximately two-thirds of the included studies were not evaluated in the previous review. 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 lowback pain. Therefore, the decision to refer for SMT should be based on costs, preferences of the patient and providers, and relative safety of the treatment options.

* Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands.

Department of General Practice, Erasmus Medical Center, Rotterdam, the Netherlands.

Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.

§ Institute of Health Sciences, Faculty of Earth and Life Sciences, VU University Medical Center, Amsterdam, the Netherlands; and

Department of Health Sciences, Faculty of Earth and Life Sciences, VU University, Amsterdam, the Netherlands.

Address correspondence and reprint requests to Sidney M. Rubinstein, DC, PhD, Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research VU University Medical Center, PO Box 7057, Room D518, 1007 MB Amsterdam, Netherlands; E-mail: sm.rubinstein@vumc.nl

Acknowledgement date: February 18, 2011. Acceptance date: March 2, 2011.

This work was supported by the Dutch Health Insurance Council (CVZ).

This article is based on Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD008112. DOI: 10.1002/14651858.CD008112.pub2, a Cochrane Review published in The Cochrane Library 2011, Issue 2 (see www.thecochranelibrary.com for information).

It is co-published with the permission of John Wiley & Sons Ltd, on behalf of the Cochrane Collaboration. Cochrane reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library should be consulted for the most recent version of the review.”

Contributions of authors: Conception and design—S.M. Rubinstein, M.W. van Tulder, W.J.J. Assendelft; Analysis and interpretation of the data—S.M. Rubinstein, M.R. de Boer, M.W. van Tulder; Drafting of the review—S.M. Rubinstein, M.W. van Tulder; critical revision of the article for important intellectual content: All members. Final approval of the article: All members. Statistical Expertise: M.R. de Boer. Administrative, technical, or logistical support: S.M. Rubinstein, M.R. de Boer. Collection and assembly of data: S.M. Rubinstein, M. van Middelkoop, M.R. de Boer, W.J.J. Assendelft (studies published before 2000).

© 2011 Lippincott Williams & Wilkins, Inc.