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Spinal Manipulative Therapy for Acute Low Back Pain: An Update of the Cochrane Review

Rubinstein, Sidney M. PhD*; Terwee, Caroline B. PhD*; Assendelft, Willem J. J. MD, PhD†,‡; de Boer, Michiel R. PhD§; van Tulder, Maurits W. PhD*,§

doi: 10.1097/BRS.0b013e31827dd89d
Cochrane Collaboration
SLIDE

Study Design. Systematic review of interventions.

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

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

Methods. An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to March 13, 2011. RCTs that examined manipulation or mobilization in adults with acute low back pain (<6-week duration) were included. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life. Two authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE (grading of recommendations assessment, development, and evaluation) was used to assess the quality of the evidence. The effects were examined for SMT versus (1) inert interventions, (2) sham SMT, (3) other interventions, and (4) SMT as adjunct therapy.

Results. We identified 20 RCTs (total participants = 2674), 12 (60%) of which were not included in the previous review. In total, 6 trials (30% of all included studies) had a low risk of bias. In general, for the outcomes of pain and functional status, there is low- to very low-quality evidence suggesting no difference in effect for SMT when compared with inert interventions, sham SMT or as adjunct therapy. There was varying quality of evidence (from very low to moderate) suggesting no difference in effect for SMT when compared with other interventions. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.

Conclusion. SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies. Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation.

We assessed the effects of spinal manipulative therapy (SMT) for acute low back pain using a systematic review. Twenty randomized controlled trials were identified (N = 2674), 6 of which had a low risk of bias. For the outcomes pain and functional status, there is low- to very low-quality evidence suggesting no difference in effect for SMT compared with inert interventions, sham SMT or as adjunct therapy and very low to moderate evidence which suggests no difference in effect when compared with other interventions. Data were particularly sparse for recovery, return-to-work, quality of life, and costs. Future research is likely to have an important impact on this assessment.

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

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

Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, 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, PhD, Department of Epidemiology and Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands; E-mail: sm.rubinstein@vumc.nl

Acknowledgement date: October 7, 2012. Acceptance date: October 7, 2012.

This article is based on Rubinstein SM, Terwee CB, Assendelft WJJ, de Boer MR, van TulderMW. Spinal manipulative therapy for acute low back pain. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No. CD008880. DOI: 10.1002/14651858.CD008880.pub2.

This Cochrane review was published in The Cochrane Library 2012, issue 9 (see www.thecochranelibrary.com for more information).

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, grants, payment for lecture.

© 2013 Lippincott Williams & Wilkins, Inc.