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Do Manual Therapies Help Low Back Pain? A Comparative Effectiveness Meta-analysis

Menke, J. Michael DC, PhD

doi: 10.1097/BRS.0000000000000230
Health Services Research

Study Design. Meta-analysis methodology was extended to derive comparative effectiveness information on spinal manipulation for low back pain.

Objective. Determine relative effectiveness of spinal manipulation therapies (SMTs), medical management, physical therapies, and exercise for acute and chronic nonsurgical low back pain.

Summary of Background Data. Results of spinal manipulation treatments of nonsurgical low back pain are equivocal. Nearly 40 years of SMT studies were not informative.

Methods. Studies were chosen on the basis of inclusion in prior evidence syntheses. Effect sizes were converted to standardized mean effect sizes and probabilities of recovery. Nested model comparisons isolated nonspecific from treatment effects. Aggregate data were tested for evidential support as compared with shams.

Results. Of 84% acute pain variance, 81% was from nonspecific factors and 3% from treatment. No treatment for acute pain exceeded sham's effectiveness. Most acute results were within 95% confidence bands of that predicted by natural history alone. For chronic pain, 66% of 98% was nonspecific, but treatments influenced 32% of outcomes. Chronic pain treatments also fit within 95% confidence bands as predicted by natural history. Though the evidential support for treating chronic back pain as compared with sham groups was weak, chronic pain seemed to respond to SMT, whereas whole systems of clinical management did not.

Conclusion. Meta-analyses can extract comparative effectiveness information from existing literature. The relatively small portion of outcomes attributable to treatment explains why past research results fail to converge on stable estimates. The probability of treatment superiority matched a binomial random process.

Treatments serve to motivate, reassure, and calibrate patient expectations—features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain.

Level of Evidence: 1

Supplemental Digital Content is Available in the Text.Nearly 4 decades of spinal manipulation studies were analyzed to extract comparative effectiveness information for nonsurgical back pain. Outcomes were overwhelmingly attributable to natural history and nonspecific factors. Supervising patient exercises while motivating, reassuring, and calibrating their expectations might reduce future medicalization of this self-limiting condition.

From the Division of Psychology, School of Medicine, International Medical University, Kuala Lumpur, Malaysia.

Address correspondence and reprint requests to J. Michael Menke, DC, PhD, Division of Psychology, School of Medicine, International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000 Kuala Lumpur, Malaysia; E-mail:

Acknowledgment date: June 5, 2013. First revision date: October 21, 2013. Second revision date: December 22, 2013. Acceptance date: January 2, 2014.

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

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

© 2014 by Lippincott Williams & Wilkins