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IMPORTANCE Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT. OBJECTIVE To systematically review studies of the effectiveness and harms of SMT for acute (Յ6 weeks) low back pain.

BACKGROUND CONTEXT Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain. However, questions remain about their efficacy, dosing, safety, and how these approaches compare with other therapies. PURPOSE The present study aims to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain. STUDY DESIGN/SETTING This is a systematic literature review and meta-analysis. OUTCOME MEASURES The present study measures self-reported pain, function, health-related quality of life, and adverse events. METHODS We identified studies by searching multiple electronic databases from January 2000 to March 2017, examining reference lists, and communicating with experts. We selected randomized controlled trials comparing manipulation or mobilization therapies with sham, no treatment, other active therapies, and multimodal therapeutic approaches. We assessed risk of bias using Scottish Intercollegiate Guidelines Network criteria. Where possible, we pooled data using random-effects meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to determine the confidence in effect estimates. This project is funded by the National Center for Complementary and Integrative Health under Award Number U19AT007912. RESULTS Fifty-one trials were included in the systematic review. Nine trials (1,176 patients) provided sufficient data and were judged similar enough to be pooled for meta-analysis. The standardized mean difference for a reduction of pain was SMD=−0.28, 95% confidence interval (CI) −0.47 to −0.09, p=.004; I2=57% after treatment; within seven trials (923 patients), the reduction in disability was SMD=−0.33, 95% CI −0.63 to −0.03, p=.03; I2=78% for manipulation or mobilization compared with other active therapies. Subgroup analyses showed that manipulation significantly reduced pain and disability, compared with other active comparators including exercise and physical therapy (SMD=−0.43, 95% CI −0.86 to 0.00; p=.05, I2=79%; SMD=−0.86, 95% CI −1.27 to −0.45; p<.0001, I2=46%). Mobilization interventions, compared with other active comparators including exercise regimens, significantly reduced pain (SMD=−0.20, 95% CI −0.35 to −0.04; p=.01; I2=0%) but not disability (SMD=−0.10, 95% CI −0.28 to 0.07; p=.25; I2=21%). Studies comparing manipulation or mobilization with sham or no treatment were too few or too heterogeneous to allow for pooling as were studies examining relationships between dose and outcomes. Few studies assessed health-related quality of life. Twenty-six of 51 trials were multimodal studies and narratively described. CONCLUSION There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Multimodal programs may be a promising option.

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Purpose Multifocal intraocular lenses (IOLs) offer the possibility of spectacle-free vision following cataract surgery compared to standard IOLs. Existing systematic reviews have generally concluded that multifocal IOLs result in better uncorrected near vision and greater spectacle independence, but more unwanted visual phenomena such as glare and halos, compared to monofocal IOLs. However, the certainty of evidence has been low for most outcomes, and pooled analyses have grouped together technologically obsolete lenses with newer lenses, potentially obscuring differences in performance across different lens types. Methods We performed a systematic review searching for RCTs of a multifocal IOL to a standard IOL or monovision that reported spectacle independence, visual acuity, or quality of life. Databases were searched from 1/1/2006-4/30/2017. Existing reviews were used to identify older studies. Title/abstract screening and data extraction were done in duplicate. Where possible, random effects metaanalysis was performed to synthesize results. In addition to comparing multifocal IOLs as a group to monofocal IOLs, we also compared newer diffractive lenses to obsolete or refractive lenses. Results Twenty-five eligible studies were identified. There was no difference in pooled estimates of corrected or uncorrected distance vision between multifocal and standard IOLs. Compared to monofocal IOLs, multifocal IOLs had statistically significantly better pooled results for the outcome of near vision (10 studies, 1025 patients, mean difference in logMAR of-0.26 (95% CI-0.37,-0.15)); spectacle dependence (12 studies, 1237 patients, relative risk of 0.27 (95% CI 0.20, 0.38)) and borderline significantly better quality of vision (6 studies, 596 patients, standardized mean difference of-0.54, (95% CI-1.12, 0.04)). Compared to monofocal IOLs, multifocal IOLs had statistically significantly worse pooled results for the outcomes of glare (9 studies, 847 patients, risk ratio of 1.36 (95% CI 1.15, 1.61) and halos (7 studies, 754 patients, risk ratio of 3.14 (95% CI 1.63, 6.08). Newer multifocal lenses had statistically significantly better outcomes than older diffractive lenses or refractive lenses, when compared to monofocal IOLs, in near vision, quality of vision, and risk of halos. Conclusions Multifocal IOLs compared to standard IOLs or monovision result in better uncorrected near vision and a higher proportion of patients who achieve spectacle independence, but greater risk of unwanted visual phenomena. Newer diffractive lenses may be better than refractive lenses in near vision and quality of vision outcomes, with less risk of halos than older diffractive lenses and refractive lenses.