Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials

Abstract

Objective To assess the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain. Design Systematic review and meta-analysis of randomised controlled trials. Data sources Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, and trial registries up to 4 May 2018, including reference lists of eligible trials and related reviews. Eligibility criteria for selecting studies Randomised controlled trials examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded, as was grey literature. No restrictions were applied to language or setting. Review methods Two reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence. The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months. Quality of evidence was assessed using GRADE. A random effects model was used and statistical heterogeneity explored. Results 47 randomised controlled trials including a total of 9211 participants were identified, who were on average middle aged (35-60 years). Most trials compared SMT with recommended therapies. Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief (mean difference −3.17, 95% confidence interval −7.85 to 1.51) and a small, clinically better improvement in function (SMD −0.25, 95% confidence interval −0.41 to −0.09). High quality evidence suggested that compared with non-recommended therapies SMT results in small, not clinically better effects for short term pain relief (mean difference −7.48, −11.50 to −3.47) and small to moderate clinically better improvement in function (SMD −0.41, −0.67 to −0.15). In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. Statistical heterogeneity could not be explained. About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT. Conclusion SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.

The Nordic maintenance care program: maintenance care reduces the number of days with pain in acute episodes and increases the length of pain free periods for dysfunctional patients with recurrent and persistent low back pain - a secondary analysis of a pragmatic randomized controlled trial

“…If two visits were separated by 3 weeks without visits (i.e. defined as two separate treatment periods in the statistical model), the analysis would then double count the last 3 weeks [5][6][7] in the first treatment period and the first 3 weeks [1][2][3] in the following treatment period. The mean number of visits for the whole cohort over 12 months was six visits, so the probability of double counting weeks without pain (as described above) was considered low, with little risk of distorting the results.…”

“…A modest number of interventions have been shown to be effective in managing and treating recurrent and persistent LBP [3]. However, only exercise and exercise combined with education have been shown to reduce the number of new episodes [4][5][6][7].…”

Non-pharmacological treatment of low back pain in primary care

“…However, the evidence for both treatments is mixed. A recent systematic review suggested that spinal manipulation was no better than sham therapy for reducing pain or function at 6 and 12 months 22. A Cochrane review recommends against massage as an effective therapy for chronic LBP 23…”

The effect of a single spinal manipulation on cardiovascular autonomic activity and the relationship to pressure pain threshold: a randomized, cross-over, sham-controlled trial

“…mobilizations or high velocity low amplitude (HVLA) manipulations, are commonly used to treat musculoskeletal pain by chiropractors, osteopaths, and physical therapists [1]. Despite their common use and some clinical evidence supporting their efficacy [2][3][4], the mechanisms underlying these clinical effects are not really understood. The study of these potential mechanisms requires experimental research assessing body responses following the intervention.…”