Review of the literature
Efficacy of spinal manipulative therapy for low back pain of less than three months' duration

https://doi.org/10.1016/j.jmpt.2003.08.010Get rights and content

Abstract

Objectives

To review the efficacy of spinal manipulation for low back pain of less than 3 months duration.

Data sources

Randomized clinical trials on spinal manipulative therapy for low back pain were identified by searching EMBASE, CINAHL, MEDLINE, and the Physiotherapy Evidence Database (PEDro).

Study selection

Outcome measures of interest were pain, return to work, adverse events, disability, quality of life, and patient satisfaction with therapy.

Data extraction

Methodological assessment of the trials was performed using the PEDro scale. Trials were grouped according to the type of intervention, outcome measures, and follow-up time. Where there were multiple studies with sufficient homogeneity of interventions, subjects, and outcomes, the results were analyzed in a meta-analysis using a random effects model.

Data synthesis

Thirty-four papers (27 trials) met the inclusion criteria. Three small studies showed spinal manipulative therapy produces better outcomes than placebo therapy or no treatment for nonspecific low back pain of less than 3 months duration. The effects are, however, small. The findings of individual studies suggest that spinal manipulative therapy also seems to be more effective than massage and short wave therapy. It is not clear if spinal manipulative therapy is more effective than exercise, usual physiotherapy, or medical care in the first 4 weeks of treatment.

Conclusions

Spinal manipulative therapy produces slightly better outcomes than placebo therapy, no treatment, massage, and short wave therapy for nonspecific low back pain of less than 3 months duration. Spinal manipulative therapy, exercise, usual physiotherapy, and medical care appear to produce similar outcomes in the first 4 weeks of treatment.

Introduction

Spinal manipulative therapy is one of the most common therapies for acute and subacute low back pain, although its use is not universally supported. The guideline developed by the Royal College of General Practitioners1 recommends spinal manipulative therapy, defined as manual loading of the spine using short or long leverage methods, for patients with acute and subacute low back pain without radiculopathy, although the guideline does not make recommendations concerning timing of the intervention. The New Zealand Acute Low Back Pain Guide2 and the guidelines from the US Agency for Health Care Policy and Research3 recommend spinal manipulative therapy but only during the first 4 to 6 weeks of symptoms. In contrast, spinal manipulative therapy is not even mentioned in the Dutch clinical guideline for back pain.4

The information provided in these guidelines1, 2, 3, 4 is derived from the many systematic reviews conducted on the topic. Interestingly, these systematic reviews draw inconsistent conclusions.5, 6, 7 Most of these reviews have used qualitative approaches to synthesizing trial findings.8 It has recently been shown that the agreement between similar qualitative approaches to classifying strength of evidence is poor.9 Moreover, the qualitative approaches often involve some form of “vote counting” (counting of significant studies), even though vote counting is extremely insensitive to the true treatment effects,10 and it ignores the size of the effect of treatment. Thus, the inconsistency of findings of existing systematic reviews of spinal manipulative therapy may be a consequence of the qualitative methods used in the reviews.

We conducted a meta-analysis to assess the efficacy of manual therapy techniques in the treatment of nonspecific low back pain of less than 3 months duration.

Section snippets

Criteria for considering studies for the review

Only full journal articles describing randomized or quasi-randomized controlled trials were accepted. There was no language restriction. Participants had to be adults with nonspecific low back pain of less than 3 months duration, as reported by the median or mean duration of symptoms. The trials must have investigated 1 or more of the following types of spinal manipulative therapy: high-velocity, low-amplitude thrust, joint manipulation; low-velocity, small- or large-amplitude joint

Results

Thirty-four of the 118 identified articles met the inclusion criteria. The CINAHL database yielded 16 of the 34 eligible articles; EMBASE yielded 21; MEDLINE yielded 24; and PEDro yielded all 34 eligible articles. Of the 34 relevant articles, 11 articles shared data from 4 trials, giving a total of 27 trials.22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 The total sample size was 3817 patients with nonspecific low back pain. Mean or median duration of pain ranged from 3 days to 12 weeks. Most

Discussion

Clinical practice guidelines are meant to optimize the management of various pathological conditions based on scientific evidence. However, existing guidelines provided conflicting recommendations concerning the management of nonspecific low back pain of less than 3 months’ duration.

Koes et al54 performed an international comparison of clinical practice guidelines on low back pain and reported that recommendations concerning spinal manipulative therapy were more contradictory than for any other

Conclusion

Spinal manipulative therapy produces slightly better outcomes than placebo therapy, no treatment, massage, and short wave therapy for nonspecific low back pain of less of 3 months duration. Spinal manipulative therapy, exercise, usual physiotherapy, and medical care appear to produce similar outcomes in the first 4 weeks of treatment. We would advocate that developers of clinical guidelines should consider the sizes of effect of spinal manipulative therapy before making recommendations.

References (62)

  • Gow P, Griffith R, Grimes P, Kendall N, McNaughton H, Nicholson R, et al. New Zealand acute low back pain guide....
  • National Guideline Clearinghouse. Low back pain or sciatica in the primary care setting. Available at:...
  • W.J.J. Assendelft et al.

    Effectiveness of manipulative therapy in low back painsystematic literature reviews and guidelines are inconclusive

    Ned Tijdschr Geneeskd

    (1998)
  • M.W. Van Tulder et al.

    Conservative treatment of acute and chronic non-specific low back pain

    Spine

    (1997)
  • W.J.J. Assendelft et al.

    The effectiveness of chiropractic for treatment of low back painan update and attempt at statistical pooling

    J Manipulative Physiol Ther

    (1996)
  • B.W. Koes et al.

    Spinal manipulation for low back pain—an updated systematic review of randomised clinical trials

    Spine

    (1996)
  • A.D. Furlan et al.

    A critical review of reviews on the treatment of chronic low back pain

    Spine

    (2001)
  • L.V. Hedges et al.

    Vote-counting methods in research synthesis

    Psychol Bull

    (1980)
  • M. Van Tulder et al.

    Method guidelines for systematic reviews in the Cochrane collaboration back review group for spinal disorders

    Spine

    (1997)
  • Green S, Deeks J, Savio F. Meta-analysis of continuous data: does the end justify the mean? Proceedings of the 9th...
  • N.M. Hadler et al.

    A benefit of spinal manipulation as adjunctive therapy for acute low-back paina stratified controlled trial

    Spine

    (1987)
  • D.C. Cherkin et al.

    A comparison of physical therapy, chiropractic manipulation, and provision of an education booklet for the treatment of patients with low back pain

    N Engl J Med

    (1998)
  • Oxman A. Preparing and maintaining systematic reviews. In: Cochrane collaboration handbook. Oxford: Cochrane...
  • J.L. Fleiss

    The statistical basis of meta-analysis

    Stat Methods Med Res

    (1993)
  • S. Blomberg et al.

    A controlled, multicentre trial of manual therapy in low back pain—initial status, sick-leave, and pain score during follow-up

    Scand J Prim Health Care

    (1992)
  • S. Blomberg et al.

    A controlled, multicentre trial of manual therapy with steroid injections in low-back painfunctional variables, side effects and complications during four months follow-up

    Clin Rehabil

    (1993)
  • S. Blomberg et al.

    Manual therapy with steroid injections in low-back pain—improvement of quality of life in a controlled trial with four months follow-up

    Scand J Prim Health Care

    (1993)
  • S. Blomberg et al.

    A randomized study of manual therapy with steroid injections in low-back pain—telephone interview follow-up of pain, disability, recovery and drug consumption

    Eur Spine J

    (1994)
  • C.J. Hsieh et al.

    Functional outcomes of low back paincomparison of four treatment groups in a randomised controlled trial

    J Manipulative Physiol Ther

    (1992)
  • M.H. Pope et al.

    A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain

    Spine

    (1994)
  • T.W. Meade et al.

    Low back pain of mechanical originrandomized comparison of chiropractic and hospital outpatient treatment

    BMJ

    (1990)
  • Cited by (61)

    • Utilization of Low Back Pain Patient Reported Outcome Measures Within Chiropractic Literature: A Descriptive Review

      2018, Journal of Manipulative and Physiological Therapeutics
      Citation Excerpt :

      The results of the literature search processes are illustrated in Figure 1. A total of 144 articles were identified that used LBP PROMs within chiropractic research.10-153 A total of 75 different PROMs were identified from within these articles.

    • Efficacy of Caudal Epidural Steroid Injection with Targeted Indwelling Catheter and Manipulation in Managing Patients with Lumbar Disk Herniation and Radiculopathy: A Prospective, Randomized, Single-Blind Controlled Trial

      2018, World Neurosurgery
      Citation Excerpt :

      Currently, the efficacy of some medical interventions is conflicting.7 Spinal manipulations are widely used, and systematic reviews have also shown that these manipulations are more effective than placebos.8-10 Much evidence shows that moderate manipulation is more effective than sham manipulation that generates back and leg pain.11

    • Stratified models of care

      2013, Best Practice and Research: Clinical Rheumatology
    View all citing articles on Scopus
    View full text