Journal of Manipulative and Physiological Therapeutics
Review of the literatureEfficacy of spinal manipulative therapy for low back pain of less than three months' duration
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.
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