This systematic review evaluated the benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain. Randomised controlled trials conducted in adults 18 years and older with more than 50% of participants reporting pain lasting more than 3 months were included. Spinal manipulative therapy was compared against guideline-recommended interventions, non-guideline-recommended interventions, sham spinal manipulation, and combined therapies. Risk of bias was assessed using the criteria described by Cochrane Back and Neck Review group. Primary outcomes were pain intensity (0-100 scale) and back specific functional status. Treatment effects were reported at 1, 3, 6 and 12 months post-randomisation.
47 trials were included (n = 9,211 participants). Several health professionals were involved in providing treatment, with most being chiropractors (16 studies) or physiotherapists (14 studies).
Compared to guideline-recommended interventions, moderate quality evidence suggests that spinal manipulative therapy was not better for pain at 1 month (mean difference -3.17, 95% confidence interval (CI) -7.85 to 1.51) and 12 months (mean difference -1.86, 95% CI -4.79 to 1.07). A statistically significant difference was found at 6 months (mean difference -3.09, 95% CI -5.42 to -0.77) but this was not considered to be clinically relevant. Compared to interventions not recommended by guidelines, spinal manipulative therapy was significantly better at reducing pain at 1 month (mean difference -7.48, 95% CI -11.50 to -3.47, high quality evidence), 6 months (mean difference -7.54, 95% CI -13.29 to -1.79, moderate quality evidence), and 12 months (mean difference -7.80, 95% CI-14.19 to -1.41). Compared to sham spinal manipulation, there was low quality evidence that spinal manipulative therapy did not reduce pain at 1 month (mean difference -7.55, 95% CI -19.86 to 4.76), and very low quality evidence that it did not reduce pain at 6 months (mean difference 0.96, 95% CI -6.34 to 8.26) and 12 months (mean difference 0.20, 95% CI -5.33 to 5.37).
For back specific functional status, there was moderate quality evidence that spinal manipulative therapy was statistically better to guideline-recommended treatments at 1 month, but not at 6 and 12 months. Compared to interventions not recommended by guidelines, there was high quality evidence that spinal manipulative therapy was significantly better at 1 month, and these effects were clinically relevant, with moderate and low quality evidence that spinal manipulative therapy was statistically and clinically better than interventions not recommended by guidelines at 6 and 12 months, respectively. Compared to sham spinal manipulation, there was low quality evidence that spinal manipulation improved functional status at 1 month, and this improvement was clinically relevant.
Spinal manipulative therapy produces similar effects to guideline-recommended therapies for chronic low back pain, and it appears to be better than non-guideline-recommended interventions for improvement in function in the short-term.
Rubinstein SM, et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ 2019;364:l689
