Cochrane for Clinicians
Putting Evidence into Practice
Spinal Manipulative Therapy for Low Back Pain
Am Fam Physician. 2005 Feb 1;71(3):464-465.
This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The practice recommendations in this activity are available online at http://www.cochrane.org/cochrane/revabstr/AB000447.htm.
A 42-year-old woman presents with low back pain that started after she had moved furniture a week earlier. She wants pain relief as quickly as possible and asks if she should go to a chiropractor.
Should we recommend spinal manipulation as a treatment for low back pain?
In the short term, manipulative therapy is as effective for acute or chronic low back pain as other treatments such as analgesics, physical therapy, exercises, back school, and routine care from a primary care physician. Radiation of pain, type of manipulation, and use of multiple modalities do not alter these results.
There are many options for treatment of acute and chronic low back pain: physical therapy, exercise, analgesics, muscle relaxants, acupuncture, manipulation, exercise, and massage. Most patients get better within six weeks regardless of treatment. The Agency for Health Care Policy and Research guidelines of 1994,2 as well as other, more recent national guidelines, recommend manipulation for acute low back pain without radiculopathy, and some guidelines recommend it for chronic low back pain. This review, which looked at clinical trials through January 2000, evaluated the role of spinal manipulative therapy.
Background. Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain.
Objectives. To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and incorporating data from recent high-quality randomized controlled trials (RCTs) into the analysis.
Search Strategy. The authors1 searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL through January 2000, using the Back Group search strategy. References from previous systematic reviews also were screened.
Selection Criteria. RCTs that evaluated spinal manipulative therapy for patients with low back pain were selected if they included at least one day of follow-up and at least one clinically relevant outcome measure.
Data Collection and Analysis. Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (e.g., traction, corset, bed rest, home care, topical gel, no treatment, diathermy, minimal massage).
Primary Results. A total of 39 RCTs were identified. Meta-regression models were developed for acute and chronic pain, short-term and long-term pain, and function. In patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10 mm difference on a 100 mm visual analog scale [95 percent confidence interval, 2 to 17 mm]) or therapies judged to be ineffective or harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results in patients with chronic low back pain were similar. Radiation of pain, study quality, profession of the manipulator, and use of manipulation alone or in combination with other therapies did not affect these results.
Reviewers' Conclusions. There is no evidence that spinal manipulative therapy is superior to other standard treatments in patients with acute or chronic low back pain.
These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in the Cochrane Library. Their content has, as far as possible, been checked with the authors of the originalreviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minorediting changes have been made to the text (http://www.cochrane.org).
The evidence in this review shows that manipulation is as effective as analgesics, physical therapy, exercise, and usual care from a family physician. Manipulation is better than sham therapy and several methods that have been shown to be ineffective or harmful, such as traction, corsets, bed rest, diathermy, and no therapy. The studies included in the review examined all types of patients with back pain, including those with radicular pain. Many of the studies examined multiple therapies used concurrently, which made the analysis more difficult. There was no evidence that manipulation was better for any subgroup of low back pain.
The Randomized Osteopathic Manipulation Study,3 which was not part of this review, examined osteopathic manipulation and found short-term improvement at two and six months compared with usual care. Another recent study4 of osteopathic treatment for chronic pain found that therapy was as effective as sham treatment. This raises the question of whether treatment causes a placebo effect, perhaps because of the extra time spent with patients. A recent review5 compared acupuncture and massage with manipulation. There was some initial evidence that massage therapy is effective and may reduce the cost of care. The anticipated results of the United Kingdom Back Pain, Exercise, and Manipulation trial6 comparing exercise, manipulation, or both with standard primary care in 1,350 patients for one year should provide additional data to help answer this question.
KATHERINE MARGO, M.D., is predoctoral director and assistant professor of family and community medicine at the University of Pennsylvania School of Medicine, Philadelphia, where she also serves as associate residency director. Dr. Margo received her medical degree from State University of New York Upstate Medical University, Syracuse, and completed a family medicine residency at St. Joseph's Hospital in Syracuse.
Address correspondence to Katherine Margo, M.D., Department of Family Practice and Community Medicine, University of Pennsylvania School of Medicine, 2 Gates/3400 Spruce St., Philadelphia, PA 19104 (e-mail: firstname.lastname@example.org). Reprints are not available from the author.
1. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev. 2004;(4):CD000447.
2. Bigos SJ. Acute low back problems in adults. Rockville, Md.: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994.
3. Williams NH, Wilkinson C, Russell I, Edwards RT, Hibbs R, Linck P, et al. Randomized osteopathic manipulation study (ROMANS): pragmatic trial for spinal pain in primary care. Fam Pract. 2003;20:662-9.
4. Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine. 2003;28:1355-62.
5. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med. 2003;138:898-906.
6. Brealey S, Burton K, Coulton S, Farrin A, Garratt A, Harvey E, et al. UK Back pain Exercise And Manipulation (UK BEAM) trial—national randomised trial of physical treatments for back pain in primary care: objectives, design and interventions. BMC Health Serv Res. 2003;3:16.
The Cochrane Abstract is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Katherine Margo, M.D., presents a clinical scenario and question based on the Cochrane Abstract, along with the evidence-based answer and a full critique of the abstract.
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