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The effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain: an individual participant data meta-analysis

Our take

Does spinal manipulative therapy improve pain and function in adults with chronic low back pain more than, or as much as, other conservative treatments?

This individual participant data meta-analysis pooled 21 randomized trials (4,223 patients) to test spinal manipulative therapy (SMT) for chronic low back pain. There is moderate quality evidence that SMT produces outcomes for pain and function that are similar to (not better and not worse than) recommended treatments like exercise, with comparable findings when SMT was added to other care or compared with non-recommended treatments. The authors conclude SMT is a reasonable option for chronic low back pain, though it offers no clear advantage over other recommended care.

Mixed pictureRead paper
Meta-analysis4,223 ParticipantsModerate evidence

Key points

  1. Spinal manipulative therapy (SMT) covers both manipulation (high-velocity thrusts) and mobilization (slower, gentler techniques) of the spine.
  2. Pooling raw patient data (rather than published averages) lets the analysts adjust for baseline pain and function, giving a more precise effect estimate.
  3. For pain and function, SMT was statistically similar to recommended treatments at 1, 3, 6, and 12 months, so neither approach was clearly better.
  4. SMT was also similar to non-recommended treatments, similar as an add-on to other care, and manipulation was similar to mobilization.
  5. There was moderate evidence that SMT modestly reduced medication use compared with recommended care at some time points.

How it was conducted

Design
One-stage individual participant data meta-analysis of randomized controlled trials (PROSPERO CRD42015025714)
Search
Electronic databases from 2000 to April 2016, updated to October 2020, plus reference lists of trials and reviews
Participants
21 of 43 eligible RCTs provided data, totaling 4,223 adults with chronic (12+ weeks) low back pain
Intervention
Spinal manipulation or mobilization versus recommended, non-recommended, sham, or adjuvant comparators
Outcomes
Self-reported pain (0 to 100 scale) and back-specific function (RMDQ), at 1, 3, 6, and 12 months
Analysis
Random-effects ANCOVA adjusted for baseline using REML, intention-to-treat; GRADE for certainty

What they found

  • SMT vs recommended interventions, pain at 1 month: MD -3.0 (95% CI -6.9 to 0.9), 10 trials, 1,922 participants, not significant.
  • SMT vs recommended interventions, function at 1 month: SMD -0.2 (95% CI -0.4 to 0.0), 10 trials, 1,939 participants.
  • Largest pain difference, SMT vs recommended at 3 months: MD -6.6 (95% CI -13.0 to -0.2), 9 trials.
  • SMT vs non-recommended interventions, pain at 1 month: MD -6.6 (95% CI -10.8 to -2.3), 5 trials, 755 participants.
  • SMT plus intervention vs intervention alone, pain at 1 month: MD -7.4 (95% CI -12.7 to -2.1), 5 trials, 762 participants.
  • Manipulation vs mobilization, pain at 1 month: MD -1.5 (95% CI -6.8 to 3.9), 3 trials, 321 participants; no significant difference.
  • All primary outcomes were rated moderate quality on GRADE, mostly downgraded for inconsistency.

Limitations

  • Only 21 of 43 eligible trials (about 50%) shared their individual participant data.
  • Categorizing comparators as recommended versus non-recommended required judgment and was not always clear-cut.
  • No SMT versus sham comparison was possible because only one study provided sham data, so a true placebo-controlled estimate is missing.
  • Most analyses showed statistical inconsistency between trials, which lowered the certainty of the evidence.

Why it matters

For patients
Spinal manipulation or mobilization is a reasonable choice for long-term low back pain, working about as well as exercise or other recommended care rather than clearly better.
For clinicians
SMT can be offered for chronic low back pain as one of several similarly effective options, and may modestly cut medication use, but it is not superior to recommended care.
For readers
Large pooled patient-level data confirm SMT matches, but does not beat, other recommended treatments for chronic low back pain.

Source

doi:10.1016/j.physio.2021.03.006

Read the original paper
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