Key messages
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Spinal manipulative therapy (SMT – a hands-on treatment where a therapist moves joints in the spine) may slightly reduce pain and moderately improve function compared to 'sham' (fake) SMT.
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SMT may moderately reduce pain and may substantially improve function compared to no treatment.
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Less than half of studies reported on adverse (unwanted or harmful) effects. While adverse effects, including muscle soreness and a temporary increase in low back pain, were common, no serious adverse effects related to SMT were observed.
What is non-specific chronic low back pain?
Low back pain is a common and disabling disorder, representing a great burden to society. It often results in reduced quality of life, time lost from work, and substantial medical expenses. Chronic low back pain is defined here as pain lasting longer than 12 weeks. We focused on people with pain predominantly located in the lower back and those with pain radiating into the buttocks and legs.
How is chronic low back pain treated?
Spinal manipulative therapy (SMT) is a common treatment for chronic low back pain and is practised worldwide by healthcare professionals, including chiropractors, manual therapists, and osteopaths. SMT is a 'hands-on' treatment of the spine, including both manipulation and mobilisation to reduce pain, improve function, and help people return to usual activities. SMT may include gentle movements and stretching (known as mobilisation), or quick, controlled pushes often accompanied by an audible ‘pop’ (known as manipulation) to help improve someone's range of motion and reduce their pain.
What did we find out?
We wanted to find out if SMT improved pain and function, or caused harm, in people with chronic low back pain. We did not include people with low back pain caused by a specific condition, such as infection, tumour, or fracture.
What did we do?
We searched for studies that compared SMT to:
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fake or 'sham' SMT;
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no treatment;
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other 'conservative' treatment, meaning simple, non-surgical care, such as exercise.
We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. This is an update of a review, last published in 2011.
What did we find?
In this updated review, we identified 76 studies involving 11,866 people (published from 1978 to 2024) assessing the effects of SMT in people with chronic low back pain. The participants were a mix of women and men, and most were middle-aged. Most studies took place in high-income countries (53 studies, e.g. USA and UK), while 23 studies took place in middle-income countries (e.g. Brazil, India). None were in low-income countries.
Main results: benefits
A difference of 10 points on a 100-point scale is considered meaningful for patients—it can reflect a noticeable improvement in symptoms.
Comparison between SMT and sham SMT
Pain
People receiving SMT rated their pain on average 7.0 points better on a 0 to 100 scale one month after the start of SMT compared with those who had sham SMT.
Function
People receiving SMT rated their function on average 8.8 points better on a 0 to 100 scale one month after the start of SMT compared with people who had sham SMT.
Comparison between SMT and no treatment
Pain
People receiving SMT rated their pain on average 14 points better on a 0 to 100 scale one month after the start of SMT compared with people who had no treatment.
Function
People receiving SMT rated their function on average 12.9 points better on a 0 to 100 scale one month after the start of SMT compared with people who had no treatment.
Comparison between SMT and other conservative treatment
Pain
People receiving SMT rated their pain on average 4.7 points better on a 0 to 100 scale one month after the start of SMT compared with people who had another conservative treatment.
Function
People receiving SMT rated their function on average 4.9 points better on a 0 to 100 scale one month after the start of SMT compared with people who had another conservative treatment.
Main results: harms
Only a few studies reported on the adverse effects (i.e. unwanted or harmful effects) of SMT. These included muscle soreness and a temporary increase in low back pain. No serious adverse effects related to SMT were observed.
What are the limitations of the evidence?
We have little confidence in the evidence because the studies used a variety of SMT techniques, tested them in varied amounts, and the reported results greatly varied. Several studies included few participants, and some studies were poorly conducted. Therefore, the effects of SMT may be overestimated.
How current is this review?
The review is current to 18 October 2024.
Read the full abstract
Many therapies exist for the treatment of low-back pain including spinal manipulative therapy (SMT), which is a worldwide, extensively practiced intervention.
Objectives
To evaluate the benefits and harms of SMT compared to (1) sham SMT/placebo intervention, (2) no treatment, and (3) other conservative interventions in people with chronic LBP (18+ years old).
Search strategy
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, two other databases, and two trial registers up to 18 October 2024, unrestricted by language. We also screened the reference lists of all included studies and relevant systematic reviews, and approached content experts to identify potentially missing studies.
Selection criteria
RCTs which examined the effectiveness of spinal manipulation or mobilisation in adults with chronic low-back pain were included. No restrictions were placed on the setting or type of pain; studies which exclusively examined sciatica were excluded. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life.
Data collection and analysis
Two review authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the quality of the evidence. Sensitivity analyses and investigation of heterogeneity were performed, where possible, for the meta-analyses.
Main results
We included 26 RCTs (total participants = 6070), nine of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. In general, there is high quality evidence that SMT has a small, statistically significant but not clinically relevant, short-term effect on pain relief (MD: -4.16, 95% CI -6.97 to -1.36) and functional status (SMD: -0.22, 95% CI -0.36 to -0.07) compared to other interventions. Sensitivity analyses confirmed the robustness of these findings. There is varying quality of evidence (ranging from low to high) that SMT has a statistically significant short-term effect on pain relief and functional status when added to another intervention. There is very low quality evidence that SMT is not statistically significantly more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.
Authors' conclusions
When SMT is compared to sham SMT/placebo, it may result in a small improvement in pain and medium improvement in functional status in adults with chronic low back pain. When compared to no treatment, SMT may result in a medium improvement in pain and a large improvement in functional status. When compared to other conservative interventions, SMT may result in little to no difference in pain and a small improvement in functional status. The evidence is of low to very low certainty, largely due to the fact that the effects of SMT were examined in trials conducted in different settings and populations, with different types of SMT technique, dosage, and frequency of treatment. Continuing to conduct RCTs in the same manner will neither strengthen the evidence nor our confidence in it.
Funding
This Cochrane review had no dedicated funding, only 'in-kind' support from the Department of General Practice, Erasmus Medical Center, Rotterdam, Netherlands, and the Department of Health Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Science Research Institute, Netherlands.
Registration
Protocol (2009): DOI: 10.1002/14651858.CD008112
Original review (2011): DOI: 10.1002/14651858.CD000447.pub2
