Spinal Manipulation Better Than Sham Therapies for Low Back Pain

Laurie Barclay, MD

June 02, 2003

June 2, 2003 — Two systematic review articles published in the June 3 issue of the Annals of Internal Medicine look at the use of manual therapy for low back pain. The first shows that there is no evidence that spinal manipulation is superior to other standard treatments for chronic low back pain. The second finds evidence that massage and spinal manipulation may have small clinical benefits, but there is a lack of evidence for acupuncture. Massage therapy may be the only manual therapy that offers a reduction in healthcare costs.

"Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of [spinal manipulative] therapy for low back pain," write Willem J. J. Assendelft, MD, PhD, from the Cochrane Back Review Group, and colleagues. "We conclude that spinal manipulative therapy is one of several options of only modest effectiveness for patients with low back pain."

This meta-analysis identified 39 randomized controlled trials from MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews.

Spinal manipulative therapy was clinically and statistically superior only to sham manipulation or to the group of therapies judged to be ineffective or even harmful, such as traction, corset, bed rest, home care, topical gel, no treatment, and minimal massage. Compared with sham therapy, the difference on a 100-mm visual analogue scale was 10 mm (95% confidence interval, 2 - 17 mm).

There was no evidence that spinal manipulative therapy was either superior or inferior to other recommended therapies, including analgesics, exercises, physical therapy, and education about back injury prevention and ways to deal with back pain (back school).

The authors report no potential financial conflicts of interest, and this study had no external funding.

In the second review, the authors extracted data from systematic reviews of randomized controlled trials published since 1995, including 20 evaluating the effectiveness, safety, and cost of acupuncture, three evaluating massage therapy, and 26 evaluating spinal manipulation for persistent back pain.

All of these treatments appeared to be relatively safe. Massage had some benefit and was the only modality that reduced healthcare costs. Spinal manipulative therapy had small clinical benefits comparable to those of analgesics, physical therapy, or back exercises. Because of the poor quality of the trials, the effectiveness of acupuncture remains unclear.

"Because there is growing evidence that patient expectations affect outcomes, allowing patients to choose the treatment they believe will be most helpful may improve results," the authors write. "The decisions to offer complementary and alternative medicine therapies to patients should consider effectiveness, safety, costs, the relative effectiveness of these therapies compared with conventional treatments, and patient preferences and expectations."

The second author is the former research director of the Northwest Institute of Acupuncture and Oriental Medicine.

Ann Intern Med. 2003;138:871-881, 898-906

Reviewed by Gary D. Vogin, MD

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