Spinal manipulation produces small but durable relief of lower back pain

Janis Kelly

December 16, 2004

Dec 16, 2004

York, UK - The UK Back Pain Exercise and Manipulation (UK BEAM) study, the largest randomized trial of back pain intervention ever done, has concluded that spinal manipulation (chiropractic, osteopathy, or manipulative physiotherapy) provides significant relief, that exercise adds a bit more when combined with manipulation, and that this approach is often more cost-effective than conventional approaches to managing lower back pain [ 1 ]. Coauthor Dr Martin Underwood (Institute of Community Health Sciences, London, UK) tells rheuma wire that the 1300-patient study is likely to provide useful data for the UK National Health Service (NHS) and for other insurers considering the costs of spinal manipulation. The trial was reported in the December 10, 2004 issue of the BMJ.

Since our economic analysis showed that both manipulation and combined treatment improve general quality of life at modest cost, both provide good value for money.

"Since our economic analysis showed that both manipulation and combined treatment improve general quality of life at modest cost, both provide good value for money," Underwood says.

Manipulation, exercise compared

The trial recruited 1300 patients whose back pain had not improved after receiving "best care" in general practice. "Best care" was defined as encouraging patients to continue with normal activities and avoid rest.

Patients were randomized among 6 treatment groups:

  • Best care (control group).

  • Best care plus a class-based exercise program.

  • Best care plus manipulation in a private-practice setting.

  • Best care plus manipulation in an NHS clinic.

  • Best care plus manipulation in a private practice, followed by exercise.

  • Best care plus manipulation in an NHS clinic, followed by exercise.

The spinal-manipulation treatments were done by chiropractors, osteopaths, or physiotherapists. Manipulative techniques were selected by the individual healthcare provider from a menu of treatment options developed by the 3 professional associations associated with these practitioners.

Although not specified in the article, Underwood says that 633/686 (92%) of those randomized to a manipulation package received the predefined "basic minimum treatment" of 2 treatment sessions. Subjects could receive up to 8 20-minute sessions over 12 weeks. "The relationship between number of treatment sessions and outcome is likely to be complex," Underwood says. "For example, people could terminate their course of treatment because of successful treatment or unsuccessful treatment or other reasons." The investigators will be exploring these issues further in a future paper.

Patients completed questionnaires on their general health, back pain, beliefs, and psychological well-being before being randomly assigned to a treatment. They completed further questionnaires at 1, 3, and 12 months after randomization.

"Hands-on" approach appears to have durable effects

The benefit from the manipulation package was still statistically significant after one year, unlike that from the exercise program.

As might be expected, patients in all treatment groups reported various degrees of improvement in back function and reduced pain over time. The baseline Roland disability score was about 9.0 for all groups. A difference of 2.5 in Roland scores is generally regarded as clinically significant in back-pain trials. The control group improved to 6.83 at 3 months and 5.47 at 12 months. Adding manipulation and/or exercise to "best care" further improved disability scores by:

  • Manipulation plus exercise: 1.9 at 3 months, 1.3 at 12 months.

  • Manipulation alone: 1.6 at 3 months, 1.0 at 12 months.

  • Exercise alone: 1.4 at 3 months, 0.4 at 12 months.

"The manipulation package that we used produced a slightly larger effect on disability than the exercise program at 3 months. The benefit from the manipulation package was still statistically significant after 1 year, unlike that from the exercise program. These benefits were obtained in the context of all participants receiving an active management message from their general practitioner," Underwood says. "Although the combination of the manipulation package followed by the exercise program yielded the most clinical benefit to participants, the benefit of adding exercise to manipulation was small."

Some patients benefited more from manipulation than others, and Underwood recommends offering manipulation generally, since it is not yet possible to predict in advance which patients are most likely to benefit.

Benefits seen as small but probably real

Underwood points out that few trials of physical treatment for low back pain have shown very large benefits from treatment and that the size of the benefits in this trial are in line with those found in other positive studies. Furthermore, all of the participating clinicians had been trained in the basic management of low back pain, which might have reduced the relative benefits of manipulation and exercise in this study by pumping up improvements in the control group.

"However," Underwood says, "designing the trial in this way and ensuring that all participants received treatment with supporting advice to keep active means that we can be more confident that the reported benefits are real and specific to the interventions tested. We are therefore confident that we have found a real and important benefit from the manipulation package and combined-treatment packages. The benefits of the exercise program were smaller and transient and are less important."

"Now that we have been able to show a convincing benefit from a manipulation package, the 2 challenges for the future are to identify which patients will gain the greatest benefit from the package and which part or parts of the package account for its beneficial effect," Underwood says. The latter point was raised in a "rapid response" letter to the journal from Dr Edzard Ernst (Peninsula Medical School, Exeter, UK), who suggested that the improvements attributed to manipulation "are compatible with a nonspecific effect caused by touch [ 2 ]."


1. UK BEAM trial team. United Kingdom back pain exercise and manipulation (UK BEAM) randomized trial: effectiveness of physical treatments for back pain in primary care. British Medical Journal 2004; 329:1377-1385.

2. Ernst E. Correspondence. BMJ; published online before print December 6, 2004. Available at: http://www.bmj.com.


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