Spinal Manipulation: Modest Benefit in Acute Low Back Pain

Veronica Hackethal, MD

April 11, 2017

Spinal manipulation modestly improves pain and function in acute low back pain, a new systematic review and meta-analysis has found. Results were published online April 11 in JAMA.

"The principal conclusion of this review was that SMT [spinal manipulation therapy] treatments for acute low back pain were associated with statistically significant benefit in pain and function at up to 6 weeks, that was, on average, clinically modest," lead author Paul G. Shekelle, MD, PhD, from the West Los Angeles Veterans Affairs Medical Center, California, and colleagues write.

Citing a Cochrane Review, the authors note that the amount of benefit was about the same as for nonsteroidal anti-inflammatory drugs (NSAIDs).

Back pain represents one of the most common reasons why patients seek care, with an estimated 50% or more of people experiencing back pain in their lifetime, the authors explain. Many treatments exist, including analgesics, muscle relaxants, exercises, physical therapy, heat, and spinal manipulation. Yet none have proven better than any other.

Moreover, past reviews of spinal manipulation have yielded conflicting evidence about its effectiveness in low back pain.

To update past reviews, researchers searched four different databases for studies about spinal manipulation in the treatment of acute low back pain, with a follow-up of 6 weeks or shorter. The analysis included 26 studies published between January 2011 and February 2017, and excluded patients with sciatica and chronic low back pain.

Fifteen randomized controlled trials (RCTs) covering 1711 patients had moderate-quality evidence suggesting spinal manipulation significantly improves lower back pain (pooled mean improvement in the 100-mm visual analog pain scale, −9.95 (95% confidence interval, −15.6 to −4.3).

Twelve RCTs covering 1381 patients had moderate-quality evidence showing spinal manipulation significantly improves function (pooled mean effect size, −0.39; 95% confidence interval, −0.71 to −0.07).

No serious adverse events were reported. Review of large case series showed that 50% to 67% of patients who received spinal manipulation experienced minor, transient adverse events, including increased pain, muscle stiffness, and headache.

The authors note that many case reports have described serious harms associated with spinal manipulation. However, because these case reports could not evaluate causality, the meta-analysis did not include them.

Large variability existed between studies, which could not be explained by type of clinician, type of manipulation, study quality, or whether patients received spinal manipulation alone or combined with other therapies.

In a linked editorial, Richard Deyo, MD, MPH, from the Oregon Health and Science University in Portland, discussed the controversies surrounding spinal manipulation for treating low back pain.

Although the current meta-analysis and a recent review and guidelines by the American College of Physicians did not find spinal manipulation to be less effective than conventional treatment, mainstream medicine does not widely accept this treatment modality. Several issues may explain this hesitancy, according to Dr Deyo.

First, the biological rationale for how spinal manipulation improves low back pain remains unclear. Second, the safety of spinal manipulation remains a concern. Case reports have described serious events, which are nevertheless "extremely rare," Dr Deyo points out. In contrast, renal and gastrointestinal adverse effects of NSAIDs are common. Also, low back pain represents one of the most common reasons for prescribing opioids in the United States, with associated risks for dependency and overdose.

Another consideration: How long do the effects of spinal manipulation last? Some studies have suggested fewer benefits with longer-term follow-up.

Finally, cost of care may be an issue. Spinal manipulation entails multiple visits, which may be more expensive than NSAIDs. Conversely, caring for renal and gastrointestinal complications of NSAIDs and prescription opioid abuse may ultimately cost more than spinal manipulation.

Nevertheless, Dr Deyo concludes: "[I]f manipulation is at least as effective and as safe as conventional care, it may be an appropriate choice for some patients with uncomplicated acute low back pain. This is an area in which a well-informed patient's decisions should count as much as a practitioner's preference."

This study was funded by the Veterans Affairs Quality Enhancement Research Initiative. Dr Shekelle reports receiving personal fees from ECRI Institute and UpToDate. Dr Deyo reports grants from the National Institutes of Health, Agency for Health Care Research and Quality, Centers for Disease Control and Prevention, and Patient-Centered Outcomes Research Institute and personal fees from UpToDate, Kaiser Permanente, and NuVasive.

JAMA. 2017;317:1418-1419, 1451-1460. Published online April 11, 2017.

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