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Review
. 2017 Apr 11;317(14):1451-1460.
doi: 10.1001/jama.2017.3086.

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis

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Free PMC article
Review

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis

Neil M Paige et al. JAMA. .
Free PMC article

Erratum in

  • Error in 2 Figures.
    JAMA. 2017 Jun 6;317(21):2239. doi: 10.1001/jama.2017.5715. JAMA. 2017. PMID: 28586870 No abstract available.
  • Incorrect Data in Text.
    JAMA. 2017 Nov 28;318(20):2048. doi: 10.1001/jama.2017.16766. JAMA. 2017. PMID: 29183047 No abstract available.

Abstract

Importance: Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT.

Objective: To systematically review studies of the effectiveness and harms of SMT for acute (≤6 weeks) low back pain.

Data sources: Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms.

Data extraction and synthesis: Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

Main outcomes and measures: Pain (measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale), function (measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index [range, 0-100]), or any harms measured within 6 weeks.

Findings: Of 26 eligible RCTs identified, 15 RCTs (1711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, -9.95 [95% CI, -15.6 to -4.3]). Twelve RCTs (1381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, -0.39 [95% CI, -0.71 to -0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT.

Conclusions and relevance: Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.

Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Shekelle reports receiving personal fees from ECRI Institute and UpToDate. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Literature Search Flow Chart
CINAHL indicates Cumulative Index of Nursing and Allied Health Literature.
Figure 2.
Figure 2.. Short-term Pain Outcomes in Randomized Clinical Trials of Effectiveness of Spinal Manipulative Therapy for Acute Low Back Pain (N = 1421)
NR indicates not reported; NRS, numeric rating scale (range, 0-10; converted to 0-100); ONRS, other numeric rating scale (including ranges of 0-10, 0-70, and 0-100; all converted to 0 to 100); VAS, visual analog scale (ranges of, 0-100 mm or 1-10, converted to 0-100). Size of the data markers represent weight based on the randomized meta-analysis. A high score indicates worse pain. Quality score uses the Cochrane Back and Neck Risk of Bias tool (range, 0-11). aOutcome data not reported by group, only between-group data reported.
Figure 3.
Figure 3.. Short-term Function Outcomes in Randomized Clinical Trials of Effectiveness of Spinal Manipulative Therapy for Acute Low Back Pain (N = 1049)
NR indicates not reported; ODI, Oswestry Disability Index (range, 0-100); RMDQ, Roland Morris Disability Questionnaire (range, 0-24). Size of the data markers represent weight based on the randomized meta-analysis. Quality score uses the Cochrane Back and Neck Risk of Bias tool (range, 0-11). aOutcome data not reported by group, only between-group data reported.

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