Moderators of the Effect of Spinal Manipulative Therapy on Pain Relief and Function in Patients with Chronic Low Back Pain: An Individual Participant Data Meta-analysis

Spine (Phila Pa 1976). 2021 Apr 15;46(8):E505-E517. doi: 10.1097/BRS.0000000000003814.


Study design: Individual participant data (IPD) meta-analysis.

Objective: The aim of this study was to identify which participant characteristics moderate the effect of spinal manipulative therapy (SMT) on pain and functioning in chronic LBP.

Summary of background: The effects of SMT are comparable to other interventions recommended in guidelines for chronic low back pain (LBP); however, it is unclear which patients are more likely to benefit from SMT compared to other therapies.

Methods: IPD were requested from randomized controlled trials (RCTs) examining the effect of SMT in adults with chronic LBP for pain and function compared to various other therapies (stratified by comparison). Potential patient moderators (n = 23) were a priori based on their clinical relevance. We investigated each moderator using a one-stage approach with IPD and investigated this interaction with the intervention for each time point (1, 3, 6, and 12 months).

Results: We received IPD from 21 of 46 RCTs (n = 4223). The majority (12 RCTs, n = 2249) compared SMT to recommended interventions. The duration of LBP, baseline pain (confirmatory), smoking, and previous exposure to SMT (exploratory) had a small moderating effect across outcomes and follow-up points; these estimates did not represent minimally relevant differences in effects; for example, patients with <1 year of LBP demonstrated more positive point estimates for SMT versus recommended therapy for the outcome pain (mean differences ranged from 4.97 (95% confidence interval, CI: -3.20 to 13.13) at 3 months, 10.76 (95% CI: 1.06 to 20.47) at 6 months to 5.26 (95% CI: -2.92 to 13.44) at 12 months in patients with over a year LBP. No other moderators demonstrated a consistent pattern across time and outcomes. Few moderator analyses were conducted for the other comparisons because of too few data.

Conclusion: We did not identify any moderators that enable clinicians to identify which patients are likely to benefit more from SMT compared to other treatments.Level of Evidence: 2.

Publication types

  • Meta-Analysis

MeSH terms

  • Adult
  • Chronic Pain / diagnosis
  • Chronic Pain / therapy*
  • Data Analysis*
  • Female
  • Humans
  • Low Back Pain / diagnosis
  • Low Back Pain / therapy*
  • Male
  • Manipulation, Spinal / methods*
  • Manipulation, Spinal / trends
  • Middle Aged
  • Pain Management / methods*
  • Pain Management / trends
  • Pain Measurement / methods
  • Randomized Controlled Trials as Topic / methods
  • Recovery of Function / physiology*
  • Treatment Outcome