The Effectiveness of Spinal Manipulation Relative to Other Therapies for Low Back Pain

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The summary below is from the full report titled "Spinal Manipulative Therapy for Low Back Pain. A Meta-Analysis of Effectiveness Relative to Other Therapies." It is in the 3 June 2003 issue of Annals of Internal Medicine (volume 138, pages 871-881). The authors are W.J.J. Assendelft, S.C. Morton, E.I. Yu, M.J. Suttorp, and P.G. Shekelle.

What is the problem and what is known about it so far?

Low back pain is a common problem that often goes away after several days or weeks, but in some persons may persist for months or years. The main goal in treating low back pain is to decrease pain and allow patients to resume their normal activities. Some doctors and researchers assume that various traditional treatments are helpful for low back pain; these include drugs (pain killers, anti-inflammatory drugs, and muscle relaxants), physical therapy, back exercises, and education about ways to prevent back injury and to deal with back pain (sometimes called back school). Some treatments have been shown to be unhelpful; they include traction, bed rest, corsets, topical gels, heat therapy, and certain types of massage. Spinal manipulation is an alternative treatment for low back pain. For spinal manipulation, a specially trained person (chiropractor, osteopathic physician, or physical therapist) uses his or her hands to move the bones in the spine. Some guidelines for the treatment of low back pain recommend spinal manipulation, while others do not. One of the reasons experts disagree about the role of spinal manipulation in the treatment of low back pain is that some have compared it to a mix of traditional therapies rather than to each therapy individually.

Why did the researchers do this particular study?

To compare spinal manipulation to other individual therapies for low back pain.

Who was studied?

Rather than do a new study, the authors looked at published studies. Patients included in these previous studies were the focus of this work.

How was the study done?

The researchers searched the medical literature by using computerized databases to find studies that compared spinal manipulation to one of seven categories of other treatments for low back pain: general practitioner care, pain killers, physical therapy, exercises, back school, a collection of ineffective therapies (for example, traction, bed rest, and heat therapy), or sham manipulation. Sham manipulation meant that the patients thought they were getting spinal manipulation but were not. The therapists just touched their backs without performing the specific movements involved in real spinal manipulation. The researchers found 39 studies that met these criteria and collected information about each study and its results. Then they used a method called meta-analysis to combine the results of studies that looked at the same category of treatment and calculated the effectiveness of spinal manipulation compared with that treatment.

What did the researchers find?

Spinal manipulation was more effective than sham therapy and therapies already known to be unhelpful. However, it was no more or less effective than general practitioner care, pain killers, physical therapy, exercise, or back school.

What were the limitations of the study?

The effectiveness of spinal manipulation compared with other therapies may change as new studies are done and new drugs or new spinal manipulation techniques are developed. In addition, many patients with low back pain receive several types of treatment at once.

What are the implications of the study?

This analysis suggests that spinal manipulation is no more or no less effective than traditional therapies for low back pain.