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Research Review: Spinal manipulation therapy for chronic lower back pain

Dr. Shawn   

Features Research

SMT for chronic LBP

Low back pain remains a significant healthcare problem, one that challenges patients, clinicians and policymakers alike.

Study title: Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials
Authors: Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW
Publication Information: British Medical Journal (BMJ) 2019; 364: l689. doi: 10.1136/bmj.l689

Background information
Low back pain remains a significant healthcare problem, one that challenges patients, clinicians and policymakers alike. Spinal manipulative therapy (SMT) is widely used as a mainstay treatment for low back pain and has been the subject of several randomized, controlled trials which have been summarized in earlier reviews by the authors and have acted as a basis for recommendations in current clinical practice guidelines.

Despite the existing evidence and support within clinical guidelines, recommendations regarding the use of SMT for low back pain are not without dispute. While considered a front-line treatment in some jurisdictions, SMT is also viewed as a complimentary treatment amongst a broader treatment package in others. Recent guideline summaries have indeed recommended SMT as a second line therapy.


The purpose of the current review is to update an earlier Cochrane review by the same authors, which found no clinically relevant difference between SMT and other effective interventions for low back pain. The review sought to examine the effectiveness of SMT on pain relief and improvement of function at the short, intermediate and long-term follow-ups.

Pertinent results:
Included Studies: 47 trials were eligible for inclusion, 21 of which were not included in the previous review. 9211 total patients were included, with sample sizes in individual trials ranging from 21 to 1334. The average age of participants was 35-60 yrs. Practitioners varied and included chiropractors, physical/manual therapists, osteopaths, medical doctors or naturopaths. Treatment techniques involved were primarily high velocity, low amplitude thrust (HVLA), low velocity, low amplitude thrust (LVLA), passive movement techniques, or a combination of HVLA and LVLA.


  1. SMT vs. Recommended Interventions: Moderate quality evidence suggested that SMT was significantly better than recommended interventions at 6 months but not at 1 month or 12 months, although the effect size was not clinically relevant. Moderate quality evidence also indicated that back specific functional status was improved at 1 month, but not at 6 or 12 months, although this improvement was not significant.
  2. SMT vs. Non-recommended Interventions: High quality evidence indicated that SMT resulted in a small, statistically significant effect, although it was not clinically significant. Moderate and low-quality evidence indicated that SMT resulted in not-significant improvements at 6 and 12 months, respectively. Small to moderate improvements in back specific functional status were noted with SMT at 1, 6 and 12 months.
  3. SMT vs. Sham SMT: SMT was not shown to improve pain when compared with sham SMT at 1, 6 or 12 months, although the evidence was low to very low quality for this outcome. SMT demonstrated a moderate to strong improvement over sham SMT with respect to back specific functional status, although no improvement was noted at 6 or 12 months.
  4. SMT as Adjunctive Therapy: When used as an adjunctive therapy, SMT demonstrated a significant but not clinically relevant improvement in both pain and back specific functional status at 1 and 12 months, but not at 6 months.

Applications, conclusions
Overall, the authors conclude:

  1. ”In the treatment of chronic low back pain in adults, moderate quality evidence suggests that spinal manipulative therapy (SMT) results in similar outcomes to recommended therapies for short, intermediate, and long term pain relief as well as improvement in function.”
  2. SMT results in clinically better effects in the short-term with respect to functional status when compared with non-recommended therapies, sham SMT or when SMT is used as an adjunctive therapy. The evidence is varied regarding pain relief in this comparison.

Dr. SHAWN THISTLE is a practising chiropractor, educator, international speaker, knowledge-transfer leader, evidence-based health care advocate, entrepreneur and medicolegal consultant. He founded RRS Education in 2006 and currently acts as the company’s CEO. RRS Education helps chiropractors and other manual medicine clinicians around the world integrate research into patient care via weekly research reviews, online courses and seminars.

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