Spine J. 2010 (Oct); 10 (10): 918–40
Simon Dagenais DC, PhD, Ralph E. Gay DC, MD, Andrea C. Tricco PhD, Michael D. Freeman PhD, MPH, DC and John M. Mayer DC, PhD
Palladian Health, 2732 Transit Rd, West Seneca, NY 14224, USA. firstname.lastname@example.org
This issue of The Spine Journal includes a review of the scientific evidence supporting spinal manipulative therapy (SMT) for low back pain. The results were quite favorable and reflect a growing body of evidence supporting SMT over medications and other conservative options. SMT research demonstrates “equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up.” The authors conclude by recommending that other health care providers consider SMT as a viable option if self care or education fails to provide pain relief.
Another review of national and international guidelines conducted this year by Koes et. al. pointed out the disparities between guidelines with respect to spinal manipulation and the use of drugs for both chronic and acute low back pain. Another review of guidelines published in June 2010 also noted a great degree of similarity between guidelines and that “Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy.” Although there is always a need for more evidence, the evidence over the last few years is providing much stronger support for SMT and that evidence is slowly finding its way into major clinical guidelines both in the United States and internationally.
BACKGROUND CONTEXT: Low back pain (LBP) continues to be a very prevalent, disabling, and costly spinal disorder. Numerous interventions are routinely used for symptoms of acute LBP. One of the most common approaches is spinal manipulation therapy (SMT).
PURPOSE: To assess the current scientific literature related to SMT for acute LBP.
PATIENT SAMPLE: Not applicable.
OUTCOME MEASURES: Not applicable.
DESIGN: Systematic review (SR).
METHODS: Literature was identified by searching MEDLINE using indexed and free text terms. Studies were included if they were randomized controlled trials (RCTs) published in English, and SMT was administered to a group of patients with LBP of less than 3 months. RCTs included in two previous SRs were also screened, as were reference lists of included studies. Combined search results were screened for relevance by two reviewers. Data related to methods, risk of bias, harms, and results were abstracted independently by two reviewers.
RESULTS: The MEDLINE search returned 699 studies, of which six were included; an additional eight studies were identified from two previous SRs. There were 2,027 participants in the 14 included RCTs, which combined SMT with education (n=5), mobilization (MOB) (n=4), exercise (n=3), modalities (n=3), or medication (n=2). The groups that received SMT were most commonly compared with those receiving physical modalities (n=7), education (n=6), medication (n=5), exercise (n=5), MOB (n=3), or sham SMT (n=2). The most common providers of SMT were chiropractors (n=5) and physical therapists (n=5). Most studies (n=6) administered 5 to 10 sessions of SMT over 2 to 4 weeks for acute LBP. Outcomes measured included pain (n=10), function (n=10), health-care utilization (n=6), and global effect (n=5). Studies had a follow-up of less than 1 month (n=7), 3 months (n=1), 6 months (n=3), 1 year (n=2), or 2 years (n=1). When compared with various control groups, results for improvement in pain in the SMT groups were superior in three RCTs and equivalent in three RCTs in the short term, equivalent in four RCTs in the intermediate term, and equivalent in two RCTs in the long term. For improvement in function, results from the SMT groups were superior in one RCT and equivalent in four RCTs in the short term, superior in one RCT and equivalent in one RCT in the intermediate term, and equivalent in one RCT and inferior in one RCT in the long term. No harms related to SMT were reported in these RCTs.
CONCLUSIONS: Several RCTs have been conducted to assess the efficacy of SMT for acute LBP using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone.
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