JAMA. 2017 (Apr 11); 317 (14): 1418–1419 ~ FULL TEXT
Richard A. Deyo, MD, MPH
Department of Family Medicine,
Oregon Health and Science University,
Although approximately 200 treatment options are available to treat low back pain,  no single treatment is clearly superior. Furthermore, the etiology of back pain is often unclear, possibly contributing to treatment strategies for low back pain often being determined by preferences of the clinical care practitioner.
Spinal manipulative therapy (SMT) is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors. Chiropractic therapy is not widely accepted by some traditional health care practitioners. This may be, at least in part, because some early practitioners of chiropractic care rejected the germ theory, immunizations, and other scientific advances.
However, chiropractic care is popular today with the
US public. According toa 2012 report, among patients with back
or neck pain, approximately 30% sought care from a
chiropractor.  In a 2013 survey by Consumer Reports magazine
involving 14,000 subscribers with low back pain, chiropractic
care had the largest proportion of “highly satisfied”
patients.  Among approximately 4,000 respondents who had
seen a chiropractor, 59% were highly satisfied compared with
55% who saw a physical therapist and 34% who saw a primary
care physician. In addition to chiropractors, some physical
therapists and osteopathic physicians provide SMT.
A 1983 systematic review on treatments for lowback pain
included 2 fair-quality randomized trials and concluded that
“some types of spinal manipulation seem to have short-term,
but not long-term benefits.”  In this issue of JAMA, Paige and
colleagues present a sophisticated systematic review and meta-analysis,
including 26 eligible randomized trials of manipulation
for acute back pain (≤6weeks).  Their analysis was based
on a thorough search of the literature, excluding studies of patients with
sciatica or chronic back pain. Each trial was evaluated
for risk of bias, and studies with similar outcome measures
and follow-up intervals were pooled for meta-analysis.
Based on 15 clinical trials (1,711 patients) that provided moderate-
quality evidence, the authors concluded that for patients with
acute lowback pain,SMT was associated with modest
improvement in pain (pooled mean improvement in
100–mm visual analog pain scale, —9.95mm [95%CI, —15.6 to
—4.3]), and based on 12 trials (1,381 patients) that provided moderate-
quality evidence, that SMT was associated with modest
improvements in function (pooled mean effect size, —0.39[95%
CI, —0.71 to—0.07]) in the short-term in comparison with sham
manipulation, usual care, or other treatments.
As the authors point out, there have been conflicting
findings from previous systematic reviews on SMT for lowback
pain. The review by Paige et al includes heterogeneity in manipulative
techniques, clinician training, patient selection, and
results. The magnitude of benefit appears small on average,
although overall results typically combine patients with substantial
benefit, those with a small amount of benefit, and those
with none. In addition, the review by Paige et al includes no
information about important outcomes like minimizing
medication use or faster return to work. Unlike medication
trials that include administration of placebo, blinding of physical
treatments is difficult, and was not used in most clinical
trials included in the systematic review.
The lack of blinding in many of the clinical trials can limit
the validity of the results. Most volunteers for clinical trials
probably anticipate that they will benefit from SMT, and generally
view the treatment favorably. These patients may be
disappointed if they are randomly assigned to a control group,
and this may affect their perceived improvement, essentially,
a nocebo effect (a nocebo is a detrimental effect arising from
negative treatment expectations). If this is true, little is
known about the results among patients who may view SMT
Nonetheless, the conclusions of the systematic review by
Paige et al are generally consistent with another recently completed
systematic review and clinical guideline from the
American College of Physicians. [6, 7] The guideline concluded
that most patients with acute low back pain improve with time,
regardless of treatment. Thus, therapy is often directed simply
at symptom relief while natural healing occurs. The guideline
also concluded that patients with acute or subacute
low back pain should consider non-pharmacological treatment
with heat, massage, acupuncture, or SMT. None of the
trials in the study by Paige et al or the American College of
Physicians systematic review suggested that SMT was less effective
than conventional care.
Nonetheless, physicians infrequently recommend SMT.
Part of the hesitation, despite a growing clinical trial literature,
may involve uncertainty about its biological rationale.
It remains unclear how SMT relieves low back pain,
although hypothetical biological pathways suggest repositioning
of the facet joints, repositioning of disc material, reducing
muscle tension or stiffness, freeing adhesions around a prolapsed
disc, or mechanical stimulation of large nerve fibers
that might inhibit transmission of nociceptive impulses. 
The hands-on, high-touch nature of treatment; an ongoing
patient-clinician relationship through repeated visits; an
expectation of change; a feeling of empowerment; and clinician
enthusiasm, reassurance, and conviction may all be
therapeutic.  Even though this mechanistic uncertainty is disconcerting,
it is important to acknowledge that for many patients
with acute back pain without radiculopathy, a precise
pathoanatomical cause of the pain cannot be identified.  It is
not surprising that the mechanism of action for some treatments
Another concern is the safety of SMT. Although there are
case reports of serious complications, such as the cauda
equina syndrome, these are extremely rare in the lumbar
spine. None of the randomized trials or large observational
studies reviewed by Paige et al identified any serious complications.
In contrast, renal and gastrointestinal adverse
effects of nonsteroidal anti-inflammatory drugs are common.
For example, among patients taking non-steroidal anti-inflammatory
drugs, renal function abnormalities occur in
approximately 1% of patients,  and superficial gastric erosions
or asymptomatic ulcers may occur in up to 5% to 20%
of users.  Furthermore, low back pain is among the most
common reasons for prescribing opioids in the United States.
Among patients initiating opioid therapy, about 5% become
long-term opioid users, with associated risks of dependency,
addiction, and overdose. [12, 13]
The duration of effects from SMT is also unclear. The
systematic review by Paige et al was limited to 6 weeks of
follow-up, a relatively short follow-up period. Fewer studies
have addressed long-term outcomes, and some suggest that
benefits of SMT are less in trials with longer-term follow-up. 
Nonetheless, most patients with acute back pain desire rapid
short-term improvement and early return to normal activities.
Exercise therapy and mind-body interventions may have
an important role for more durable relief. [15, 16]
Costs of care are also important. Because SMT typically
involves multiple visits, this therapy is likely to be more
expensive than medication such as non-steroidal anti-inflammatory
drugs. However, the cost of caring for complications
from pharmacologic therapies may exceed the costs
of SMT. For example, the US societal cost of prescription
opioid abuse in 2007 was estimated at $55.7 billion, with
health care costs and workplace costs each contributing
almost half.  In a previous report, patients who sought alternative
treatments such as chiropractic care for back pain did
not incur higher overall treatment costs compared with those
who received only conventional care. 
Concerns also exist about claims of exceptional benefit
from some chiropractors. For example, there is no biological
evidence to support spinal manipulation as an effective therapy
for diabetes, heart failure, or thyroid disease.
However, it appears that SMT is a reasonable treatment option
for some patients with low back pain. The systematic review
by Paige et al suggests a treatment effect similar in magnitude
to nonsteroidal anti-inflammatory drugs. Further
research will better identify which patients are most likely to
benefit, and what manipulation techniques are most effective.
In the meantime, if manipulation is at least as effective
and as safe as conventional care, it may be an appropriate choice
for some patients with uncomplicated acute low back pain. This
is an area in which a well-informed patient’s decisions should
count as much as a practitioner’s preference.
Conflict of Interest Disclosures:
Dr Deyo has
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest.
He reports receiving grants from the National
Institutes of Health, Agency for Health Care
Research and Quality, the Centers for Disease
Control and Prevention, and Patient-Centered
Outcomes Research Institute and personal fees
from UpToDate, Kaiser Permanente, and NuVasive.
Haldeman S, Dagenais S.
A supermarket approach to the evidence-informed management of chronic low back pain.
Spine J. 2008;8(1):1-7.
Martin BI, Gerkovich MM, Deyo RA, et al.
The Association of Complementary and Alternative
Medicine Use and Health Care
Expenditures for Back and Neck Problems
Med Care. 2012 (Dec); 50 (12): 1029–1036
Relief for your aching back: what worked for our readers
Conservative therapy for low back pain.
Paige NM, Myiake-Lye IM, Booth MS, et al.
Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for
Acute Low Back Pain: Systematic Review and Meta-analysis
JAMA. 2017 (Apr 11); 317 (14): 1451–1460
Chou R, Deyo R, Friedly J, et al.
Nonpharmacologic Therapies for Low Back Pain: A Systematic Review
for an American College of Physicians Clinical Practice Guideline
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 493–505
Qaseem A, Wilt TJ, McLean RM, Forciea MA;
Noninvasive Treatments for Acute, Subacute, and Chronic
Low Back Pain:
A Clinical Practice Guideline From the American College of Physicians
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 514–530
Meeker WC, Haldeman S.
Chiropractic: A Profession at the Crossroads
of Mainstream and Alternative Medicine
Annals of Internal Medicine 2002 (Feb 5); 136 (3): 216–227
Diagnostic evaluation of LBP: reaching a specific diagnosis is often impossible.
Arch Intern Med. 2002;162(13):1444-1447.
Whelton A, Hamilton CW.
Nonsteroidal anti-inflammatory drugs: effects on kidney function.
J Clin Pharmacol. 1991;31(7): 588-598.
Vonkeman HE, van de Laar MAFJ.
Nonsteroidal anti-inflammatory drugs: adverse effects and their prevention.
Semin Arthritis Rheum. 2010;39(4): 294-312.
Deyo RA, Hallvik SE, Hildebran C, et al.
Association between initial opioid prescribing patterns and subsequent long-term use among opioid-naïve patients.
J Gen Intern Med. 2017;32(1): 21-27.
Edlund MJ, Martin BC, Russo JE, DeVries A,
Braden JB, Sullivan MD.
The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic
noncancer pain: the role of opioid prescription.
Clin J Pain. 2014;30(7):557-564.
Furlan AD, Yazdi F, Tsertsvadze A, et al.
Complementary and alternative therapies for back pain II.
Evid Rep Technol Assess (Full Rep). 2010;194 (194):1-764.
van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van TulderMW.
Exercise therapy for chronic nonspecific low-back pain.
Best Pract Res Clin Rheumatol. 2010;24(2):193-204.
Cherkin DC, Sherman KJ, Balderson BH, et al.
Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic lowback pain.
Birnbaum HG, White AG, Schiller M,Waldman T, Cleveland JM, Roland CL.
Societal costs of prescription opioid abuse, dependence, and misuse in the United States.
Pain Med. 2011;12(4):657-667
Return to the LOW BACK PAIN Section