Clinical Inquiries

Does spinal manipulation relieve back pain?

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YES, spinal manipulation therapy (SMT) reduces lower back pain and improves the ability to perform everyday activities more than sham therapies (strength of recommendation [SOR]: A, multiple randomized controlled trials [RCTs] and systematic reviews), but it’s no more or less effective than pain medication, physical therapy, exercise, back school, or care given by a general practitioner (SOR: A, meta-analysis).

Insufficient evidence exists to conclude that the effectiveness of SMT varies with the presence or absence of radiating pain or the profession or training of the manipulator.

Evidence summary

Low back pain, defined as pain between the thoracic cage and proximal thighs, is the fifth most common reason for physician visits in the United States.1,2 The pain can be characterized by its duration: acute, <4 weeks; subacute, >4 weeks but <3 months; and chronic, >3 months.1,3

Pharmacologic treatments for low back pain include nonsteroidal anti-inflammatory agents, opioids, and muscle relaxants.2,3 Nonpharmacologic options comprise exercise, physical therapy, massage, acupuncture, and yoga.2,3 Self-care includes handouts, books, heat, cognitive-behavioral therapy, and interdisciplinary rehabilitation. Traction, corsets, bed rest, home care, and diathermy are considered harmful.3

How SMT compares with other treatments
A 2004 Cochrane meta-analysis of 39 RCTs with a total of 5486 patients concluded that SMT was superior to placebo and as effective as all other treatments in reducing low back pain.3 SMT wasn’t more helpful than other forms of treatment.1,3 Neither the professional training of the SMT provider nor the patient’s level of radiating pain was associated with better outcomes.3

Compared with patients who received sham therapy for acute low back pain, SMT-treated patients showed a 10-mm improvement in pain on a visual analog scale (VAS) (95% confidence interval [CI], 2-17 mm) and no statistically significant difference in function on the Roland-Morris Disability Questionnaire (RMDQ).3 No significant clinical or statistical differences were noted between SMT and conventional care/analgesics, physical therapy/exercise, and back school.

SMT patients reported only slightly more pain reduction (4 mm on a 100-mm scale [95% CI, 1-8 mm]) and no significant improvement in function compared with patients treated with nonbeneficial modalities, such as traction, bed rest, or topical gel.

Patients with chronic low back pain showed a 19-mm improvement in pain on the VAS (95% CI, 3-35 mm) and functional gains of 3.3 mm on the RMDQ (95% CI, 0.6-6.0 mm) compared with patients receiving sham therapy.

Complications from SMT are rare
The American Pain Society (APS) and the American College of Physicians (ACP) recently published a comprehensive review of RCTs published from 2000 to 2006 that examined nonpharmacologic treatments for low back pain.2 They evaluated 69 trials in 10 systematic reviews of the efficacy of SMT. Five higher-quality reviews reached conclusions consistent with the Cochrane review—there was no difference between SMT and other effective therapies. Two lower-quality reviews (based on 1-3 trials with low numbers) found SMT superior to other effective treatments.1,2

Based on a review of more than 70 controlled trials, the APS and ACP concluded that the risk of a serious complication from SMT (worsening lumbar disk herniation or cauda equina syndrome) is rare, less than 1 per 1 million patient visits.2


The APS and ACP guidelines recommend adding nonpharmacologic therapies such as SMT for acute, subacute, and chronic low back pain when patients don’t improve with self-care.4

The opinions and assertions contained herein are the private views of the authors and not to be construed as official or as reflecting the views of the US air Force medical Service or the US air Force at large.

Evidence-based answers from the Family Physicians Inquiries Network

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