By Bridget Carey, MD
Assistant Professor of Neurology and Assistant Attending Neurologist at NewYork-Presbyterian/Weill Cornell Medical Center; Assistant Attending Neurologist at the Hospital For Special Surgery
Dr. Carey reports no financial relationships relevant to this field of study.
SYNOPSIS: Spinal manipulative therapy for acute low back pain may provide some benefit, but carries a significant risk of treatment-associated pain.
SOURCE: Paige NM, Miake-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;317:1451-1460.
This review and meta-analysis investigated the potential benefits and harms from spinal manipulative therapy (SMT) as a treatment for acute low back pain. The authors performed a meta-analysis of randomized clinical trials (RCTs) extracted from the medical literature between January 2011 and February 2017. In addition, narrative descriptions of studies that did not meet criteria for statistical inclusion in the meta-analysis were included in the review.
Acute low back pain was defined as low back pain of a duration ≤ 6 weeks. The predominant patient population of the included studies had symptoms of axial low back pain, but a subpopulation of patients who also endorsed sciatic (radicular) symptoms were included. In the analysis, however, studies consisting solely of patients with radicular pain were excluded.
SMT refers to manual therapy performed on the back. Per the authors, SMT is “a term that encompasses a large variation in the type of manual therapy.” For the purpose of this analysis, the intervention had to be classified as either a “thrust” or “non-thrust” technique; other variants of manipulation were excluded. The intervention could be performed by a physical therapist, chiropractor, osteopathic practitioner, or a physician.
In all studies, SMT was assessed in comparison to an alternative treatment, such as medication, exercises, physical therapy, or sham-SMT. Effectiveness was measured through outcomes of pain and functional status. In addition, the potential for harm was evaluated. Outcomes were assessed at two time-points: 2 weeks or less (immediate term) and 3-6 weeks (short term).
Paige et al included 26 RCTs in the statistical analysis for effectiveness (outcome measures of pain and functional status). The assessment of adverse events included eight articles, including RCTs and observational studies. Pain outcomes were reported using the 100 mm visual analog scale (VAS), 11-point numeric rating scale, or other numerical pain scales. For both immediate and short-term outcome points, a modest but statistically significant benefit was seen for SMT over the alternative treatment (mean effect of -9.95 mm for short term and -9.76 mm for immediate on VAS scale).
Functional status outcomes were reported using the Roland-Morris Low Back Pain and Disability Questionnaire (RMDQ) or the Oswestry Disability Index. A modest but statistically significant benefit was seen for SMT over the alternative treatment at both immediate and short-term outcome points (improvement by 1-2.5 points in the RMDQ score).
The assessment of adverse effects was based on eight studies (N ranging from 68-1,058 patients). Harms were assessed by patient questionnaire, and 50-67% of patients reported “mild transient harms,” including but not limited to complaints of transient local discomfort, increase in pain, headaches, and/or muscle stiffness. Serious adverse events, which have been reported in case reports and in other reviews, are acknowledged by the authors, but not included for evaluation in this review.
COMMENTARY
This is a thorough review of the medical literature pertaining to the role of SMT in patients with acute low back pain. The data indicate that overall SMT probably is slightly helpful in the management of acute axial back pain in the short term (< 6 weeks), while at the same time associated with frequent transient increases in pain.
Despite a thorough meta-analysis, limitations to the interpretation and implementation of these findings are significant. A main issue is that SMT is not well-defined. Practitioners trained in different fields perform different manipulation procedures, in concert with additional therapeutic modalities. Therefore, it is not possible from the information provided in this review to link a specific method of therapy (or manipulation) to a specific outcome.
Further, it is notable that more than half of the patients who undergo SMT experience transient treatment-associated pain. The severity and duration of this pain was not stratified or described, nor was it factored into the analysis. Therefore, whether this transient pain is “worth” the modest improvements in short-term pain and functional metrics is not at all clear. Prospective or retrospective trials of specific protocols for SMT that are standardized between providers would be more helpful in the determination of beneficial interventions.
Spinal manipulative therapy for acute low back pain may provide some benefit, but carries a significant risk of treatment-associated pain.
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