Association of Spinal Manipulative Therapy With Clinical Benefit
and Harm for Acute Low Back Pain: Systematic Review
and Meta-analysis

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:

FROM:   JAMA. 2017 (Apr 11);   317 (14):   1451–1460 ~ FULL TEXT

Neil M. Paige, MD, MSHS, Isomi M. Miake-Lye, BA, Marika Suttorp Booth, MS,
Jessica M. Beroes, BS, Aram S. Mardian, MD, Paul Dougherty, DC,
Richard Branson, DC, Baron Tang, PT, DPT, Sally C. Morton, PhD,
Paul G. Shekelle, MD, PhD

West Los Angeles Veterans Affairs Medical Center,
Los Angeles, California.

Commentary from the Illinois Chiropractic Society

JAMA Endorses Spinal Manipulation

For the second time in as many months, a prominent medical journal has endorsed spinal manipulation for the management of low back pain. [1] On April 11th 2017, JAMA published a systematic review of 26 randomized clinical trials in order to evaluate the safety and effectiveness of spinal manipulation for low back pain.

The authors concluded:

“Among patients with acute low back pain, spinal manipulative therapy was associated with improvements in pain and function with only transient minor musculoskeletal harms.”

This study comes on the heels of a February 2017 Clinical Practice Guideline from the
American College of Physicians recommending spinal manipulation for acute,
sub-acute, and chronic low back pain (LBP).

These high-quality studies in respected medical journals add to a growing list of scientific support for spinal manipulation therapy (SMT). So why are our offices not flooded with medical referrals? An editorial accompanying the JAMA study provides perspective as to why some medical providers may be reluctant to refer to chiropractic physicians:

“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 to a 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 4000 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.

“Serious complications (related to SMT) are extremely rare… if spinal manipulation is at least as effective and as safe as conventional care, it may be an appropriate choice for patients with uncomplicated low back pain”.

The emerging health care model dictates that all providers embrace proven clinically effective treatments, regardless of long-standing philosophical bias. If we expect medical providers to advance their thinking to accept validated chiropractic therapies, we must first be willing to reciprocate. By working together to provide evidence-based patient-centric care, we can advance our profession to become the undeniable first choice for both patients and providers.


  1. 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 (Apr 11);   317 (14):   1451–1460

  2. Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee
    of the American College of Physicians.
    Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
    A Clinical Practice Guideline From the American College of Physicians

    Ann Intern Med. 2017 (Apr 4);   166 (7):   514–530

  3. Deyo RA.
    The Role of Spinal Manipulation in the Treatment of Low Back Pain
    JAMA. 2017 (Apr 11);   317 (14):   1418–1419

The Abstract:

IMPORTANCE:   Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT.

OBJECTIVE:   To systematically review studies of the effectiveness and harms of SMT for acute (≤6 weeks) low back pain.

DATA SOURCES:   Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms.

DATA EXTRACTION AND SYNTHESIS:   Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

MAIN OUTCOMES AND MEASURES:   Pain (measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale), function (measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index [range, 0-100]), or any harms measured within 6 weeks.

FINDINGS:   Of 26 eligible RCTs identified, 15 RCTs (1,711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, -9.95 [95% CI, -15.6 to -4.3]). Twelve RCTs (1,381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, -0.39 [95% CI, -0.71 to -0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT.

CONCLUSIONS AND RELEVANCE:   Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.

Key Points

Question   Is the use of spinal manipulative therapy in the management of acute (≤6 weeks) low back pain associated with improvements in pain or function?

Findings   In this systematic review and meta-analysis of 26 randomized clinical trials, spinal manipulative therapy was associated with statistically significant benefits in both pain and function, of on average modest magnitude, at up to 6 weeks. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported in more than half of patients in the large case series.

Meaning   Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function and with transient minor musculoskeletal harms.

From the FULL TEXT Article:


Back pain is among the most common symptoms prompting patients to seek care. Lifetime prevalence estimates of low back pain exceed 50%. [1] Many treatments are used for acute back pain. None of the therapies for acute back pain has been established as superior to others. Treatments include analgesics, muscle relaxants, exercises, physical therapy modalities, heat, spinal manipulative therapy (SMT), and others. [2]

There have been multiple systematic reviews on spinal manipulation. A 2003 review concluded SMT was associated with statistically significant benefits compared with a sham manipulation, but not compared with other effective treatments for acute low back pain. [3] Since then, the most recent Cochrane review on the subject concluded that SMT was not associated with statistically significant benefits comparedwith other interventions or sham SMT, [4] but another Cochrane review of “combined chiropractic interventions” (which included SMT as part of the intervention) concluded the opposite. [5] A third review assessed SMT for patients with back pain of less than 3 months duration and concluded it was associated with benefits compared with placebo treatment, no treatments, or massage, [6] and a fourth review concluded “the efficacy of manipulation for patients with acute or chronic low back pain remains unconvincing.” [7]

As new trials continue to be published, [8–13] and given these differences in conclusions among studies, this review was conducted to provide updated estimates of the effectiveness and harms associated with spinal manipulation compared with other nonmanipulative therapies for adults with acute low back pain.


The principal conclusion of this review was that SMT treatments for acute low back pain were associated with statistically significant benefit in pain and function at up to 6 weeks, that was, on average, clinically modest. The size of the benefit for pain (–9.95 mm) is about the same as the benefit for nonsteroidal anti-inflammatory drugs in acute lowback pain (–8.39 mm) according to the Cochrane review on this topic. [27] For function, the effect size of –0.39 is approximately equivalent to an improvement in the RMDQ score of between 1 and 2.5 points, using the range of SDs for the RMDQ in the included studies. However, heterogeneity was high, and could not be explained by differences in patients, clinicians, type of manipulation, study quality, or timing of the outcome. Evaluation of these differences was limited by the quality of reporting in the primary studies.

This review adds to the existing literature by including a greater number of eligible RCTs in the pooled analysis than prior reviews, and also providing a higher level of precision to the pooled analysis. For example, 2 prior reviews included 37 and 45 RCTs and did not perform a pooled analysis. Another review included 27 studies, [6] but patients could have had pain for up to 3months’ duration, and it is unclear howmany RCTs were included in their pooled analysis and whether or not they pooled sham-controlled studies with active therapy comparisons. The most recent Cochrane review on SMT for acute low back pain reports pooled results for pain and function at 4–week follow-up that included only 3 studies for each outcome. [4] In the current review, 10 studies for pain and 6 studies for function were included in pooled analyses for short-term outcomes.

The studies reporting the largest benefits were 3 studies that used clinical criteria to select patients as more likely to benefit. [32–34] In a recent RCT, the physical therapy research team reported statistically significant benefits of much smaller magnitude. [9] Possible hypotheses include that the comparison group (usual care along with education and reassurance based on The Back Book) was more effective than the exercises given to the comparison groups in the prior studies or that it is due to patient selection, as the most recent study recruited patients directly from primary care and not from patients already referred to physical therapy (and therefore possibly having less successful spontaneous improvement). The recent study also selected patients using a modification of the prediction rule that is more pragmatic for clinical implementation but is known to sacrifice specificity in identifying likely SMT responders.


This study has limitations. First, there were limitations in the quantity and quality of the original research. More studies were classified as low quality than high quality. Nevertheless, high quality studies tended to report larger benefits. Second, some studies did not describe the manipulation in sufficient detail to allow application in practice. Third, there was significant unexplained heterogeneity. There were too few studies to use meta-regression methods to simultaneously test for variables possibly associated with heterogeneity. The most fruitful area for further research is likely to be assessing the role of patient selection and type of SMT on explaining heterogeneity in treatment effects. Fourth, the minimum clinically important difference for these outcomes has not been well established, raising questions about the size of the clinical benefit. Fifth, the possibility of publication bias exists, although no statistical evidence for it was detected.


Among patients with acute lowback pain, spinal manipulation therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.


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