title: Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies.
abstract: BACKGROUND
  Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain.
  
  
  OBJECTIVE
  To resolve the discrepancies related to use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis.
  
  
  METHODS
  MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews.
  
  
  METHODS
  Randomized, controlled trials of patients with low back pain that evaluated spinal manipulative therapy with at least 1 day of follow-up and at least one clinically relevant outcome measure.
  
  
  METHODS
  Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage).
  
  
  RESULTS
  Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results.
  
  
  CONCLUSIONS
  There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.
authors.affiliation: The Cochrane Back Review Group, Toronto, Ontario, Canada.
authors.forename: Willem J J
authors.initials: WJ
authors.lastname: Assendelft
authors.forename: Sally C
authors.initials: SC
authors.lastname: Morton
authors.forename: Emily I
authors.initials: EI
authors.lastname: Yu
authors.forename: Marika J
authors.initials: MJ
authors.lastname: Suttorp
authors.forename: Paul G
authors.initials: PG
authors.lastname: Shekelle
mesh_terms: D000208:Acute Disease; D000700:Analgesics / Q000627:therapeutic use; D002908:Chronic Disease; D005081:Exercise Therapy; D006801:Humans; D017116:Low Back Pain / Q000628:therapy*; D020393:Manipulation, Spinal; D010353:Patient Education as Topic; D026741:Physical Therapy Modalities; D010821:Physicians, Family
chemical_list: D000700:Analgesics