title: Combined chiropractic interventions for low-back pain.
abstract: BACKGROUND
  Chiropractors commonly use a combination of interventions to treat people with low-back pain (LBP).
  
  
  OBJECTIVE
  To determine the effects of combined chiropractic interventions (that is, a combination of therapies, other than spinal manipulation alone) on pain, disability, back-related function, overall improvement, and patient satisfaction in adults with LBP, aged 18 and older.
  
  
  METHODS
  We searched: The Cochrane Back Review Group Trials Register (May 2009), CENTRAL (The Cochrane Library 2009, Issue 2), and MEDLINE (from January 1966), EMBASE (from January 1980), CINAHL (from January 1982), MANTIS (from Inception) and the Index to Chiropractic Literature (from Inception) to May 2009. We also screened references of identified articles and contacted chiropractic researchers.
  
  
  METHODS
  All randomised trials comparing the use of combined chiropractic interventions (rather than spinal manipulation alone) with no treatment or other therapies.
  
  
  METHODS
  At least two review authors selected studies, assessed the risk of bias, and extracted the data using standardised forms. Both descriptive synthesis and meta-analyses were performed.
  
  
  RESULTS
  We included 12 studies involving 2887 participants with LBP. Three studies had low risk of bias. Included studies evaluated a range of chiropractic procedures in a variety of sub-populations of people with LBP.No trials were located of combined chiropractic interventions compared to no treatment. For acute and subacute LBP, chiropractic interventions improved short- and medium-term pain (SMD -0.25 (95% CI -0.46 to -0.04) and MD -0.89 (95%CI -1.60 to -0.18)) compared to other treatments, but there was no significant difference in long-term pain (MD -0.46 (95% CI -1.18 to 0.26)). Short-term improvement in disability was greater in the chiropractic group compared to other therapies (SMD -0.36 (95% CI -0.70 to -0.02)). However, the effect was small and all studies contributing to these results had high risk of bias. There was no difference in medium- and long-term disability. No difference was demonstrated for combined chiropractic interventions for chronic LBP and for studies that had a mixed population of LBP.
  
  
  CONCLUSIONS
  Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.
authors.affiliation: School of Chiropractic and Sports Science, Murdoch University, Faculty of Health Sciences, Murdoch, Australia, 6150.
authors.forename: Bruce F
authors.initials: BF
authors.lastname: Walker
authors.forename: Simon D
authors.initials: SD
authors.lastname: French
authors.forename: William
authors.initials: W
authors.lastname: Grant
authors.forename: Sally
authors.initials: S
authors.lastname: Green
mesh_terms: D000208:Acute Disease; D000328:Adult; D002684:Chiropractic / Q000379:methods*; D006801:Humans; D017116:Low Back Pain / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
references.citation: Spine (Phila Pa 1976). 2006 Mar 15;31(6):611-21; discussion 622
references.pmid: 16540862
references.citation: Cochrane Database Syst Rev. 2004;(1):CD000447
references.pmid: 14973958
references.citation: Orthop Clin North Am. 1991 Apr;22(2):263-71
references.pmid: 1826550
references.citation: J Manipulative Physiol Ther. 1999 Jul-Aug;22(6):376-81
references.pmid: 10478769
references.citation: J Manipulative Physiol Ther. 1996 Nov-Dec;19(9):570-82
references.pmid: 8976475
references.citation: Asia Pac J Public Health. 2003;15(2):79-87
references.pmid: 15038680
references.citation: J Manipulative Physiol Ther. 1995 Feb;18(2):57-64
references.pmid: 7790784
references.citation: Ann Intern Med. 2002  Feb 5;136(3):216-27
references.pmid: 11827498
references.citation: Br J Gen Pract. 2002 Jun;52(479):475-80
references.pmid: 12051212
references.citation: J Chiropr Med. 2008 Jun;7(2):59-65
references.pmid: 19674721
references.citation: J Manipulative Physiol Ther. 2009 Mar-Apr;32(3):203-9
references.pmid: 19362230
references.citation: J Chiropr Med. 2007 Mar;6(1):15-9
references.pmid: 19674689
references.citation: Spine (Phila Pa 1976). 1995 Feb 1;20(3):312-7
references.pmid: 7732467
references.citation: Spine (Phila Pa 1976). 1987 Sep;12(7):702-6
references.pmid: 2961085
references.citation: CMAJ. 2009 May 12;180(10):E47-57
references.pmid: 19372436
references.citation: J Manipulative Physiol Ther. 1999 Sep;22(7):436-43
references.pmid: 10519559
references.citation: BMJ. 1995 Aug 5;311(7001):349-51
references.pmid: 7640538
references.citation: J Manipulative Physiol Ther. 1995 Sep;18(7):453-6
references.pmid: 8568427
references.citation: J Manipulative Physiol Ther. 2000 Oct;23(8):557-63
references.pmid: 11050613
references.citation: Med Care. 2001 Sep;39(9):956-67
references.pmid: 11502953
references.citation: J Rheumatol. 2001 Feb;28(2):431-8
references.pmid: 11246692
references.citation: Emerg Med J. 2001 May;18(3):205-7
references.pmid: 11354213
references.citation: BMC Musculoskelet Disord. 2007 Sep 18;8:94
references.pmid: 17877825
references.citation: BMJ. 2008 Apr 26;336(7650):924-6
references.pmid: 18436948
references.citation: Spine (Phila Pa 1976). 2002 Oct 15;27(20):2193-204
references.pmid: 12394892
references.citation: BMC Med Res Methodol. 2003 Dec 22;3:28
references.pmid: 14690550
references.citation: J Manipulative Physiol Ther. 2006 Feb;29(2):107-14
references.pmid: 16461169
references.citation: Spine (Phila Pa 1976). 2007 Jan 15;32(2):151-8
references.pmid: 17224808
references.citation: Med Care. 2005 May;43(5):428-35
references.pmid: 15838406
references.citation: Pain. 1998 Aug;77(2):201-207
references.pmid: 9766838
references.citation: J Am Board Fam Pract. 2002 Nov-Dec;15(6):463-72
references.pmid: 12463292
references.citation: J Manipulative Physiol Ther. 2005 May;28(4):259-64
references.pmid: 15883579
references.citation: J Manipulative Physiol Ther. 2005 Sep;28(7):493-501
references.pmid: 16182023
references.citation: Spine J. 2006 Mar-Apr;6(2):131-7
references.pmid: 16517383
references.citation: J Altern Complement Med. 2005 Feb;11(1):109-17
references.pmid: 15750369
references.citation: Spine (Phila Pa 1976). 1997 Oct 1;22(19):2254-63; discussion 2263-4
references.pmid: 9346146
references.citation: J Altern Complement Med. 2006 Sep;12(7):659-68
references.pmid: 16970536
references.citation: Spine (Phila Pa 1976). 1997 Sep 15;22(18):2167-77
references.pmid: 9322328
references.citation: Spine (Phila Pa 1976). 2008 Dec 15;33(26):2923-8
references.pmid: 19092626
references.citation: Spine (Phila Pa 1976). 2009 Aug 15;34(18):1929-41
references.pmid: 19680101
references.citation: Technol Health Care. 2005;13(6):453-62
references.pmid: 16340089
references.citation: BMC Health Serv Res. 2003 Aug 01;3(1):16
references.pmid: 12892566
references.citation: Spine (Phila Pa 1976). 1987 Apr;12(3):264-8
references.pmid: 2954221
references.citation: Spine J. 2004 Sep-Oct;4(5):574-83
references.pmid: 15363431
references.citation: J Manipulative Physiol Ther. 1996 Oct;19(8):499-507
references.pmid: 8902660
references.citation: Spine (Phila Pa 1976). 2004 Jan 1;29(1):79-86
references.pmid: 14699281
references.citation: BMJ. 2004 Dec 11;329(7479):1377
references.pmid: 15556955
references.citation: J Manipulative Physiol Ther. 1993 Jan;16(1):7-13
references.pmid: 8423429
references.citation: N Engl J Med. 1998 Oct 8;339(15):1021-9
references.pmid: 9761803
references.citation: J Manipulative Physiol Ther. 2002 Oct;25(8):E8-E17
references.pmid: 12381983
references.citation: Chiropr Osteopat. 2006 Aug 24;14:19
references.pmid: 16930489
references.citation: J Manipulative Physiol Ther. 2002 Mar-Apr;25(3):162-7
references.pmid: 11986577
references.citation: Spine (Phila Pa 1976). 1984 Apr;9(3):301-4
references.pmid: 6233718
references.citation: BMJ. 2000 Jun 10;320(7249):1577-8
references.pmid: 10845966
references.citation: Best Pract Res Clin Rheumatol. 2005 Aug;19(4):593-607
references.pmid: 15949778
references.citation: Spine J. 2008 Jan-Feb;8(1):8-20
references.pmid: 18164449
references.citation: Spine J. 2004 May-Jun;4(3):335-56
references.pmid: 15125860
references.citation: J Altern Complement Med. 2008 Jun;14(5):465-73
references.pmid: 18564952
references.citation: Pain. 2000 Jan;84(1):95-103
references.pmid: 10601677
references.citation: Eur Spine J. 2006 Jul;15(7):1070-82
references.pmid: 16341712
references.citation: J Manipulative Physiol Ther. 2004 Jun;27(5):327-35
references.pmid: 15195040
references.citation: Spine (Phila Pa 1976). 1995 Aug 1;20(15):1668-73
references.pmid: 7482015
references.citation: Spine (Phila Pa 1976). 2003 Jul 15;28(14):1490-502; discussion 1502-3
references.pmid: 12865832
references.citation: J Manipulative Physiol Ther. 2005 Jan;28(1):3-11
references.pmid: 15726029
references.citation: Spine (Phila Pa 1976). 2000 Oct 1;25(19):2501-13
references.pmid: 11013503
references.citation: J Clin Epidemiol. 2009 May;62(5):485-8
references.pmid: 19348973
references.citation: Phys Ther. 2009 Jul;89(7):698-704
references.pmid: 19465372
references.citation: J Manipulative Physiol Ther. 1991 Feb;14(2):104-9
references.pmid: 1826920
references.citation: BMJ. 1990 Jun 2;300(6737):1431-7
references.pmid: 2143092
references.citation: J Manipulative Physiol Ther. 2004 Jul-Aug;27(6):388-98
references.pmid: 15319761
references.citation: Spine (Phila Pa 1976). 2002 Jun 1;27(11):1142-8
references.pmid: 12045509
references.citation: Trials. 2009 Jun 03;10:37
references.pmid: 19493350
references.citation: J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):178-85
references.pmid: 17416271
references.citation: J Spinal Disord. 2000 Jun;13(3):205-17
references.pmid: 10872758
references.citation: J Manipulative Physiol Ther. 1992 Jan;15(1):4-9
references.pmid: 1531488
references.citation: Am J Public Health. 2002 Oct;92(10):1628-33
references.pmid: 12356612
references.citation: Spine (Phila Pa 1976). 1998 Sep 1;23(17):1875-83; discussion 1884
references.pmid: 9762745
references.citation: Altern Ther Health Med. 2009 May-Jun;15(3):36-40
references.pmid: 19472863