title: Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review.
abstract: METHODS
  Systematic review of interventions.
  
  
  OBJECTIVE
  To assess the effects of spinal manipulative therapy (SMT) for chronic low-back pain.
  
  
  BACKGROUND
  SMT is one of the many therapies for the treatment of low-back pain, which is a worldwide, extensively practiced intervention.
  
  
  METHODS
  Search methods. An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to June 2009. Selection criteria. RCTs that examined manipulation or mobilization in adults with chronic low-back pain were included. The primary outcomes were pain, functional status, and perceived recovery. Secondary outcomes were return-to-work and quality of life. Data collection and analysis. Two authors independently conducted the study selection, risk of bias assessment, and data extraction. GRADE was used to assess the quality of the evidence.
  
  
  RESULTS
  We included 26 RCTs (total participants = 6070), 9 of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. There is a high-quality evidence that SMT has a small, significant, but not clinically relevant, short-term effect on pain relief (mean difference -4.16, 95% confidence interval -6.97 to -1.36) and functional status (standardized mean difference -0.22, 95% confidence interval -0.36 to -0.07) in comparison with other interventions. There is varying quality of evidence that SMT has a significant short-term effect on pain relief and functional status when added to another intervention. There is a very low-quality evidence that SMT is not more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.
  
  
  CONCLUSIONS
  High-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority.
authors: Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands. sm.rubinstein@vumc.nl
authors: Sidney M
authors: SM
authors: Rubinstein
authors: Marienke
authors: M
authors: van Middelkoop
authors: Willem J J
authors: WJ
authors: Assendelft
authors: Michiel R
authors: MR
authors: de Boer
authors: Maurits W
authors: MW
authors: van Tulder