title: Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  Of 26 eligible RCTs identified, 15 RCTs (1711 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 (1381 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
  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.
authors.affiliation: West Los Angeles Veterans Affairs Medical Center, Los Angeles, California.
authors.forename: Neil M
authors.initials: NM
authors.lastname: Paige
authors.affiliation: West Los Angeles Veterans Affairs Medical Center, Los Angeles, California.|University of California, Los Angeles Fielding School of Public Health, Los Angeles.
authors.forename: Isomi M
authors.initials: IM
authors.lastname: Miake-Lye
authors.affiliation: RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica.
authors.forename: Marika Suttorp
authors.initials: MS
authors.lastname: Booth
authors.affiliation: West Los Angeles Veterans Affairs Medical Center, Los Angeles, California.
authors.forename: Jessica M
authors.initials: JM
authors.lastname: Beroes
authors.affiliation: Phoenix Veterans Affairs Healthcare System, Phoenix, Arizona.
authors.forename: Aram S
authors.initials: AS
authors.lastname: Mardian
authors.affiliation: Canandaigua Veterans Affairs Medical Center, Rochester, New York.
authors.forename: Paul
authors.initials: P
authors.lastname: Dougherty
authors.affiliation: Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota.
authors.forename: Richard
authors.initials: R
authors.lastname: Branson
authors.affiliation: White River Junction Veterans Affairs Medical Center, White River Junction, Vermont.
authors.forename: Baron
authors.initials: B
authors.lastname: Tang
authors.affiliation: Virginia Tech, Blacksburg.
authors.forename: Sally C
authors.initials: SC
authors.lastname: Morton
authors.affiliation: West Los Angeles Veterans Affairs Medical Center, Los Angeles, California.|RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica.
authors.forename: Paul G
authors.initials: PG
authors.lastname: Shekelle
mesh_terms: D059787:Acute Pain / Q000628:therapy*; D000328:Adult; D006801:Humans; D017116:Low Back Pain / Q000628:therapy*; D020393:Manipulation, Spinal / Q000009:adverse effects / Q000379:methods*; D064887:Observational Studies as Topic; D010147:Pain Measurement; D016032:Randomized Controlled Trials as Topic; D020127:Recovery of Function