Spinal Manipulative Therapy May Offer Pain Relief

Spinal manipulative therapy has been shown to offer some pain relief for patients who suffer from acute back pain, researchers reported in this week’s issue of JAMA. 

The study, a systematic review and meta-analysis of 15 randomized clinical trials, showed that the practice is associated with a statistically significant, but moderate, relief from short-lived acute back pain of six weeks or less. 

In an editorial that accompanied the study, Richard A Deyo, M.D., of Oregon Health and Science University, wrote that although physicians infrequently recommend SMT, approximately 30% of patients with back or neck pain see a chiropractor. A survey shows these patients are “highly satisfied” patients but in reality, no single treatment is superior to another, he wrote.

“Further research will better identify which patients are most likely to benefit, and what manipulation techniques are most effective. In the meantime, if manipulation is at least as effective and as safe as conventional care, it may be an appropriate choice for some patients with uncomplicated acute low back pain,” Dr. Deyo wrote.

Randomized controlled trials and meta-analyses published in recent years have reported contradictory results in terms of the effectiveness of SMT in relieving pain and in improving function due to back pain. A 2003 review found that SMT offered statistically significant benefits, but not as compared to other treatments(*). A review of “combined chiropractic interventions” found that SMT was associated with statistically significant benefits (**). 

There is little research on the use of chiropractic care in osteoarthritis which is associated with chronic back pain, but a 2009 study of 70 patients with lumbar spinal stenosis published in the Journal of Chiropractic Medicine raises the possibility that the practice could potentially relieve symptoms of lumbar spinal stenosis - yet there is no definitive evidence the practice relieves pain or improves function.

In general, patients with back pain are usually treated with analgesics, muscle relaxants, exercise, physical therapy and heat, among other clinically-proven treatments.

The study

The JAMA study was led by Paul G. Shekelle, M.D., Ph.D., of the West Los Angeles Veterans Affairs Medical Center. The review is based on a search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE and Current Nursing and Allied Health Literature. The final analysis included 15 clinical trials (1,711 patients) that were published between January 1, 2011 and February 6, 2017.

The studies that were included in the review provided moderate quality evidence reporting statistically significant associations between SMT and improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, −9.95 [95% CI, −15.6 to −4.3]). Twelve other clinical trials (1,381 patients) showed that this therapy led to statistically significant improvements in function (pooled mean effect size, −0.39 [95% CI, −0.71 to −0.07]). 

In this study, pain, function, quality of life and harms were the priori primary outcome measures in this study (it did not included quality of life). Pain was measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale). Function was measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index (using a range of 0-100).

The chiropractic care was administered by physical therapists in 13 studies, chiropractors in seven studies, medical doctors in five studies and osteopathic physicians in three studies. The patients reported few adverse effects. In one large case series cited in the review, 50-67% of patients treated with spinal manipulative therapy (SMT) experienced minor cases of increased pain, muscle stiffness and headache. 

Conclusions

“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 six weeks, that was, on average, clinically modest,” the authors wrote.

Overall, the patients in the studies improved just slightly more (-9.95 mm) than patients who were treated with nonsteroidal anti-inflammatory drugs (−8.39 mm).

The heterogeneity of the studies were high, so the researchers could not account for differences in patient types, clinicians, type of manipulation, study quality or timing of the outcome.

Disclosures:

This work was funded by the Veterans Affairs Quality Enhancement Research Initiative as part of the Evidence Synthesis Program.

References:

Neil M. Paige, MD, MSHS; Isomi M. Miake-Lye, BA; Marika Suttorp 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. April 11, 2017. 317(14):1451-1460. DOI:10.1001/jama.2017.3086

Richard A. Deyo, MD, MPH. "The Role of Spinal Manipulation in the Treatment of Low Back Pain," JAMA. 2017;317(14):1418-1419. doi:10.1001/jama.2017.3085

Kent Stuber, DC, Sandy Sajko, DC, MSc, Kevyn Kristmanson, DC. "Chiropractic treatment of lumbar spinal stenosis: a review of the literature." Journal of Chiropractic Medicine, June 2009. DOI: http://dx.doi.org/10.1016/j.jcm.2009.02.001

(*) Assendelft  WJ, Morton  SC, Yu  EI, Suttorp  MJ, Shekelle  PG.  Spinal manipulative therapy for low back pain: a meta-analysis of effectiveness relative to other therapies.  Ann Intern Med. 2003;138(11):871-881. 

(**) Walker  BF, French  SD, Grant  W, Green  S.  Combined chiropractic interventions for low-back pain.  Cochrane Database Syst Rev. 2010;(4):CD005427.