Abstract
Background context
Despite the many published randomized clinical trials (RCTs), a substantial number
of reviews and several national clinical guidelines, much controversy still remains
regarding the evidence for or against efficacy of spinal manipulation for low back
pain and neck pain.
Purpose
To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB)
for the management of low back pain (LBP) and neck pain (NP), with special attention
to applying more stringent criteria for study admissibility into evidence and for
isolating the effect of SMT and/or MOB.
Study design
RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented
primary outcome measures (eg, patient-rated pain, disability, global improvement and
recovery time).
Methods
Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized
trials were identified by a comprehensive search of computerized and bibliographic
literature databases up to the end of 2002. Two reviewers independently abstracted
data and assessed study quality according to eight explicit criteria. A best evidence
synthesis incorporating explicit, detailed information about outcome measures and
interventions was used to evaluate treatment efficacy. The strength of evidence was
assessed by a classification system that incorporated study validity and statistical
significance of study results. Sixty-nine RCTs met the study selection criteria and
were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to
100. Forty-three RCTs met the admissibility criteria for evidence.
Results
Acute LBP: There is moderate evidence that SMT provides more short-term pain relief
than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly
used physical therapy treatment strategy.
Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious
prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short
term when compared with placebo and general practitioner care, and in the long term
compared to physical therapy. There is limited to moderate evidence that SMT is better
than physical therapy and home back exercise in both the short and long term. There
is limited evidence that SMT is superior to sham SMT in the short term and superior
to chemonucleolysis for disc herniation in the short term. However, there is also
limited evidence that MOB is inferior to back exercise after disc herniation surgery.
Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes
in the short and long term when compared with placebo and with other treatments, such
as McKenzie therapy, medical care, management by physical therapists, soft tissue
treatment and back school.
Acute NP: There are few studies, and the evidence is currently inconclusive.
Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner
management for short-term pain reduction but that SMT offers at most similar pain
relief to high-technology rehabilitative exercise in the short and long term.
Mix of acute and chronic NP: The overall evidence is not clear. There is moderate
evidence that MOB is superior to physical therapy and family physician care, and similar
to SMT in both the short and long term. There is limited evidence that SMT, in both
the short and long term, is inferior to physical therapy.
Conclusions
Our data synthesis suggests that recommendations can be made with some confidence
regarding the use of SMT and/or MOB as a viable option for the treatment of both low
back pain and NP. There have been few high-quality trials distinguishing between acute
and chronic patients, and most are limited to shorter-term follow-up. Future trials
should examine well-defined subgroups of patients, further address the value of SMT
and MOB for acute patients, establish optimal number of treatment visits and consider
the cost-effectiveness of care.
Keywords
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Article info
Publication history
Accepted:
June 2,
2003
Received:
February 26,
2003
Footnotes
☆FDA device/drug status: not applicable.
☆Gert Bronfort, DC, PhD, holds the Greenawalt Endowed Research Chair, funded through a restricted grant from Foot Levelers, Inc.
Identification
Copyright
© 2004 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
