Articles3 June 2003
A Meta-Analysis of Effectiveness Relative to Other Therapies
Background:
Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain.
Purpose:
To resolve the discrepancies related to use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis.
Data Sources:
MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews.
Study Selection:
Randomized, controlled trials of patients with low back pain that evaluated spinal manipulative therapy with at least 1 day of follow-up and at least one clinically relevant outcome measure.
Data Extraction:
Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage).
Data Synthesis:
Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results.
Conclusions:
There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.
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Author, Article, and Disclosure Information
Affiliations:
From The Cochrane Back Review Group, Toronto, Ontario, Canada, and Amsterdam, the Netherlands; Dutch College of General Practitioners, Utrecht, the Netherlands; RAND, Santa Monica, California; and Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California.
Grant Support: No external funding was obtained for this study.
Acknowledgments: The authors thank the members of the Editorial Board of the Cochrane Back Review Group for constructive comments on the protocol and draft version of this article. They also thank Bart W. Koes, PhD, and Maurits W. van Tulder, PhD, for helping develop some of the methods of searching and quality assessment used in this review.
Disclosures: None disclosed.
Corresponding Author: Paul G. Shekelle, MD, PhD, RAND, 1700 Main Street, PO Box 2138, Santa Monica, CA 90407; e-mail, [email protected]
Current Author Addresses: Dr. Assendelft: Dutch College of General Practitioners, Lomanlaan 103, Utrecth, the Netherlands.
Drs. Morton, Suttorp, and Shekelle: RAND, 1700 Main Street, PO Box 2138, Santa Monica, CA 90407.
Dr. Yu: University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109.
Author Contributions: Conception and design: W.J.J. Assendelft, P.G. Shekelle.
Analysis and interpretation of the data: W.J.J. Assendelft, S.C. Morton, E.I. Yu, M.J. Suttorp, P.G. Shekelle.
Drafting of the article: W.J.J. Assendelft, S.C. Morton, P.G. Shekelle.
Critical revision of the article for important intellectual content: W.J.J. Assendelft, S.C. Morton, M.J. Suttorp, P.G. Shekelle.
Final approval of the article: W.J.J. Assendelft, M.J. Suttorp, P.G. Shekelle.
Statistical expertise: S.C. Morton, M.J. Suttorp, P.G. Shekelle.
Administrative, technical, or logistic support: E.I. Yu, M.J. Suttorp, P.G. Shekelle.
Collection and assembly of data: W.J.J. Assendelft, S.C. Morton, E.I. Yu, M.J. Suttorp, P.G. Shekelle.
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