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I have chronic low back pain. Will it help me to have spinal manipulative therapy?

Spinal manipulative therapy, which includes mobilization and manipulation, is widely used to treat low back pain. It has similar effectiveness to other recommended therapies such as exercise and drug therapies. It may be better than receiving no treatment. It may be something that you can add to other therapies you are currently undergoing for your back pain.

What is the evidence?

Researchers looked at patients with chronic low back pain who received spinal manipulative therapy (SMT) and compared them to patients that received other therapies. They measured pain and back-related functional status. They found that:

  • There were no clinically important differences in pain or back-related functional status between SMT and other therapies such as exercise therapy and drug therapy
  • SMT improved back-related function compared no treatment and wait-list control
  • There were no clinically important differences in pain or back-related functional status between SMT and sham-SMT.
  • Adding SMT to other therapies may improve back-specific functional status
  • There was no difference between mobilization and manipulation for pain or function at 1 month

What kind of study was this?

This was a systematic review. A systematic review summarises all available studies on a health care intervention to provide high quality evidence on the effectiveness of that health care intervention.

Who participated in the study? This review included 47 randomized controlled trials of 9211 adults who had chronic low back pain (pain lasting for more than three months). These trials took place in the USA, Europe, India, Pakistan, and North Africa.

How was the study done? The reviewers included studies that compared spinal manipulation therapy (including mobilization and manipulation) to other known therapies for low back pain, including those that have been recommended in national treatment guidelines, and those that are not recommended.

Spinal manipulation therapy


Other therapies

Spinal manipulation therapy included any hands-on treatment of the spine. This included:

Mobilization: Small passive movements, which may be applied as gentle stretches to individual vertebrae.

Manipulation: Manipulation involves twisting the back to the end of its range and then giving a sudden quick thrust. It is often accompanied with a “click” or “pop” sound.

Treatment was delivered by chiropractors, manual and physical therapists, medical manipulators, orthomanual therapists, osteopaths, or bonesetters.

Other therapies that were considered were those that were recommended in treatment guidelines for low back pain, and those that were not recommended.

Recommended treatments included non-drug (such as exercise) and drug therapies (eg, non-steroidal anti-inflammatories)

Not recommended: No treatment, wait list control, light soft tissue massage, and electrotherapies.

Why was this research done?

Spinal manipulative therapy is widely used around the world to treat low back pain. In some countries it is recommended as a first-line option, in others as a component of a treatment package which may include other therapies such as exercise, and in some countries it is not recommended at all. Recent evidence suggests that spinal manipulative therapy should be considered a second line or additional therapy, after exercise or cognitive behavioural therapy.  

This Evidence Summary is based on the following article:

Rubinstein SM, de Zoete A, van Middelkoop M, et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019 Mar 13;364:l689. doi: 10.1136/bmj.l689. PubMed

Published: Wednesday, May 1, 2019
Last Updated: Wednesday, May 22, 2019