This systematic review assessed the effect of spinal manipulative therapy (SMT), the hallmark therapy of chiropractors, on pain and function for chronic low back pain (LBP) using individual participant data (IPD) meta-analyses.

Of the 42 RCTs fulfilling the inclusion criteria, the authors obtained IPD from 21 (n=4223). Most trials (s=12, n=2249) compared SMT to recommended interventions. The analyses showed moderate-quality evidence that SMT vs recommended interventions resulted in similar outcomes on

  • pain (MD -3.0, 95%CI: -6.9 to 0.9, 10 trials, 1922 participants)
  • and functional status at one month (SMD: -0.2, 95% CI -0.4 to 0.0, 10 trials, 1939 participants).

Effects at other follow-up measurements were similar. Results for other comparisons (SMT vs non-recommended interventions; SMT as adjuvant therapy; mobilization vs manipulation) showed similar findings. SMT vs sham SMT analysis was not performed, because data from only one study were available. Sensitivity analyses confirmed these findings.

The authors concluded that sufficient evidence suggest that SMT provides similar outcomes to recommended interventions, for pain relief and improvement of functional status. SMT would appear to be a good option for the treatment of chronic LBP.

In 2019, this team of authors published a conventional meta-analysis of almost the same data. At this stage, they concluded as follows: SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.

Why was the warning about risks dropped in the new paper?

I have no idea.

But the risks are crucial here. If we are told that SMT is as good or as bad as recommended therapies, such as exercise, responsible clinicians need to decide which treatment they should recommend to their patients. If effectiveness is equal, other criteria come into play:

  • cost,
  • risk,
  • availability.

Can any reasonable person seriously assume that SMT would do better than exercise when accounting for costs and risks?

I very much doubt it!

27 Responses to Spinal manipulation therapy is as good (or bad) for chronic back pain as other options … and should therefore NOT be recommended

  • “ Studies of spinal manipulation (i.e. high-velocity low-amplitude techniques) as well as mobilization (i.e. low-velocity low-amplitude techniques) were included.”

  • Interesting, considering the potential risk of some of the medications given for this condition.

    “There is moderate quality evidence that SMT results in a medium reduction in medication use compared to recommended interventions at two of the four time points (largest difference at six months.”

  • @ DC

    Re the American College of Physicians’ recommendation for spinal manipulation, it’s highly dubious:

    “That guideline contains that great mystery of all the guidelines: how they can make strong recommendations based on low-quality evidence? Got me. It is the alchemy of guidelines, turning digested straw into spun gold. Here is the text. The effect of spinal manipulation is unimpressive:

    ‘Low-quality evidence showed that spinal manipulation was associated with a small effect on function compared with sham manipulation; evidence was insufficient to determine the effect on pain. Low-quality evidence showed no difference in pain relief at 1 week between spinal manipulation and inert treatment (educational booklet, detuned ultrasound, detuned or actual short-wave diathermy, antiedema gel, or bed rest), although 1 trial showed better longer-term pain relief (3 months) with spinal manipulation. Function did not differ between spinal manipulation and inert treatment at 1 week or 3 months. Moderate-quality evidence showed no difference between spinal manipulation and other active interventions for pain relief at 1 week through 1 year or function (analyses included exercise, physical therapy, or back school as the comparator). Low-quality evidence showed that a combination of spinal manipulation plus exercise or advice slightly improved function at 1 week compared with exercise or advice alone, but these differences were not present at 1 or 3 months.’

    Anyone impressed? Not me. It is the usual pseudo-medical analysis, a hodgepodge of weak studies show marginal aka placebo effect.”

    Continues here:

    • Their goal is not to impress you. Their goal is to look at the evidence available and determine what may be the better options for an initial approach to help those with me CLBP.

      The shift is to avoid some “strong” pharmaceuticals, if possible, as they tend to carry a higher risk of moderate to severe adverse effects, with little to no clinical advantage over other approaches.

      There are current guidelines, based upon their review of the research, which state that SMT is an option if combined with certain active approaches.

      If you don’t agree, write and publish your own clinical guidelines for nsCLBP. Good luck.

      (Psst: these guidelines are often written by MDs, PhDs and/or PTs)

      “Out of these therapies, only two are recommended, and only when implemented as adjunctive therapy: pain neuroscience education and spinal manipulative therapy. All other inactive interventions (i.e., therapeutic ultrasound, kinesiotape, transcutaneous electrical nerve stimulation, massage and osteopathic interventions) are not recommended for CLBP management based on available evidence.“

      “While physically inactive treatments (like manual therapy) appear to have potentially positive effects, they should not be used as sole treatment but rather in a multimodal approach focusing mainly on activating the patient.”

      J. Clin. Med. 2019, 8, 1063; doi:10.3390/jcm807106

  • DC wrote: “If you don’t agree, write and publish your own clinical guidelines for nsCLBP.”

    I certainly wouldn’t include SMT performed by chiropractic/chiropractors in any guidelines due to the chiropractic ‘bait and switch’ still being so rife…

    It’ll be interesting to see if the UK’s NICE includes SMT in its next guidelines for low back pain…

    …bearing in mind this and that the robust scientific data for spinal manipulation are increasingly showing it to be pretty valueless.

  • BW: I certainly wouldn’t include SMT performed by chiropractic/chiropractors

    Well, that switches the topic from a procedure to a profession. How about we stick with the topic.

    BW: It’ll be interesting to see if the UK’s NICE includes SMT in its next guidelines for low back pain…

    Time will tell

    BW, from the article: Manual therapy and psychological therapy are optional add-ons but exercise is compulsory.

    Pretty much what I initially wrote: Current evidence suggests trying a multimodal approach to chronic nonspecific low back pain with exercise being the baseline. Spinal manipulation is one additional option to consider.


  • DC wrote: “Spinal manipulation is one additional option to consider”

    But beware chiropractors being involved for reasons already given, i.e.

    Whilst not forgetting…

    The writing seems to be on the wall, IMO.

    • as I tell people…choose your chiropractor wisely.

      • DC wrote: “as I tell people…choose your chiropractor wisely”

        @ DC

        I’m sure you are a drop in the ocean with that advice. Besides, if the chiropractic regulators did their job properly, chiropractic customers wouldn’t have to ‘choose wisely’ in the first place. Currently, this is what most of them *unwittingly* face:


        “Chiropractic is perhaps the most common and egregious example of the bait and switch in medicine. The deception begins with the name itself – ‘chiropractic’ fails the basic test of transparency because it is not unambiguously defined…someone may go to see a chiropractor and think they will be seeing a medical professional who will treat their musculoskeletal symptoms, but in reality they will see the practitioner of a cult philosophy of energy healing. So-called ‘straight’ chiropractors (who make up an estimated 30% of all chiropractors) still adhere to the original philosophy of chiropractic invented by ‘magnetic healer’ D.D. Palmer, which is based upon the claim that an undetected life energy called ‘Innate Intelligence’ flows through the spinal cord and nerves and is responsible for health. Such chiropractors will treat any disease or ailment with spinal manipulation. Most other so called ‘mixer’ chiropractors reject the notion of Innate Intelligence either partially or entirely, but still incorporate other pseudosciences into their practice.”


        It makes you wonder why guidelines don’t specifically warn against using chiropractors in a multimodal approach.

        • BW… It makes you wonder why guidelines don’t specifically warn against using chiropractors in a multimodal approach.

          Because that’s not the purpose or responsibility of those formulating clinical guidelines.

          • DC wrote: “Current evidence suggests trying a multimodal approach to chronic nonspecific low back pain with exercise being the baseline. Spinal manipulation is one additional option to consider.”

            @ DC

            Given the ongoing, serious problems with chiropractic – especially with regard to the chiropractic ‘bait and switch’ – do you agree that using chiropractors in a multimodal approach is essentially a ‘lucky dip’ for patients?

            If no, why? If yes, what can be done about it?

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Subscribe via email

Enter your email address to receive notifications of new blog posts by email.

Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted but you must tick the box: “Save my name, email, and website in this browser for the next time I comment.”

The most recent comments from all posts can be seen here.