Many systematic reviews have summarized the evidence on spinal manipulative therapy (SMT) for low back pain (LBP) in adults. Much less is known about the older population regarding the effects of SMT. This paper assessed the effects of SMT on pain and function in older adults with chronic LBP in an individual participant data (IPD) meta-analysis.

Electronic databases were searched from 2000 until June 2020; reference lists of eligible trials and related reviews were also searched. Randomized controlled trials (RCTs) were considered if they examined the effects of SMT in adults with chronic LBP compared to interventions recommended in international LBP guidelines. The authors of trials eligible for the IPD meta-analysis were contacted and invited to share data. Two review authors conducted a risk of bias assessment. Primary results were examined in a one-stage mixed model, and a two-stage analysis was conducted in order to confirm the findings. The main outcomes and measures were pain and functional status examined at 4, 13, 26, and 52 weeks.

A total of 10 studies were retrieved, including 786 individuals; 261 were between 65 and 91 years of age. There was moderate-quality evidence that SMT results in similar outcomes at 4 weeks (pain: mean difference [MD] – 2.56, 95% confidence interval [CI] – 5.78 to 0.66; functional status: standardized mean difference [SMD] – 0.18, 95% CI – 0.41 to 0.05). Second-stage and sensitivity analysis confirmed these findings.

The authors concluded that SMT provides similar outcomes to recommended interventions for pain and functional status in the older adult with chronic LBP. SMT should be considered a treatment for this patient population.

This is a fine analysis. Unfortunately, its results are less than fine. Its results confirm what I have been saying ad nauseam: we do not currently have a truly effective therapy for back pain, and most options are as good or as bad as the rest. This is most frustrating for everyone concerned, but it is certainly no reason to promote SMT as usually done by chiropractors or osteopaths.

The only logical solution, in my view, is to use those options that:

  • are associated with the least risks,
  • are the least expensive,
  • are widely available.

However you twist and turn the existing evidence, the application of these criteria does not come up with chiropractic or osteopathy as an optimal solution. The best treatment is therapeutic exercise initially taught by a physiotherapist and subsequently performed as a long-term self-treatment by the patient at home.


7 Responses to Spinal manipulative therapy for older adults with chronic low back pain fails to generate convincing results

  • Best treatment? Hopefully we can do better.

    “Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD ‐9.1, 95% CI ‐12.6 to ‐5.6) and functional limitations outcomes (MD ‐4.1, 95% CI ‐6.0 to ‐2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD ‐12.2, 95% CI ‐19.4 to ‐5.0) or non‐exercise physical therapy (MD ‐10.4, 95% CI ‐15.2 to ‐5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI ‐3.1 to 5.1).”

    Regarding this:

    “…therapeutic exercise initially taught by a physiotherapist.”

    Many trace the profession back to the gymnast Per Henrik Ling who around 1813 recommended massage, manipulation and exercise. However the term Physiotherapie didn’t appear until 1851. It was during the First World War that the profession started to take form which is about the same time the chiropractic profession started to teach and incorporate physiotherapeutic approaches into the care of back pain patients.

    • why not show the full conclusion of this paper?

      We found moderate‐certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low‐certainty evidence) and functional limitations outcomes (moderate‐certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

      • I was after the most relevant part: “These effects did not meet our prespecified threshold for clinically important difference.”

        • so, you decide what is ‘most relevant’? interesting!

          • Yes, when looking at a MA one wants to see if clinically important differences were found…that is the most relevant part, at least to me. Others, well, they can determine what is the most relevant finding of a MA.

  • Your point about choosing the therapy associated with least risks is an important one. The paper authors note “Adverse events were often not reported by trial authors, and when reported there was no uniformity in how this was done, particularly for older patients”. In my view it is a mistake for the authors to suggest that “SMT should be considered a treatment option in this patient population” when the level of risk from SMT has not been adequately assessed. When deciding which treatments to offer, it’s risk / benefit analysis that matters (as well as cost of course) and I don’t think it makes sense to recommend a therapy for which only the benefit has been assessed.

    • From their reference:

      “Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT.”

      A comparative study of walking vs usual care (not specific to the elderly) found:

      “A total of 600 adverse events were reported, 250 by those in usual care and nearly 350 by those in the intervention. After worsening back pain (27%), musculoskeletal events were the most commonly reported events (19%), followed by cardiovascular events (14%), infection (11%), and medical procedures (9%). There were three times as many musculoskeletal events in the intervention compared to the usual care group.”

      Of course adherence can be an issue as well:

      “The most frequently stated reasons for nonadherence was that exercise did not help or aggravated pain (33%).”

      Of course the consensus is moving away from such unimodal approaches:

      “Consistent with this sentiment, there was 100% consensus with the statement, “Multidisciplinary and multimodal approaches represent the strategy to solve the problem of non-responsive pain” (S10).”

      As I first stated: we have more work to do to understand the complexities of chronic low back pain in the elderly and the best approaches to address it.

      For example:

      “Brain age was associated with lower gray matter density in numerous brain regions. CLBP was associated with greater BA, which was more profound in later life.”

      And some are questioning some of the pharmaceutical approaches in treating acute back pain which some think may contribute to developing chronic back pain.

      “Analysis of pain trajectories of human subjects reporting acute back pain in the UK Biobank identified elevated risk of pain persistence for subjects taking NSAIDs. Thus, despite analgesic efficacy at early time points, the management of acute inflammation may be counterproductive for long-term outcomes of LBP sufferers.”

      How that may affect conservative outcomes is unknown.

      Have a nice day.

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