SMT for acute low-back pain – what the evidence say

Shawn Thistle
August 16, 2017
Written by
A number of systematic reviews have been performed on spinal manipulative therapy (SMT), although their findings have been conflicting.

Study title: Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain: systematic review and meta-analysis
Authors: Paige N, Miake-Lye I, Booth M et al.
Publication information: JAMA 2017; 317(14): 1451-1460. doi:10.1001/jama.2017.3086

A number of systematic reviews have been performed on spinal manipulative therapy (SMT), although their findings have been conflicting. This review was initiated to address the divergent conclusions among studies and to include new trials that have been published since the previous reviews. The objectives were to provide updated estimates of the effectiveness and harms associated with SMT compared with other nonmanipulative therapies for adults with acute low back pain.

Forty articles were identified that were relevant to effectiveness, with eight additional articles relevant to adverse events. Twenty-six RCTs were included in the final data synthesis.

Summary of evidence
Physical therapists provided the SMT in 13 of the studies, chiropractors in seven studies, medical doctors in five studies, and osteopathic physicians in three studies. Twelve studies were categorized as high quality and 14 were classified as low quality. None of the studies met the criterion for blinding of providers and only four of them met the criterion for blinding of patients.

Short-term pain outcomes (from three to six weeks) demonstrated a mean reduction of −9.95mm on the 100mm visual analogue scale, favoring treatment with SMT compared with other treatments.

For immediate-term pain outcomes (at two weeks or less), the overall random-effects pooled estimate was a reduction of −9.76mm compared with other treatments.

The overall random-effects pooled estimate for short-term function was an effect size of −0.39 favouring treatment with SMT. For immediate-term function, the overall random-effects pooled estimate was an effect size of −0.24 favoring treatment with SMT.

When considering three studies independent from the others, pooling their data resulted in much larger effect sizes for short-term function that was more than three times greater than the average for other SMT studies. Interestingly, these three studies used a clinical prediction rule to identify patients that would most likely benefit from SMT.

Harms associated with SMT

Only five publications reported on specific harms, although none of them were thought to be related to the treatment. There were, however, complaints that “the treatment hurts” which was statistically more common among patients receiving SMT as compared with those receiving medical care. Of the 26 RCTs included in the pooled analyses, harms were not described in 18 publications and only nonspecific comments about harms were offered in three publications.

In studies that prospectively assessed harms, mild, transient harms were reported by 50 per cent to 67 per cent of patients, most commonly reported as local discomfort or increased pain.

No serious harms were reported.

Application, conclusions
For acute low back pain, SMT produced statistically significant advantages for both pain and function at follow-up to six weeks.

The benefit for acute low back pain was similar to the amount of benefit associated with nonsteroidal anti-inflammatory drugs (NSAIDs).

The effect size for the improvement of function is roughly equivalent to an improvement in the RMDQ score of between 1 and 2.5 points.

The authors considered the reported amount of improvement in pain and function to be clinically modest.

The quality of evidence was judged to be moderate. The quality of evidence that SMT is commonly associated with transient minor musculoskeletal harms was judged to be high. Nevertheless, similar harms are also common following manual therapy that does not involve SMT.

A separate editorial by Dr. Richard Deyo, a distinguished low-back pain researcher, was published in the same issue of JAMA. Deyo reported there are approximately 200 treatment options available to treat low-back pain, though no single treatment is clearly superior. This systematic review by Paige and colleagues showed that manipulation is at least as effective and as safe as conventional care for patients with uncomplicated acute low back pain.


Dr. SHAWN THISTLE is the founder and CEO of RRS Education, providing weekly research reviews, online courses and seminars to help busy clinicians integrate current research evidence rationally into practice. For more information, visit: www.rrseducation.com. Shawn can be reached by email at
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