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Journal: Cochrane Database of Systematic Reviews Date: 01/2026, (1):. doi: Subito , type of study: srma

Full text    (https://doi.org//10.1002/14651858.CD008112.pub3)

Keywords:

chronic low back pain [51]
CLBP [3]
SMT [3]
spinal manipulative treatment [1]
Cochrane review [11]
systematic review [427]
meta analysis [75]

Abstract:

Rationale Many therapies exist for the treatment of chronic low back pain (LBP), including spinal manipulative therapy (SMT), which is a worldwide, extensively practised intervention. The effectiveness of SMT for chronic LBP is not without dispute. This Cochrane review is an update of a Cochrane systematic review published in 2011. Objectives To evaluate the benefits and harms of SMT compared to (1) sham SMT/placebo intervention, (2) no treatment, and (3) other conservative interventions in people with chronic LBP (18+ years old). Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, two other databases, and two trial registers up to 18 October 2024, unrestricted by language. We also screened the reference lists of all included studies and relevant systematic reviews, and approached content experts to identify potentially missing studies. Eligibility criteria We included randomised controlled trials (RCTs) that examined the effect of spinal manipulation or mobilisation in adults with chronic LBP compared to sham SMT/placebo, no treatment, and other conservative interventions. We placed no restrictions on the setting. We excluded studies that exclusively examined sciatica. Outcomes Our critical outcomes were pain, functional status, and adverse events. The primary time point was one month for pain and functional status. We evaluated adverse events at the end of the intervention. Risk of bias We assessed bias in the included studies using the original Cochrane risk of bias tool (RoB 1). Synthesis methods Where possible, we synthesised results using meta‐analysis with a generic inverse‐variance approach and random‐effects models; otherwise, we used narrative synthesis. We assessed the certainty of evidence using the GRADE approach. Our main comparisons were SMT versus (1) sham SMT/placebo treatment, (2) no treatment, and (3) other conservative interventions at one month. We converted all pain scales to a 100‐point scale. Included studies Seventy‐six RCTs (11,866 participants) met our inclusion criteria, 50 (66%) of which were not included in the previous version of this review. Seventeen trials (2021 participants) compared SMT to sham SMT/placebo, and four trials (435 participants) compared SMT to no treatment. Most trials (43, including 8291 participants) examined the effect of SMT compared to other conservative interventions. The remaining trials examined other comparisons. Treatment allocation was appropriately conducted in just four sham SMT/placebo‐controlled trials (24%), while only six trials 'blinded' participants to the intervention (35%), indicating a high risk of selection and performance bias. Similarly, the no‐treatment controlled trials were as susceptible to selection bias (50%) and performance bias (75%). All trials were conducted in high‐income (n = 53) or middle‐income (n = 23) countries. In most studies, the population was middle‐aged and included men and women. Synthesis of results SMT versus sham SMT/placebo We found very low‐certainty evidence (downgraded for inconsistency and study limitations) that SMT may result in a small reduction in pain compared to sham SMT/placebo at one month (mean difference (MD) ‐7.01, 95% confidence interval (CI) ‐12.48 to ‐1.53; I 2 = 94%; 16 studies, 1570 participants) and very low‐certainty evidence (downgraded for study limitations and inconsistency) that SMT may result in a medium improvement in functional status compared to sham SMT/placebo at one month (standardised mean difference (SMD) ‐0.41, 95% CI ‐0.69 to ‐0.13; I 2 = 82%; 13 studies, 1416 participants), but the evidence is very uncertain. SMT versus no treatment We found very low‐certainty evidence (downgraded for study limitations, inconsistency, and imprecision) that SMT may result in a medium reduction in pain compared to no treatment at one month (MD ‐13.99, 95% CI ‐27.33 to ‐0.66; I 2 = 89%; 4 studies, 325 participants), but the evidence is very uncertain. We found low‐certainty evidence (downgraded for study limitations and imprecision) that SMT may result in a large improvement in functional status compared to no treatment at one month (SMD ‐0.84, 95% CI ‐1.32 to ‐0.35; I 2 = 71%; 4 studies, 312 participants). SMT versus other conservative interventions Low‐certainty evidence (downgraded for inconsistency) indicated that SMT may result in little to no difference in pain (MD ‐4.72, 95% CI ‐8.26 to ‐1.17; I 2 = 89%; 31 studies, 4109 participants) and may result in a small improvement in functional status (SMD ‐0.25, 95% CI ‐0.38 to ‐0.11; I 2 = 73%; 28 studies, 3940 participants) compared to other conservative interventions at one month. These effects, however, should be interpreted with caution due to the substantial statistical heterogeneity for which there is no clear explanation. Less than half of the studies (47%) reported on adverse events, of which 12 studies reported these systematically. Adverse events in the SMT group were limited to muscle soreness, stiffness, and/or transient increase in pain. None of the studies registered any serious complications related to either the experimental or control group treatment. The evidence is very uncertain about the adverse effects of SMT. Authors' conclusions When SMT is compared to sham SMT/placebo, it may result in a small improvement in pain and medium improvement in functional status in adults with chronic low back pain. When compared to no treatment, SMT may result in a medium improvement in pain and a large improvement in functional status. When compared to other conservative interventions, SMT may result in little to no difference in pain and a small improvement in functional status. The evidence is of low to very low certainty, largely due to the fact that the effects of SMT were examined in trials conducted in different settings and populations, with different types of SMT technique, dosage, and frequency of treatment. Continuing to conduct RCTs in the same manner will neither strengthen the evidence nor our confidence in it. Funding This Cochrane review had no dedicated funding, only 'in‐kind' support from the Department of General Practice, Erasmus Medical Center, Rotterdam, Netherlands, and the Department of Health Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Science Research Institute, Netherlands. Registration Protocol (2009): DOI: 10.1002/14651858.CD008112 Original review (2011): DOI: 10.1002/14651858.CD000447.pub2 Plain language summary What are the benefits and risks of spinal manipulative therapy for chronic low back pain? Key messages Spinal manipulative therapy (SMT – a hands‐on treatment where a therapist moves joints in the spine) may slightly reduce pain and moderately improve function compared to 'sham' (fake) SMT. SMT may moderately reduce pain and may substantially improve function compared to no treatment. Less than half of studies reported on adverse (unwanted or harmful) effects. While adverse effects, including muscle soreness and a temporary increase in low back pain, were common, no serious adverse effects related to SMT were observed. What is non‐specific chronic low back pain? Low back pain is a common and disabling disorder, representing a great burden to society. It often results in reduced quality of life, time lost from work, and substantial medical expenses. Chronic low back pain is defined here as pain lasting longer than 12 weeks. We focused on people with pain predominantly located in the lower back and those with pain radiating into the buttocks and legs. How is chronic low back pain treated? Spinal manipulative therapy (SMT) is a common treatment for chronic low back pain and is practised worldwide by healthcare professionals, including chiropractors, manual therapists, and osteopaths. SMT is a 'hands‐on' treatment of the spine, including both manipulation and mobilisation to reduce pain, improve function, and help people return to usual activities. SMT may include gentle movements and stretching (known as mobilisation), or quick, controlled pushes often accompanied by an audible ‘pop’ (known as manipulation) to help improve someone's range of motion and reduce their pain. What did we find out? We wanted to find out if SMT improved pain and function, or caused harm, in people with chronic low back pain. We did not include people with low back pain caused by a specific condition, such as infection, tumour, or fracture. What did we do? We searched for studies that compared SMT to: fake or 'sham' SMT; no treatment; other 'conservative' treatment, meaning simple, non‐surgical care, such as exercise. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes. This is an update of a review, last published in 2011. What did we find? In this updated review, we identified 76 studies involving 11,866 people (published from 1978 to 2024) assessing the effects of SMT in people with chronic low back pain. The participants were a mix of women and men, and most were middle‐aged. Most studies took place in high‐income countries (53 studies, e.g. USA and UK), while 23 studies took place in middle‐income countries (e.g. Brazil, India). None were in low‐income countries. Main results: benefits A difference of 10 points on a 100‐point scale is considered meaningful for patients—it can reflect a noticeable improvement in symptoms. Comparison between SMT and sham SMT Pain People receiving SMT rated their pain on average 7.0 points better on a 0 to 100 scale one month after the start of SMT compared with those who had sham SMT. Function People receiving SMT rated their function on average 8.8 points better on a 0 to 100 scale one month after the start of SMT compared with people who had sham SMT. Comparison between SMT and no treatment Pain People receiving SMT rated their pain on average 14 points better on a 0 to 100 scale one month after the start of SMT compared with people who had no treatment. Function People receiving SMT rated their function on average 12.9 points better on a 0 to 100 scale one month after the start of SMT compared with people who had no treatment. Comparison between SMT and other conservative treatment Pain People receiving SMT rated their pain on average 4.7 points better on a 0 to 100 scale one month after the start of SMT compared with people who had another conservative treatment. Function People receiving SMT rated their function on average 4.9 points better on a 0 to 100 scale one month after the start of SMT compared with people who had another conservative treatment. Main results: harms Only a few studies reported on the adverse effects (i.e. unwanted or harmful effects) of SMT. These included muscle soreness and a temporary increase in low back pain. No serious adverse effects related to SMT were observed. What are the limitations of the evidence? We have little confidence in the evidence because the studies used a variety of SMT techniques, tested them in varied amounts, and the reported results greatly varied. Several studies included few participants, and some studies were poorly conducted. Therefore, the effects of SMT may be overestimated. How current is this review? The review is current to 18 October 2024.

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