spinal manipulative therapy

Lower back pain is a condition that affects a large proportion of individuals and for which treatments, such as spinal manipulative therapy (SMT), have a debatable efficacy. To clarify the effectiveness of SMT, a group of investigators performed a systematic literature review and show that SMT modestly improves pain and function while adverse effects of this therapy remain unclear.


Lower back pain is a condition that affects roughly half of the population at some point in their life. Although it does not have any life-threatening consequences, it seriously impairs the quality of life of many people and has serious economic implications in part due to absenteeism in the workplace.

Current treatments for this condition include analgesics, muscle relaxant, exercises, physical therapy modalities, heat and spinal manipulative theory (SMT) among others. For many reasons, the efficacy of this latter treatment is still debated in the scientific literature. Indeed, despite the extensive number of studies trying to address this question, the results are conflicting and largely inconclusive.

To clarify the situation, a group of Californian practitioners led by Dr. Paul Shekelle performed a systematic manual curation and review of the literature to draw an accurate conclusion about this question in a recent publication in JAMA1. To do so, they searched four biomedical databases and after manually filtering out studies deemed irrelevant, assessed 49 of them. These reviews served as resources to draw a more exhaustive list of experimental reports addressing SMT. After further exclusion criteria were applied, they retained 26 reports that investigated the effectiveness of SMT and 8 that investigated the adverse effects of the therapy. Importantly, the authors were only interested in studies that studied the short-term impacts of SMT on back pain, defined as the first 6 weeks following treatment start.

Overall, the authors observed a modest, yet statistically significant, effect of SMT on pain relief as well as on the functional status of the individuals. Pain relief was improved to a similar extent as administration of standard analgesic drugs. This conclusion applied to almost all studies retained in the final analysis, although a very high degree of heterogeneity in the results was observed. Regarding the adverse effects, the conclusion is less clear. Indeed, while up to 50-67% of patients consistently reported suffering from transient pain after treatment, a report investigating adverse effects associated with many other forms of manual therapy, including SMT, found no difference of this parameter compared with other related therapies. In summary, this systematic literature review suggests that SMT is associated with only modest beneficial outcomes for patients suffering from lower back pain. However, owing to the criteria applied in their final choice of studies, their conclusions do not necessarily hold true over longer periods of SMT treatment. Finally, further analysis appears necessary to determine which parameters account for the high level of heterogeneity observed in the results reported.


Written By: Samuel Rochette M.Sc

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