More Research Needed—Especially on Cost-Effectiveness

Newswise — Philadelphia, Pa. (June 22, 2011) – Spinal manipulative therapy (SMT) has significant but very small benefits for patients with chronic low back pain, according to a special review article in the June 1 issue of Spine. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

"High-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with low back pain," concludes the report. The lead author was Sidney M. Rubinstein of VU University Medical Center, Amsterdam.

Updated Review Assembles Data from 26 Clinical TrialsThe researchers performed a comprehensive review of the medical research literature to identify randomized controlled trials—the most reliable type of scientific study—of SMT for adult patients with chronic low back pain. In all studies, patients were randomly assigned to SMT or some other comparison treatment: either an active treatment such as exercise or physical therapy or an inactive placebo treatment.

The studies could include any type of "hands-on" spinal treatment. In the studies, SMT was most commonly delivered by chiropractors or physical therapists, although many different types of professionals were involved.

The review identified 26 randomized trials including more than 6,000 patients. About two-thirds of the studies were not been included in a previous review published in 2004. The studies varied in quality—only 9 of the 26 trials were considered at "low risk of bias."

Taken together, the studies provided high-quality evidence that SMT has a statistically significant short-term effect in reducing pain and improving function in patients with chronic low back pain. There was also evidence of "varying quality" that SMT has a short-term effect when added to other treatments.

Though 'Significant,' Benefits of SMT Are SmallHowever, the positive effects of SMT were very small and not likely to be "clinically relevant," Dr. Rubinstein and coauthors note. For example, the average reduction in pain scores in patients treated with SMT was only about 4 points on a 100-point scale. The benefits seemed to decrease over time, and were no longer significant after one year.

Overall, there was no strong evidence that SMT was more effective than inactive or placebo treatments. Very few studies looked at how SMT affected recovery from chronic low back pain, the ability to return to work, the quality of life, or the cost of medical care. There were no serious complications of SMT.

Low back pain is a very common and disabling disorder that carries not only high direct medical costs but also high indirect costs such as missed work time. Spinal manipulation is widely used in the treatment of back pain. However, the research evidence to support its effectiveness is inconclusive, leading to conflicting recommendations.

Based on the updated review, SMT provides "statistically significant" improvement for patients with chronic low back pain. However, questions remain as to whether the improvement is clinically relevant, and even whether SMT is more effective than inactive comparison treatments. On balance, Dr. Rubinstein and colleagues conclude, "[T]here is evidence that SMT is neither superior nor inferior to other effective treatments for patients with chronic low-back pain."

More and higher-quality studies of SMT for low back pain are needed—especially for long-term outcomes such as return to work. There is also a "dire need" for cost-effectiveness studies, the researchers write. In the meantime, they conclude, "The decision to refer for SMT should be based on costs, preferences of the patient and providers, and relative safety of the treatment options."

# # #About SpineRecognized internationally as the leading journal in its field, Spine ( is an international, peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of spine. It is the leading subspecialty journal for the treatment of spinal disorders. Only original papers are considered for publication with the understanding that they are contributed solely to Spine. According to the latest ISI Science Citation Impact Factor, Spine ranks highest among general orthopaedic journals and subspecialty titles.

About Lippincott Williams & Wilkins Lippincott Williams & Wilkins (LWW) is a leading international publisher for healthcare professionals and students with nearly 300 periodicals and 1,500 books in more than 100 disciplines publishing under the LWW brand, as well as content-based sites and online corporate and customer services.

LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2010 annual revenues of €3.6 billion ($4.7 billion).

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