SMT Associated with Modest Improvements in Pain and Function

A new systematic review and meta-analysis has found among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function and with transient minor musculoskeletal harms. The results were published online, April 11 in JAMA.

Low back pain (LBP) is a leading cause of disability, with acute LBP contributing to this burden. Chiropractors and other professions use SMT amongst other modalities to help manage acute LBP.1

The recent systematic review and meta-analysis by Paige et al. investigated the effectiveness of spinal manipulative therapy (SMT) for acute low back pain (aLBP) without sciatica compared to sham or alternative treatments.2 An editorial by Professor Richard Deyo was published alongside the review.3 The intervention was delivered by physical therapists (13 studies), chiropractors (7 studies), medical doctors (5 studies) or osteopaths (3 studies). Studies were assessed for risk of bias using the Chochrane Back and Neck Risk of Bias tool4 and evidence assessed using GRADE criteria.5

Twenty-six eligible studies were included of which 15 studies provided moderate-quality evidence that SMT provided moderate improvement in pain, and 12 studies provided a similar level of improvement in disability. 

Transient minor musculoskeletal harms were reported by approximately half the patients with no serious adverse events reported as a result of SMT, which is not the case for some other therapies commonly prescribed for aLBP. For example, nonsteroidal anti-inflammatory drugs and opioids can have higher risk profiles for impaired renal function and gastric erosions, or risk of dependency and addiction respectively.3

These results are consistent with the recently published ACP clinical guidelines for non-invasive treatments for acute low back pain, which recommends spinal manipulation (low-quality evidence, small effect).6 The reported treatment effects are similar in magnitude to nonsteroidal anti-inflammatory drugs.

Reported limitations include the wide variation in results that was not explained by the study data, and 14 of the 26 studies were classified as low quality. 

Interpretation for the chiropractic clinician

For patients seeking care for acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. 

Chiropractors must always discuss with the patient the reported benefit vs. risk of spinal manipulative therapy for their acute episode, with this study and other recently published guidelines representing a positive message to consider spinal manipulation as a therapy option. Any intervention must be delivered with the clinician cognisant of the natural history for acute low back pain which we know is favourable for the majority of patients by 12 weeks.7,8

Importantly, after the acute episode has passed, chiropractors should discourage continued passive therapy which is not supported by the evidence, but instead encourage exercise, preventative strategies and resilience, which are.

Aron Downie 
BSc MChiro MPhil (PhD cand.)



  1.  Kassebaum NJ, Arora M, Barber RM, Bhutta ZA, Brown J, Carter A, et al. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet.388(10053):1603-58.
  2.  Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS, Dougherty P, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-60.
  3.  Deyo R. The Role of Spinal Manipulation in the Treatment of Low Back Pain (Editorial). JAMA. 2017;317(14):1418.
  4.  Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ (Clinical research ed). 2011;343:d5928-d.
  5.  GRADE working group. Accessed April 13, 2017. Available from:
  6.  Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of P. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017.
  7.  Vasseljen O, Woodhouse A, Bjørngaard JH, Leivseth L. Natural course of acute neck and low back pain in the general population: the HUNT study. Pain. 2013;154(8):1237-44.
  8.  Downie AS, Hancock MJ, Rzewuska M, Williams CM, Lin CW, Maher CG. Trajectories of acute low back pain: a latent class growth analysis. Pain. 2016;157(1):225-34.