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In adults with acute low back pain, spinal manipulation improves pain and function by a small amount in the short term

Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017;317:1451-60.

Review questions

In adults with acute low back pain (pain lasting for 6 weeks or less), does spinal manipulative therapy (spinal manipulation) reduce pain or improve functioning more than other therapies? What are the harms?


Most people will have low back pain at some point in their lives. Anyone can get low back pain although it is more common as you get older. The cause of low back pain is often unknown.

There are many treatments for acute low back pain. These include pain-relieving and muscle-relaxing drugs, heat, exercise, physical therapy, and spinal manipulation. Spinal manipulation involves hands-on therapies, including chiropractic therapy. This review assessed how well spinal manipulation works compared with other therapies.

How the review was done

The researchers did a systematic review of studies available up to February 2017.

They found 26 randomized controlled trials with 2,908 people who had an average age of 26 to 44 years.

The key features of the studies were:

  • people were adults with low back pain lasting for 6 weeks or less;
  • treatment was spinal manipulation alone or with other therapies, including chiropractic care;
  • spinal manipulation was done by physical therapists, chiropractors, medical doctors, or osteopaths;
  • spinal manipulation was compared with different therapies (mainly pain-relieving drugs, exercise, physical therapy, or usual care) or sham therapy (placebo); and
  • people were followed for up to 6 weeks.

Studies done only in people with sciatica or those in hospital were excluded.

What the researchers found

Compared with another therapy, spinal manipulation:

  • improved pain by a small amount for up to 6 weeks; and
  • improved function by a small amount at 3 to 6 weeks.

The effects of spinal manipulation were quite different (heterogeneous) across trials.

Few trials compared spinal manipulation with sham therapy.

There wasn’t much information reported about the adverse effects of spinal manipulation compared with other therapies.



In adults with acute low back pain, spinal manipulative therapy improves pain and functioning by a small amount in the short term.

Spinal manipulative therapy (SMT) vs another therapy in adults with acute low back pain


Follow-up period

Number of trials (number of people)

Absolute effects of SMT


2 weeks or less

9 trials (663 people)*

On average, SMT reduced pain scores by about 10 points out of 100, although results varied  across the trials*.


3 to 6 weeks

10 trials (1142 people)

On average, SMT reduced pain scores by about 10 points out of 100, although results varied across trials.


2 weeks or less

7 trials (491 people)*

No difference between SMT and other therapies.


3 to 6 weeks

6 trials (762 people)

On average, SMT improved functioning by a small amount, although results varied across trials.

*Additional information was obtained from a more detailed report of this trial: Shekelle PG, Paige NM, Miake-Lye IM, et al. The effectiveness and harms of spinal manipulative therapy for the treatment of acute neck and lower back pain: A systematic review. Washington, DC: US Department of Veterans Affairs: 2017 Apr.

Related Topics


A harmless, inactive, and simulated treatment.
Randomized controlled trials
Studies where people are assigned to one of the treatments purely by chance.
Systematic review
A comprehensive evaluation of the available research evidence on a particular topic.

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