Spinal manipulative therapy for chronic low-back pain
Editorial Group: Cochrane Back Group
Published Online: 16 FEB 2011
Assessed as up-to-date: 5 DEC 2009
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD008112. DOI: 10.1002/14651858.CD008112.pub2.
- Publication Status: Edited (no change to conclusions)
- Published Online: 16 FEB 2011
Many therapies exist for the treatment of low-back pain including spinal manipulative therapy (SMT), which is a worldwide, extensively practiced intervention.
To assess the effects of SMT for chronic low-back pain.
An updated search was conducted by an experienced librarian to June 2009 for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2009, issue 2), MEDLINE, EMBASE, CINAHL, PEDro, and the Index to Chiropractic Literature.
RCTs which examined the effectiveness of spinal manipulation or mobilisation in adults with chronic low-back pain were included. No restrictions were placed on the setting or type of pain; studies which exclusively examined sciatica were excluded. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life.
Data collection and analysis
Two review authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the quality of the evidence. Sensitivity analyses and investigation of heterogeneity were performed, where possible, for the meta-analyses.
We included 26 RCTs (total participants = 6070), nine of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. In general, there is high quality evidence that SMT has a small, statistically significant but not clinically relevant, short-term effect on pain relief (MD: -4.16, 95% CI -6.97 to -1.36) and functional status (SMD: -0.22, 95% CI -0.36 to -0.07) compared to other interventions. Sensitivity analyses confirmed the robustness of these findings. There is varying quality of evidence (ranging from low to high) that SMT has a statistically significant short-term effect on pain relief and functional status when added to another intervention. There is very low quality evidence that SMT is not statistically significantly more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.
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 chronic low-back pain. Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT, and data related to recovery.
Plain language summary
Spinal manipulative therapy for chronic low-back pain
Spinal manipulative therapy (SMT) is an intervention that is widely practiced by a variety of health care professionals worldwide. The effectiveness of this form of therapy for the management of chronic low-back pain has come under dispute.
Low-back pain is a common and disabling disorder, which represents a great burden to the individual and society. It often results in reduced quality of life, time lost from work and substantial medical expense. In this review, chronic low-back pain is defined as low-back pain lasting longer than 12 weeks. For this review, we only included cases of low-back pain that were not caused by known underlying conditions, for example, infection, tumour, or fracture. We also included patients whose pain was predominantly in the lower back, but may also have radiated (spread) into the buttocks and legs.
SMT is known as a "hands-on" treatment of the spine, which includes both manipulation and mobilisation. In manual mobilisations, the therapist moves the patient’s spine within their range of motion. They use slow, passive movements, starting with a small range and gradually increasing to a larger range of motion. Manipulation is a passive technique where the therapist applies a specifically directed manual impulse, or thrust, to a joint, at or near the end of the passive (or physiological) range of motion. This is often accompanied by an audible ‘crack’.
In this updated review, we identified 26 randomised controlled trials (represented by 6070 participants) that assessed the effects of SMT in patients with chronic low-back pain. Treatment was delivered by a variety of practitioners, including chiropractors, manual therapists and osteopaths. Only nine trials were considered to have a low risk of bias. In other words, results in which we could put some confidence.
The results of this review demonstrate that SMT appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy. However, it is less clear how it compares to inert interventions or sham (placebo) treatment because there are only a few studies, typically with a high risk of bias, which investigated these factors. Approximately two-thirds of the studies had a high risk of bias, which means we cannot be completely confident with their results. Furthermore, no serious complications were observed with SMT.
In summary, SMT appears to be no better or worse than other existing therapies for patients with chronic low-back pain.
可用於治療下背痛的療法很多，包括脊椎徒手推拿治療（spinal manipulative therapy, SMT），此療法已在全球廣泛使用。
由一位有經驗的圖書館員在CENTRAL （The Cochrane Library2009，第2期）、MEDLINE、EMBASE、CINAHL、PEDro與脊骨神經醫學文獻索引（the Index to Chiropractic Literature）
納入檢視整脊術徒手推拿（spinal manipulation）與脊椎活動手法（spinal mobilization）對成人慢性下背痛之有效性的隨機分組對照試驗（RCT）。未針對醫療機構或疼痛類型設限；僅檢視坐骨神經痛的試驗則予以排除。主要評估指標為疼痛、功能狀態與自覺復原。次要評估指標為恢復工作與生活品質。
總共納入26項隨機分組對照試驗（受試者總數= 6070），其中9項具有低偏差風險。所納入的試驗中約有三分之二（N = 18）尚未在先前的文獻回顧中進行評估。一般而言，高品質的證據顯示，相較於其他療法，脊椎徒手推拿治療對於疼痛紓解（MD：-4.16，95%信賴區間：-6.97至-1.36）與功能狀態（SMD：-0.22，95%信賴區間：-0.36至-0.07）具有統計顯著性但不具臨床相關性的小幅短期療效。靈敏度分析證實這些發現的可信度高。有各種品質的證據（低至高品質）顯示，在另一種療法以外再給予脊椎徒手推拿治療時，對於疼痛紓解與功能狀態具有統計顯著性的短期效果。有低品質的證據顯示，根據統計，就短期疼痛紓解或功能狀態而言，相較於無效療法（inert interventions）或虛擬脊椎徒手推拿治療（sham SMT），脊椎手法治療的效果並未顯著較高。復原、恢復工作、生活品質與照護費用方面的資料極少。脊椎手法治療不會造成嚴重的併發症。
脊椎徒手推拿治療（spinal manipulative therapy， SMT）已獲全球許多醫療照護專業人員廣泛使用。惟此種療法對於治療慢性下背痛的有效性仍有爭議。
由 East Asian Cochrane Alliance 翻譯
翻譯由 此翻譯計畫由臺灣行政院衛生福利部經費補助，臺北醫學大學實證醫學研究中心統籌。 資助