Spinal Manipulation No Better Than Other Standard Treatments for Back Pain

Spinal manipulation performed by chiropractors and others to treat back pain is no better than standard treatments for sore backs, according to a new analysis by researchers from RAND Health.

The findings, reported in the June 3 edition of the Annals of Internal Medicine, temper previous enthusiasm for spinal manipulation that was based, at least in part, on a 1992 RAND study. The earlier study suggested that spinal manipulation may provide better relief than other therapies used at the time.

“Spinal manipulation is one of several therapies that may provide some relief for back pain,” said the new study's senior author, Dr. Paul Shekelle of RAND and the Greater Los Angeles Veterans Affairs Healthcare System. “But there is no evidence that spinal manipulation is better than other things that your physician can now recommend to you. The conclusion that spinal manipulation is superior to available medical therapies is not warranted.”

“Unfortunately, all of these treatments for back pain are at best only modestly effective,” Shekelle added.

Spinal manipulation involves manually adjusting individual vertebrae that have abnormal movement patterns or fail to function normally.

The new RAND analysis examined dozens of studies that compared spinal manipulation and other therapies for treatment of back pain—including pain relief medicine, exercise and physical therapy. Researchers found evidence that spinal manipulation was superior only to sham therapies or to a collection of treatments with no evidence of effectiveness, or worse, with evidence of harm. Such therapies include bed rest, topical gels, traction, heat and magnet therapy, and minimal massage.

No differences were seen for the type of back pain (acute or chronic pain) treated by spinal manipulation, the type of practitioner who performed the manipulation, and whether the manipulation was done in combination with other therapies.

Spinal manipulation is a widely used treatment for back pain and is performed primarily by chiropractors, although it also is practiced by physical therapists, osteopathic physicians and a small number of physicians. While spinal manipulation is a recommended treatment in national guidelines on back pain, the scientific literature remains mixed on its effectiveness.

Shekelle said the findings from the new review are different than RAND's earlier studies because new data were available.

“What we have learned since our last study is that some of the methods to treat back pain—such as bed rest—are worse than doing nothing,” Shekelle said. “Spinal manipulation hasn't changed. But the medical therapy has improved because we're getting rid of those therapies that cause harm.”

Researchers performed the new voluntary review for the Cochrane Back Review Group, an organization that reviews studies of the effectiveness of care for back ailments. Shekelle and his colleagues analyzed findings from 39 randomized controlled trials that compared the many available treatments for back pain.

Researchers suggest that future studies of spinal manipulation should focus on the cost effectiveness of treatment. A key issue that should be examined is the number of treatments needed to achieve the most benefit, according to researchers.

Dr. William J.J. Assendelft of the Dutch College of General Practitioners was co-leader of the study. Other authors of the report are: Sally C. Morton and Marika J. Suttorp of RAND, and Emily I. Yu of the Greater Los Angeles Veterans Affairs Healthcare System.

RAND Health is the nation's largest independent health policy research organization, with a broad research portfolio that focuses on medical quality, health care costs and delivery of health care, among other topics.