Spinal manipulation – 

No better than other treatments for chronic low back pain 

Low back pain is a prevalent and disabling disorder. Spinal manipulation therapy is widely used to treat 

this condition and has a prominent role in all national guidelines on the management of back pain, although 

guideline recommendations vary. While this therapy has been studied in many randomized clinical trials, it 

has produced conflicting results, and previous studies have compared spinal manipulation with a combination 

of therapies rather than with individual therapies. The aim of this study was to directly compare spinal 

manipulative therapy with other individual therapies, including 1) sham therapy, 2) conventional general 

practitioner care and analgesics, 3) physical therapy and exercise, 4) treatments considered to lack benefit or to 

be harmful (i.e., traction, bed rest, topical gel, corset), and 5) back school (treatments that did not 

conventionally fit into any other group). 

Through a literature review, researchers analyzed information from 53 articles on 38 studies and assessed 

acute or chronic pain, short-term and long-term pain, as well as function. Studies included in the literature 

review were limited to the following criteria: adult patients with low back pain, regardless of radiation pattern; 

comparison of manipulation or mobilization for low back pain with another treatment or control; inclusion of at 

least one clinically relevant outcome measure (i.e., pain, global movement); follow-up occurred for at least 1 

day; and the study was published as a full report before January, 2001. 

Findings from this study show that compared with other advocated therapies for low back pain – 

including analgesics, physical therapy, exercises, or back school – spinal manipulative therapy had neither 

statistically nor clinically significant benefits. Spinal manipulative therapy had benefits only when compared 

with either sham manipulation or therapies judged to be ineffective or even harmful. Thus, while some patients 

with low back pain may prefer spinal manipulation to traditional therapies, there is no evidence that it will result 

in better outcomes. Because chronic low back pain is a painful burden for the sufferer and a high cost to society 

due to loss of work and substantial healthcare expenses, these results are important to clinicians as well as 

health care policy makers. 

Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. 

A meta-analysis of effectiveness relative to other therapies. Annals of Internal Medicine. 2003 Jun 3;138(11):871-81. 

Review. Also, Summary for patients in: Ann Intern Med. 2003 Jun 3;138(11):I33. 

Dr. Shekelle is part of HSR&D’s Center for the Study of Healthcare Provider Behavior and the 

Greater Los Angeles VA Healthcare System. 

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