The effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain: an individual participant data meta-analysis

Annemarie de Zoete, Sidney M. Rubinstein, Michiel R. de Boer, Raymond Ostelo, Martin Underwood, Jill A. Hayden, Laurien M. Buffart, Maurits W. van Tulder, G. Bronfort, N. E. Foster, C. G. Maher, J. Hartvigsen, P. Balthazard, F. Cecchi, M. L. Ferreira, M. R. Gudavalli, M. Haas, B. Hidalgo, M. A. Hondras, C. Y. HsiehK. Learman, P. W. McCarthy, T. Petersen, E. Rasmussen-Barr, E. Skillgate, Y. Verma, L. Vismara, B. F. Walker, T. Xia, N. Zaproudina

Research output: Contribution to journalReview articlepeer-review

Abstract

STUDY DESIGN: Individual participant data (IPD) meta-analysis.

OBJECTIVE: The aim of this study was to identify which participant characteristics moderate the effect of spinal manipulative therapy (SMT) on pain and functioning in chronic LBP.

SUMMARY OF BACKGROUND: The effects of SMT are comparable to other interventions recommended in guidelines for chronic low back pain (LBP); however, it is unclear which patients are more likely to benefit from SMT compared to other therapies.

METHODS: IPD were requested from randomized controlled trials (RCTs) examining the effect of SMT in adults with chronic LBP for pain and function compared to various other therapies (stratified by comparison). Potential patient moderators (n = 23) were a priori based on their clinical relevance. We investigated each moderator using a one-stage approach with IPD and investigated this interaction with the intervention for each time point (1, 3, 6, and 12 months).

RESULTS: We received IPD from 21 of 46 RCTs (n = 4223). The majority (12 RCTs, n = 2249) compared SMT to recommended interventions. The duration of LBP, baseline pain (confirmatory), smoking, and previous exposure to SMT (exploratory) had a small moderating effect across outcomes and follow-up points; these estimates did not represent minimally relevant differences in effects; for example, patients with <1 year of LBP demonstrated more positive point estimates for SMT versus recommended therapy for the outcome pain (mean differences ranged from 4.97 (95% confidence interval, CI: -3.20 to 13.13) at 3 months, 10.76 (95% CI: 1.06 to 20.47) at 6 months to 5.26 (95% CI: -2.92 to 13.44) at 12 months in patients with over a year LBP. No other moderators demonstrated a consistent pattern across time and outcomes. Few moderator analyses were conducted for the other comparisons because of too few data.

CONCLUSION: We did not identify any moderators that enable clinicians to identify which patients are likely to benefit more from SMT compared to other treatments.Level of Evidence: 2.

Original languageEnglish (US)
Pages (from-to)121-134
Number of pages14
JournalPhysiotherapy
Volume112
DOIs
StatePublished - Apr 15 2021

Bibliographical note

Funding Information:
Ethical approval: The study protocol was approved by the Review Board of the coordinating institution (EMGO Institute VU University Amsterdam). The protocol has also been approved by the Ethical Committee (Ref. No. 2015.554) of the VU University. Funding: This systematic review was funded by a grant from European Chiropractic Union Research Fund Contract No A.14.03. Conflict of interest: ADZ works in clinical practice as a chiropractor and treats patients with chronic low-back pain.

Funding Information:
MU was Chair of the NICE accreditation advisory committee until March 2017 for which he received a fee. He is chief investigator or co-investigator on multiple previous and current research grants from the UK National Institute for Health Research, Arthritis Research UK and is a co-investigator on grants funded by the Australian NHMRC . He is a NIHR Senior Investigator. He has received travel expenses for speaking at conferences from the professional organisations hosting the conferences. He is a director and shareholder of Clinvivo Ltd. that provides electronic data collection for health services research. He is part of an academic partnership with Serco Ltd. related to return to work initiatives. He is a co-investigator on a study receiving support in kind from Orthospace Ltd. He is an editor of the NIHR journal series, and a member of the NIHR Journal editors group, for which he receives a fee. He has published multiple papers on LBP some of which are referenced in this paper. He was lead author on one study included in the IPD meta-analysis. The authors declare they have no competing interests.

Funding Information:
Ethical approval: The study protocol was approved by the Review Board of the coordinating institution (EMGO Institute VU University Amsterdam). The protocol has also been approved by the Ethical Committee (Ref. No. 2015.554) of the VU University. Funding: This systematic review was funded by a grant from European Chiropractic Union Research Fund Contract No A.14.03. Conflict of interest: ADZ works in clinical practice as a chiropractor and treats patients with chronic low-back pain.SMR reports grants from European Chiropractor's Union, grants from Netherlands Chiropractic Association, grants from European Centre for Chiropractic Research Excellence, grants from Belgian Chiropractic Association, during the conduct of the study; and SMR works in clinical practice as a chiropractor and treats patients with chronic low-back pain.MU was Chair of the NICE accreditation advisory committee until March 2017 for which he received a fee. He is chief investigator or co-investigator on multiple previous and current research grants from the UK National Institute for Health Research, Arthritis Research UK and is a co-investigator on grants funded by the Australian NHMRC. He is a NIHR Senior Investigator. He has received travel expenses for speaking at conferences from the professional organisations hosting the conferences. He is a director and shareholder of Clinvivo Ltd. that provides electronic data collection for health services research. He is part of an academic partnership with Serco Ltd. related to return to work initiatives. He is a co-investigator on a study receiving support in kind from Orthospace Ltd. He is an editor of the NIHR journal series, and a member of the NIHR Journal editors group, for which he receives a fee. He has published multiple papers on LBP some of which are referenced in this paper. He was lead author on one study included in the IPD meta-analysis. The authors declare they have no competing interests.

Publisher Copyright:
© 2021 The Author(s)

Keywords

  • Individual participant data
  • Low back pain
  • Spinal manipulative therapy
  • Chronic Pain/diagnosis
  • Pain Management/methods
  • Humans
  • Middle Aged
  • Randomized Controlled Trials as Topic/methods
  • Recovery of Function/physiology
  • Male
  • Treatment Outcome
  • Pain Measurement/methods
  • Manipulation, Spinal/methods
  • Data Analysis
  • Adult
  • Female
  • Low Back Pain/diagnosis

PubMed: MeSH publication types

  • Meta-Analysis
  • Journal Article

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