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Management Brief No. 107

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Management eBriefs
Issue 107January 2016

The report is a product of the VA/HSR Evidence Synthesis Program.

Systematic Review: Spinal Manipulative Therapy for Acute Neck and Lower Back Pain

Evidence about the effectiveness of spinal manipulative therapy (SMT) or chiropractic care for acute back or neck pain is mixed and more research is needed to explain why similar studies reach different results, according to a recent review of the scientific literature conducted by the Evidence-based Synthesis Program (ESP) Center at the West Los Angeles VA Medical Center. This review searched for existing systematic reviews and meta-analyses on spinal manipulation for back pain, and updated these with searches for new randomized controlled trials comparing SMT to other therapies.

Back and neck pain are common ailments, and most people can expect at least one episode of acute back and/or neck pain in their lifetime. SMT is one of many available treatments within the VA healthcare system. Other treatments include, but are not limited to analgesics, muscle relaxants, bed rest, exercises, physical therapy modalities, heat, ice, and acupuncture. Several prior reviews on spinal manipulation have concluded that SMT is superior to sham, but not clearly superior to other effective treatments for acute low-back pain. However, the most recent Cochrane Review concluded that SMT is not more effective than any other intervention or sham. One goal of this ESP review was to help resolve disagreements in the results from prior reviews.

While the ESP review found a small to moderate effect size in favor of SMT for treating acute and short-term back pain without sciatica, there was significant variation in the results across studies: "some studies of SMT found positive results, while others, for the same outcome, found essentially no benefit." Based on these mostly unexplained differences, the authors conclude that "the large degree of heterogeneity may limit the enthusiasm of some clinicians and policymakers for advocating more widespread use of SMT." Overall, the review found evidence of statistically significant benefits for pain and function that were, on average, clinically modest. However, there was great heterogeneity in the results of individual studies, and some suggestion that patient selection and the type of spinal manipulative therapy given increases the size of the benefit.

Overall, the authors of this ESP review concluded that a better understanding of what contributes to patient selection and intervention may improve the consistency of the results for SMT for acute low back pain. The study reporting the largest benefit for treatment with SMT used a clinical prediction rule to identify patients who were good candidates for this treatment. Good targets for additional studies include an independent replication of this study, or new RCTs with more detailed data collection on the patient clinical characteristics and details of the SMT intervention. For neck pain, authors stated that there are simply too few studies to draw firm conclusions, and additional RCTs are warranted. Attention should be paid to collecting clinical variables and details of the intervention to use in the exploration of possible heterogeneity of treatment effects.

Reviewers found only 5 studies with a total of 198 patients where SMT was compared with a non-SMT treatment (NSAID, detuned ultrasound, neck collar, TENS, and heat; some trials had more than one comparator) for acute neck pain, and the authors conclude there is low evidence that SMT improves outcomes. Evidence on the relationship between opiate use and SMT-treated acute back and/or neck pain was deemed insufficient, as was the quality of evidence regarding SMT and outcomes for patients with low back pain and sciatica.

With regard to harms, authors found high-quality evidence that transient minor musculoskeletal adverse events are common following SMT, although they point out that these events may be equally common following non-SMT manual therapy.

VA healthcare providers have had a significant increase in requests for chiropractic care since these services became covered by the VA. With an increased focus on interdisciplinary care within the VA, findings from an evidence synthesis about the effectiveness of SMT will help VA identify approaches for treating acute neck and lower back pain, and will help ensure VA is providing Veterans with optimal healthcare services.

The ESP report was developed based on a nomination from operational partners Lucille Beck, PhD, Deputy Chief Patient Care Services Officer, Rehabilitation and Prosthetic Services (10P4R); Anthony Lisi, DC, Director, VHA Chiropractic Service Rehabilitation and Prosthetic Services, Section Chief, Chiropractic Service, VA Connecticut Healthcare System; and David Chandler, PhD, Deputy Chief Consultant, Rehabilitation and Prosthetic Services (10P4R). The report will be used by the Office of Rehabilitation and Prosthetic Services (10P4R) Chiropractic Service, to inform VA clinical practice and national policy as the VA continues to implement chiropractic services across the country.

Shekelle PG, Paige NM, Miake-Lye IM, Beroes JM, Booth MS, Shanman R. The Effectiveness and Harms of Chiropractic Care for the Treatment of Acute Neck and Lower back Pain: A Systematic Review. VA ESP Project #05-226; 2015.

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A Cyberseminar session will be held to discuss this ESP report on Monday, April 18, 2016 from 12:00pm to 1:00pm ET. To register, please visit the HSR&D Cyberseminar site.

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Read past HSR&D Management e-Briefs on the HSR&D website.

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.


This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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