Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials

doi:10.1136/bmj.l689

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BMJ. 2019; 364: l689.
Published online 2019 Mar 5. doi: 10.1136/bmj.l689
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Table 1
Summary of treatment effects and GRADE summary of findings for all comparisons among trials included in systematic review of spinal manipulative therapy (SMT) for chronic low back pain
Analyses Effect estimate* (95% CI) No of studies No of participants I² (%) Quality of evidence (reason for downgrading)
Primary analyses

SMT versus recommended therapies
Pain:
1 month −3.17 (−7.85 to 1.51) 17 3155 92 Moderate (inconsistency)
6 months −3.09 (−5.42 to −0.77) 11 2462 58 Moderate (inconsistency)
12 months −1.86 (−4.79 to 1.07) 10 2502 69 Moderate (inconsistency)
Functional status:
1 month −0.25 (−0.41 to −0.09) 16 3090 76 Moderate (inconsistency)
6 months −0.09 (−0.21 to 0.03) 12 2672 50 Moderate (inconsistency)
12 months −0.09 (−0.23 to 0.04) 11 2635 62 Moderate (inconsistency)

SMT versus non-recommended therapies
Pain:
1 month −7.48 (−11.50 to −3.47) 8 991 55 High
6 months −7.54 (−13.29 to −1.79) 4 372 35 Moderate (imprecision)
12 months −7.80 (−14.19 to −1.41) 1 169 0 Low (inconsistency, imprecision)
Functional status:
1 month −0.41 (−0.67 to −0.15) 7 835 67 High
6 months −0.29 (−0.50 to −0.09) 4 373 0 Moderate (imprecision)
12 months −0.42 (−0.72 to −0.11) 1 169 100 Low (inconsistency, imprecision)

SMT versus sham SMT
Pain:
1 month −7.55 (−19.86 to 4.76) 8 831 96 Low (limitations, inconsistency)
6 months 0.96 (−6.34 to 8.26) 2 114 35 Very low (limitations, inconsistency, imprecision)
12 months 0.20 (−5.33 to 5.73) 1 63 0 Very low (limitations, inconsistency, imprecision)
Functional status:
1 month −0.73 (−1.35 to −0.11) 6 748 91 Low (limitations, inconsistency)
6 months −0.12 (−0.50 to 0.25) 2 114 0 Very low (limitations, inconsistency, imprecision)
12 months −0.19 (−0.69 to 0.31) 1 63 0 Very low (limitations, inconsistency, imprecision)

SMT as adjuvant therapy
Pain:
1 month −6.93 (−10.36 to −3.49) 6 1046 41 Moderate (limitations)
6 months −6.77 (−14.07 to 0.53) 2 143 0 Low (limitations, imprecision)
12 months −3.31 (−6.60 to −0.02) 2 1000 12 Moderate (limitations)
Functional status:
1 month −0.29 (−0.55 to −0.03) 4 955 62 Moderate (limitations)
6 months −0.30 (−0.64 to 0.03) 2 142 0 Low (imprecision, inconsistency)
12 months −0.21 (−0.34 to −0.09) 1 994 0 Low (imprecision, inconsistency)

Secondary analyses

HVLA SMT versus LVLA SMT
Pain:
1 month 0.32 (−3.05 to 3.69) 4 509 0 Moderate (inconsistency)
6 months No data available – – – –
12 months No data available – – – –
Functional status:
1 month 0.16 (−0.42 to 0.74) 4 520 90 Low (inconsistency–two levels)
6 months 0.16 (−0.14 to 0.46) 1 175 0 Low (limitations, imprecision)
12 months No data available – – – –

HVLA=high velocity, low amplitude;
LVLA=low velocity, low amplitude.

Analyses	Effect estimate* (95% CI)	No of studies	No of participants	I² (%)	Quality of evidence (reason for downgrading)
Primary analyses

SMT versus recommended therapies
Pain:
1 month	−3.17 (−7.85 to 1.51)	17	3155	92	Moderate (inconsistency)
6 months	−3.09 (−5.42 to −0.77)	11	2462	58	Moderate (inconsistency)
12 months	−1.86 (−4.79 to 1.07)	10	2502	69	Moderate (inconsistency)
Functional status:
1 month	−0.25 (−0.41 to −0.09)	16	3090	76	Moderate (inconsistency)
6 months	−0.09 (−0.21 to 0.03)	12	2672	50	Moderate (inconsistency)
12 months	−0.09 (−0.23 to 0.04)	11	2635	62	Moderate (inconsistency)

SMT versus non-recommended therapies
Pain:
1 month	−7.48 (−11.50 to −3.47)	8	991	55	High
6 months	−7.54 (−13.29 to −1.79)	4	372	35	Moderate (imprecision)
12 months	−7.80 (−14.19 to −1.41)	1	169	0	Low (inconsistency, imprecision)
Functional status:
1 month	−0.41 (−0.67 to −0.15)	7	835	67	High
6 months	−0.29 (−0.50 to −0.09)	4	373	0	Moderate (imprecision)
12 months	−0.42 (−0.72 to −0.11)	1	169	100	Low (inconsistency, imprecision)

SMT versus sham SMT
Pain:
1 month	−7.55 (−19.86 to 4.76)	8	831	96	Low (limitations, inconsistency)
6 months	0.96 (−6.34 to 8.26)	2	114	35	Very low (limitations, inconsistency, imprecision)
12 months	0.20 (−5.33 to 5.73)	1	63	0	Very low (limitations, inconsistency, imprecision)
Functional status:
1 month	−0.73 (−1.35 to −0.11)	6	748	91	Low (limitations, inconsistency)
6 months	−0.12 (−0.50 to 0.25)	2	114	0	Very low (limitations, inconsistency, imprecision)
12 months	−0.19 (−0.69 to 0.31)	1	63	0	Very low (limitations, inconsistency, imprecision)

SMT as adjuvant therapy
Pain:
1 month	−6.93 (−10.36 to −3.49)	6	1046	41	Moderate (limitations)
6 months	−6.77 (−14.07 to 0.53)	2	143	0	Low (limitations, imprecision)
12 months	−3.31 (−6.60 to −0.02)	2	1000	12	Moderate (limitations)
Functional status:
1 month	−0.29 (−0.55 to −0.03)	4	955	62	Moderate (limitations)
6 months	−0.30 (−0.64 to 0.03)	2	142	0	Low (imprecision, inconsistency)
12 months	−0.21 (−0.34 to −0.09)	1	994	0	Low (imprecision, inconsistency)

Secondary analyses

HVLA SMT versus LVLA SMT
Pain:
1 month	0.32 (−3.05 to 3.69)	4	509	0	Moderate (inconsistency)
6 months	No data available	–	–	–	–
12 months	No data available	–	–	–	–
Functional status:
1 month	0.16 (−0.42 to 0.74)	4	520	90	Low (inconsistency–two levels)
6 months	0.16 (−0.14 to 0.46)	1	175	0	Low (limitations, imprecision)
12 months	No data available	–	–	–	–