Current issues of ACP Journal Club are published in Annals of Internal Medicine


Review: Spinal manipulation increases short-term recovery in low-back pain

ACP J Club. 1993 Mar-April;118:49. doi:10.7326/ACPJC-1993-118-2-049

Related Content in this Issue
• Companion Abstract and Commentary: Spinal Manipulation for Back and Neck Pain: A Review

Source Citation

Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med. 1992 Oct 1;117:590-8.



To review the efficacy and complications of lumbar spinal manipulation for outpatients with low-back pain.

Data sources

Articles were identified through Index Medicus and a MEDLINE search using the MeSH terms chiropractic, manipulation, and backache. Additional articles were identified by reviewing the bibliographies of retrieved articles and by consulting expert orthopedists and chiropractors.

Study selection

All randomized controlled trials evaluating the use of spinal manipulation in outpatients were considered, along with important case series, textbooks, and reviews. All articles on complications of manipulation were reviewed. 58 studies, including 25 randomized controlled trials, were reviewed.

Data extraction

Controlled trials were assessed for quality based on patient selection, follow-up, description of the intervention, and outcome measurement. Outcomes, including pain relief and functional status, were extracted and combined using a hierarchical Bayesian model.

Main results

No systematic report of the frequency of complications has been published. Reports of complications come from case reports and suggest that the risk, although potentially serious, is small. The combined results of 7 studies evaluating recovery from acute pain (< 3 wk duration) and subacute pain (3 to 13 wk duration) showed that manipulation increased the probability of recovery after 2 or 3 weeks of treatment (P < 0.001) (Table). This conclusion was unchanged by sensitivity analysis examining different meta-analysis methods and subgrouping of studies by quality. The benefit disappeared within a few weeks, which is consistent with the natural history of the disease. Of 2 comparable studies evaluating spinal manipulation for chronic low-back pain (pain > 13 wk duration), 1 showed a benefit and the other did not. The combined results of 2 studies evaluating spinal manipulation in patients with low-back pain and sciatic nerve irritation showed a 10% (95% CI -2% to 21%) improvement in recovery at 4 weeks.


Spinal manipulation increases the probability of recovery at 2 to 3 weeks in outpatients with acute and subacute low-back pain. Data are insufficient to evaluate the efficacy for chronic low-back pain and back pain with sciatica.

Sources of funding: In part, California Chiropractic Foundation and the Foundation for Chiropractic Education and Research.

For article reprint: Dr. P.G. Shekelle, RAND, 1700 Main Street, P.O. Box 2138, Santa Monica, CA 90406-2138, USA. FAX 310-451-6917.

Table. Spinal manipulation for short-term (2 to 3 weeks) recovery from chronic and acute low-back pain

Outcome Weighted spinal manipulation Weighted control RBI (95% CI) NNT (CI)
Recovery 69% 53% 27% (13 to 43) 7 (5 to 11)

*Abbreviations defined in Glossary; RBI, NNT, and CI calculated from data in article.


The literature on back pain is fascinating. Back pain causes considerable functional disability and has an associated extensive literature spanning many years. The quality of the earlier studies was often poor and resulted in the use of therapies that provided little benefit. Recent investigative efforts have honed existing knowledge and helped focus on unanswered questions.

This meta-analysis of spinal manipulation for low-back pain provides a significant contribution to the medical literature. Manipulation provides some early benefit for acute and subacute nonspecific low-back pain but no known long-term benefit; efficacy is unclear for chronic pain or pain with sciatica. Variability in manipulation techniques may account for variability in effectiveness. This therapy is one of several effective modalities for acute low-back pain, including analgesics, 2 days of bed rest, physical therapy, and back school.

Because no therapy is clearly superior, economic evaluation is important (1). To fully assess cost effectiveness, we need more information on benefits and potential risks. Without proven benefit in preventing recurrences or chronic, disabling pain, bed rest may remain the most cost-effective, conservative therapy.

Clinicians should remember that manipulation is only proven effective for acute and subacute nonspecific low-back pain (not for specific clinical syndromes, e.g., herniated disc, central spinal stenosis, post-laminectomy, or spondylolisthesis). Additional screening to reduce complications by accurately diagnosing malignancy, infection, or coagulopathy increases the cost of manipulation. Finally, as the authors state, we need rigorous randomized trials to compare conservative therapies, using clinically homogeneous low-back pain syndromes, well-defined interventions, valid measures of functional outcomes, systematic assessment of complications, and economic evaluation.

Valerie Lawrence, MD
University of TexasSan Antonio, Texas, USA


1. Lawrence VA, Tugwell P, Gafni A, Kosuwon W, Spitzer WO. Acute low back pain and economics of therapy: the literature loop approach. J Clin Epidemiol. 1992;45:301-11.