A 2013 Cochrane review was recently published regarding the effects of Spinal Manipulative Therapy (SMT) for acute low back pain. The review identified 20 randomized control trials with inclusion criteria being adults 18 or older with a mean duration of low back pain of six weeks or less & participants with or without radiating pain. In general the review found that SMT for the outcomes of pain and functional status had low to very low quality evidence. This suggests that there is no difference when treating a patient with SMT vs. another intervention. The conclusion stated that "SMT is no more effective for acute low back pain than inert interventions, sham SMT, or as adjunct therapy. SMT also seems to be no better than other recommended therapies."
For someone who is entering an Orthopaedic Residency with a strong emphasis in manual therapy, this information was astounding. I have seen the short and long term benefits of manipulation and mobilization first-hand in the clinic. How could the evidence be so contradictory? When discussing this article with an OCS/ fellow trained manual therapist, he had the following comments to make:
"This review like many others on manipulative therapy have similar pitfalls:
Operational definitions- Spinal manipulative therapy (SMT) includes every hands on intervention: thrust, non-thrust, mobs, etc. I thinking it would make for a more valid study to really try and separate the types of therapies out. Apples and oranges in my book.
SMT alone- we have known that SMT without exercise for low back and neck pain provides very minimal effect. Let’s move on from the thinking that SMT is a panacea and look at what actually happens in the clinic.
Minimal subgrouping of patients- classification of patients is vital. Any physical therapist can perform SMT, regardless of training or expertise. Whether the patients are sub-grouped based off of a CPR, patient preference, or therapist experience/critical thinking, not all patients will respond from treatment types the same. After all LBP is a symptom and not a diagnosis.
Multiple low quality studies- there is still a void in the literature. Minimal high quality articles regarding SMT are performed by PT’s using the above qualifiers. Therefore, most RCT’s are really just comparing a bunch of low quality research and finding the same conclusions.
This study is helpful in that it adds to the body of literature. However, I don’t think it is clinically useful, because it does not adequately describe practice patterns. Humans are extremely complex and manual therapy will only be THE answer in a small subgroup of patients. Everyone else needs a uniquely tailored solution based on the biopsychosocial state, fitness level, and impairments."
I found all of these points to be true. Additionally, it allowed me to realize that I too often skim to the conclusion and results section of an article without fully interpreting the research process that goes into finding these results. Understanding the operational definitions and the quality of studies that were researched will alter the authors conclusive points and change your ability to translate this information into a practical clinical setting. The biggest battle which stands between us and our research is the complexity of the human being. We are all so unique. While 2 patients may present the same impairments, there are a myriad number of factors that will go into how they respond to your treatment session.
Rubinstein S, et al. "Spinal Manipulative Therapy for Acute Low Back Pain: An Update of the Cochrane Review." SPINE. 2013; 38.3: E158-E177.
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