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

BMJ 2019; 364 doi: (Published 13 March 2019) Cite this as: BMJ 2019;364:l689
  1. Sidney M Rubinstein, associate professor1,
  2. Annemarie de Zoete, doctoral student1,
  3. Marienke van Middelkoop, associate professor2,
  4. Willem J J Assendelft, professor3,
  5. Michiel R de Boer, associate professor1,
  6. Maurits W van Tulder, professor14
  1. 1Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
  2. 2Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands
  3. 3Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, Netherlands
  4. 4Department of Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
  1. Correspondence to: S M Rubinstein s.m.rubinstein{at} (or @SM_Rubinstein)
  • Accepted 7 February 2019


Objective To assess the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain.

Design Systematic review and meta-analysis of randomised controlled trials.

Data sources Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, and trial registries up to 4 May 2018, including reference lists of eligible trials and related reviews.

Eligibility criteria for selecting studies Randomised controlled trials examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded, as was grey literature. No restrictions were applied to language or setting.

Review methods Two reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence. The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months. Quality of evidence was assessed using GRADE. A random effects model was used and statistical heterogeneity explored.

Results 47 randomised controlled trials including a total of 9211 participants were identified, who were on average middle aged (35-60 years). Most trials compared SMT with recommended therapies. Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief (mean difference −3.17, 95% confidence interval −7.85 to 1.51) and a small, clinically better improvement in function (SMD −0.25, 95% confidence interval −0.41 to −0.09). High quality evidence suggested that compared with non-recommended therapies SMT results in small, not clinically better effects for short term pain relief (mean difference −7.48, −11.50 to −3.47) and small to moderate clinically better improvement in function (SMD −0.41, −0.67 to −0.15). In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. Statistical heterogeneity could not be explained. About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT.

Conclusion SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.


  • Contributors: SMR, MWvT, and WJJA conceived and designed the study. SMR, AdeZ, MRdeB, and MWvT analysed and interpreted the data. SMR, AdeZ, and MWvT drafted the review. All authors critically revised the article for important intellectual content and gave final approval for the article. MRdeB provided statistical expertise. SMR provided administrative, technical, and logistical support. SMR, AdeZ, and MvM (2011 publication) and MRdeB and WJJA (2004 publication) collected and assembled the data. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: None.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: SMR received personal grants from the European Chiropractors’ Union (ECU), the European Centre for Chiropractic Research Excellence (ECCRE), the Belgian Chiropractic Association (BVC) and the Netherlands Chiropractic Association (NCA) for his position at the Vrije Universiteit Amsterdam. He also received funding for a research project on chiropractic care for the elderly from the European Centre for Chiropractic Research and Excellence (ECCRE). AdeZ received a grant from the European Chiropractors’ Union (ECU) (grant No A14.03), for an independent study on the effects of SMT. SMR and AdeZ declare that they work in their own private clinics as chiropractors. The remaining authors received no support from any organisation for the submitted work; have no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and have no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: Details of the characteristics of the included studies are available from the corresponding author at

  • Transparency: All authors affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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