Intended for healthcare professionals

Rapid response to:

Clinical Review

Diagnosis and treatment of low back pain

BMJ 2006; 332 doi: (Published 15 June 2006) Cite this as: BMJ 2006;332:1430

Rapid Response:

Spinal manipulation, therapeutic massage and acupuncture for low back pain: an update

Editor: We are pleased to read this excellent review on the clinical
management of low back pain (LBP) by Koes and colleagues. Whilst the
clinical evidences for spinal manipulation and acupuncture have been
mentioned briefly in the effectiveness table (table 2) along with various
conventional therapies, we believe CAM should have higher profile and
include effectiveness of therapeutic massage.

Two systematic reviews mapped the evidence of acupuncture for LBP
(Furlan et al 05, Manheirmer et al 05). Furlan et al suggested that
acupuncture reduces pain and improves functions for chronic LBP when
compared to no treatment or sham therapy, but this evidence originated
from short term observation. Manheirmer et al have quantified
acupuncture’s short term benefit in their meta-analyses, which reported
the standardized mean differences between acupuncture vs. no treatment
(0.69 {95%CI, 0.40 to 0.98, 8 trials}) and acupuncture vs. sham treatment
(0.54 {95%CI, 0.35 to 0.73}).Evidence also showed that acupuncture
effectively augments conventional treatment. For its longer term benefit
for chronic LBP, a recent pragmatic randomized controlled trial (RCT)
(Thomas et al 05) has reported that acupuncture was significantly more
effective in reducing bodily pain than usual care at 24 months. It is also
found that GP referral to acupuncture service is cost effective over a 2
year period. The present data is insufficient for reaching firm
conclusions regarding its effectiveness for acute low back pain

A recently updated systematic review (Assendelft et al 04, updated
Feb 06) reported that spinal manipulative therapy is superior to sham
intervention, and its effectiveness is clinically and statistically
equivalent to GP care, analgesics, physical therapy, exercise and back
school. The results hold for both acute and chronic low back pain. In a
three year pragmatic trial, spinal manipulation provided a 29% higher
improvement compared hospital outpatient care in terms of total Oswestry
scores and patient satisfaction. It is highlighted that the effect of
chiropractic on pain reduction was particularly clear (Meada et al 95).

For chronic low back pain, a systematic review of eight RCT (Furlan
02, updated Aug 05) (of which only 5 are of high quality) has suggested
that massage’s effectiveness is equal to corsets and exercise, and
superior to relaxation, acupuncture and self care education. However it is
inferior when compared to manipulation and TENS. A comparatively longer
term benefit is observed, with beneficial effects lasted at least one year
after the end of the treatment. Potential for augmenting exercise and
education’s effect is highlighted. However, evidence from high quality RCT
for massage is rather limited and more research on the topic is warranted.

In conclusion, current evidences suggested that acupuncture and
therapeutic massage may effective CAM modalities for chronic LBP, while
spinal manipulation may be useful for both acute and chronic LPB.

Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman
BM. Acupuncture and dry-needling for low back pain. The Cochrane Database
of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI:

Manheimer E. White A. Berman B. Forys K. Ernst E. Meta-analysis:
acupuncture for low back pain. Annals of Internal Medicine. 142(8):651-63,
2005 Apr 19.

Thomas KJ, MacPherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell
M, Fitter M, Roman M, Walters S, Nicholl JP. Longer term clinical and
economic benefits of offering acupuncture care to patients with chronic
low back pain. Health Technol Assess. 9(32): iii-iv, ix-x, 1-109, 2005

Assendelft WJJ, Morton SC, Yu Emily I, Suttorp MJ, Shekelle PG.
Spinal manipulative therapy for low-back pain. The Cochrane Database of
Systematic Reviews 2004, Issue 1. Art. No.: CD000447. DOI:

Meade TW. Dyer S. Browne W. Frank AO. Randomised comparison of
chiropractic and hospital outpatient management for low back pain: results
from extended follow up. BMJ. 311(7001):349-51, 1995 Aug 5.

Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low-back pain.
The Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.:
CD001929. DOI: 10.1002/14651858.CD001929.

Competing interests:
None declared

Competing interests: No competing interests

28 August 2006
Vincent Chung
Chinese Medicine Practitioner, PhD Student
Prof Sian Griffiths
School of Public Health, Chinese University of Hong Kong, China