Spinal manipulative treatments do not provide RELIEF for chronic low back pain

Spinal manipulative therapies such as spinal manipulation and spinal mobilization did not seem effective for the management of mild-to-moderate chronic low back pain (LBP) in young adults, the RELIEF* trial has shown.

“Manipulative therapies are a common conservative treatment approach for LBP,” noted the researchers. Manipulation-based techniques employ a high-velocity, low-amplitude force typically accompanied by an audible sound from ≥1 joint, while mobilization strategies make use of a low-velocity, low-force approach that usually does not produce audible joint sounds. [J Man Manip Ther 2007;15:143-154]

Although both are proven effective for acute and subacute LBP, evidence for chronic LBP is mixed. [Am J Emerg Med 2017;35:1576-1577; Spine 2015;40:209-217; J Can Chiropr Assoc 2014;58:456-466; J Am Osteopath Assoc 2016;116:144-155]

“[U]nderstanding their relative effectiveness is an important and unresolved issue … Our findings indicated that spinal manipulation and spinal mobilization were no more effective than a well-chosen placebo in reducing pain and disability in patients with chronic LBP,” said the researchers.

A total of 162 participants (mean age 25 years, 57 percent women) with chronic LBP (mean NPRS** score 4.3) were randomized 1:1: to receive twice-weekly sessions of either spinal manipulation, spinal mobilization, or sham inert cold laser therapy (placebo) for 3 weeks. [JAMA Network Open 2020;doi:10.1001/jamanetworkopen.2020.12589]

No significant differences were observed in terms of changes in NPRS scores between spinal manipulation and spinal mobilization (0.24; p=0.45), spinal manipulation and placebo (−0.03; p=0.92), or spinal mobilization and placebo (−0.26; p=0.39).

The results were no different in terms of changes in self-reported disability scores between spinal manipulation and spinal mobilization (−1.00; p=0.14), spinal manipulation and placebo (−0.07; p=0.92), or spinal mobilization and placebo (0.93; p=0.17).

“Although we hypothesized that [both techniques] would be more effective in reducing pain and disability [vs] placebo … this hypothesis was not supported by the data … [These findings suggest that both] manipulative therapy techniques do not appear to be effective for chronic LBP, at least among relatively young individuals with mild-to-moderate back pain,” said the researchers.

“[We had] relatively young [adult participants] with only mild-to-moderate chronic LBP with low levels of self-reported disability,” they added. However, evidence suggests that the differences in baseline characteristics and prognosis among young, middle-aged, and older individuals with LBP are relatively small. [Eur J Pain 2017;21:866-873]

Nonetheless, while young adults do not often seek medical attention for LBP compared with older cohorts, the average symptom duration of the study participants was >6 years, they added. “Thus, this is potentially an understudied cohort, and data on treatment effectiveness of manual therapies is needed.”

 “[Taken together,] these findings provide additional evidence about the limits of manipulative therapies in chronic LBP,” said the researchers. Despite the lack of efficacy of both techniques in this setting, the findings underscore their potential in severe and/or acute LBP, as shown by existing data. [JAMA 2017;317:1451-1460]

Future studies employing a pragmatic trial design approach are recommended to provide further understanding of the potential additive benefits of these therapies, they added.