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Experts question study of spinal manipulative therapy for low back pain

By Melanie Hinze
Local experts have questioned the conclusions of a recent study published in the BMJ, which assessed spinal manipulative therapy (SMT) as a treatment for low back pain.

The study authors concluded that, ‘SMT produces similar effects to recommended therapies for chronic low back pain but results in clinically better effects for short term improvement in function compared with non-recommended therapies, sham therapy [placebo], or when added as an adjuvant therapy’.

However, two local experts told Pain Management Today that the authors’ conclusions regarding benefits over placebo appear to be at odds with the study’s findings.

Professor Rachelle Buchbinder, NHMRC Senior Principal Research Fellow and Director of the Monash Department of Clinical Epidemiology at the Cabrini Institute, Melbourne, said that if you look closely at the results of SMT versus placebo, ‘there was no benefit of SMT for pain at any time point and the very small benefit for function, which was only seen at one month, was due to one extreme outlier, which when removed meant there was no longer any benefit for function either’.

The BMJ study was a systematic review and meta-analysis of 47 randomised controlled trials, incorporating 9211 participants aged 35 to 60 years who had chronic low back pain. Eight of these trials, involving 831 participants, compared SMT with placebo.

Physiotherapist and Marie Sklodowska-Curie Global Fellow at The University of Sydney, Dr Mary O’Keeffe, said ‘The lack of benefit of SMT over placebo/sham therapy to improve a person’s pain and function indicates that SMT is unlikely to have any direct benefits and observed improvements are the result of contextual and other effects’.

‘This questions its use as a stand-alone therapy,’ she added.

In a rapid response electronic letter to the editor, Dr O’Keefe concluded, ‘These results demonstrate no convincing evidence for the superiority of SMT over sham SMT and a lack of clinically important benefit of SMT when compared with any other treatment’.

‘It is likely that the apparent equivalence with both “recommended” and “non-recommended” therapies tells us more about the disappointing effectiveness of those approaches than it does about the benefit of SMT,’ she added.
BMJ 2019; 364: l689.