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Spinal Manipulation for Low-Back Pain

Paul G. Shekelle, MD, MPH; Alan H. Adams, DC; Mark R. Chassin, MD, MPH, MPP; Eric L. Hurwitz, DC, MS; and Robert H. Brook, MD, ScD
[+] Article and Author Information

Grant Support: In part by the California Chiropractic Foundation and the Foundation for Chiropractic Education and Research (grant 89-038).

Requests for Reprints: Paul G. Shekelle, MD, MPH, RAND, 1700 Main Street, P.O. Box 2138, Santa Monica, CA 90406-2138.

Current Author Addresses: Drs. Shekelle and Brook: RAND, 1700 Main Street, P.O. Box 2138, Santa Monica, CA 90406-2138.

Dr. Adams: Los Angeles College of Chiropractic, 16200 East Amber Valley Drive, P.O. Box 1166, Whittier, CA 90609-1166.

Dr. Chassin: New York State Department of Health, Empire State Plaza, Corning Tower Building, Albany, NY 12237.

Dr. Hurwitz: Department of Epidemiology, School of Public Health, University of California, Los Angeles, CA 90024.


Ann Intern Med. 1992;117(7):590-598. doi:10.7326/0003-4819-117-7-590
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Purpose: To review the use, complications, and efficacy of spinal manipulation as a treatment for low-back pain.

Data Identification: Articles were identified through a MEDLINE search, review of articles' bibliographies, and advice from expert orthopedists and chiropractors.

Study Selection: All studies reporting use and complications of spinal manipulation and all controlled trials of the efficacy of spinal manipulation were analyzed. Fifty-eight articles, including 25 controlled trials, were retrieved.

Data Analysis: Data on the use and complications of spinal manipulation were summarized. Controlled trials of efficacy were critically appraised for study quality. Data from nine studies were combined using the confidence profile method of meta-analysis to estimate the effect of spinal manipulation on patients' pain and functional outcomes.

Results of Data Synthesis: Chiropractors provide most of the manipulative therapy used in the United States for patients with low-back pain. Serious complications of lumbar manipulation, including paraplegia and death, have been reported. Although the occurrence rate of these complications is unknown, it is probably low. For patients with uncomplicated, acute low-back pain, the difference in probability of recovery at 3 weeks favoring treatment with spinal manipulation is 0.17 (for example, increase in recovery from 50% to 67%; 95% probability limits of estimate, 0.07 to 0.28). For patients with low-back pain and sciatic nerve irritation, the difference in probabilities of recovery at 4 weeks is 0.098 (probability limits, — 0.016 to 0.209).

Conclusions: Spinal manipulation is of short-term benefit in some patients, particularly those with uncomplicated, acute low-back pain. Data are insufficient concerning the efficacy of spinal manipulation for chronic low-back pain.

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