Research Review By Dr. Kent Stuber©


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Date Posted:

December 2011

Study Title:

Comparative effectiveness of exercise, acupuncture, and spinal manipulation for low back pain


Standaert CJ, Friendly J, Erwin MW, et al.

Author's Affiliations:

Departments of Rehabilitation Medicine, Orthopaedic Surgery and Sports Medicine, and Neurological Surgery, University of Washington; Division of Orthopaedic Surgery, The Spine Programme, Toronto Western Research Institute, Toronto Western Hospital, University of Toronto

Publication Information:

Spine 2011; 36: S120-S130.

Background Information:

The incidence and prevalence of low back pain are both well documented. Chronic low back pain can be a source of tremendous pain and disability to patients, and can be frustrating for practitioners to manage. In general, the management of chronic low back pain is non-surgical, but the question remains as to which conservative treatment options are likely the best for patients with chronic low back pain? Another issue with chronic low back pain is the associated costs due to treatment, which can be substantial. Exercise, spinal manipulation, and acupuncture have each been held out to be potentially valuable in the management of chronic low back pain.

However, the relative effectiveness and cost-effectiveness of these treatments requires further evaluation based on the current state of the literature, and this review sought to investigate these questions comparing those three treatments only with one another.

Pertinent Results:

Only two studies met the inclusion criteria of the review. Both evaluated structured exercise programs in comparison with SMT. Both the SMT and exercise groups improved in terms of pain and function in both studies but without substantial differences between the two treatments. The types of practitioners providing the SMT and the exercise programs involved in the two studies were considered dissimilar.

The authors rated the strength of the evidence that compared structured exercise with SMT as low, meaning that they had low confidence that the evidence yields the true effects of the interventions and that further research may change this conclusion. No studies that compared acupuncture with either exercise or SMT were included, nor were any studies that sufficiently evaluated cost-effectiveness or different sub-groups. These areas were found by the authors to have “insufficient” evidence to formulate a conclusion.

Clinical Application & Conclusions:

The authors concluded that based on the low level of evidence included in this review that structured exercise programs and SMT appear to have roughly equal benefit for chronic LBP from the standpoints of pain intensity and functioning. None of the three treatments were found to be clearly superior. Clinical benefit from either SMT or structured exercise should be apparent within 8 weeks of care. As such, for chronic low back patients an 8 week trial of structured exercise or SMT appears to be warranted.

In the absence of substantial clinical benefit after 8 weeks of one of these treatments, consideration should be given to re-evaluation and possible referral or alteration of treatment approach. However this recommendation is only weak based on the level and amount of evidence available.

The authors could not speculate as to the possible benefit of acupuncture compared with the other two therapies due to a lack of available evidence. The authors also could not determine which of the three therapies was most cost-effective or potentially of benefit to different sub-groups with chronic low back pain due to the lack of such studies and analyses.

Study Methods:

This was a systematic review of the literature that set out to find RCTs and meta-analyses on patients with low back pain who received one of SMT or exercise therapy or acupuncture in both comparison groups. Chronic low back pain was defined as pain for at least 3 months in patients with or without leg pain.

The search was done in Medline and the Cochrane Collaboration only, in English. This review was different in that subjects had to receive one of the above mentioned treatments only (not combined treatments) and only in comparison with one of the other above mentioned treatments. The review set out to answer five specific questions regarding the effectiveness of the three different treatments under study compared to one another, or if certain subgroups appear to respond better than others or if one of these treatments is more cost effective.

Study quality / level of evidence was assessed using a criteria set by the Journal of Bone and Joint Surgery, American Volume. Fixed-effect and random-effect estimates were performed. The overall strength of the literature was also determined.

Study Strengths / Weaknesses:

The biggest weakness of this article was the lack of articles that actually met the review’s inclusion criteria. This may speak to the inclusion criteria of this study being too stringent. A more expansive search (more databases, in more languages) may have been advisable. However, it is more likely that this is simply a case of the literature in this area being limited.

Acupuncture in particular was noted to have substantial weakness in terms of a lack of supporting evidence that could meet the inclusion criteria of the review; again a broader search in additional languages may have yielded more admissible articles on acupuncture.

As such, strong conclusions cannot be made from this article. Having said that, perhaps the greatest strength of this review is the unique inclusion criteria as previous systematic reviews of the management of chronic low back pain have not evaluated only studies that compare spinal manipulation or exercise therapy or acupuncture to one another. This removes the evaluation of “usual care” or sham treatments or combined therapies and should allow for the more clinically useful evaluation of therapy versus therapy only.

Additional References:

  1. Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 2010; 10(6): 514-529.
  2. Indrakanti SS, Weber MH, Takemoto SK, Hu SS, Polly D, Berven SH. Value-based Care in the Management of Spinal Disorders: A Systematic Review of Cost-utility Analysis. Clin Orthop Relat Res 2011; Nov 1: Epub ahead of print.
  3. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine 2011; 36(13): E825-46.