By far the majority of patients that we see here at the clinic are suffering from back pain – and the largest chunk of those struggle with low back pain. While there’s much more to what chiropractors (and especially multidisciplinary clinics like Complete Chiropractic) have to offer, it’s likely that if you’ve been to a chiropractor, its for back pain.
What is SMT?
SMT (or spinal manipulation therapy) is the broad term which includes chiropractic treatments. The study we’ll be looking at today considered SMT to be any kind of hands-on treatment of the spine, including both mobilisation and manipulation. Mobilisations use low-grade velocity, small or large amplitude passive movement techniques within the patient’s range of motion and control, whereas manipulation uses a high-velocity impulse or thrust applied to a synovial joint over a short amplitude at or near the end of the passive or physiological range of motion. In plain English, that’s a gentle pressing force, or a targeted adjusting force – the latter is often accompanied by an audible crack, which is perhaps what chiropractors are best known for!
The biggest short term advantage of SMT, over “traditional”drug-based approaches, is just that, the absence of drugs. We’ve written many times on this blog about the potential side effects of long term drug usage, which SMT avoids completely. Over the longer term, many studies have suggested that SMT is the best way to resolve, and then reduce the risk of a reoccurrence of a painful back complaint.
Is SMT the “recommended” treatment?
Once upon a time, the answer to this question was no – in many (read most) countries, drug-based therapies, or non-specific physiotherapy were the main options for the treatment of back pain. In the UK, drug-based approaches are still the most commonly recommended by GP’s, however, this is beginning to change, with some (sadly still few) NHS commissioning groups now offering chiropractic as a treatment.
In some countries, however, SMT is now considered a first-line treatment option[1], whereas in others it is recommended as a component of a broader treatment package including exercise, or is not included or mentioned at all.[2] The most recent summary of these guidelines suggests that SMT should be considered a second-line or adjuvant treatment option, after exercise or cognitive behavioural therapy.[3]
For the purposes of the study we examine today, SMT was not considered a recommended treatment – these were instead a drug-based approach, or an exercised based approach. Also considered with treatment methodologies without significant evidence for back pain, such as electrotherapy.
Is SMT effective?
The latest study[4], a meta-study (which is to say, a study of studies, taking into account a very large population group) examined individuals from 47 randomised controlled trials including a total of 9211 participants, with an average age from 35-60.Studies were considered eligible if they included adults (≥18 years) and if more than 50% of the study population had pain lasting more than three months. Most of the studies looked at SMT specifically, however studies where the observed differences were thought to be due to the unique contribution of SMT, which may include studies in which SMT was delivered as part of a package of care were also included.
Excluded from the study were participants with postpartum low back pain or pelvic pain due to pregnancy, pain unrelated to the lower back, postoperative studies, patients with serious pathology, and studies that examined “maintenance care” or prevention (as opposed to initial treatment); in addition to studies that were designed to test the immediate post-intervention effect of a single treatment only as well as those studies that exclusively examined back-related conditions (eg, sciatica).
Taking all these conditions into account, the results were clear:
SMT vs. recommended therapies (ie. Drugs and exercise)
The results showed that SMT was as effective as the recommended approaches at one and 12 months, but interestingly, seemed to be more effective at the 6-month mark. The study also suggested SMT results in a small, statistically better effect than recommended interventions at one month but not statistically better effect at six and 12 months. Overall, we can, therefore, say that SMT improves functionality quickly in the short term, and reduces pain as well as the recommended therapies – but gives better medium-term care performance. This, of course, comes without the risk of drug usage!
SMT vs. Non recommended therapies
The results showed that SMT provided a better reduction in pain at one, six and 12 months, vs non-recommended approaches. Similarly, back-specific functional capacity was better in the SMT group than for non-recommended therapies.
SMT with other therapies
The results suggested that SMT results in a small statistically significant and clinically better effect at one month, and (while less strongly indicated) that SMT results in a small, statistically significant and clinically better effect at 12 months – when paired with an appropriate complementary therapy. Interestingly, the results suggest that this dual approach did not lead to a statistically significant effect at six months.
Take away points
Meta studies always produce complex statistics, which chiropractors can spend a great deal of time debating – but for you as a patient, there are a couple of key points to take away –
- Spinal manipulation therapy, was, on the whole, as effective as drug-based approaches
- SMT can deliver the same benefits without the drug-related risk
- SMT is more effective than treatments not specifically recommended for back pain
- Around the world, the value of Chiropractic approaches is slowly being recognised, expect to see SMT based approaches play a greater role in the future.
[1] Qaseem A, Wilt TJ, McLean RM, Forciea MA;
Clinical Guidelines Committee of the American College of Physicians.
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline From the American College of Physicians
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 514–530
[2] Bons SCS, Borg MAJP, Van den Donk M, et al.
NHG guideline for aspecific low-back pain, 2017.
[3] Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM.
Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions
Lancet. 2018 (Jun 9); 391 (10137): 2368–2383
[4] Sidney M Rubinstein, Annemarie de Zoete, Marienke van Middelkoop, Willem J J Assendelft, Michiel R de Boer, and Maurits W van Tulder, Benefits and Harms of Spinal Manipulative Therapy for the Treatment
of Chronic Low Back Pain: Systematic Review and Meta-analysis
of Randomised Controlled Trials. British Medical Journal 2019 (Mar 13); 364: l689
