Moderators of the effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain: An individual participant data meta-analysis

STUDY DESIGN: Individual participant data (IPD) meta-analysis OBJECTIVE.: To identify which participant characteristics moderate the effect of spinal manipulative therapy (SMT) on pain and functioning in chronic LBP.

SUMMARY OF BACKGROUND: The effects of SMT are comparable to other interventions recommended in guidelines for chronic low back pain (LBP); however, it is unclear which patients are more likely to benefit from SMT compared to other therapies.

METHODS: IPD were requested from randomized controlled trials (RCTs) examining the effect of SMT in adults with chronic LBP for pain and function compared to various other therapies (stratified by comparison). Potential patient moderators (n = 23) were a-priori based on their clinical-relevance. We investigated each moderator using a one-stage approach with IPD and investigated this interaction with the intervention for each time point (1, 3, 6 and 12 months).

RESULTS: We received IPD from 21/46 RCTs (n = 4223)). The majority (12 RCTs, n = 2249) compared SMT to recommended interventions. The duration of LBP, baseline pain (confirmatory), smoking and previous exposure to SMT (exploratory) had a small moderating effect across outcomes and follow-up points; these estimates did not represent minimally relevant differences in effects; for example, patients with less than one year of LBP demonstrated more positive point estimates for SMT vs recommended therapy for the outcome pain, (mean differences ranged from 4.97 (95% CI: -3.20 to 13.13) at three months, 10.76 (1.06 to 20.47) at six months to 5.26 (-2.92 to 13.44) at twelve months in patients with over a year LBP. No other moderators demonstrated a consistent pattern across time and outcomes. Few moderator analyses were conducted for the other comparisons because of too few data.

CONCLUSION: We did not identify any moderators that enable clinicians to identify which patients are likely to benefit more from SMT compared to other treatments.

LEVEL OF EVIDENCE: 2.