Low Back Pain (LBP)

Clinical Practice Guidelines (CPG)

  • This CPG by the Canadian Chiropractic Guideline Initiative recommended for acute LBP: SMT, usual medical when deemed beneficial, advice (posture, staying active), reassurance, education and self-management strategies; for chronic LBP: SMT or SMT as part of multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial); for chronic LBP with leg pain: SMT, home exercise (positioning and stabilization), advice and education.1
  • The American College of Physicians developed this CPG for noninvasive treatments for acute, subacute and chronic LBP, which it recommends be used before pharmacological treatments.2
  • This set of recommendations on 20 non-surgical interventions for nonspecific LBP and LBP with radiculopathy of < 12 weeks duration is based on 2 CPGs from the Danish Health authority. It recommends treatment with patient education, supervised exercise, and manual therapy. It recommends against acupuncture, routine imaging, targeted treatment, extraforaminal glucocorticoid injection, acetaminophen, NSAIDs, and opioids.3


  • A 2017 systematic review of CPGs found that most high-quality guidelines recommend education, staying active/exercise, manual therapy and acetaminophen/NSAIDs as first-line treatments for LBP, although it stated that the recommendation for acetaminophen for acute LBP is challenged by recent evidence and needs updating.4
  • A 2017 systematic review of nonpharmacologic therapies for LBP found that evidence supports the effectiveness of exercise, psychological therapies, tai chi, mindfulness-based stress reduction, multidisciplinary rehabilitation, spinal manipulation, massage, yoga and acupuncture for chronic low back pain.5
  • A 2018 systematic review on manipulation and mobilization for chronic LBP found that There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Multimodal programs may be a promising option.6
  • A 2019 systematic review of kinesiotaping (KT) for chronic LBP found very low to moderate quality evidence that KT was no better than any other intervention.7
  • A 2017 systematic review of SMT for acute LBP found that SMT was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms.8
  • A 2019 scoping review on dosage (frequency of application of SMT) found that treatment frequency does not significantly affect clinical outcomes during and following an SMT treatment period.9
  • A 2019 systematic review of SMT for chronic LBP found that SMT produces similar effects to recommended therapies for chronic low back pain, but greater improvement in function than non-recommended interventions in the short term.10
  • A 2018 systematic review by the Agency for Healthcare Research and Quality on noninvasive nonpharmacological treatment for chronic pain found that massage, yoga, psychological therapies (primarily cognitive behavioral therapy), exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation were associated with slight improvements in function for chronic LBP.11

Randomized Controlled Trials

  • A 2017 RCT investigated the efficacy of shoe orthotics with or without chiropractic treatment (SMT, hot or cold packs and soft tissue massage) for chronic low back pain compared with no treatment. Six weeks of prescription shoe orthotics significantly improved back pain and dysfunction compared with no treatment; greater improvement in function was shown with orthotics plus chiropractic care.12
  • A 2019 RCT investigated the short-term effects of a modified Flexion-Distraction (FD) technique compared to high-velocity low-back spinal manipulation (HVLA-SM) for chronic LBP. Greater improvements in pain and function occurred in the FD group.13
  • A 2019 RCT compared exercise therapy (ET), manipulation therapy (MT), and a combination of the 2 (EMT) for sacroiliac joint dysfunction. Exercise and manipulation therapy appear to be effective in reducing pain and disability in patients with SIJD, but combination of these 2 therapies did not show significantly better results than either approach iseparately.14
  • A 2019 RCT compared medical care, group exercise, and manual therapy plus individualized exercise for lumbar stenosis. At 6 months, there were no between-group differences in mean outcome scores or responder rates. Conclusions and Relevance: A combination of manual therapy/individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, although all 3 interventions were associated with improvements in long-term walking capacity.15
  • A 2019 RCT investigated chiropractic maintenance care compared to symptom-guided care for recurrent or persistent LBP. MC was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific LBP but it resulted in a higher number of treatments. For selected patients with recurrent or persistent non-specific LBP who respond well to an initial course of chiropractic care, MC should be considered an option for tertiary prevention.16

Other Study Designs

  • A 2018 study reported on the development of an evidence-based set of consensus recommendations on an integrated care pathway for DCs, primary care providers, and mental health professionals who manage veterans with LBP, with or without mental health comorbidity, within VA health care facilities.17
  • A 2018 quasi-experimental clinical study investigated the effect of lumbar and sacroiliac joint (SIJ) manipulation in 20 patients with lumbar disc herniation (LDH) concomitant with SIJ hypomobility. It found that 5 sessions of lumbar and SIJ manipulation improved pain and functional disability.18


  1. Bussières AE, Stewart G, Al-Zoubi F, et al. Spinal manipulative therapy and other conservative treatments for low back pain: A guideline from the Canadian Chiropractic Guideline Initiative. J Manipulative Physiol Ther. 2018;41(4):265-293.
  2. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. FREE FULL TEXT
  3. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60-75.
  4. Wong JJ, Cote P, Sutton DA, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain. 2017;21(2):201-216. FREE FULL TEXT
  5. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med. 2017;166(7):493-505. FREE FULL TEXT
  6. Coulter ID, Crawford C, Hurwitz EL, et al. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J. 2018;18(5):866-879. FREE FULL TEXT
  7. Luz Junior MAD, Almeida MO, Santos RS, Civile VT, Costa LOP. Effectiveness of kinesio taping in patients with chronic nonspecific low back pain: a systematic review with meta-analysis. Spine (Phila Pa 1976). 2019;44(1):68-78.
  8. Paige NM, Miake-Lye IM, Booth MS, et al. Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain: systematic review and meta-analysis. JAMA. 2017;317(14):1451-1460. FREE FULL TEXT
  9. Pasquier M, Daneau C, Marchand AA, Lardon A, Descarreaux M. Spinal manipulation frequency and dosage effects on clinical and physiological outcomes: A scoping review. Chiropr Man Ther. 2019;27(23): 12 p. FREE FULL TEXT
  10. Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019;364:l689. FREE FULL TEXT
  11. Skelly AC, Chou R, Dettori JR, et al. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018. FREE FULL TEXT
  12. Cambron JA, Dexheimer JM, Duarte M, Freels S. Shoe orthotics for the treatment of chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2017;98(9):1752-1762. FREE FULL TEXT
  13. Carrasco-Martinez F, Ibanez-Vera AJ, Martinez-Amat A, Hita-Contreras F, Lomas-Vega R. Short-term effectiveness of the flexion-distraction technique in comparison with high-velocity vertebral manipulation in patients suffering from low-back pain. Complement Ther Med. 2019;44:61-67.
  14. Nejati P, Safarcherati A, Karimi F. Effectiveness of exercise rherapy and manipulation on sacroiliac joint dysfunction: a randomized controlled trial. Pain Physician. 2019;22(1):53-61. FREE FULL TEXT
  15. Schneider MJ, Ammendolia C, Murphy DR, et al. Comparative clinical effectiveness of nonsurgical treatment methods in patients with lumbar spinal stenosis: a randomized clinical trial. JAMA Netw Open. 2019;2(1):e186828. FREE FULL TEXT
  16. Eklund A, Jensen I, Lohela-Karlsson M, et al. The Nordic Maintenance Care program: effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain-A pragmatic randomized controlled trial. PLoS One. 2018;13(9):e0203029. FREE FULL TEXT
  17. Lisi AJ, Salsbury SA, Hawk C, et al. Chiropractic integrated care pathway for low back pain in veterans: results of a Delphi consensus process. J Manipulative Physiol Ther. 2018;41(2):137-148. FREE FULL TEXT
  18. Shokri E, Kamali F, Sinaei E, Ghafarinejad F. Spinal manipulation in the treatment of patients with MRI-confirmed lumbar disc herniation and sacroiliac joint hypomobility: a quasi-experimental study. Chiropr Man Therap. 2018;26:16. FREE FULL TEXT