Main Study Findings and Author’s Conclusions

Ismat Kanga; Melissa Severn

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Kanga I, Severn M. Manual Therapy for Recent-Onset or Persistent Non-Specific Lower Back Pain: A Review of Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Aug 2.

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Manual Therapy for Recent-Onset or Persistent Non-Specific Lower Back Pain: A Review of Clinical Effectiveness and Guidelines [Internet].

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Appendix 4Main Study Findings and Author’s Conclusions

Table A5Summary of Findings of Included Systematic Reviews and Meta-Analyses

Main Study Findings	Author’s Conclusion
Paige et al. 2017²⁰
Spinal manipulation vs. other treatments (sham SMT, analgesics, exercises, physical therapy, etc.) analgesics, exercises, physical therapy, etc.) Meta-Analyses Association With Pain Short-term pain: Mean effect of -9.95mm ( 95% CI, -15.6 to -4.3; I²= 67%) on a 0-100mm scale in favour of SMT in comparison with other treatments Immediate-term pain: Mean effect of -9.76mm (95% CI, -17.0 to -2.5) on a 0-100mm scale in favour of SMT in comparison to comparison to other treatments Association With Function Short-term function: Effect size of -0.39 (95%CI, -0.71 to -0.07; I²= 72%) in favour of SMT in comparison with other treatments Immediate-term function: No statistically significant effect on function (effect size -0.24mm; 95% CI, -0.55 to 0.08) Studies Considered Separately 4 RCTs excluded from pooled analysis due to common characteristics ◦ 2 low quality RCTs reported benefits in favour of SMT ◦ 1 high quality RCT stratified patients according to a clinical prediction rule identifying patients most likely to benefit from SMT; those identified as more likely to benefit from SMT, showed benefit in function at 1 week ◦ 1 high quality RCT used the same clinical predication rule. SMT group had statistically significant benefits in pain and function, but the magnitude of benefits was smaller in comparison to the other 3 studies. Adverse Events 8 RCTs prospectively investigated harms in patients receiving SMT using a questionnaire 50% to 67% of patients reported mild, transient harms Local discomfort or increased pain were most frequently reported	The quality of evidence was judged as moderate that treatment with SMT was associated with improved pain and function in patients with acute low back pain” (p1457)²⁰ “The quality of evidence was judged as high that SMT is commonly associated with transient minor musculoskeletal harms, although they may be equally common following non-SMT manual therapy.”(p1457)²⁰ “The principal conclusion of this review was that SMT treatments for acute low back pain were associated with statistically benefit in pain and function at up to 6 weeks, that was, on average clinically modest.”(p1457)²⁰
Rothberg and Friedman, 2017¹¹
Spinal Manipulation RCT of 240 patients ◦ Randomized into 4 groups: diclofenac 50mg, b.i.d. + sham therapy, placebo + SMT, diclofenac + SMT, and placebo + sham therapy. ◦ All patients received advice from their GP and were prescribed acetaminophen 1g q.i.d. ◦ Groups did not differ in number of days to sustained pain freedom, level of pain measured via VAS, functional impairment on ODI or patient perceptions RCT of 104 patients ◦ Received standard care (acetaminophen, diclofenac, and dihydrocodeine) with or without spinal manipulation ◦ No statistically significant differences reported between groups for pain measured via VAS or analgesic use Massage No eligible studies identified in the initial review or updated search	“for patients with acute or subacute, nonradicular LBP, available evidence does not support the use of spinal manipulation or exercise therapy in addition to standard medical therapy. There is insufficient evidence to determine if yoga or massage is beneficial.”(p61)¹¹
Yeganeh et al., 2017³
Chiropractic vs. physical therapy modalities Meta-analysis pooled patients (n= 204) from 3 RCTs on spinal manipulation, manual therapy and massage therapy demonstrated no statistically significant effects on pain, function or range of motion ◦ Pain : SMD 0.13 (95% CI, -0.72 to 0.99; I² = 87.4%) at 2 weeks; SMD 0.02 (95% CI, -0.67 to 0.70; I² = 80.5%) at 6 weeks ◦ Disability: SMD -0.02 (95% CI, -0.76 to 0.72; I² 83.3%) at 2 weeks ◦ Flexion range of motion : SMD 0.50 (95% CI, -0.02 to 1.02; I² = 66.6%) at 2 weeks	Authors report “chiropractic may have a favourable effect on self-reported pain and functional limitations on NSCLBP.”(p11)³ despite no statistically significant differences in pain, function or range of motion. “the results should be interpreted in the context of the limitations identified, particularly in relation to the heterogeneity in the study characteristics and the low methodological quality in many of the included studies.”(p11)³
Chou et al., 2016⁶
The authors graded the strength of evidence (SOE) from insufficient to high (Appendix 5, Table A7). Massage Acute LBP : Massage vs. sham ◦ Low SOE: 1 SR (2 RCTs) – Statistically significant effect on pain (SMD -0.92; 95% CI, -1.35 to -0.48) and function (SMD -1.76; 95% CI, -3.19 to -0.32) in the short-term(1 week) Chronic LBP: Massage vs. usual care ◦ Low SOE ◦ 1 RCT found benefit of structural or relaxation massage on function (mean, 2.5 to 2.9 on RMDQ) at 10 weeks Subacute to Chronic LBP : Massage vs. other interventions ◦ Moderate SOE: 1 SR massage has short-term benefits on pain (MD -0.6 to -0.94 on 0 to 10 scale) and function Subacute to Chronic LBP : Massage + other activeintervention vs. other intervention ◦ Low SOE ◦ 1 SR (5 RCTs) massage +active intervention has positive effect on short-term pain; no differences observed for function or long-term pain ◦ 2 RCTs on massage + exercise demonstrated similar findings to the SR Different massage techniques ◦ Insufficient SOE due to heterogeneity in studies and small treatment effects Adverse events ◦ Low SOE ◦ 2 RCTs reported soreness during and posttreatment ◦ No trials reported serious adverse events Spinal manipulation Acute LBP: SMT vs. sham ◦ Low SOE : 1 SR(2 RCTs) SMT has positive effect on function ◦ Insufficient SOE : 1 RCT found no statistically significant effect on pain ( mean difference -0.50, 95% CI, -1.39 to 0.39) Acute LBP :SMT vs. inert treatments ◦ Low SOE : 1 SR ◦ No statistically significant differences in pain at 1 week (WMD 0.14 on a 0 to 10 scale; 95% CI, -0.69 to 0.96; I²= 27%; 3 RCTs) and function at 1 week (SMD -0.08; 95% CI, -0.37 to 0.21; I²=0%; 2 RCTs) or 3 months(SMD -0.28; 95% CI, -0.59 to 0.02) Acute LBP: SMT vs. active interventions ◦ Moderate SOE ◦ 1 SR found no statistically significant difference in pain at 1 week(WMD 0.06 on a 0 to 10 scale; 95% CI, -0.53 to 0.65; I²=0%; 3 RCTs), 1 month (WMD -0.15 on a 0 to 10 scale; 95% CI, -0.49 to 0.18; I²=0%; 3 RCTs), 3 to 6 months (WMD -0.20 on a 0 to 10 scale; 95% CI, -1.13 to 0.73; I²=81%; 3 RCTs) or 1 year (mean difference 0.40; 95% CI, -0.08 to 0.88;1 RCT) ◦ No statistically significant differences were found for function at any follow-up interval Acute LBP: SMT + exercise or advice vs. exercise or advice ◦ 4 RCTs from 1 SR found SMT + exercise or advice group had a statistically significant effect on function at 1 week (SMD -0.41; 95% CI, -0.73 to -0.10; I² =18%) , but no significant difference at 1 month ( SMD -0.09; 95% CI, -0.39 to 0.21; I² = 37%) or 3 months (SMD -0.22, 95% CI, -0.61 to 0.16; I² = 41%) Chronic LBP: SMT vs. sham ◦ Low SOE ◦ 1 SR (3 RCTs) found no statistically significant effect on pain (WMD -3.24 on a 0 to 100 scale; 95% CI, -13.62 to 7.15; I² = 53%) ◦ 1 RCT found no statistically significant effect on function (SMD, -0.45; 95% CI -0.97 to 0.06) ◦ 1 RCT not included in the SR reported similar results Chronic LBP: SMT vs. inert treatment ◦ Low SOE : 1 RCT; SMT group reported greater improvement in the “main complaint” (mean difference 0.9 on a 0 to 10 scale; 95% CI, 0.1 to 1.7) Chronic LBP: SMT vs. other interventions ◦ Moderate SOE ◦ 1 SR found SMT group reported statistically significant pain relief at 1 month (WMD -2.76 on a 0 to 100 scale, 95% CI, -5.19 to -0.32; I² = 27%; 6 RCTs) and 6 months (WMD -3.07 on a 0 to 100 scale, 95% CI, -5.42 to -0.71; I² = 0%; 4RCTs), but not at 12 months; (WMD -0.76 on a 0 to 100 scale, 95% CI, -3.19 to 1.66; I² = 0%) ◦ Statistically significant improvement in function at 1 month (SMD -0.17; 95% CI, -0.29 to -0.06; I² = 3%; 6 RCTs), but not at 6 months or 12 months ◦ 3 RCTs not included in review reported similar results Chronic LBP: SMT + active intervention vs. other intervention ◦ Low SOE:1 SR ◦ Statistically significant effect on pain relief at 1 month (WMD -5.88 on a 0 to 100 scale, 95% CI, -10.85 to -0.90; I² = 0%; 3 RCTs), 3 months (WMD -7.23 on a 0 to 100 scale, 95% CI, -11.72 to -2.74; I² = 43%; 2 RCTs), and 12 months (WMD -3.31 on a 0 to 100 scale, 95% CI, -6.60 to -0.02; I² = 12%; 2 RCTs) ◦ Statistically significant effect on function at 1 month (SMD -0.40; CI, -0.73 to -0.07; I² = 0%; 2 RCTs), 3 months (SMD -0.22; CI, -0.38 to -0.06; I² = 33%; 2 RCTs), and 12 months(SMD -0.21; CI, -0.34 to -0.09; I² = 0%; 2 RCTs) ◦ 1 RCT not included in SR reported similar findings Radicular LBP: SMT + home exercise and advice vs. home exercises and advice ◦ Low SOE : 1 RCT found SMT group reported greater improvement in leg and back pain at 12 weeks(mean difference 1 point on a 0 to 10 scale) and non- statistically significant effect at 52 weeks (mean difference 0.3 to 0.7 points on a 0 to 10 scale) Adverse Events ◦ Low SOE ◦ Muscle soreness or temporary increase in pain most commonly reported ◦ No serious adverse events reported Traction Traction vs. placebo, sham, or no treatment, LBP with o without radiculopathy ◦ Insufficient SOE :1 SR (13 RCTs) no effect of traction on pain, function or other outcomes; 2 of the 13 trials reported favourable effects on radicular pain Traction vs. physiotherapy ◦ Low SOE: no difference between traction and physiotherapy Traction vs. other interventions, LBP with or without radiculopathy ◦ Low SOE :1 SR (15 RCTs) with low strength of evidence found no effect on pain or function Different traction techniques ◦ Low SOE : 1 SR ( 5 RCTs) reported no differences in between types of traction Adverse Events ◦ Low SOE: No adverse events reported in any trial and no difference in risk of adverse event in comparison to placebo	“Our findings regarding the effectiveness of massage, acupuncture, and manipulation were generally consistent with the APS/ACP review in showing some beneficial, primarily short-term effects.”(p207)⁶ “Spinal manipulation was no more effective than sham manipulation for chronic low back pain, but manipulation was as effective as other interventions thought to be effective.”(p207)⁶ “Few trials evaluated the effectiveness of treatments for radicular low back pain, but the available evidence found that benzodiazepines, corticosteroids, traction, and spinal manipulation were not effective or were associated with small effects (SOE: low)”(pvii).⁶ “Harms were not well-reported in trials of nonpharmacological therapies, though serious adverse events appear rare.”(p207)⁶ “Severe neurological complications were not reported in trials of lumbar spinal manipulation”(p207)⁶
Hall et al.,2016¹³
Manual therapy vs. usual care or standard prenatal care Statistically significant effect of manual therapy on ◦ Pain intensity (SMD -0.70; 95% CI, -1.10 to -0.30) ◦ Pain disability (SMD-0.62; 95% CI, -0.93 to -0.31) Manual therapy vs. relaxation Statistically significant effect on pain intensity (SMD -0.77; 95% CI, -1.22 to -0.32) Manual therapy vs. sham No statistically significant effect demonstrated on ◦ Pain intensity (SMD 0.05; 95%CI, -0.15 to 0.26) ◦ Pain disability (SMD -0.08; 95% CI, -0.40 to 0.25)	“the results indicated a moderate treatment effect of manual therapies for decreasing pain intensity compared to usual care and relaxation, and a moderate effect on pain disability compared to usual care.” (p7)¹³ “ no positive effect on manual therapies were found for either pain intensity or pain disability when compared to sham interventions”(p7)¹³ “This review also found positive effects for pain disability for craniosacral technique and osteopathy compared to usual care”(p7)¹³ “These findings are consistent with a recent Cochrane review suggesting moderate-quality evidence from individual studies that indicate osteopathic manipulative therapy significantly reduced LBP and disability” (p7)¹³ “There is currently limited evidence to support the use of manual therapies including massage and osteopathic manipulative treatment as an option for managing LBP and PGP during pregnancy. Current research is associated with risk of publication and methodological biases, and lack of robust control comparisons.”(p8)¹³
Macedo et al. 2016¹⁹
Acute LBP : Motor control exercises vs. spinal manipulation SR included 1RCT of low quality No statistically significant difference in pain relief at short-term (two to four weeks) follow-up (MD 9.00 on a 0 to 100 scale; 95% CI, -1.56 to 19.56) No statistically significant difference in disability at short-term follow-up (MD 4.00 on a 0 to 100 scale ; 95% CI, -3.38 to 11.38) and long-term ( one year) follow-up (MD 3.70 on a 0 to 100 scale; 95% CI, -4.10 to 11.50	“This review provides evidence of very low to moderate quality indicating no clinically important differences in outcome with motor control exercise (MCE) compared to other forms of treatment for patients with acute low back pain (LBP). Specifically, low-quality evidence when MCE is compared to spinal manipulative therapy for pain at short-term follow-up and for disability at short-term and long-term follow-up .” (p18)¹⁹
Poquet et al., 2016²¹
Back schools vs. manual therapies SR included 1 RCT (n=99) Back schools vs. myofascial therapy No statistically significant difference in pain (10cm VAS scale) at short-term follow-up (MD -0.65; 95%CI, -1.49 to 0.19) and intermediate follow-(MD -0.70; 95% CI, -1.92 to 0.52) No statistically significant difference in disability at short-term follow-up (MD -1.54; 95% CI -3.88 to 0.80) and intermediate-term follow-up (MD -1.58; 95% CI, -4.02 to 0.86) No statistically significant difference in risk of adverse events between groups (RR 1.59; 95% CI, 0.48 to 5.30) Transient exacerbation of symptoms most commonly reported adverse event Back schools vs. joint manipulation No statistically significant difference in pain (10cm VAS scale) at short-term follow-up (MD -0.45; 95% CI, -1.33 to 0.43) and intermediate follow-( MD -0.11; 95% CI, -1.39 to 1.17) No statistically significant difference in disability at short-term follow-up (MD -0.16; 95% CI, -2.50 to 2.18) and intermediate-term follow-up (MD 0.19; 95% CI, -2.30 to 2.68) No statistically significant difference in risk of adverse events between groups (RR 1.02; 95% CI, 0.35 to 2.94) Transient exacerbation of symptoms most commonly reported adverse event Back schools vs. joint manipulation + myofascial therapy No statistically significant difference in pain (10cm VAS scale) at short-term (MD 0.09; 95%CI, -0.68 to 0.86) and intermediate follow-up (MD 0.05; 95% CI, -1.13 to 1.23) No statistically significant difference in disability at short-term (MD 0.53; 95% CI, -1.60 to 2.66) and intermediate-term follow-up (MD -0.08; 95% CI, -2.33 to 2.17) No statistically significant difference in risk of adverse events between groups (RR 0.93; 95% CI, 0.34 to 2.57)	“According to the adapted GRADE approach, there was very low quality evidence of no difference between back schools and placebo (or sham or attention control) or comparison treatments (physical therapies, myofascial therapy, joint manipulation, advice) in terms of pain, disability, work status and adverse events for any time of follow-up.”(p28)²¹
Ruddock et al., 2016²²
Spinal manipulation vs. sham manipulation Results from SR: Pain: SMT group reported lower levels of pain posttreatment and at follow-up in 5 of the 6 included RCTs Function: SMT group reported improved OLBPDQ scores in 2 of the 4 included RCTs Adverse Events: 3 RCTs reported adverse events, transient local discomfort and tiredness was reported in 1 RCT and 2 reported no adverse events occurred Results from MA: SMT group reported reduction in pain at follow-up (SMD -0.36 on a 100-mm VAS; 95% CI, -0.59 to -0.12; I2 < 0.1%; 4 RCTs)	“results of the meta-analysis suggest a greater reduction in pain scores among participants receiving SM in comparison to those receiving an effective sham placebo. This finding remained consistent when looking at pain recorded at immediately posttreatment and follow-up”(p173)²² “In terms of clinical relevance, this is only a small to moderate effect,[53,54] and the CIs are wide. Caution is needed before drawing conclusions because most studies had some degree of RoB”(p173)²² “given the small number of studies included in this analysis, we should be cautious of making strong inferences based on these results.” (p165)²²
Saragiotto et al., 2016¹⁸
Chronic LBP : Motor control exercise vs. manual therapy Manual therapy included spinal manipulation, mobilization, soft-tissue therapy, and physiotherapy Pain No statistically significant difference between groups at short-term (MD -4.36 on a 0 to 100 scale; 95% CI, - 9.52 to 0.81; 3 RCTs), intermediate (MD -7.05 on a 0 to 100 scale; 95% CI, -14.20 to 0.11 4RCTs), and long-term follow-up (MD -3.67 on a 0 to 100 scale; 95% CI, - 9.28 to 1.94, 4 RCTs) Disability No statistically significant difference between groups at short-term (MD -2.79 scale ; 95% CI, -6.60 to 1.02, 3 RCTs), intermediate (MD -3.28; 95% CI, -6.97 to 0.40, 4 RCTs) and long-term follow-up ((MD 3.40; 95% CI, - 7.87 to 1.07, 4 RCTs) Function No statistically significant difference between groups at short-term (MD 0.20; 95% CI, -1.82 to 2.22; 1 RCT) , intermediate (MD -0.90 on 0 to 100 scale; 95% CI, - 3.01 to 1.21; 1 RCT) and long-term follow-up (MD 0.50; 95% CI on a 0 to 100 scale, -1.61 to 2.61; 1 RCT) Global Impression of Recovery No statistically significant difference at short-term (MD 0.50 on a 0 to 100 scale; 95% CI, -0.12 to 1.12; 1 RCT), intermediate (MD 0.20 on a 0 to 100; 95% CI, - 0.58 to 0.98; 1 RCT) and long-term follow-up (MD 0.60; 95% CI, -0.24 to 1.44; 1 RCT) Adverse Events 2 RCTs reported no adverse events occurring	“We did not find a clinically important difference between MCE and manual therapy for any of the outcomes investigated, with moderate to high quality evidence.”¹⁸
Bervoets et al., 2015¹⁷
Massage vs. no treatment control Pain No statistically significant effect of massage at short-term follow-up (MD -12; 95% CI, -32 to 8 on a 0 to 100 scale; I²= 81%; 2 RCTs) Function Statistically significant difference in function measured via RMDQ (0 to 24) at short-term follow-up (MD -2.5; 95% CI, -3.4 to -1.6, I² = 0%; 2 RCTs) Massage vs. active treatments Pain 1 RCT, greater pain reduction in massage group vs. joint mobilization; no benefit over spinal manipulation Function 2 RCTs, in the short-term no improvement in function over acupuncture or relaxation; relaxation superior to massage in the long-term	““It was concluded that, in the short term, there is moderate-level evidence that massage reduces pain compared to no treatment in people with shoulder pain but not in those with low back pain” (p112)¹⁷ “there is moderate-level evidence that massage improves function compared to no treatment in people with low back pain”(p112)¹⁷ “When massage is compared to another active treatment, no clear benefit was evident.” (p106)¹⁷
Furlan et al. 2015²³
Acute LBP Massage vs. inactive controls Pain Statistically significant difference at short-term follow-up (SMD -1.24; 95% CI, -1.85 to -0.64; 1 RCT) Function No statistically significant difference at short-term follow-up (SMD -0.50; 95% CI, -1.06 to 0.06; 1 RCT) Sub-Acute and Chronic LBP Massage vs. inactive controls Pain Statistically significant effect at short-term follow-up (SMD -0.75; 95% CI, -0.90 to -0.60; I² = 0%; 7 RCTs), but not at long-term follow-up ( SMD 0.02; 95% CI, - 0.15 to 0.18; I² = 0%; 3 RCTs) Function Statistically significant effect at short-term follow-up (SMD -0.72; 95% CI, -1.05 to -0.39; I² = 74%; 6 RCTs), but not at long-term follow-up ( SMD -0.16; 95% CI, -0.32 to 0.01; I² = 0%; 3 RCTs) Massage vs. active controls Pain Statistically significant effect at short-term follow-up (SMD -0.37; 95% CI, -0.62 to -0.13; I² = 68%; 12 RCTs) and long-term follow-up (SMD -0.40; 95% CI, -0.80 to -0.01; I² = 86%; 5 RCTs) Function No statistically significant difference at short-term (SMD -0.24; 95% CI, -0.62 to 0.13; I² = 79%; 6 RCTs) and long-term follow-up (SMD -0.21; 95% CI, -0.60 to 0.17; I² = 82%; 4 RCTs) Adverse Events No difference in adverse events vs. inactive controls (RD 0.06; 95% CI, 0.00 to 0.11; I² = 73%; 4 RCTs) and active controls ( RD 0.01; 95% CI, -0.01 to 0.03; I² = 0%; 5 RCTs) Increased pain most commonly reported adverse event	“very little confidence that massage is an effective treatment for LBP. Acute, sub-acute and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up. Functional improvement was observed in participants with subacute and chronic LBP when compared with inactive controls, but only for the short-term follow-up.”(p2)²³
Liddle and Pennick 2015¹⁶
Low back pain: Manual therapy + usual prenatal care vs. 1 RCT found added benefit from adding OMT to usual care on pain ( effect size -7.11; 95% CI, -10.30 to - 3.93) and functional disability ( effect size -2.25; 95% CI, -3.18 to -1.32) in comparison to usual care alone 1 RCT found no statistically significant difference in pain ( effect size 0.14; 95% CI, -0.26 to 0.53) or functional disability (effect size 0.35; 95% CI, -0.06 to 0.76) in OMT + usual care group in comparison to prenatal care + placebo ultrasound 1 RCT found OMT + usual care more effective in pain reduction in comparison to usual prenatal care ( between-group mean difference 3.5; 95% CI, 2.4 to 4.6) 1 RCT found no statistically significant difference in pain or functional disability between exercise, NET and SMT groups LBP (including pelvic pain): Manual therapy + usual prenatal care vs. usual prenatal care + waiting list 1 RCT found OMT statistically significant reduction in pain and improved functional disability Adverse Events No serious adverse events were reported in any included RCT	For mixed populations of low back and pelvic pain “Findings suggested that craniosacral therapy, osteomanipulative therapy or a multi-modal intervention (manual therapy, exercise and education) may be of benefit.”(p3)¹⁶

: APS/ACP = American Pain Society/ American College of Physicians; b.i.d. = twice a day; CI= confidence interval; LBP = low back pain; MA = meta-analysis; MD = mean difference; MCE = motor control exercise; NET = neuro emotional technique; NSCLBP = nonspecific chronic low back pain; ODI/OLBPDQ = Oswestry low back pain disability questionnaire; OMT = osteomanipulative therapy/osteopathic manipulative therapy; q.i.d. = four times a day; RCT = randomized controlled trial; RD= risk difference; RMDQ = Roland Morris Disability Questionnaire; RR= relative risk; SOE = strength of evidence; SR = systematic review; SMD = standardized mean difference; SMT = spinal manipulative therapy; VAS = visual analog scale; WMD = weighted mean difference.

Table A6Summary of Recommendations in Included Guidelines

Findings and Recommendations	Grade/Strength of Recommendation
Qaseem et al. 2017²⁴
“Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence).”(p521)	Strength of Recommendation: Strong (“benefits are finely balanced with risks and burden or appreciable uncertainty exists about the magnitude of benefits and risks, a recommendation is classified as weak. Patient preferences may strongly influence the appropriate therapy.”(p198)²⁸)
“Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence).”(p521)	Strength of Recommendation: Strong
NICE, 2016²⁵
“Do not offer traction for managing low back pain with or without sciatica,”(p19)	Strength of Recommendation: Do not offer (“recommendations for activities or interventions that should (or should not) be used”(p172)³¹)
“Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as a part of a treatment package including exercise, with or without psychological therapy.”(p19)	Strength of Recommendation: Consider (“recommendations for activities or interventions that could be used”(p172) ³¹)
Côté et al., 2015⁸
Recent onset non-specific low back pain
“Consider a maximum of seven sessions over one month of manipulation.”(p246)	Strength of Recommendation: Could Wording used to convey the strength: Consider (“Interventions have similar outcomes” or “Offers a choice of interventions or whether to have an intervention at all” (p59)⁸)
Persistent non-specific low back pain
“Consider a maximum of nine sessions over 12 weeks of manipulation or mobilization*.”(p249)	Strength of Recommendation: Could Wording used to convey the strength: Consider (“Interventions have similar outcomes” or “Offers a choice of interventions or whether to have an intervention at all” (p59)⁸)
“Consider a maximum of ten sessions over ten weeks of clinical massage or relaxation massage*.”(p250)	Strength of Recommendation: Could Wording used to convey the strength: Consider (“Interventions have similar outcomes” or “Offers a choice of interventions or whether to have an intervention at all” (p59)⁸)
Recent onset lumbar disc herniation with radiculopathy
“Consider a maximum of 20 sessions over 6 weeks of manipulation for symptomatic relief.”*(p259)	Strength of Recommendation: Could Wording used to convey the strength: Consider (“Interventions have similar outcomes” or “Offers a choice of interventions or whether to have an intervention at all” (p59)⁸)

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Kanga I, Severn M. Manual Therapy for Recent-Onset or Persistent Non-Specific Lower Back Pain: A Review of Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Aug 2. Appendix 4, Main Study Findings and Author’s Conclusions.
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