Research Review: Spinal Manipulation vs. NSAID (Diclofenac) for Acute Low Back Pain

Article: Spinal high-velocity low amplitude manipulation in acute nonspecific low back pain: a double-blinded randomized controlled trial in comparison with diclofenac and placebo.

Authors: von Heymann WJ, Schloemer P, Timm J, Muehlbauer B.

Publication Information: Spine (Phila Pa 1976). 2013 Apr 1;38(7):540-8. doi: 10.1097/BRS.0b013e318275d09c.

Comment from Dr. Jeff Williams

The importance and impact of low back pain cannot be overstated at this point. Low back pain has commanded center stage in discussions on topics such as disability, workers compensation, and the opioid crisis our nation is currently experiencing. Below are several often-quoted stats on low back pain in general:

  • Eight out of every 10 people will experience back pain.1
  • Low back pain is the single leading cause of disability worldwide.2
  • Back pain is the second most common reason for visits to the doctor’s office, right behind upper-respiratory infections.3
  • More than one in three adults say back pain impacts everyday activities, including sleep.4
  • Back pain costs more than $100 billion every year when factoring in lost wages and productivity, in addition to legal and insurance overhead costs.5

The purpose of this randomized, double-blinded, placebo-controlled, parallel trial was to compare high-velocity low-amplitude spinal manipulation with chemical treatment. In this case, the chemical treatment was diclofenac, a nonsteroidal anti-inflammatory (NSAID). The trial also included comparison with placebo.

According to WebMD, diclofenac “is used to relieve pain, swelling (inflammation), and joint stiffness caused by arthritis.”6

Why They Did It

Considering the staggering impact of low back pain, the authors of this trial felt there were too few studies comparing spinal manipulation to nonsteroidal anti-inflammatory drugs or placebo. They aimed to test patient satisfaction and function, time off from work, and rescue medication, specifically.

How They Did It

  • 101 patients were included in the trial, all suffering acute low back pain (LBP) for more than 48 hours.
  • The patients were recruited from five outpatient practices.
  • The participants were randomly separated into three groups:
    • Spinal manipulation and placebo-diclofenac
    • Sham manipulation and diclofenac
    • Sham manipulation and placebo-diclofenac
  • The outcomes were registered by a second, blinded researcher and included the following outcome assessment measurements:
    • Self-rated physical disability
    • SF-12 questionnaire to estimate function
    • Time off from work
    • Rescue medication utilized between the start of the trial (baseline) and 12 weeks following the randomization of the participants.
  • Due to ethical reasons (patients had a high degree of pain) the placebo group had to be closed earlier than originally planned.

What They Found

  • 37 of the original 101 subjects underwent spinal manipulation.
  • 38 underwent treatment via diclofenac.
  • 25 subjects received no treatment.

When the authors compared the two active-treatment groups to the control (nontreatment) group, there was significant superiority noted for the two active-treatment groups. However, when they compared the high-velocity, low-amplitude spinal manipulation group to the diclofenac group, they recorded significant increase in efficacy in the former. In addition, no adverse effects were noticed in those who received spinal manipulation.

Wrap It Up

In the conclusion of the abstract, the authors stated, “In a subgroup of patients with acute nonspecific LBP, spinal manipulation was significantly better than nonsteroidal anti-inflammatory drug diclofenac and clinically superior to placebo.”

Although we do not have research comparing chiropractic care to any and all other nonsteroidal anti-inflammatory medications on the market today, this paper was one more step in further validating spinal manipulation as an effective and safe way of approaching the treatment of acute low back pain.

Dr. Williams is an actively practicing chiropractor, teacher, speaker, chiropractic advocate, vlogger/blogger, philanthropist, Anatomy & Physiology professor and podcast host. He is the founder and host of “The Chiropractic Forward Podcast,” addressing chiropractic care today through the use of chiropractic research reviews. Contact Dr. Williams at [email protected].

(Note from the ACA Editorial Advisory Board: While the research that is the focus of this article was published in 2013, it remains current in concept and is still valuable evidence for clinicians to consider.)


  1. “12 Ways to Improve Back Pain,”, accessed Feb. 2, 2018
  2. “The global burden of low back pain: estimates from the Global Burden of Disease 2010 study” accessed Feb. 2, 2018
  3. “Back Pain Facts and Statistics,”, accessed Feb. 2, 2018
  4. “American Physical Therapy Association (2012) Most Americans Live with Low Back Pain – and Don’t Seek Treatment. [Online] Available from:, accessed February 2, 2018
  5. “Estimating Cost of Care for Patients with Acute Low Back Pain: A Retrospective Review of Patient Records,”, accessed Feb. 2, 2018
  6. “Diclofenac Sodium,, accessed Feb. 2, 2018