REVIEW ARTICLE A systematic review on the effectiveness of complementary and alternative medicine for chronic non-specific low-back pain Sidney M. Rubinstein • Marienke van Middelkoop • Ton Kuijpers • Raymond Ostelo • Arianne P. Verhagen • Michiel R. de Boer • Bart W. Koes • Maurits W. van Tulder Received: 7 October 2009 / Revised: 24 January 2010 / Accepted: 21 February 2010 Ó The Author(s) 2010. This article is published with open access at Springerlink.com Abstract The purpose of this systematic review was to assess the effects of spinal manipulative therapy (SMT), acupuncture and herbal medicine for chronic non-specific LBP. A comprehensive search was conducted by an experienced librarian from the Cochrane Back Review Group (CBRG) in multiple databases up to December 22, 2008. Randomised controlled trials (RCTs) of adults with chronic non-specific LBP, which evaluated at least one clinically relevant, patient-centred outcome measure were included. Two authors working independently from one another assessed the risk of bias using the criteria rec- ommended by the CBRG and extracted the data. The data were pooled when clinically homogeneous and statisti- cally possible or were otherwise qualitatively described. GRADE was used to determine the quality of the evi- dence. In total, 35 RCTs (8 SMT, 20 acupuncture, 7 herbal medicine), which examined 8,298 patients, fulfilled the inclusion criteria. Approximately half of these (2 SMT, 8 acupuncture, 7 herbal medicine) were thought to have a low risk of bias. In general, the pooled effects for the studied interventions demonstrated short-term relief or improvement only. The lack of studies with a low-risk of bias, especially in regard to SMT precludes any strong conclusions; however, the principal findings, which are based upon low- to very-low-quality evidence, suggest that SMT does not provide a more clinically beneficial effect compared with sham, passive modalities or any other intervention for treatment of chronic low-back pain. There is evidence, however, that acupuncture provides a short-term clinically relevant effect when compared with a waiting list control or when acupuncture is added to another intervention. Although there are some good results for individual herbal medicines in short-term individual trials, the lack of homogeneity across studies did not allow for a pooled estimate of the effect. In general, these results are in agreement with other recent systematic reviews on SMT, but in contrast with others. These results are also in agreement with recent reviews on acupuncture and herbal medicine. Randomized trials with a low risk of bias and adequate sample sizes are direly needed. Keywords Systematic review Á Spinal manipulative therapy Á Acupuncture Á Herbal medicine Á Low-back pain Electronic supplementary material The online version of this article (doi:10.1007/s00586-010-1356-3) contains supplementary material, which is available to authorized users. S. M. Rubinstein (&) Á R. Ostelo Á M. W. van Tulder Department of Epidemiology and Biostatistics and EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands e-mail: SM.Rubinstein@vumc.nl M. van Middelkoop Á A. P. Verhagen Á B. W. Koes Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands T. Kuijpers Dutch Institute for Health Care Improvement CBO, Utrecht, The Netherlands R. Ostelo Á M. R. de Boer Á M. W. van Tulder Department of Health Sciences, Faculty of Earth and Life Sciences and EMGO Institute for Health and Care Research, VU University, Amsterdam, The Netherlands 123 Eur Spine J DOI 10.1007/s00586-010-1356-3