Manipulation of the Lumbar Spine and
SI JointTHE EVIDENCE
Four major Clinical Practice Guidelines (CPGs) dealing with the management of
LBP have been published.1, 2, 4, 16 The following paragraphs contain the key findings and
strength of evidence taken from the portion of the CPG that dealt specifically with
manipulation. It should be noted that while manipulation did not receive the highest
possible weight-of-evidence rating, it received the highest rating level given to any
treatment that was evaluated.1994- Agency for Health Care, Policy, and related Research (AHCPR); rating scale:
A D (best to worst)4
Manipulation can be helpful for patients with acute low back problems without
radiculopathy when used within the first month of symptoms. (Strength of Evidence = B
When findings suggest progressive or severe neurologic deficits, an appropriate
diagnostic assessment to rule out serious neurologic conditions is indicated before
beginning manipulation therapy (Strength of Evidence= D). For patients with
radiculopathy, the scientific evidence was also inconclusive about either the effectiveness
or the potential harms of manipulation.
http://text.nlm.nih.gov/ftrs/pick?collect=ahcpr&dbName=lbpc&cd=1&t=9193604761996- Royal College of General Practitioners (RCGP); rating scale: 3 1 stars (best
Within the first six weeks of onset of acute or recurrent low back pain,
manipulation provides better short-term improvement in pain and activity levels and
higher patient satisfaction than the treatments to which it has been compared (Strength of
Evidence= 3 stars).
The risks of manipulation for low back pain are very low, provided patients are selected
and assessed properly and it is carried out by a trained therapist or practitioner.
Manipulation should not be used in patients with severe or progressive neurological
deficit in view of the rare but serious risk of neurological complication (Strength of
Evidence= 2 stars).
1998- /ew Zealand Guidelines; rating scale: Strong Weak (best to worst)1
Manual loading of the spine using short or long leverage methods is safe and
effective in the first 4-6 weeks of acute low back symptoms (Strength of Evidence =
1999- DoD/VA Low-Back Pain Guidelines; rating scale: (A-D)2
When used within the first month of symptoms, manipulation can be helpful for
patients with acute LBP without radiculopathy. Strong theoretical arguments exist to
couple manipulation with an active exercise and education regime. Additionally, the
panel felt strongly that manipulation should be considered as a method to speed
reactivation of the patient.
When findings suggest progressive or severe neurological deficits, an appropriate
diagnostic assessment to rule out serious neurological conditions is indicated before
beginning manipulation therapy. Selected patients with a nonprogressive radiculopathy
may benefit from a trial of spinal manipulation.
There is insufficient evidence to recommend manipulation for all patients with
The following information is attributed to peer-reviewed publications regarding
the indications, safety, and comparative safety of spinal manipulation in general:
Indications: Although the need to identify which individuals are most likely to benefit
from manipulation has been recognized,9 no definitive criteria have clearly been
established. However, one systematic review found common characteristic of individuals
who responded to manual therapy and the early results of one prospective trial are
-Based on a meta-analysis, DiFabio reported the following characteristics of
patients with LBP who were likely to benefit from manual therapy intervention:
a. Duration of current episode less than one month;
b. Acute onset;
c. Pain free at least 6 months prior to the current episode;
d. No history of previous manipulation or surgery;
e. No evidence of systemic illness, structural deformity, or loss of strength or
muscle stretch reflexes; f. Not pregnant; and
f. Were not receiving payments or involved in litigation related to their
condition. Gender was non-significant.7
-Flynn and colleagues found in a recent trial8 that subjects who had the following
examination findings responded with dramatic success to manipulation
(successful response to manipulation defined by a 50% reduction in Oswestry
score in less than 5 days):
a. Fear Avoidance Behavior Questionnaire work subscale score <18;
b. Duration of symptoms 15 days or less;
c. No symptoms distal to the knee;
d. Lumbar spine hypomobility at any level;
e. Either hip with greater than 35 degrees of internal rotation. Patients with 3 or
more of any of these findings have a high likelihood of dramatic success.
These subjects had severe LBP with Oswestry scores > 30 but did not have
significant sensory-motor loss. While the 3 or more findings predicted dramatic
success, patients with fewer findings may respond more favorably than the
passage of time.
Harm: The estimated rate of occurrence of cauda equina syndrome as a complication of
lumbar spinal manipulation is estimated to be on the order of less than one case per 100
million manipulations.13 Overall serious or severe complication of lumbar spinal
manipulation seem to be rare.5
Senstad et.al.11 reported the following complications resulting from 4712 manipulative
treatments (all regions) in 1058 patients:
-55% of individuals had local discomfort, headache, tiredness, or radiating discomfort.
These symptoms were mild or moderate in 85% of these individuals and 74% resolved
within 24 hours.
-Dizziness, nausea, hot skin or other complaints accounted for less than 5% of
-Muscle and joint soreness are relatively common but rarely lead to even shortterm
impairment in functional status.
Comparative Harm: It is helpful to consider the safety and complications associated
with what is perhaps the most frequently prescribed treatment for acute LBP---nonsteroidal
anti-inflammatory drugs (NSAIDs)---
in order to put the safety of manipulation in context.
-Major side effects involve the GI tract, and 1% to 3% of users are thought to
develop GI bleeding due to NSAID use.15
-Each year, 7,600 deaths and 76,000 hospitalizations in the U.S. may be
attributable to NSAIDs.14
-Standard NSAIDs produce side effects in just less than 30% of exposed
individuals, especially if used for more than 4 weeks.10
-COX-2 inhibitors have not established a clinically meaningful safety advantage
There is overwhelming evidence for the safety and effectiveness of manipulation
for the treatment of patients with acute low back pain. Fortunately, the evidence we have
suggests that manipulation of the lumbo-sacral spine in patients with acute LBP elicits a
robust treatment effect despite the variety of factors associated with its application
(professional discipline, techniques, prescription parameters, etc.). Unfortunately, many
physical therapists (PTs) and probably other health care professionals appear to be
reluctant to use manipulation in the treatment of patients with acute LBP despite evidence
for its effectiveness. This reluctance is best illustrated by the following quote: Over the
past 10 years, for example, we have seen some very compelling evidence supporting
manipulation for patients with acute LBP, yet manipulation is used by physical therapists
in typical outpatient settings at a lower-than-expected rate. What seems to be
incontrovertible is the fact that evidence exists to support the use of certain treatment
procedures for patients with LBP and, like other health care professionals, physical
therapists' behavior, in many instances, does not comply with such guidelines.6
A detailed review of the evidence also suggests that the safety and effectiveness
of manipulation is not dependent on type of practitioner, technique used, or years of
experience.4, 12 In other words, safe and effective manipulation of the lumbo-sacral spine
is not the exclusive domain of any single profession nor an esoteric skill that requires
years of training to develop. To be sure, there are still many questions that remain to be
answered, such as: How do I identify patients who are likely to respond to
manipulation?; How do I identify patients who are likely to have an adverse response
to manipulation?; and What manipulative techniques are most effective? Positive
steps are currently being taken to address these and many other important questions.8
However, these unanswered questions are not a sufficient excuse to withhold an effective
treatment (manipulation) from patients suffering with acute LBP.
1. Manipulation is safe and effective in the short-term for relief of acute LBP. Safety and
effectiveness are not dependent upon the type of practitioner or technique used.
2. Given the know efficacy of other treatments for acute LBP, manipulation should be
utilized frequently in the management of patients with acute LBP. However, in spite of
the evidence, manipulation is currently being underutilized, by PTs in particular, in the
management of LBP.
3. Serious complications due to manipulation are extremely rare. Minor complications are
frequent, resolve rapidly, and in the majority of cases these complications are no different
than sensory or affective phenomenon often experienced during normal daily activities.
4. The efficacy and safety of manipulation for patients with LBP and radiculopathy are
1. New Zealand Acute Low Back Pain Guide. Wellington, NZ: ACC and National Health
2. VHA/DoD Clinical Practice Guideline for the Management of Low Back Pain or
Sciatica in the Primary Care Setting. The Low Back Pain Workgroup with support
from: The Office of Performance and Quality. VHA Headquarters, Washington, DC;
Quality Management Directorate, United States Army MEDCOM; The External Peer
Review Program. West Virginia Medical Institute, Inc. Birch & Davis Associates, Inc.
3. FDA Arthritis Advisory Committee Briefing Document- VIOXX Gastrointestinal
Safety NDA 21-042/052, February 8, 2001.
4. Bigos S, Bowyer O, Braen G, Brown K, Deyo R, Haldeman S. Acute Low Back
Problems in Adults. Rockville, Maryland: Agency for Health Care Policy and Research,
Public Health Service, US Department of Health and Human Services, 1994.
5. Bronfort G. Spinal manipulation: current state of research and its indications.
Neurologic Clinics 1999; 17:91-111.
6. Delitto A. Clinicians and researchers who treat and study patients with low back pain:
are you listening? Physical Therapy 1998; 78:705-7.
7. DiFabio R. Efficacy of Manual Therapy. Physical Therapy 1992; 72:853-864.
8. Flynn T, Fritz J, Whitman J, Wainner R et al. Characteristics of patients who respond
best to sacroiliac region manipulation. submitted to Spine, in review 2001.
9. Frymoyer J. Point of View. Spine 2001; 26:738.
10. Hungin A. Nonsteroidal anti-inflammatory drugs: overused or underused in
osteoarthritis? American Journal of Medicine 2001; 110:8S-11S.
11. Senstad O, Leboeuf-Yde C, Borchgrevink C. Frequency and characteristics of side
effects of spinal manipulative therapy. Spine 1997; 22:435-40; discussion 440-1.
12. Shekelle PG, Adams AH, Chassin MR. The Appropriateness of Spinal Manipulation
for Low-Back Pain: Project Overview and Literature Review. Santa Monica, CA: RAND
13. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation
for low-back pain. Annals of Internal Medicine 1992; 117:590-8.
14. Tamblyn R, Berkson L, Dauphinee WD, et al. Unnecessary prescribing of NSAIDs
and the management of NSAID-related gastropathy in medical practice. Annals of
Internal Medicine 1997; 127:429-38.
15. Tannenbaum H, Davis P, Russell AS, et al. An evidence-based approach to
prescribing NSAIDs in musculoskeletal disease: a Canadian consensus. Canadian NSAID
Consensus Participants. CMAJ 1996; 155:77-88.
16. Waddell G, Feder G, McIntosh A, M L, A H. Low Back Pain Evidence Review.
London: Royal College of General Practitioners, 1996.