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Spinal Manipulation: The Right Choice For Relieving Low Back Pain

Spinal Manipulation: The Right Choice for Relieving Low Back Pain

The Chiro.Org Blog


Spinal High-velocity Low Amplitude Manipulation in Acute Nonspecific Low Back Pain: A Double-blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo

Spine 2013 (Apr 1); 38 (7): 540–548

von Heymann, Wolfgang J. Dr. Med; Schloemer, Patrick Dipl. Math; Timm, Juergen Dr. RER, NAT, PhD; Muehlbauer, Bernd Dr. Med

Competence Center for Clinical Studies; and †Institute for Biometrics, University of Bremen, Bremen, Germany


Thanks to Dynamic Chiropractic for access to these Key Findings from the study

  • “There was a clear difference between the treatment groups: the subjects [receiving] spinal manipulation showed a faster and quantitatively more distinct reduction in the RMS” (compared to subjects receiving diclofenac therapy).

  • “Subjects [also] noticed a faster and quantitatively more distinct reduction in [their] subjective estimation of pain after manipulation. … A similar observation was made when comparing the somatic part of the SF-12 inventory … indicating that the subjects experienced better quality of life after the spinal manipulation compared to diclofenac.”

  • “The rescue medication was calculated both for the mean cumulative dose (numbers of 500 mg paracetamol tablets) and for the number of days on which rescue medication was taken. … In the diclofenac arm, the patients on average took almost 3 times as many tablets and the number of days [taking the tablets] was almost twice as high” compared to patients in the manipulation arm. While the authors note that these results were not significant due to large between-individual variations (meaning a few patients could have taken many tablets, throwing off the overall totals), it still suggests that value of spinal manipulation vs. drug therapy (because even if both patient groups had taken the same amount of rescue medication for the same number of days, it wouldn’t discount the fact that patients in the manipulation group showed significant improvement on outcome variables compared to patients in the diclofenac group).

The Abstract

Editor’s Note: For that small group of nay-sayers out there, yes, this article does not mention the word Chiropractic, but this study utilized side-posture High-velocity Low Amplitude (HVLA) Manipulation (aka Diversified Technique), which is what is taught in every chiropractic school, and is practiced by the great bulk of Chiropractors around the world for the last 118 years. Hear me now and believe me later: No one does it better! The next natural study would be to pit chiropractic care, in all it’s glory (diversified vs. drop tables vs. instrument adjusting etc.), against basic SMT, as practiced by these German individuals.

NOTE: See previous, brilliant studies below

STUDY DESIGN:   A randomized, double-blinded, placebo-controlled, parallel trial with 3 arms.

OBJECTIVE:   To investigate in acute nonspecific low back pain (LBP) the effectiveness of spinal high-velocity low-amplitude (HVLA) manipulation compared with the nonsteroidal anti-inflammatory drug diclofenac and with placebo.

SUMMARY OF BACKGROUND DATA:   LBP is an important economical factor in all industrialized countries. Few studies have evaluated the effectiveness of spinal manipulation in comparison to nonsteroidal anti-inflammatory drugs or placebo regarding satisfaction and function of the patient, off-work time, and rescue medication.

METHODS:   A total of 101 patients with acute LBP (for <48 hr) were recruited from 5 outpatient practices, exclusion criteria were numerous and strict. The subjects were randomized to 3 groups:

(1) spinal manipulation and placebo-diclofenac;

(2) sham manipulation and diclofenac;

(3) sham manipulation and placebo-diclofenac.

Outcomes registered by a second and blinded investigator included self-rated physical disability, function (SF-12), off-work time, and rescue medication between baseline and 12 weeks after randomization.

RESULTS:   Thirty-seven subjects received spinal manipulation, 38 diclofenac, and 25 no active treatment. The placebo group with a high number of dropouts for unsustainable pain was closed praecox. Comparing the 2 active arms with the placebo group the intervention groups were significantly superior to the control group. Ninety subjects were analyzed in the collective intention to treat. Comparing the 2 intervention groups, the manipulation group was significantly better than the diclofenac group (Mann-Whitney test: P = 0.0134). No adverse effects or harm was registered.

CONCLUSION:   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.


A Previous (and brilliant) Series of Studies

Chiropractic Goes Head-to-Head With Acupuncture, NSAIDs and Muscle Relaxants

One of the most dramatic outcomes in a randomized clinical trial was offered by Giles and Muller in a multidisciplinary spinal pain unit of the Townsville General Hospital in Australia.

Here, 115 patients experiencing chronic [>13 weeks] of back and neck pain were randomly allocated to either medication with NSAIDs [Celebrex or Vioxx], needle acupuncture, or chiropractic spinal manipulation by means of high-amplitude, low-velocity applications to a vertebral joint.

At the end of 9 weeks of treatment, the highest proportion of individuals reaching full recovery [asymptomatic status] was found for manipulation [27.3%], followed by acupunture [9%] and medication [5%].

For improvements in disability [Oswestry scale], and range of motion, the chiropractic cohort again displayed superior outcomes.

While improvements in pain scores [VAS] for the back were greatest for the chiropractic intervention [50% vs 15% for acupuncture, 0% for NSAIDs], they were slightly inferior to those obtained by acupuncture for neck pain [42% vs 50% for acupuncture, 0% for NSAIDs]. [1]

These results were later found to be sustained for most patients at 1-year of follow-up. [2]


1.   Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation
Spine (Phila Pa 1976) 2003 (Jul 15); 28 (14): 1490–1502

2.   Long-term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes
J Manipulative Physiol Ther 2005 (Jan); 28 (1): 3–11

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