Spine J. 2008 (Jan); 8 (1): 213–225 ~ FULL TEXT
Gert Bronfort, DC, PhDa, Mitch Haas, DC, MA, Roni Evans, DC, MS, Greg Kawchuk, DC, PhD, Simon Dagenais, DC, PhD
Northwestern Health Sciences University,
2501 W 84th St,
Bloomington, MN 55431, USA.
The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence Informed Management of Chronic Low Back Pain Without Surgery.
Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.
KEYWORDS: Chronic low back pain; Spinal manipulative therapy (SMT); Spinal mobilization (MOB); Low back pain,
manipulation, spinal; Meta-analysis
From the FULL TEXT Article:
For the purpose of this review, spinal manipulative therapy
(SMT) is defined as the application of high-velocity,
low-amplitude manual thrusts to the spinal joints slightly
beyond the passive range of joint motion.  Spinal mobilization
(MOB) is defined as the application of manual
force to the spinal joints within the passive range of joint
motion that does not involve a thrust.
Although the practice of spinal manipulation is now frequently
associated with chiropractic – which began as a profession
in 1895 – it predates any modern health profession
and dates back thousands of years. Spinal manipulation is believed
to have been practiced in China as far back as 2700 BC.  In India, spinal manipulation was historically practiced
as an act of hygiene and related techniques were considered
a component of surgery.  Hippocrates, in his book On
Joints, was the first to give a formal definition to the technique
of manipulation; his belief in the spine as the epicenter
of holistic bodily health is well known.  As a testament to
its long history of use, there are now more randomized controlled
trials (RCTs) examining SMT for low back pain
(LBP) than any other intervention for that indication. 
There are many subtypes of SMT currently in use,
including several named technique systems combining
patient assessment and management. The most common
type of SMT technique has been termed “diversified’’ because
it incorporates many of the aspects taught in these
different systems. It consists of the application of a high-velocity,
low-amplitude (HVLA) thrust to the spine with
the practitioner’s hand to distract spinal zygapophyseal
joints slightly beyond their passive range of joint motion
into the paraphysiologic space.  There are many specific
HLVA techniques available to practitioners of SMT that can
be modified according to patient need. This type of SMT
has also been termed short-lever SMT, because the thrust
is applied directly to the spine. It is distinguished from
long-lever SMT, originally from the osteopathic tradition,
in which force is not provided to the spine directly, but
from rotation of the patient’s thigh and leg.
MOB is defined
as the application of manual force to the spinal joints within
the passive range of joint motion; it does not involve a thrust
and may include traction through the use of specialized
treatment tables. There are other types of SMT that are
not covered by this review, including instrument-assisted
procedures and low-force manual procedures.
Before performing SMT, the practitioner must conduct
a thorough physical examination that includes manual
palpation of the lumbar and sacral areas to assess local
tenderness, inflammation, and identify areas of segmental
dysfunction/hypomobility to which SMT will be applied.
SMT for LBP is typically performed with the patient in
a side-lying position on a cushioned treatment table. The
practitioner then positions the patient’s torso, hips, arms,
and legs according to the desired type of SMT, places the
“stabilizing’’ hand on the patient’s arms, and contacts the
legs using the practitioner’s thigh or leg. The practitioner
places the thrusting ’’treatment’’ hand over either the superior
or inferior vertebra of the target spinal motion segment
to which SMT will be applied. The practitioner introduces
a slow force to preload the target spinal joints, and then administers
a HVLA thrust with the direction, velocity, and
amplitude determined by the examination and desired joint
movement. The manual thrust is assisted by a “body drop’’
produced by contraction of the abdominal and leg muscles.  This thrust is often accompanied by an audible
cracking or popping sound, which represents the formation
and dissolution of small gas bubbles within the joint cavity
resulting from pressure changes as the articular surfaces
momentarily separate in response to the HVLA thrust. [5, 6]
Practitioner, setting, and availability
In most jurisdictions, SMT is considered a controlled
health act and must be delivered by a licensed health practitioner.
The vast majority of SMT (previously estimated at
94%) in North America is provided by Doctors of Chiropractic
(DCs), who receive extensive training in manual examination
and manual therapies during their 4 years of
education and clinical internship; licensing requirements
differ considerably outside the United States.  A minority
of SMT is provided by Doctors of Osteopathy and physical
therapists, who receive additional training in SMT
where permitted by state licensure laws, and naturopathic
doctors where permitted. SMT is most often administered
in the private practice of DCs. In rare cases, SMT may be
performed in conjunction with anesthesia or injections,
which would require that it be performed in an outpatient
surgical center. Medicine-assisted manipulation, including
manipulation under anesthesia, is discussed elsewhere in
the supplement. SMT is widely available throughout the
United States, with an estimated 60,000 licensed DCs practicing
across the country.
Pertinent Current procedural terminology (CPT) codes
98940, Chiropractic manipulative treatment (CMT); spinal, one to two regions;
98941, CMT; spinal, three to four regions;
98942, CMT; spinal, five regions.
The cost of a single session of SMT, which may include
multiple applications of SMT, is approximately $50, though
charges and reimbursement vary considerably among practitioners
and payers. Additional CPT codes and charges
may apply if adjunct therapies are administered in conjunction
with SMT, such as heat, ice, electrical stimulation, assisted
stretching, myofascial release, massage, or exercise.
Cost comparisons have been performed alongside only
in a few of the randomized studies. On the basis of the retrospective
cost estimations in the British Meade trial ,
the authors argued that the potential cost savings over
a 3–year period were higher for patients with LBP managed
by chiropractors than for patients managed by hospital outpatient
departments. [8, 9]
In the trial by Cherkin et al. ,
the mean costs of care over a 2–year period were very similar
for the physical therapy and chiropractic groups, but
were about three times higher compared with the booklet
Skargren et al.  found no difference in the
cost-effectiveness ratio between chiropractic and physical
therapy in the management of neck and back pain in Sweden.
The UK BEAM trial  is the largest study with
a prespecified comprehensive cost-effectiveness design,
and the authors concluded that SMT is a cost-effective addition
to “best care’’ for back pain in general practice.
SMT alone probably gives better value for money than
SMT followed by exercise.
SMT is routinely reimbursed by a variety of third-party
payers including Medicare, Medicaid, worker’s compensation
insurance, motor vehicle collision health insurance,
and various forms of managed care health insurance including
preferred provider organizations and health maintenance
organizations. Many of these payers have established
upper limits on the number of sessions of SMT that are
reimbursed for specific conditions or time periods, subject
to modifications if adequate documentation and justification
Mechanism of action
Many hypotheses related to the mechanism of action for
SMT and MOB focus on the immediate consequences of
applying external force to the tissues of the spine. It is
thought that if target tissues are relatively rigid (eg, bone),
the applied force may cause the tissue to displace, whereas
if the target tissue is relatively non-rigid, the applied force
may cause it to deform. Several studies related to SMT
and MOB have examined the immediate effects of tissue
displacement or deformation, including
(1) altering orientation or position of anatomic structures,
(2) unbuckling of structures,
(3) release of entrapped structures, and
(4) disruption of adhesions. [13, 14]
Other hypotheses regarding the mechanism of action for
SMT and MOB have focused on the consequences of
tissues being displaced or deformed by such procedures,
including the response of neurological, cell, or matrix systems
to the input forces of SMT and MOB.  The greatest
body of evidence in this area relates to the neurological
system, where evidence suggests that SMT impacts primary
afferent neurons from paraspinal tissues, the motor control
system, and pain processing. 
Focusing mainly on the immediate and consequential
mechanism of action underscores the complementary nature
of biomechanical studies compared with studies that
investigate downstream system effects or attempt to segregate
these interactions.  Although work to date is encouraging,
it must be emphasized that at present, the
exact mechanisms of action for any effects attributable to
SMT or MOB remains unknown.  Although this does
not negate their clinical efficacy, it may act to hinder their
acceptance and delivery by the wider scientific and healthcare
Diagnostic testing required
Given that the cause of chronic low back pain (CLBP)
cannot be identified in the majority of cases, meaningful
tests to identify alterations in entities relevant to LBP is difficult
at best. As a result of these circumstances, and assuming
that the chronicity of a complaint is unrelated to
a diagnosable entity that has gone undetected, diagnostic
testing as a precursor to the application of SMT is performed
typically to rule out the presence of certain contraindications
or red flags.  These red flags often suggest
the presence of malignancy, infection, spondyloarthritis,
or neurological conditions that are not appropriate to treat
with conservative interventions such as SMT.  In the
absence of these red flags, imaging or other laboratory-based
diagnostics are of limited value.
Indications and contraindications
Various countries and organizations have published clinical
practice guidelines for the treatment of LBP-based systematic
reviews of evidence. In general, the recommended
indication for SMT or MOB is nonspecific mechanical CLBP.
Contraindications for SMT include “red flags’’ as described
by the AHCPR guidelines (fever, unrelenting night
pain or pain at rest, pain with below knee numbness or weakness,
leg weakness, loss of bowel or bladder control, progressive
neurological deficit, direct trauma, unexplained weight
loss, and history of cancer).  Other contraindications specific
to SMT or MOB include fracture, severe osteoporosis, or
trauma causing tissue disruption to the treated area.
Little research has been performed to evaluate which
CLBP patients are best suited for SMT or MOB. Generally,
SMT or MOB may be recommended for CLBP patients
who do not have contraindications as discussed above. In
addition, SMT or MOB may not be the best choice for patients
who cannot increase activity/workplace duties, are
physically deconditioned, and have psychosocial barriers
to recovery. 
Recent work on acute LBP has begun to identify characteristics
that distinguish which patients may respond favorably
to SMT including
(1) duration of LBP less than 16 days;
(2) symptoms that remain proximal to the knee;
(3) fear-avoidance belief questionnaire (FABQ) scores less than 19;
(4) hypomobility of the lumbar spine; and
(5) hip rotation greater than 35 degrees. 
In a 6–month follow-
up, when three of these five markers were present, subjects
were observed to experience significantly greater
benefits from manipulation. More studies are needed to
identify which CLBP patients are likely to benefit from
SMT or MOB.
Evidence of efficacy
The purpose of this study was to assess the efficacy of
SMT and MOB for the management of CLBP by updating
a previous systematic review that included literature published
through 2002.  An updated literature search
(through 2006) for RCTs evaluating the therapeutic efficacy
of SMT or MOB for CLBP was performed using the same
strategy.  Additionally, citation tracking of references in
relevant publications was used, including the non-indexed
chiropractic, osteopathic, physical therapy, and medical
journals. Abstracts from proceedings and unpublished trials
were not included.
To be included in this review, each study was required to
have greater than or equal to 10 subjects receiving SMT or
MOB and main outcome measures had to be patient oriented
(eg, pain, global improvement, low-back disability,
recovery time, work loss, medication use, and functional
A best evidence synthesis incorporating explicit information
about outcome measures, interventions, magnitude of
treatment differences, and associated p-values was used to
evaluate treatment efficacy. [21–23] Two authors (MH and
GB) independently extracted and recorded relevant data
from each article. Outcomes were normalized to a 0– to 100
(percentage)-point scale whenever possible and between-group
differences are reported in the text in percentage points
on the 100–point scale. Studies were classified into two
categories: CLBP (≥12 wk) and mixed duration with
Follow-up was defined as short term if less than 3 months,
and long term if equal to greater than 3 months.
A list of eight items was used to assess methodological
quality [3, 24, 25] (Table 1). Two reviewers performed the
methodological scoring of the RCTs independently (MH
and GB), and differences were resolved by consensus. The
trials for which GB was the primary author were scored by
two other authors of this review. Because of their familiarity
with the literature, the reviewers could not be blinded.
The criteria for determining the level of evidence of efficacy
is detailed in a previous publication  and summarized
in Table 2. All eligible RCTs were considered
regardless of their results. Statistical pooling of two or
more trials was considered if they were homogeneous in
terms of patient population, interventions, outcomes, and
follow-up time points. Methodological quality and
statistical significance were then considered to determine
the evidence level.
An RCT was excluded from evidence synthesis under
the following conditions:
(1) the main outcome measure was not patient rated;
(2) there was inadequate quantitative information for the main outcome;
(3) the trial was designed to test the immediate postintervention effect of a single treatment without a follow-up period; and
(4) SMT or MOB was combined with other therapies and it was not possible to isolate its unique contribution to the overall treatment effect.
The search strategy identified 42 studies assessing SMT/
MOB for CLBP, eight more than the previous systematic
review.  Comparison therapies included acupuncture,
back school, bed rest, corset, diathermy, education advice,
electrical modalities, exercise, heat, injections, massage
and trigger point therapy, medication, no treatment, placebo,
physical therapy, sham SMT, and ultrasound. The
number of SMT treatments varied from 1 to 24 and follow-
up from immediate posttreatment to 3 years. Among
the studies considered in evidence, 11 trials (n = 1,199) assessed
CLBP and 8 trials (n = 3,422) investigated a mix of
acute and CLBP patients. The methodological quality
scores of the studies ranged from 6 to 81 (Table 3). The
20 LBP studies excluded from evidence and the reasons
for ineligibility are summarized in Table 4. The primary exclusion
criterion was the inability to isolate a unique contribution
of SMT/MOB to the treatment effect.
The studies were too dissimilar in terms of patient characteristics,
outcome measures, time points, and type of
treatment comparisons to allow for statistical pooling.
Thirteen RCTs on CLBP were identified, including nine
for SMT and four for MOB [26–39]; two RCTs were excluded [40, 41] (Table 5). Of the trials remaining in evidence,
the methodological quality scores ranged from 38 to 81 and
five were of moderate to high quality (score $50) (Table 6).
Since 1990, official LBP guidelines have been developed
by national health-care agencies and advisory groups in
North America, Europe, Israel, New Zealand, and Australia.
These guidelines can quickly become outdated as the number
of trials increases and the methodology of both trials and
guideline development improves. The most recent and most
comprehensive evidence-based guideline efforts addressing
CLBP have occurred in Europe.  A summary of the national
guideline conclusions regarding recommendation for
the use of SMT for CLBP is shown in Table 2.
A recent review of systematic reviews of RCTs on SMT by
Ernst and Canter concluded that SMT is not an effective intervention
and given the possibility of adverse effects, suggests
that SMT is not a recommendable treatment.  The
Ernst review is severely limited in its approach because of an
incomplete quality assessment, lack of prespecified rules to
evaluate the evidence, and several erroneous assumptions.  Ernst goes further to conclude that bias exists in systematic
reviews performed by chiropractors, particularly members
of our group. We refuted this assertion , and have
attempted to be as transparent as possible in our methodology,
which details a priori defined standard and acceptable
methods for conducting systematic reviews. [45, 46] Table 7 summarizes the conclusions from the latest systematic reviews.
The conclusion of this review, which includes the results
of the latest published RCTs, is consistent with the latest
high-quality evidence-based systematic reviews. [47, 48]
Clinicians should exercise caution when generalizing the
findings of systematic reviews to clinical practice. Disparate
patient populations are likely to be included in reviews
and potentially important distinguishing characteristics,
such as condition severity, are not always carefully defined.
In addition, diverse SMT/MOB therapeutic approaches are
applied by providers with different backgrounds and training,
which may affect outcomes.
Chronic low back pain
The literature provides moderate evidence for several
conclusions regarding SMT and MOB for CLBP (Table 8). In terms of patient-rated pain, SMT with strengthening
exercise is similar in effect to prescription nonsteroidal
anti-inflammatory drugs with exercise in both the short
term and long term.  There is also moderate evidence
that SMT/MOB is superior to usual medical care and placebo
for patient improvement. [34, 35] High-dose SMT is
superior to low-dose SMT for pain in the very short term
and similar in the short term.  Flexion-distraction MOB
is superior to a combined exercise program for pain in the
short term and superior/similar in the long term. [31, 32] Flexion-
distraction MOB also has a similar effect on disability as
a combined exercise program [31, 32] There is limited evidence
in the short term for the following in pain/disability reduction:
SMT is superior to chemonucleolysis, medication,
and acupuncture; and MOB is inferior to exercise for disc
herniation. [27–30, 38] The evidence is inconclusive as to
whether SMT is superior to sham SMT for pain in the short
term  and whether MOB is similar in effect to exercise
for pain in both the short term and long term. [36, 37]
Mixed duration predominantly CLBP
Nine trials addressed mixed populations that had predominantly
CLBP. Eight met the criteria for admissibility,
six of which dealt exclusively with SMT, one dealt with
MOB, and one with SMT/MOB [8, 9, 11, 12, 49–54]. One
trial was excluded  (Table 9). The methodological quality
scores for the mixed trials considered for evidence
ranged from 31 to 63, and three of the studies were of moderate
to high quality (score>50).
The literature provides moderate to strong evidence regarding
the efficacy of SMT for mixed (but predominantly
chronic) LBP (Table 10). In terms of short- and long-term
patient-rated pain and disability, there is strong evidence
that SMT is similar in effect to a combination of medical
care with exercise or exercise instruction [12, 56] There is
also moderate evidence that SMT is superior to usual medical
care alone  and that SMT is similar to physical
therapy , both in the short term and long term. There
is moderate evidence that SMT/MOB is superior to physical
therapy and to home exercise in the long term. [51, 52]
There is limited evidence of short- and long-term superiority
of SMT to hospital outpatient care for pain and disability [8, 9], and short-term superiority of SMT to sham
SMT.  There is also limited evidence of short-term superiority
of SMT/MOB to physical therapy, home back exercise,
traction/exercise/corset, no treatment, and placebo
diathermy. [49, 51, 52] A sensitivity analysis was conducted
to evaluate the effect of changing the quality scores required
for each level of evidence in Table 2. We assessed
the effect of changing the threshold for high- and low-quality
studies 610 points in the 100–point quality scale. Overall,
sensitivity analysis showed that changing the rules of
evidence would have produced little impact on the main
conclusion of our review.
Optimally, reviews should include all trials regardless of
language.  Because of the languages spoken by the authors,
this review was restricted to English, Scandinavian,
and Dutch languages. Although an attempt was made to
identify trials in other languages, this approach was not fully
systematic and may have overlooked some relevant trials.
However, none of the over 50 reviews previously reviewed
by Assendelft et al.  included RCTs that were published
in languages other than those addressed in this review. Another
possible limitation of the current review is publication
bias.  No exhaustive effort was made to identify unpublished
research, which is more likely to have negative outcomes. [61–63] It is recognized that attempts to retrieve
unpublished data from trials are also likely to be biased. 
At least three full-scale RCTs assessing the role of SMT
in the management of CLBP are in progress at the time
of this review: one compares trunk exercise to SMT, one
assesses the effectiveness of SMT in the elderly, and one
evaluates pretreatment prediction rules for positive
SMT can be associated with relatively benign temporary
side effects including mild localized soreness or pain,
which typically does not interfere with activities of daily
living.  A large, prospective observational study of
1,058 patients who received 4,712 sessions of SMT from
102 DCs in Norway reported the following common adverse
events (AEs): local discomfort (53%), headache
(12%), tiredness (11%), radiating discomfort (10%), and
dizziness (5%) . Most of these AEs occurred within 4
hours of SMT (64%), were of mild-to-moderate severity
(85%), and disappeared the same day (74%).  It should
be noted that this study included AEs from SMT applied to
the cervical, thoracic, or lumbar areas, and was not restricted
Rare AEs that have been reported following SMT in the
lumbar region include lumbar disc herniation (LDH) and
cauda equina syndrome (CES).  Because of the low incidence
of severe AEs, the risk attributable to SMT cannot be
evaluated in RCTs. A systematic review on the safety of
SMT for LBP uncovered four studies, which reported the following
estimates of risk: 1 CES per 128 million SMT, 1 CES
per 100 million SMT,<1 CES or LDH per 1 million SMT, 1
LDH per 8 million SMT, and 1 CES per 4 million SMT. 
It should be noted that some of the cases of CES or LDH included
in the above estimates of risk occurred during manipulation
under anesthesia, which has been associated with
a greater risk of disc injury than SMT. On the basis of the
above estimates and other reports of AEs, the review authors
estimated the risk of LDH or CES following SMTat 1 event
per 3.72 million SMT. 
Discrepancies in the estimates of risk reported in the
four studies discussed above are likely attributable to heterogeneous
methodology and retrospective data sources,
in addition to the imprecise nature of combining data from
case reports and legal malpractice claims to estimate the
numerator with utilization data to estimate the denominator.
Although underreporting of rare AEs associated with SMT
may lead to underestimating the true risk, other reports
have wrongly attributed AEs to SMT.  Thus, the existing
estimates are associated with substantial uncertainty
and will only improve when more data become available
from well-designed prospective studies. 
As with all forms of conservative interventions for CLBP,
the likelihood of obtaining positive outcomes with SMT is
decreased in patients who have severe comorbidities or psychosocial
factors associated with poor recovery. Instruments
such as the yellow flags questionnaire have defined several
factors to identify patients with LBP who are at higher risk
of developing chronicity and a worsened prognosis. 
These factors are not specific to SMT and include beliefs
about appropriateness of working with current pain levels,
perceived chance of recovery in 6 months, light work, stress,
and previous number of sick days.  Low patient expectations
and low satisfaction with the care received have also
been associated with poor outcomes for SMT and LBP, suggesting
that patients who do not expect to improve with SMT
and respond poorly to an initial trial of care may fare better
with other interventions. [70, 71] Other factors associated
with poor outcomes for SMTand LBP include pain radiating
below the knee, baseline levels of pain or disability, income,
and smoking. [72, 73]
For CLBP, there is moderate evidence that SMT with
strengthening exercise is similar in effect to prescription nonsteroidal
anti-inflammatory drugs with exercise in both the
short term and long term. There is also moderate evidence
that flexion-distraction MOB is superior to exercise in the
short term and superior/similar in the long term. There is
moderate evidence that a regimen of high-dose SMT is superior
to low-dose SMT in the very short term. There is limited
to moderate evidence that SMT is better than physical therapy
and home exercise in both the short and long term. There
is also limited evidence that SMT is as good or better than
chemonucleolysis for disc herniation in the short and long
term. There is limited evidence that MOB is inferior to back
exercise after disc herniation surgery.
For mixed (but predominantly chronic) LBP, there is
strong evidence that SMT is similar in effect to a combination
of medical care with exercise instruction. There is moderate
evidence that SMT is superior to general practice
medical care and similar to physical therapy in both the short
and long term. There is limited evidence of short- and longterm
superiority of SMT over hospital outpatient care for
pain and disability. There is also limited evidence of shortterm
superiority of SMT over medication and acupuncture.
This review included an additional six trials since the
previous review. The overall quality of additional studies
was moderate to high, and their inclusion strengthened
the existing evidence regarding the efficacy of SMT/MOB
for CLBP. The preponderance of the evidence for efficacy,
including recent high-quality trials, and the estimated very
low risk of serious AEs support SMT and MOB as viable
options for the treatment of CLBP. SMT and MOB are at
least as effective as other efficacious and commonly used
Future trials should examine well-defined subgroups of
LBP patients according to validated and reliable diagnostic
classification criteria, establish the optimal number of treatment
visits, and evaluate the cost effectiveness of care using
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