A Perspective for Considering the Risks and Benefits of Spinal Manipulation in Patients with Low

Back Pain

Literature Review

Manual Therapy II

Sierra Moore
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The purpose of this study1 was to determine if patients who do not receive spinal

manipulation for their low back pain (LBP) are at an increased risk for disability in comparison

to those receiving an exercise intervention without spinal manipulation. I thought this article

was especially appropriate for this class because we have discussed how this class used to be an

elective and was not a part of the required course load. It sparked an interest in me to know

the current evidence on the effectiveness on using spinal manipulation techniques verses using

conventional therapeutic exercise exclusively with patients experiencing LBP.

The researchers used 130 patients between the ages of 18 and 60 with the primary

complaint of LBP and did not have any red flags around their diagnosis. Before participating, the

patients completed the Oswestry disability questionnaire and had a standardized physical

assessment of their condition. The patients were then randomly assigned to either an exercise

intervention group without spinal manipulation or they were randomly assigned to spinal

manipulation with an exercise intervention group. The patients participated in a total of 5

physical therapy sessions in, which the first two sessions differed from each other. During the

first two sessions, the spinal manipulation group received a standardized spinal manipulation

technique and a range of motion exercise. Then starting on the third session, the spinal

manipulation group started performing the same exercises as the exercise intervention group.

The exercises included lumbar spine strengthening and an aerobic exercise program. In order to

determine the risk of worsening disability, the patients that had a score increase of 6 or more

on the Oswestry disability questionnaire, were considered as having a worsening disability.

The researchers found that there was not a significant difference between the

treatment groups. After the first week, 11% of patients in the exercise group experienced a
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worsening in disability in comparison to the 1% of patients in the spinal manipulation group.

There were similar outcomes in the fourth week, which 11% of patients in the exercise group

had a worsening in disability compared to 3% in the spinal manipulation group.

The researchers concluded that when determining treatment for a patient and trying to

reduce the risk of worsening disability, avoiding spinal manipulation techniques should not be

considered conservative. The researchers also recognize the importance of using the prediction

rule when determining the patients that are most likely to benefit from spinal manipulation

techniques. None of the patients that were positive with the prediction rule experienced a

worsening of symptoms in the spinal manipulation group. However, the researchers note that

this may be due to the small number of patients that were found positive under the prediction

rule (n=23). The patients that were in the exercise intervention group were found to be 8x more

likely to experience a worsening in disability following the initial week in comparison to those in

the spinal manipulation group. The patient’s risk of worsening disability in the exercise

intervention group, did not decrease over the course of therapy sessions. After the four weeks

in therapy, they were still 4x more likely to experience a worsening in disability. The researchers

decided to also assess the accuracy of the predictive rule in their study. They found that

patients with symptoms lasting less than 16 days without symptoms below the knee, had an

86% chance for decreasing their disability by 50% in one week. The researchers stated that this

predictive rule would be beneficial for decision making in both a primary care setting and a

physical therapy setting.

The researchers believe that a lack of proper training could possibly be a barrier for

utilizing spinal manipulation techniques for patients with low back pain. There are a lot of
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patients that would greatly benefit, but they are not receiving spinal manipulations. There is

also limited access to properly trained practitioners that are efficient in spinal manipulation

therapy. When primary care physicians are trained in spinal manipulations, they are only able

to provide minimal benefits to their patients. The researcher proposed that in order for

patients to benefit the most from spinal manipulations when they are able to gain access, their

primary care physician should be trained to use a couple of effective techniques. In this study,

only one single standardized technique was performed by the physical therapist at the first two

sessions. This means that it is not necessary for primary care physicians to be trained with a full

tool box of manipulation techniques. The researchers also found that the most common reason

that spinal manipulation is avoided among those trained for manipulations is due to the risks.

However, risks of complications from spinal manipulations for the lumbar spine is very low. In

fact, the risk for cauda equine syndrome is less than 1 per 100 million lumbar spine

manipulations.

I thought that the quality of this evidence is very good. Some physical therapists may

avoid treating their patients with low back pain because they are afraid of the risk of worsening

their patient’s symptoms or permanently damaging structures in the lumbar spine. It makes me

wonder what the current evidence is on how many therapists avoid cervical manipulations

when their patients are good candidates for manipulation. I would be more hesitant to perform

cervical spinal manipulations than I would be for lumbar spinal manipulations. As the article

stated, the chances of risk to the lumbar spine is very low. I think that what I learned from this

article will be useful for when I work with my own patients. Exercise alone will most likely

worsen the patient’s symptoms compared to spinal manipulation combined with exercise. It
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reminds me of when we all came back from our first clinical rotations. Some of my colleagues

stated that they only had their patients perform exercise interventions and the occasional

modality. It baffled me because I think manual therapy is also very important. In the clinic I was

in, we would have every patient perform 45 minutes of exercise intervention including a 10-

minute warm-up, and then we would wrap up their session with 15 minutes of therapy. This is

how I think therapy sessions should be. Some limitations that I noticed in the article was the

lack of details in the methods section. They did not state how they spaced out their sessions,

what certifications the therapists had, how many therapists there were, demographics of the

patients, etc. I also wondered why they decided to provide spinal manipulations to only the first

two sessions. Why not space those treatments differently throughout the course of the study?

It made me wonder if they would have found a significant difference between treatment

groups if they would have provided spinal manipulations for all five treatment sessions along

with exercise intervention.

Overall, I thought this article was a very interesting read and it gave me some things to

think about. It proved my initial ideas to be true, that manual therapy is important, and it is

even more beneficial to combine it with exercise. I also found it interesting that therapists tend

to avoid spinal manipulations to the lumbar spine due to the potential risk of harm to their

patients. The implications for future practice would be to utilize spinal manipulation techniques

to my low back patients. We should want to do everything in our power to make our patients

better, and according to the article more therapists need to be including manipulation

techniques in their treatment sessions. I had more LBP patients over the summer than I can
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count, and it makes me feel good that I did perform spinal manipulations on almost all of them.

They may not have found as much relief with exercise alone.
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References

Childs, J.D., Flynn, T.W., Fritz, J.M. (2006). A perspective for considering the risk and benefits of

spinal manipulation in patients with low back pain. Manual Therapy, 11, 316-320.