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Research Review: Manipulation and mobilization for treating chronic low back pain

Dr. Shawn   

Features Research adjustment back pain chiropractic chronic pain low back pain manipulation research spinal manipulation

The purpose of this systematic review was to unravel these differences and inconsistent findings by evaluating the research on the effectiveness of mobilization and manipulation for chronic non-specific low back pain

Study title: Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis
Authors: Coulter I, Crawford C, Hurwitz E, Vernon H, Khorsan R, Suttorp Booth M, Herman PM.
Publication Information: The Spine Journal 2018; Jan 31. pii: S1529-9430(18)30016-0. doi: 10.1016/j.spinee.2018.01.013. [Epub ahead of print]
Background Information: Spinal manipulation and mobilization for the treatment of back and neck pain have been the topic of several systematic reviews, with some suggesting that the evidence in support of the view that spinal manipulative therapy is superior to other standard treatments for chronic low back pain is sparse. On the other hand, more recent systematic reviews have reported that spinal manipulation and mobilization are ‘viable’ options for treating pain. 

The purpose of this systematic review was to unravel these differences and inconsistent findings by evaluating the research on the effectiveness of mobilization and manipulation for chronic non-specific low back pain according to:

  • Different symptom durations across the spectrum of chronicity,
  • Variations in treatment techniques,
  • Variations in comparators, and
  • The impact on important patient-reported outcomes.

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Pertinent results
After screening for inclusion and reviewing hundreds of full text articles, a total of 64 publications on RCTs that reported on patients with chronic, non-specific low back pain were included in this systematic review.

Prescribed exercise was the most common intervention used in combination with a thrust or non-thrust intervention in the multimodal studies. Stretches, massage, ultrasound, education, and advice therapy were also prescribed, but less frequently.

Thrust Manipulation Compared to Mobilization: Meta-analysis showed that there was a larger reduction in pain from thrust and/or non-thrust interventions compared to an active comparator of exercise or physical therapy, and the difference was statistically significant. Notably, thrust interventions performed better than non-thrust for pain reduction. Specifically, thrust interventions resulted in a 10.75 points larger Visual Analog Scale score reduction than comparators, whereas non-thrust interventions only resulted in a 5.0-point larger reduction.

Applications, conclusions
The authors concluded that there is moderate-quality evidence in support of manipulation and mobilization in reducing pain and improving function for patients with chronic low back pain, with manipulation performing somewhat better than mobilization. Both therapies appear to be safe.

However, evidence concerning the efficacy of manipulation and mobilization compared to sham or no treatment on pain or disability is still lacking. This evidence gap is possibly related to the difficulties associated with implementing an acceptable sham manual intervention that can be successfully concealed from researchers and participants.

Clinical guidelines regarding manual therapies for chronic low back pain are somewhat different, depending on the country or region of origin. Spinal manipulation is recommended in most guidelines, whereas some do not recommend it. Why these inconsistencies exist, however, is unknown.

The authors suggested that better designed studies with more homogeneous groupings, clinically relevant patient-based outcomes, and larger clinical trials are still needed in order to inform practice decisions regarding spinal manipulation and mobilization for patients with chronic non-specific low back pain.  

Additional references

  1. Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European spine journal. 2010; 19(12): 2075-94.
  2. Pillastrini P, Gardenghi I, Bonetti F, et al. An updated overview of clinical guidelines for chronic low back pain management in primary care. Joint, bone, spine: revue du rhumatisme. 2012; 79(2): 176-85.
  3. Cheng JS, Lee MJ, Massicotte E, et al. Clinical guidelines and payer policies on fusion for the treatment of chronic low back pain. Spine. 2011;36(21 Suppl):S144-163.

Dr. Shawn Thistle is a practicing chiropractor, educator, international speaker, knowledge-transfer leader, evidence-based health care advocate, entrepreneur & medicolegal consultant. He founded RRS Education in 2006 and currently acts as the company’s CEO. RRS Education helps chiropractors and other manual medicine clinicians around the world integrate research in to patient care via weekly Research Reviews, Online Courses and Seminars.  For more information, visit:

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