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Low back pain (LBP) can be an enigma in the world of medicine. Sometimes the cause
identifiable cause. There are many ways to treat low back pain from a medical standpoint,
including medications and possible surgery, but a more conservative approach would be to get
physical therapy. Over 1/3 of the $50 billion spent annually on lower back pain in the medical
field is attributed to physical therapy visits1, making it a common and reliable source of
treatment for LBP. Treatment in these sessions can involve flexibility training, strengthening,
education, and massage. Another technique that can be used by many health practitioners,
including physical therapists, is the use of manipulations to help combat the pain patients
experience in their lower back. In typical physical therapy practice, manipulations are followed
by exercises to restore any possible imbalance that may have led to the need for a manipulation
in the first place. The question set out to be answered by this literature review is what is the
typical success rate for improving different types of low back pain using manipulative therapy?
Before performing manipulations on the lumbar spine, it is advised to quickly run through
some clinical predictive rules (CPRs) to determine likelihood of success in manipulation for that
patient and that technique. In a case series conducted by Cleland et al1, 12 patients referred to
physical therapy for low back pain were referred to the study. This study was performed to
evaluate the effectiveness of clinical predictive rules for performing an alternative side-lying
(50% reduction in pain) outcome from side-lying lumbar spine manipulations paired with
posterior pelvic tilt exercises. From this study, it was determined the current CPRs do not
universally coincide with every lumbar spine manipulative technique; however it does not mean
In a study performed by Childs et al2, 130 adult patients complaining of low back pain
were randomly assigned to either an exercise only or exercise plus manipulation group. No
patients exhibited signs of non-musculoskeletal involvement for their pain. The exercises given
to both groups focused on trunk strengthening and low-intensity aerobic training. The
manipulation group began these exercises at the 3rd visit, as the first 2 visits consisted of a
manipulative thrust and range of motion exercises. The results displayed after 4 weeks, 11% of
scale, compared to only 3% of the manipulative group. According to Childs et al, patients
with LBP who received only exercise without manipulation were eight times more likely to
experience a worsening in disability after 1 week than patients who received manipulation2.
Also stated by Childs et al2, it is important to individualize the treatment to each patient case.
From this study, it would appear combining therapeutic exercise with lumbar spine manipulative
thrusts has the most positive results compared to therapeutic exercise alone.
year old male patient with right sided hemisacralization at L5-S1 level. The patient experienced
low back pain while ruck marching for more than 20 minutes, with forward bending, and sitting
for more than 20 minutes. His pain was relieved through assuming supine position for 15
combined his manipulative therapy with a home exercise program focusing on flexibility. The
patient was seen for 4 visits over the course of 15 days, where an Oswestry scale was
performed at each session. Objectively after each manipulative thrust, the patient gained
multiple degrees of forward bending and experienced less pain. After a 4 week follow up, the
patient reported no pain with forward bending and road marching. In conclusion, Brenner
believes combining lumbosacral manipulation and therapeutic exercise shows great benefit for
Although manipulations with exercise have proven benefits, there are also cases where
manipulation alone has worked to reduce pain just as effectively. Bronfort et al4 performed a
systematic review analyzing the effects of spinal manipulation on neck and low back pain
compared to modalities, different therapies, and between professions. Acute low back pain
responded well to manipulation therapy, showing quicker results than exercises. For chronic low
back pain, it was found that manipulation plus strengthening exercises had a similar effect on
pain as NSAID treatment for short and long term relief. For subacute back pain, manipulations
worked just as well as medical treatment for long and short term decreases in pain levels. In
general, it was concluded for acute and subacute back pain, manipulations alone may be
beneficial for pain relief. However, in contrast, patients with chronic low back pain would benefit
from both manipulation and therapeutic exercise for long term relief.
From these studies, it has been determined the most successful intervention for multiple
types of low back pain has been introducing a manipulative thrust plus multiple exercises. The
manipulation resets the barrier, and the exercises help with maintenance. Although the main
question of whether or not lumbar spinal manipulations can be used universally in low back pain
has been answered, there is another underlying theme that must be addressed to achieve full
success in treatment: the treatment must be individualized to the patient for best results. Childs
et al2 experienced overall success, but there were still one or two patients who did not benefit
from manipulative thrusts. Similar to Cleland et al1, who did not experience 100% success, but
had a certain percent that did not benefit from that particular technique. Treatment must depend
on the patient. For future research, it would be recommended to investigate the relationship
between specific lumbar spine dysfunction plus manipulation and specific exercises related to
manipulative thrusts for low back pain exhibit the best results when paired with therapeutic
Works Cited
1. Cleland JA, Fritz JM, Whitman JM, Childs JD, Palmer JA. The use of a lumbar spine
http://www.jospt.org/doi/abs/10.2519/jospt.2006.36.4.209?code=jospt-site.
2. Childs JD, Flynn TW, Fritz JM. A perspective for considering the risks and benefits of
spinal manipulation in patients with low back pain. Man Ther. 2006; 11:316-320. doi:
10.1016/j.math.2005.09.002.
3. Brenner AK. Use of lumbosacral region manipulation and therapeutic exercises for a
patient with a lumbosacral transitional vertebra and low back pain. JOSPT. 2005;35(6):
4. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and
mobilization for low back pain and neck pain: A systematic review and best evidence