Manual therapy is a commonly recommended treatment of low back pain (LBP), yet few studies have directly compared the effectiveness of thrust (spinal manipulation) vs non-thrust (spinal mobilization) techniques. This study evaluated the comparative effectiveness of spinal manipulation and spinal mobilization at reducing pain and disability compared with a placebo control group (sham cold laser) in a cohort of young adults with chronic LBP.

This single-blinded (investigator-blinded), placebo-controlled randomized clinical trial with 3 treatment groups was conducted at the Ohio Musculoskeletal and Neurological Institute at Ohio University from June 1, 2013, to August 31, 2017. Of 4903 adult patients assessed for eligibility, 4741 did not meet inclusion criteria, and 162 patients with chronic LBP qualified for randomization to 1 of 3 treatment groups. Participants received 6 treatment sessions of (1) spinal manipulation, (2) spinal mobilization, or (3) sham cold laser therapy (placebo) during a 3-week period. Licensed clinicians (either a doctor of osteopathic medicine or physical therapist), with at least 3 years of clinical experience using manipulative therapies provided all treatments.

Primary outcome measures were the change from baseline in Numerical Pain Rating Scale (NPRS) score over the last 7 days and the change in disability assessed with the Roland-Morris Disability Questionnaire (scores range from 0 to 24, with higher scores indicating greater disability) 48 to 72 hours after completion of the 6 treatments.

A total of 162 participants (mean [SD] age, 25.0 [6.2] years; 92 women [57%]) with chronic LBP (mean [SD] NPRS score, 4.3 [2.6] on a 1-10 scale, with higher scores indicating greater pain) were randomized.

  • 54 participants were randomized to the spinal manipulation group,
  • 54 to the spinal mobilization group,
  • 54 to the placebo group.

There were no significant group differences for sex, age, body mass index, duration of LBP symptoms, depression, fear avoidance, current pain, average pain over the last 7 days, and self-reported disability. At the primary end point, there was no significant difference in change in pain scores between spinal manipulation and spinal mobilization (0.24 [95% CI, -0.38 to 0.86]; P = .45), spinal manipulation and placebo (-0.03 [95% CI, -0.65 to 0.59]; P = .92), or spinal mobilization and placebo (-0.26 [95% CI, -0.38 to 0.85]; P = .39). There was no significant difference in change in self-reported disability scores between spinal manipulation and spinal mobilization (-1.00 [95% CI, -2.27 to 0.36]; P = .14), spinal manipulation and placebo (-0.07 [95% CI, -1.43 to 1.29]; P = .92) or spinal mobilization and placebo (0.93 [95% CI, -0.41 to 2.29]; P = .17). A comparison of treatment credibility and expectancy ratings across groups was not statistically significant (F2,151 = 1.70, P = .19), indicating that, on average, participants in each group had similar expectations regarding the likely benefit of their assigned treatment.

The authors concluded that in this randomized clinical trial, neither spinal manipulation nor spinal mobilization appeared to be effective treatments for mild to moderate chronic LBP.

This is an exceptionally well-reported study. Yet, one might raise a few points of criticism:

  1. The comparison of two active treatments makes this an equivalence study, and much larger sample sizes are required or such trials (this does not mean that the comparisons are not valid, however).
  2. The patients had rather mild symptoms; one could argue that patients with severe pain might respond differently.
  3. Chiropractors could argue that the therapists were not as expert at spinal manipulation as they are; had they employed chiropractic therapists, the results might have been different.
  4. A placebo control group makes more sense, if it allows patients to be blinded; this was not possible in this instance, and a better placebo might have produced different findings.

Despite these limitations, this study certainly is a valuable addition to the evidence. It casts more doubt on spinal manipulation and mobilisation as an effective therapy for LBP and confirms my often-voiced view that these treatments are not the best we can offer to LBP-patients.


8 Responses to Neither spinal manipulation nor spinal mobilization is effective treatments for chronic low back pain

  • Well, it’s a great example of PhDs trying to do a study with SMT who don’t know how to do a study with SMT.

      • Or, is it the ability to know good research from sloppy research?

        It’s interesting that you didn’t point out some of more serious issues with this study.

        Try reading the study again (particularly the use of the word “complete” and the criteria of “cavitation”).

    • D(umb)C(onfused) is a real hoot…a quack and an unrepentant partisan but a hoot none the less. I’m sure he looks in the mirror each morning and says: “my DC degree is just as good as a PhD, my DC degree is just as good as a PhD….over and over. To DCs point of criticism: Chiroquackery likes to ‘thrust‘ on anything their arcane, pseudoscience “tests” tells them is subluxed, depending of course on insurance coverage or the patients’ credit card limit….so it’s a shame the Activator and some cutting-edge ‘drop-tables’ weren’t included (as they are utilized by over 70% of Chiroquackers). THEN those lowly PhDs would’ve seen some AMAZING results.

      • Well, if this is what PTs are doing in clinical practice, yes, I would say, stop doing it like that.

      • @Michael Kenny
        And the unprofessional comments from Michael Kenny continue.
        “Dumb”, “Confused”, “chiroquackery” AMAZING arguments for a physiotherapist.
        Debate the science not the person.
        Your vitriolic ad hominem’s are getting very tiresome and predictable.

        “these treatments are not the best we can offer to LBP-patients.”
        Have to agree with you. As a stand alone treatment the research is underwhelming. When used as part of a suite of therapies they have some utility. All therapeutic approaches when studied in isolation are underwhelming (including exercise and rehab). Research needs to reflect how chiro’s/physio’s/osteo’s practice. The authors discuss this in the Limitations.

        • I am not sure even PTs use spinal manipulation in this fashion.

          Regardless: Cavitation as a “complete”?

          Hasn’t research shown that cavitation has no relationship to more objective outcomes?

          There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with nonradicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment. Arch Phys Med Rehabil 2003;84:1057-60.

          The results of this pragmatic study suggest that a perceived audible pop may not relate to improved outcomes from high-velocity thrust manipulation for patients with nonradicular low back pain at either an immediate or longer-term follow-up. Journal of Manipulative and Physiological Therapeutics
          Volume 29, Issue 1, January 2006, Pages 40-45

          Even stranger is one of the authors was part of a study looking at using MRI to evaluate static and dynamic vertebral motion.

          Yet here they used cavitation or up to 4 attempts to achieve cavitation and just considered both groups as equals. Strange.

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