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A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement With Spinal Manipulation

Flynn, Timothy, PT, PhD*‡; Fritz, Julie, PT, PhD; Whitman, Julie, PT, DSc; Wainner, Robert, PT, PhD*‡; Magel, Jake, PT, DSc; Rendeiro, Daniel, PT, DSc; Butler, Barbara, PT; Garber, Matthew, PT, DSc; Allison, Stephen, PT, PhD*

Exercise Physiology and Physical Exam

Study Design. A prospective, cohort study of patients with nonradicular low back pain referred to physical therapy.

Objective. Develop a clinical prediction rule for identifying patients with low back pain who improve with spinal manipulation.

Summary of Background Data. Development of clinical prediction rules for classifying patients with low back pain who are likely to respond to a particular intervention, such as manipulation, would improve clinical decision-making and research.

Methods. Patients with nonradicular low back pain underwent a standardized examination and then underwent a standardized spinal manipulation treatment program. Success with treatment was determined using percent change in disability scores over three sessions and served as the reference standard for determining the accuracy of examination variables. Examination variables were first analyzed for univariate accuracy in predicting success and then combined into a multivariate clinical prediction rule.

Results. Seventy-one patients participated. Thirty-two had success with the manipulation intervention. A clinical prediction rule with five variables (symptom duration, fear–avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee) was identified. The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%.

Conclusion. It appears that patients with low back pain likely to respond to manipulation can be accurately identified before treatment.

From the *U.S. Army-Baylor University Graduate Program in Physical Therapy, San Antonio, Texas,

the †Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania,

and the ‡U.S. Army-Baylor University, Postprofessional Doctoral Program in Orthopaedic & Manual Physical Therapy, Fort Sam Houston, Texas.

Supported in part by a grant from the Foundation for Physical Therapy.

Acknowledgment date: October 31, 2001.

First revision date: March 7, 2002.

Acceptance date: May 6, 2002.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Foundation funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Address correspondence to Timothy W. Flynn, PT, PhD, U.S. Army-Baylor University Graduate Program in Physical Therapy, 3151 Scott Road, Room 1303, Fort Sam Houston, TX 78234-6138, USA; E-mail:

© 2002 Lippincott Williams & Wilkins, Inc.