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Similar Effects of Thrust and Nonthrust Spinal Manipulation Found in Adults With Subacute and Chronic Low Back Pain

A Controlled Trial With Adaptive Allocation

Xia, Ting, PhD; Long, Cynthia R., PhD; Gudavalli, Maruti R., PhD; Wilder, David G., PhD; Vining, Robert D., DC; Rowell, Robert M., DC, MS; Reed, William R., PhD, DC; DeVocht, James W., PhD, DC; Goertz, Christine M., PhD, DC; Owens, Edward F. Jr., DC, MS§; Meeker, William C., DC, MPH

doi: 10.1097/BRS.0000000000001373

Study Design. A three-arm controlled trial with adaptive allocation.

Objectives. The aim of this study was to compare short-term effects of a side-lying, thrust spinal manipulation (SM) procedure and a nonthrust, flexion-distraction SM procedure in adults with subacute or chronic low back pain (LBP) over 2 weeks.

Summary of Background Data. SM has been recommended in recently published clinical guidelines for LBP management. Previous studies suggest that thrust and nonthrust SM procedures, though distinctly different in joint loading characteristics, have similar effects on patients with LBP.

Methods. Participants were eligible if they were 21 to 54 years old, had LBP for at least 4 weeks, scored 6 or above on the Roland-Morris disability questionnaire, and met the diagnostic classification of 1, 2, or 3 according to the Quebec Task Force Classification for Spinal Disorders. Participants were allocated in a 3:3:2 ratio to four sessions of thrust or nonthrust SM procedures directed at the lower lumbar and pelvic regions, or to a 2-week wait list control. The primary outcome was LBP-related disability using Roland-Morris Disability Questionnaire and the secondary outcomes were LBP intensity using visual analog scale, Fear-Avoidance Beliefs Questionnaire, and the 36-Item Short Form Health Survey. The study was conducted at the Palmer Center for Chiropractic Research with care provided by experienced doctors of chiropractic. Clinicians and patients were not blinded to treatment group.

Results. Of 192 participants enrolled, the mean age was 40 years and 54% were male. Improvement in disability, LBP intensity, Fear-Avoidance Beliefs Questionnaire—work subscale, and 36-Item Short Form Health Survey—physical health summary measure for the two SM groups were significantly greater than the control group. No difference in any outcomes was observed between the two SM groups.

Conclusion. Thrust and nonthrust SM procedures with distinctly different joint loading characteristics demonstrated similar effects in short-term LBP improvement and both were superior to a wait list control.

Level of Evidence: 2

Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA

Department of Biomedical Engineering, University of Iowa, Iowa City, IA

Diagnosis & Radiology, Palmer College of Chiropractic, Davenport, IA

§Dr. Sid E. Williams Center for Chiropractic Research, Life University, Marietta, GA

Palmer College of Chiropractic—West Campus, San Jose, CA.

Address correspondence and reprint requests to Ting Xia, PhD, Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 741 Brady St, Davenport, IA 52803; E-mail:

Received 22 July, 2015

Revised 26 October, 2015

Accepted 7 November, 2015

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

Award Number 1U19 AT002006 from the National Center for Complementary and Integrative Health, U.S.

National Institutes of Health funds were received in support of this work. This investigation was conducted in a facility constructed with support from Research Facilities Improvement Grant Number C06 RR15433-01 from the National Center for Research Resources, National Institutes of Health.

Relevant financial activities outside the submitted work: board membership, consultancy, employment, grants, stocks, payment for lectures, travel/accommodations/meeting expenses.

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.