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Comparison of Spinal Manipulation Methods and Usual Medical Care for Acute and Subacute Low Back Pain: A Randomized Clinical Trial

Schneider, Michael, DC, PhD*; Haas, Mitchell, DC, MA; Glick, Ronald, MD; Stevans, Joel, DC§; Landsittel, Doug, PhD

doi: 10.1097/BRS.0000000000000724
Randomized Trial

Study Design. Randomized controlled trial with follow-up to 6 months.

Objective. This was a comparative effectiveness trial of manual-thrust manipulation (MTM) versus mechanical-assisted manipulation (MAM); and manipulation versus usual medical care (UMC).

Summary of Background Data. Low back pain (LBP) is one of the most common conditions seen in primary care and physical medicine practice. MTM is a common treatment for LBP. Claims that MAM is an effective alternative to MTM have yet to be substantiated. There is also question about the effectiveness of manipulation in acute and subacute LBP compared with UMC.

Methods. A total of 107 adults with onset of LBP within the past 12 weeks were randomized to 1 of 3 treatment groups: MTM, MAM, or UMC. Outcome measures included the Oswestry LBP Disability Index (0–100 scale) and numeric pain rating (0–10 scale). Participants in the manipulation groups were treated twice weekly during 4 weeks; subjects in UMC were seen for 3 visits during this time. Outcome measures were captured at baseline, 4 weeks, 3 months, and 6 months.

Results. Linear regression showed a statistically significant advantage of MTM at 4 weeks compared with MAM (disability = −8.1, P = 0.009; pain = −1.4, P = 0.002) and UMC (disability = −6.5, P = 0.032; pain = −1.7, P < 0.001). Responder analysis, defined as 30% and 50% reductions in Oswestry LBP Disability Index scores revealed a significantly greater proportion of responders at 4 weeks in MTM (76%; 50%) compared with MAM (50%; 16%) and UMC (48%; 39%). Similar between-group results were found for pain: MTM (94%; 76%); MAM (69%; 47%); and UMC (56%; 41%). No statistically significant group differences were found between MAM and UMC, and for any comparison at 3 or 6 months.

Conclusion. MTM provides greater short-term reductions in self-reported disability and pain scores compared with UMC or MAM.

Level of Evidence: 2

The clinical effectiveness of 2 types of spinal manipulation and medical care were compared in patients with acute back pain. Self-reported pain and disability were the outcome measures. Patients improved with all 3 treatments, however manual manipulation led to significantly greater reductions in pain and disability at the end of care (4 wk).

*School of Health and Rehabilitation Sciences, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA

Center for Outcomes Studies, University of Western States, Portland, OR

Department of Psychiatry and Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Center for Integrative Medicine at UPMC Shadyside, Pittsburgh, PA

§School of Health and Rehabilitation Sciences University of Pittsburgh, Pittsburgh, PA; and

Department of Medicine and Department of Biostatistics, Clinical & Translational Science Institute, Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA.

Address correspondence and reprint requests to Michael Schneider, DC, PhD, School of Health and Rehabilitation Sciences, Clinical and Translational Science Institute, University of Pittsburgh, Bridgeside Point 1, 100 Technology Dr, Ste 210, University of Pittsburgh, Pittsburgh, PA 15219; E-mail:

Acknowledgment date: August 25, 2014. Revision date: October 31, 2014. Acceptance date: November 3, 2014.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

The National Institutes of Health, National Center for Complementary and Alternative Medicine (NIH/NCCAM) grant no. R00 AT004196 funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, expert testimony, grants, payment for lecture, royalties, payment for development of educational presentations.

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