PATIENT-CENTERED OUTCOMES OF HIGH-VELOCITY, LOW-AMPLITUDE SPINAL MANIPULATION FOR LOW BACK PAIN: A SYSTEMATIC REVIEW
 
   

Patient-centered Outcomes of High-velocity,
Low-amplitude Spinal Manipulation for
Low Back Pain: A Systematic Review

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   J Electromyogr Kinesiol. 2012 (Oct);   22 (5):   670-691

Goertz CM, Pohlman KA, Vining RD, Brantingham JW, Long CR.

Palmer College of Chiropractic,
741 Brady St.,
Davenport, IA, United States.
christine.goertz@palmer.edu


Low back pain (LBP) is a well-recognized public health problem with no clear gold standard medical approach to treatment. Thus, those with LBP frequently turn to treatments such as spinal manipulation (SM). Many clinical trials have been conducted to evaluate the efficacy or effectiveness of SM for LBP.

The primary objective of this paper was to describe the current literature on patient-centered outcomes following a specific type of commonly used SM, high-velocity low-amplitude (HVLA), in patients with LBP. A systematic search strategy was used to capture all LBP clinical trials of HVLA using our predefined patient-centered outcomes: visual analogue scale, numerical pain rating scale, Roland-Morris Disability Questionnaire, and the Oswestry Low Back Pain Disability Index.

Of the 1,294 articles identified by our search, 38 met our eligibility criteria. Like previous SM for LBP systematic reviews, this review shows a small but consistent treatment effect at least as large as that seen in other conservative methods of care.

The heterogeneity and inconsistency in reporting within the studies reviewed makes it difficult to draw definitive conclusions. Future SM studies for LBP would benefit if some of these issues were addressed by the scientific community before further research in this area is conducted.

Palmer Research Summary Series 

In this study, authors systematically searched the scientific literature (1974-2011) reporting randomized clinical trials including high velocity, low amplitude (HVLA) spinal manipulation (SM) for low back pain (LBP).

Patient-centered outcomes measured were the:

Visual Analogue Scale (VAS)
Numerical Rating Scale (NRS)
Roland-Morris Disability Questionnaire (RM), and the
Oswestry Low Back Pain Disability Index (OSW).

Study results included:

  • Of 1294 articles identified in the initial publication search, 38 met the criteria for the study

  • The 2 most common pain rating scales were - NRS and VAS

  • The 2 most common patient-reported measures of low back function were - RM and OSW

  • Small but consistent pain reduction and functional improvement followed HVLA-SM treatment

  • Heterogeneity in study methods and inconsistency in reporting/recording pain limited more definitive conclusions


Take-home Message

HVLA SM provides a small and consistent pain reducing and functional improvement effect, greater than or equal to other conservative treatments available for patients with LBP.


Practical Application

Doctors and patients can be confident in recommending or choosing to receive HVLA-SM for LBP. The body of research supporting its effectiveness relative to other available treatments suggests patients have the choice of several treatment options. Future research would benefit from consistent study designs and pain measurement/reporting. Reporting clear details of the frequency and timing of treatments used in clinical trials would also be useful.

      Thanks to Palmer College for access to this research summary




From the FULL TEXT Article:

Introduction

Low back pain (LBP) is a well-recognized public health problem with lifetime prevalence ranging from 11% to 84% and median cost per quality-adjusted life year of $13,015 (Dagenais et al., 2008; Walker, 2000). Point prevalence within the last 3 months is estimated at 17% (Deyo et al., 2006). At the most recent meeting of the Tenth International Forum for Primary Care Research on Low Back Pain participants concluded that ‘‘the LBP epidemic remains a burden in Western countries’’ (Pransky et al., 2011).

There is no single standard approach to medical care for LBP. Carey et al. recently conducted a survey examining health care utilization patterns in patients with chronic LBP (Carey et al., 2009). They found high health care utilization in this group, with an average of 21 visits to 2.7 provider-types annually. Many of the tests and treatments used did not conform to evidence-based practice.

The authors concluded that

(1)   care utilization for chronic LBP is very high, including high use rates for advanced imaging, narcotics, and physical treatments;

(2)   use of evidence-based treatments are low when compared with current best evidence; and

(3)   many treatments are over-utilized. A recent review of clinical practice guidelines for the treatment of LBP found that acute LBP management recommendations included three interventions: patient education, acetaminophen or nonsteroidal anti-inflammatory and spinal manipulation (Dagenais et al., 2010).

Spinal manipulation (SM) is commonly used to treat low back pain (LBP). SM is the therapeutic application of a load (force) to specific body tissues (usually vertebral joints). Load delivery varies with respect to velocity, amplitude, frequency, choice of lever, and direction of force application (Herzog, 2000; Triano, 2000).

Because little is understood about the pathophysiology of most LBP, and the exact mechanism(s) of action of SM’s effect on LBP is largely unknown, clinical trials have primarily depended upon patient-perceived outcomes such as pain level and functional health status (Bronfort et al., 2008; Lawrence et al., 2008). These have traditionally been considered ‘‘soft’’ outcomes by the scientific community. However, the recent creation of the Patient-Centered Outcomes Research Institute (PCORI) in Washington, DC within the 2010 Patient Protection and Affordable Care Act by the US Congress has brought more focus and a growing acceptance of patientperceived or ‘‘patient-centered’’ outcomes, at least in the context of comparative effectiveness research. While this has been a recent phenomenon, a patient-centered perspective has always been the primary focus of SM research because of a lack of other available outcomes.

A recent article found that the most commonly used patient-based outcome assessments in chiropractic SM research were a mix of both pain and functional health status measures, including

the Visual Analogue Scale (VAS),
the Numerical Rating Scale (NRS),
the Roland Morris Disability Questionnaire (RM),
the Oswestry Low Back Pain Disability Index (OSW) and
the Short Form-36 (SF-36) (Khorsan et al., 2008).

Numerous systematic reviews evaluating the effects of various SM techniques for low back pain have been conducted over the past 10 years (Assendelft et al., 2003; Bronfort et al., 2010; Ferreira et al., 2003; Furlan et al., 2010; Koes et al., 2010; Pengel et al., 2002; Rubinstein et al., 2011; van Tulder et al., 2005; van Tulder, 2006; Walker et al., 2010). The majority have found that SM conveys a modest but consistent benefit for patients with LBP at least as large as commonly used alternative treatments. This is despite marked heterogeneity in study design and quality.

Our review is unique in that only studies comparing high-velocity, low-amplitude (HVLA) SM are included - because HVLA SM is commonly used both in clinical trials and in the clinical setting (Christensen et al., 2010). We also present these data in a way that allows us to separately consider the data from specific patient-centered outcome instruments. In this paper we present tables showing the two most commonly used pain rating scales (NRS and VAS) and the two most commonly used patient-reported measures of low back function (RM and OSW) in order to discern both similarities and differences in use and meaning. Included studies were restricted to those whose primary or secondary outcome was VAS, NRS, RM, and/or OSW. This allowed us to concentrate on studies that had similar outcome measures, decreasing heterogeneity while still including the most recent studies available. The primary objective of this paper was to describe the current literature on patient-centered outcomes in randomized controlled trials of HVLA SM in patients with low back pain.



Methods

      Sources of information

The relevant studies were identified using the following databases: PubMED (an index to Medline), the Cochrane Library, and Index to Chiropractic Literature (ICL). All databases were searched from inception through April 2011.

      Search terms and delimiters

Search terms for all databases (except ICL) were

‘‘low back pain’’ OR ‘‘back’’ OR ‘‘back pain’’ OR ‘‘back injuries’’ OR ‘‘sciatica’’ OR ‘‘LBP’’ AND ‘‘manip’’ OR ‘‘mobili’’ OR ‘‘manual therap.’’

The ICL database was searched using

‘‘low back pain’’ OR ‘‘back’’ OR ‘‘back pain’’ OR ‘‘back injuries’’ OR ‘‘sciatica’’ OR ‘‘LBP.’’

All searches were limited to those studies written in English and involving human subjects.

      Search strategy

As shown in Fig. 1, a systematic search strategy was used to capture all LBP clinical trials of SM using our predefined patientcentered outcomes. First, the sources of information were searched using the search terms and delimiters. We then cross referenced our findings with MESH headings and hand-checked reference lists of relevant studies to identify cited articles not captured by electronic searches. Two independent reviewers screened all of the potential relevant studies for selection criteria. Discrepancies were settled by a third independent reviewer (KAP). Second, abstracts were screened for absolute exclusionary criteria by an independent reviewer with any discrepancies resolved by at least three other reviewers. The final step was a full-text review for selection criteria conducted as a group by at least four of the authors.


Figure 1.   Literature retrieval process flow chart.




      Selection criteria

Articles were included if they met the following criteria:

1 - English language;

2 - non-specific low back pain as identified by the author;

3 - involved adult human subjects, 18 years of age or older;

4 - included HVLA as a category of spinal manipulative therapy;
however, studies of SM under anesthesia were excluded;

5 - a randomized clinical trial that included a separate and distinct control or comparative treatment group;

6 - articles that used intention-to-treat analysis and had extractable data;

7 - use of one or more of the following patient-centered outcomes: VAS, NRS, RM, and OSW.

SF-36 data were not included in this review because the majority of studies reviewed provided SF-36 data only when describing baseline characteristics. Studies including other forms of SM (e.g. mobilization techniques) that did not have an HVLA arm were not included. Mechanistic and basic science trials conducted on human participants were excluded as were studies where the only comparative group was another SM method.

      Operational definitions

For purposes of this review, SM was defined as a manually delivered high-velocity low-amplitude force or thrust applied to a vertebral or pelvic joint with the intent of creating a momentary separation of joint surfaces and cavitation. Components of SM, such as velocity and amplitude, have variable ranges of implementation. Most definitions of SM refer to a thrust or an increasing magnitude of force that peaks over a finite period of time (Evans, 2010; Evans and Lucas, 2010). Cavitation alone is not considered a necessary component, though it is often considered one of the goals of this procedure. Manual contacts over the intended vertebral or pelvic joint (short lever) or over distant sites (long lever) were considered under our definition of spinal manipulation.

For this review, patient-centered outcomes have been given the operational definition: patient self-report questionnaires related to pain and physical/emotional/social functioning.

Currently few methods exist to reliably confirm a specific diagnosis for the cluster of symptoms categorized as non-specific or idiopathic LBP. However, identifying specific patient characteristics of LBP can demarcate similarities and differences between study populations. We found that symptom duration varied widely among the included study population and therefore added a classification to each study based upon guideline definitions by the 2007 American College of Physicians and American Pain Society: acute pain (0-4 wks), subacute pain (4-12 wks), and chronic pain (12 or more wks) (Chou et al., 2007). Study populations were further classified according to the Quebec Task Force (QTF) classification system (Fig. 2) (Spitzer et al., 1995).


Figure 2.   Quebec task force (QTF) classification system




The timing of the primary endpoint for each study is presented in the tables. For those studies reporting outcomes at durations beyond the primary endpoint, we included the longest term followup available, up to 1 year.

      Data extraction

For each article we extracted means, standard deviations (SD) and confidence intervals (CI) from the tables and text, but not from figures. We converted VAS scores reported in cm to mm and OSW scores reported on a 50-point scale to a 100-point scale. For articles where median and interquartile ranges were reported, we assumed the median was equivalent to the mean and the interquartile range was equivalent to 1.35 times the standard deviation (Higgins and Green, 2009).

Within each group, we extracted mean changes between baseline and follow-up with confidence intervals directly from the article when possible. When only the means for baseline and follow-up were given, we calculated the difference between means recognizing that the actual mean change could differ due to missing data. When the SD of a change was given, we used it to estimate the standard error (SE) and calculate a 95% CI. When the SD of the change variable was not reported, but the SD of both the baseline and follow-up variables were, we conservatively assumed there was no correlation between baseline and follow-up measures to estimate the SD of the change variable. We then used this SD to estimate the SE and calculate a 95% CI.

Between-groups, we extracted mean differences and CIs directly from the article when possible. Some articles reported differences in mean changes and some reported differences in follow-up means adjusted for the baseline outcome variable. Some articles adjusted for covariates and others did not. We have not distinguished between these different methods. When between-group differences were not reported, we calculated them by using the reported group means. If group means were not given, we used the within-group means calculated as described above. When between-group CIs were not reported, we calculated a pooled estimate of the SDs using the reported within-group SDs or those estimated as described above when within-group SDs were not reported. The pooled estimate of the SDs was then used to estimate the standard error of the differences between means to calculate a 95% CI.

      Risk of bias

Independent quality rating went beyond the scope of this study. However, we reviewed and combined quality ratings from 2 Cochrane and 1 Agency for Healthcare Research and Quality reviews (Furlan et al., 2010; Rubinstein et al., 2011; Walker et al., 2010) for the studies included in this review.



Results

Of the 1,294 articles identified by our initial search, 38 articles met the selection criteria (Fig. 1).

The first three tables show studies that were:

(1) excluded based on abstract (Table 1); (Page 673)

(2) excluded based on full article assessment (Table 2) (Page 674); and

(3) included (Table 3) . (Page 676)

(Tables 4–7) give with-in group mean changes and between-group mean differences with 95% CIs of the VAS, NRS, RM and OSW, respectively, for the studies included in this review. Below is a description of each patient-centered outcome measure with a brief summary of our findings.

The visual analogue scale is a 100-mm line. The ends of the line are anchored with response categories, which are generally ‘‘no pain’’ at the 0 mm end of the line and a descriptor such as ‘‘unbearable pain’’ or ‘‘worst pain possible’’ at the 100 mm end of the line. The minimum clinically important difference (MCID) is defined as the smallest difference in the outcome perceived by patients as beneficial (Jaeschke et al., 1989). The MCID for VAS has been reported to range from 20 to 35 mm, with the smaller difference typically for subacute and chronic LBP patients and the larger difference for acute LBP patients (Hagg et al., 2003; Ostelo and de Vet, 2005; Vela et al., 2011). Mean change scores were similar at both short and long term followups (Table 4).

The numerical pain rating scale asks participants to rate their level of pain on an ordinal 11 point scale, anchored with response categories in which 0 represents ‘‘no pain’’ and 10 represents ‘‘unbearable pain’’ or ‘‘worst pain possible’’ (Table 5). The MCID is considered to be a change of 2.5 points (van der Roer et al., 2006). Between-group treatment effects tended to favor SM, but the differences were not clinically or statistically significant.

The modified Roland-Morris Disability Questionnaire assesses LBP-related disability and has a MCID estimated at 2-3.5 points (Bombardier et al., 2001; Ostelo and de Vet, 2005). The RM is a 1-page questionnaire and has shown both good reliability and validity (Roland and Fairbank, 2000) and is sensitive to clinical change in patients with LBP (Deyo et al., 1990; Riddle et al., 1998; Stratford et al., 2000). Within-group changes were higher in studies focused on acute LBP when compared to chronic LBP (Table 5). Between-group differences were inconsistent. With rare exceptions, long-term outcomes were similar to short-term outcomes.

The Oswestry Low Back Pain Disability Index consists of 10 questions assessing pain intensity and limitations in various activities (Fairbank et al., 1980). Scores range from 0 to 50 points and are transformed into a percentage score, or score out of 100 points. The MCID is 6%, with recent discussion suggesting that the MCID should be 10% (Ostelo et al., 2008; Vela et al., 2011). Long-term outcomes, when available, were similar to short-term outcomes (Table 6).

We were interested in summarizing effect sizes in SM and SM+ (other therapies such as physical therapy, medical care, exercise). To accomplish this goal we averaged across mean change scores within-groups and differences of mean change scores betweengroups (Table 8). A wide range of mean change scores were found both within and between-groups across all measures. Withingroup SM + scores were slightly higher. However, this was not true between-groups. The vast majority of comparison groups were active. There are too few sham control groups to draw any conclusions regarding effect sizes of active versus sham study designs.

In Table 9 we present quality ratings for the 20 articles included in this review that were evaluated for quality in one or more of 3 other reviews (Furlan et al., 2010; Rubinstein et al., 2011; Walker et al., 2010). Overall, ratings for the majority of papers showed important gaps in quality markers for RCT study design, especially related to risk of bias, influence of co-intervention, and compliance with interventions.



Discussion

Although this review specifically focused on studies with HVLA SM as the primary treatment of interest, our findings are consistent with those found in the latest reviews of SM for LBP that incorporate the most recently published trials (Assendelft et al., 2003; Bronfort et al., 2010; Ferreira et al., 2003; Furlan et al., 2010; Koes et al., 2010; Pengel et al., 2002; Rubinstein et al., 2011; van Tulder et al., 2005; van Tulder, 2006; Walker et al., 2010). We agree with previous conclusions that, although the data are generally insufficient to make strong recommendations, SM appears to be one of several effective treatment options for both acute and chronic LBP (Assendelft et al., 2003; Bronfort et al., 2004a; Koes et al., 1996; van Tulder et al., 1997; van Tulder, 2006).

We also share concerns over the highly variable quality of extant trials, small effect sizes and large variation in outcomes (Assendelft et al., 2003; Bronfort et al., 2004b; Rubinstein et al., 2011) and agree that the variation is most likely due to a combination of deficient trial methodology, inadequate execution and reporting, the large and non-quantified variation in the SM, and the unknown heterogeneity of LBP patients (Furlan et al., 2010; Hurwitz, 2011; Rubinstein et al., 2011).

The majority of studies included both pain and function as primary and/or secondary outcomes. For pain, either the VAS or NRS was used, while function was measured using either the RM or the OSW. VAS was more widely used than NRS (20 used VAS vs. 8 used NRS), while use of RM and OSW were about equally divided (20 RM vs. 16 OSW). Two studies used both RM and OSW. In the majority of studies, authors did not present a rationale for why one particular pain or function measure was chosen over others. RM was more often used when the provider type was either a DO or a DC, while those studies with a PT provider used either RM or OSW.

While formal assessment of article quality was not specifically included as part of this review effort, we did observe several issues related to quality that potentially impact our ability to derive useful conclusions from this and similar systematic reviews. For instance, we believe that the wide ranges found in pain change scores between studies are more likely to represent differences in how the data were collected rather than real differences in treatment effect. Specifics regarding VAS anchors were provided in only slightly more than half the studies and, when presented, descriptors varied widely, from ‘‘no pain’’ to ‘‘worst pain,’’ ‘‘pain as bad as it could be,’’ ‘‘max pain,’’ ‘‘worst pain you have ever felt,’’ ‘‘unbearable pain’’ or ‘‘worst imaginable pain/symptoms.’’ The time frame within which participants were asked to rate their pain also varied widely, ranging from ‘‘current’’ to ‘‘within the past 14 days.’’ It is equally difficult to evaluate NRS scores due to lack of consistency in both anchor descriptors and time frame in which the participant was asked to assess his or her pain. Time frames ranged from ‘‘current pain’’ to ‘‘pain over the past 2 weeks,’’ while anchors ranged from ‘‘no pain’’ to either ‘‘worst pain possible’’ or ‘‘worst pain imaginable.’’ In 5 out of 8 studies that used the NRS as a primary or secondary outcome, the anchor descriptors were not specified.

Substantial variability in how pain was recorded and reported, in combination with the lack of a gold standard function measure, made it difficult to adequately summarize outcomes of clinical trials of HVLA SM for LBP. For this reason we chose not to conduct a meta-analysis or formally synthesize the results. ‘‘Industry standards’’ for measuring both pain and physical functioning in patients with low back pain would make comparisons between SM studies more relevant. It has recently been suggested that assessing the functional capacity of patients may be of greater clinical value than assessing reported pain levels (Pransky et al., 2011). Also, the National Institutes of Health-funded PROMIS initiative has fostered the creation of new measures of both pain and physical functioning that may be useful in the study of LBP (Gershon et al., 2010). These are issues that warrant further discussion among SM investigators.

In our review of these papers, we became aware of other opportunities for standardization. Adherence to the recently updated CONSORT standards (Moher et al., 2010) by SM investigators would help with this effort.

Specifically, we recommend

(1) providing clear descriptions of intervention groups, including SM, in sufficient detail to allow for replication and

(2) describing eligibility criteria in detail.

Adoption of standard classifications to better describe the nature of LBP studied in a particular trial would also be useful. While diagnostic code classifications such as ICD-9 or ICD-10 are theoretically more specific, current differences in diagnostic approaches between provider types limit their usefulness in research studies. However, describing LBP according to the Quebec Task Force classifications would be an improvement over current reporting efforts. Also, while the majority of studies we reviewed reported on whether participants had acute, sub-acute or chronic LBP, definitions for these terms were not consistent.

Future studies of SM for LBP would also benefit from the adoption of reporting standards regarding SM intervention delivery. In this review, it was difficult to find consistent information regarding the frequency and/or timing of SM and other treatment visits, or the number of procedures delivered at each visit. Given the complexity of and skill level required for the delivery of SM techniques such as HVLA (Triano et al., 2004), articles would also benefit from inclusion of both the credentials of the clinicians delivering SM or related procedures and their level of expertise (e.g. years in clinical practice, experience with the SM procedure under evaluation).



Conclusion

We found that HVLA SM for LBP appears to convey a small but consistent treatment effect at least as large as that seen in other conservative methods of care. This finding is similar to that in other systematic reviews of SM of LBP. The heterogeneity and inconsistency in reporting within the studies reviewed makes it difficult to draw definitive conclusions or adequately summarize patient-centered outcomes for clinical trials of HVLA SM for LBP. These are issues that should be addressed by the scientific community before future SM studies for LBP are conducted.


Acknowledgments

We gratefully acknowledge the contributions of: clinical research fellows James Boysen, Christopher Woslanger, Julie Kumar, Christopher Roecker, Amin Neekomand, and Connie Mitchell; summer intern Laura Macko; Ying Cao; Leah Cafer; and Paige Morgenthal for help in literature searching, data extraction and manuscript preparation. We also thank Dana Lawrence and Joel Pickar for their critical review of the manuscript.



Appendix A. Thirty-eight articles that met eligibility criteria

1. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ 2004;329(7479): 1377.

2. Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. NEJM 1999;341(19):1426–31.

3. Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up. Spine (Phila Pa 1976) 2003;28(6):525–31.

4. Bicalho E, Setti JA, Macagnan J, Cano JL, Manffra EF. Immediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic low-back pain subjects. Man Ther 2010;15(5):469–75.

5. Bishop PB, Quon JA, Fisher CG, Dvorak MF. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. Spine J 2010;10(12):1055–64.

6. Bronfort G, Goldsmith CH, Nelson CF, Boline PD, Anderson AV.
Trunk Exercise Combined with Spinal Manipulative or NSAID Therapy
for Chronic Low Back Pain: A Randomized, Observer-blinded Clinical Trial

J Manipulative Physiol Ther. 1996 (Nov); 19 (9): 570–582

7. Bronfort G, Maiers MJ, Evans RL, Schulz CA, Bracha Y, Svendsen KH, et al. Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. Spine J 2011;11(7):585–98.

8. Burton AK, Tillotson KM, Cleary J. Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation. European Spine Journal 2000;9(3):202–7.

9. Cecchi F, Molino-Lova R, Chiti M, Pasquini G, Paperini A, Conti AA, et al. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Clinical Rehabilitation 2010;24(1):26–36.

10. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 1998;339(15):1021–29.

11. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Annals of Internal Medicine 2004;141(12):920–928.

12. Chown M, Whittamore L, Rush M, Allan S, Stott D, Archer M. A prospective study of patients with chronic back pain randomised to group exercise, physiotherapy or osteopathy. Physiotherapy 2008;9421–28.

13. Cleland J, Fritz J, Kulig K, Davenport TE, Eberhart S, Magel JS, et al. Comparison of the effectiveness of 3 manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial. Journal of Orthopaedic and Sports Physical Therapy 2009;39(1):A16.

14. Cramer GD, Humphreys CR, Hondras MA, McGregor M, Triano JJ. The Hmax/Mmax ratio as an outcome measure for acute low back pain. J Manipulative Physiol Ther 1993;16(1):7–13.

15. Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial. Pain 2007;131(1–2): 31–37.

16. Gibson T, Grahame R, Harkness J, Woo P, Blagrave P, Hills R. Controlled comparison of short-wave diathermy treatment with osteopathic treatment in non-specific low back pain. Lancet 1985;1(8440):1258–61.

17. Giles LG, Muller R. Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal antiinflammatory drug, and spinal manipulation. J Manipulative Physiol Ther 1999;22(6):376–81.

18. Giles LG, Muller R. Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. Spine (Phila Pa 1976) 2003;28(14): 1490–1502.

19. Grunnesjo MI, Bogefeldt JP, Svardsudd KF, Blomberg SI. A randomized controlled clinical trial of stay-active care versus manual therapy in addition to stay-active care: functional variables and pain. J Manipulative Physiol Ther 2004;27(7):431–41.

20. Hallegraeff JM, de GM, Winters JC, Lucas C. Manipulative therapy and clinical prediction criteria in treatment of acute nonspecific low back pain. Percept Mot Skills 2009;108(1): 196–208.

21. Hoiriis KT, Pfleger B, McDuffie FC, Cotsonis G, Elsangak O, Hinson R, et al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. J Manipulative Physiol Ther 2004;27(6):388–98.

22. Hondras MA, Long CR, Cao Y, Rowell RM, Meeker WC. A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain. J Manipulative Physiol Ther 2009;32(5):330–343.

23. Hough E, Stephenson R, Swift L. A comparison of manual therapy and active rehabilitation in the treatment of non specific low back pain with particular reference to a patient’s Linton & Hallden psychological screening score: a pilot study. BMC Musculoskelet Disord 2007;8: 106.106.

24. Hsieh CY, Adams AH, Tobis J, Hong CZ, Danielson C, Platt K,, et al. Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial. Spine (Phila Pa 1976) 2002;27(11):1142–48.

25. Hsieh CY, Phillips RB, Adams AH, Pope MH. Functional outcomes of low back pain: comparison of four treatment groups in a randomized controlled trial. J Manipulative Physiol Ther 1992;15(1):4–9.

26. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Belin TR, Yu F, et al. A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6–month follow-up outcomes from the UCLA low back pain study. Spine (Phila Pa 1976) 2002;27(20):2193– 204.

27. Juni P, Battaglia M, Nuesch E, Hammerle G, Eser P, van BR, et al. A randomised controlled trial of spinal manipulative therapy in acute low back pain. Annals of the Rheumatic Diseases 2009;68(9):1420–1427.

28. Mandara, A, Fusaro, A, Musicco, M, and Bado, F. A randomised controlled trial on the effectiveness of ostopathic manipulative treatment of chronic low back pain. Int J Osteopath Med 11[4], 156. 2008.

29. McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ.
Manipulation or Microdiskectomy for Sciatica?
A Prospective Randomized Clinical Study

J Manipulative Physiol Ther. 2010 (Oct);   33 (8):   576–584

30. Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ 1990;300(6737):1431–37.

31. Mohseni-Bandpei MA, Critchley J, Staunton T, Richardson B. A prospective randomised controlled trial of spinal manipulation and utlrasound in the treatment of chronic low back pain. Physio 2006;9234–42.

32. Morton JE. Manipulation in the treatment of acute low back pain. The Journal of Manual and Manipulative Therapy 1999;7(4):182–89.

35. Senna MK, Machaly SA. Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome? Spine (Phila Pa 1976) 2011;36(18):1427–37.

36. Skargren EI, Oberg BE, Carlsson PG, Gade M. Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain. Six-month follow-up. Spine (Phila Pa 1976) 1997;22(18):2167–77.

37. Wand BM, Bird C, McAuley JH, Dore CJ, MacDowell M, De Souza LH. Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise. Spine (Phila Pa 1976) 2004;29(21):2350–2356.

38. Wilkey A, Gregory M, Byfield D, McCarthy PW. A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatien



Appendix B. Eighty-five articles that were excluded based on abstract

1. Chiropracters and low back pain. Lancet 1990;336 (8709):220.

2. Aleksiev A. Longitudinal comparative study on the outcome of inpatient treatment of low back pain with manual therapy vs physical therapy. J Orthopaed Med 1995;17(1): 10–14.

3. Apeldoorn AT, Ostelo RW, van HH, Fritz JM, de Vet HC, van Tulder MW. The cost-effectiveness of a treatment-based classification system for low back pain: design of a randomised controlled trial and economic evaluation. BMC Musculoskelet Disord 2010;11:58.58.

4. Axen I, Jones JJ, Rosenbaum A, Lovgren PW, Halasz L, Larsen K, et al. The Nordic Back Pain Subpopulation Program: validation and improvement of a predictive model for treatment outcome in patients with low back pain receiving chiropractic treatment. J Manipulative Physiol Ther 2005a;28(6): 381–85.

5. Axen I, Rosenbaum A, Robech R, Larsen K, Leboeuf-Yde C. The Nordic back pain subpopulation program: can patient reactions to the first chiropractic treatment predict early favorable treatment outcome in nonpersistent low back pain? J Manipulative Physiol Ther 2005b;28(3):153–58.

6. Axen I, Rosenbaum A, Robech R, Wren T, Leboeuf-Yde C. Can patient reactions to the first chiropractic treatment predict early favorable treatment outcome in persistent low back pain? J Manipulative Physiol Ther 2002;25(7): 450–454.

7. Bennell KL, Matthews B, Greig A, Briggs A, Kelly A, Sherburn M, et al. Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord 2010;1136.

8. Boesler D, Warner M, Alpers A, Finnerty EP, Kilmore MA. Efficacy of high-velocity low-amplitude manipulative technique in subjects with low-back pain during menstrual cramping. Journal of the American Osteopathic Association 1993; 93(2):203–4.

9. . Brealey S, Burton K, Coulton S, Farrin A, Garratt A, Harvey E, et al. UK Back pain Exercise And Manipulation (UK BEAM) trial-national randomised trial of physical treatments for back pain in primary care: objectives, design and interventions [ISRCTN32683578]. BMC Health Serv Res 2003a; 3(1):16.

10. Brealey S, Burton K, Coulton S, Farrin A, Garratt A, Harvey E, et al. UK Back pain Exercise And Manipulation (UK BEAM) trial-national randomised trial of physical treatments for back pain in primary care: objectives, design and interventions [ISRCTN32683578]. BMC Health Serv Res 2003b; 3(1):16.

11. Breen A. Low back pain: comparison of chiropractic and hospital outpatient treatment. BMJ 1990;301341.

12. Brooks K. Effects of rotational mobilization versus sham mobilization of patients suffering acute low back pain. Aust J Physio 1988;35(1):60.

13. Brooks K. Effects of rotational mobilization versus sham mobilization of patients suffering acute low back pain. Aust J Physio 1989;35(1):60.

14. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project. NEJM 1995;333(14):913–17.

15. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. Chiropractic manipulation and McKenzie physiotherapy were not effective for low back pain. ACP Journal Club 1999;42.

16. Chiradejnants A. Does the choice of spinal level treated during posteroanterior (PA) mobilization affect treatment outcome? Physiotherapy Theroy and Practice 2002; 18(4):165–74.

17. Cibulka MT, Delitto A, Koldehoff RM. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain. An experimental study. Phys Ther 1988;68(9):1359–63.

18. Cleland JA, Fritz JM, Childs JD, Kulig K. Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: study protocol of a randomized clinical trial [NCT00257998]. BMC Musculoskelet Disord 2006;7:11.11.

19. Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ. Chiropractic technique procedures for specific low back conditions: characterizing the literature. J Manipulative Physiol Ther 2001;24(6):407–24.

20. Cox JM. A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain. J Manipulative Physiol Ther 2009; 32(7):601.

21. Cramer GD, Gregerson DM, Knudsen JT, Hubbard BB, Ustas LM, Cantu JA. The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: a randomized controlled trial with sixty-four subjects. Spine (Phila Pa 1976) 2002;27(22):2459–66.

22. Cramer GD, Tuck NR, Jr., Knudsen JT, Fonda SD, Schliesser JS, Fournier JT, et al. Effects of side-posture positioning and side-posture adjusting on the lumbar zygapophysial joints as evaluated by magnetic resonance imaging: a before and after study with randomization. J Manipulative Physiol Ther 2000;23(6):380–394.

23. Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teasdale N. Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: a preliminary study. J Manipulative Physiol Ther 2004;27(8):509–14.

24. Evans DW, Foster NE, Underwood M, Vogel S, Breen AC, Pincus T. Testing the effectiveness of an innovative information package on practitioner reported behavior and beliefs: the UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761]. BMC Musculoskelet Disord 2005;641.

25. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D. et al.
A Clinical Prediction Rule for Classifying Patients with Low Back Pain
who Demonstrate Short-term Improvement with Spinal Manipulation

Spine (Phila Pa 1976). 2002 (Dec 15);   27 (24):   2835–2843

26. French SD, Green S, Forbes A. Reliability of chiropractic methods commonly used to detect manipulable lesions in patients with chronic low-back pain. J Manipulative Physiol Ther 2000;23(4):231–38.

27. Fritz JM, Whitman JM, Flynn TW, Wainner RS, Childs JD. Factors related to the inability of individuals with low back pain to improve with a spinal manipulation. Phys Ther 2004;84(2):173–90.

28. Geisser ME, Wiggert EA, Haig AJ, Colwell MO. A randomized, controlled trial of manual therapy and specific adjuvant exercise for chronic low back pain. Clin J Pain 2005;21(6):463–70.

29. Gemmell HA. Treatment of chronic low-back pain with low force manipulation. Chiroprac J Aust 1992;22(2): 54–60.

30. Gunby P. Study to evaluate manipulation therapy. JAMA 1983;249(23):3148–50.

31. Haas M, Goldberg B, Aickin M, Ganger B, Attwood M. A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: 2- week to 48-month follow-up. J Manipulative Physiol Ther 2004;27(3):160–169.

32. Haas M, Sharma R, Stano M. Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain. J Manipulative Physiol Ther 2005;28(8):555–63.

33. Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO, et al. Manipulative therapy and/or NSAIDs for acute low back pain: design of a randomized controlled trial [ACTRN012605000036617]. BMC Musculoskelet Disord 2005; 657.

34. Harvey E, Burton AK, Moffett JK, Breen A. Spinal manipulation for low-back pain: a treatment package agreed to by the UK chiropractic, osteopathy and physiotherapy professional associations. Man Ther 2003;8(1):46–51.

35. Hawk C, Phongphua C, Bleecker J, Swank L, Lopez D, Rubley T. Preliminary study of the reliability of assessment procedures for indications for chiropractic adjustments of the lumbar spine. J Manipulative Physiol Ther 1999;22(6):382– 89.

36. Hemmila HM, Keinanen-Kiukaanniemi SM, Levoska S, Puska P. Does folk medicine work? A randomized clinical trial on patients with prolonged back pain. Arch Phys Med Rehabil 1997;78(6):571–77.

37. Hemmila HM, Keinanen-Kiukaanniemi SM, Levoska S, Puska P. Long-term effectiveness of bone-setting, light exercise therapy, and physiotherapy for prolonged back pain: a randomized controlled trial. J Manipulative Physiol Ther 2002;25(2):99–104.

38. Henchoz Y, de GP, Norberg M, Paillex R, So AK. Role of physical exercise in low back pain rehabilitation: a randomized controlled trial of a three-month exercise program in patients who have completed multidisciplinary rehabilitation. Spine (Phila Pa 1976) 2010;35(12): 1192–99.

39. Heymans MW, Anema JR, de Vet HC, van MW. Does flexiondistraction help treat chronic low back pain? Nat Clin Pract Rheumatol 2006;2(7):360–361.

40. Hildebrandt J, Pfingsten M, Saur P, Jansen J. Prediction of success from a multidisciplinary treatment program for chronic low back pain. Spine (Phila Pa 1976) 1997;22(9): 990–1001.

41. Hoskins W, Pollard H. The effect of a sports chiropractic manual therapy intervention on the prevention of back pain, hamstring and lower limb injuries in semi-elite Australian Rules footballers: a randomized controlled trial. BMC Musculoskelet Disord 2010;11:64.64.

42. Jayson MI, Sims-Williams H, Young S, Baddeley H, Collins E. Mobilization and manipulation for low-back pain. Spine (Phila Pa 1976) 1981;6(4):409–16.

43. Kane RL, Olsen D, Leymaster C, Woolley FR, Fisher FD. Manipulating the patient. A comparison of the effectiveness of physician and chiropractor care. Lancet 1974;1(7870):1333–36.

44. Koes BW, Bouter LM, Knipschild PG, van Mameren H, Houben JP, Verstegen G. The effectiveness of manual therapy, physical therapy and continued treatment by the general practitioner for back and neck complaints. Aust Physio 1990;36(3):191.

45. Koes BW, Bouter LM, Knipshild PG, van MH, Essers A, Houben JP, et al. The effectiveness of manual therapy, physiotherapy and continued treatment by the general practitioner for chronic nonspecific back and neck complaints: design of a randomized clinical trial. J Manipulative Physiol Ther 1991;14(9):498–502.

46. Kohlbeck FJ, Haldeman S, Hurwitz EL, Dagenais S. Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain. J Manipulative Physiol Ther 2005;28(4):245–52.

47. Kokjohn K, Schmid DM, Triano JJ, Brennan PC. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. J Manipulative Physiol Ther 1992;15(5):279–85.

48. Koldas DS, Sonel TB, Kurtais Y, Atay MB. Comparison of three different approaches in the treatment of chronic low back pain. Clin Rheumatol 2008;27(7):873–81.

49. Laird R, Hughes P. Manipulative therapy and back care education: a comparative trial of two treatment methods. Aust J Physio 1988;34(1):55.

50. Leboeuf-Yde C, Axen I, Jones JJ, Rosenbaum A, Lovgren PW, Halasz L, et al. The Nordic back pain subpopulation program: the long-term outcome pattern in patients with low back pain treated by chiropractors in Sweden. J Manipulative Physiol Ther 2005a;28(7):472–78.

51. Leboeuf-Yde C, Gronstvedt A, Borge JA, Lothe J, Magnesen E, Nilsson O, et al. The nordic back pain subpopulation program: demographic and clinical predictors for outcome in patients receiving chiropractic treatment for persistent low back pain. J Manipulative Physiol Ther 2004;27(8):493–502.

52. Leboeuf-Yde C, Gronstvedt A, Borge JA, Lothe J, Magnesen E, Nilsson O, et al. The Nordic back pain subpopulation program: a 1-year prospective multicenter study of outcomes of persistent low-back pain in chiropractic patients. J Manipulative Physiol Ther 2005b;28(2):90–96.

53. Licciardone JC, Buchanan S, Hensel KL, King HH, Fulda KG, Stoll ST. Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: a randomized controlled trial. Am J Obstet Gynecol 2010;202(1):43–48.

54. Maiers M, Hartvigsen J, Schulz C, Schulz K, Evans R, Bronfort G.
Chiropractic and Exercise for Seniors With Low Back Pain or Neck Pain:
The Design of Two Randomized Clinical Trials

BMC Musculoskelet Disord. 2007 (Sep 18); 8: 94

55. Martin PR, Rose MJ, Nichols PJ, Russell PL, Hughes IG. Physiotherapy exercises for low back pain: process and clinical outcome. International Rehabilitation Medicine 1986;8(1):34–38.

56. Mayer TG, Gatchel RJ, Keeley J, McGeary D, Dersh J, Anagnostis C. A randomized clinical trial of treatment for lumbar segmental rigidity. Spine (Phila Pa 1976) 2004;29(20): 2199–205.

57. Meade TW. Effectiveness of chiropractic and physiotherapy in the treatment of low back pain. A critical discussion of the British Randomized Clinical Trial. J Manipulative Physiol Ther 1991;14(7):444–46.

58. Moffett JA, Frost H. Back to fitness programme: the manual for physiotherapists to set up the classes. Physio 2000;86(6): 295–305.

59. Mooney V. Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up. Spine (Phila Pa 1976) 2004;29(1): 107–8.

60. Nyiendo J, Haas M, Goodwin P. Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: a practice-based feasibility study. J Manipulative Physiol Ther 2000;23(4): 239–45.

61. Rainbow DM, Weston JP, Brantingham JW, Globe G, Lee F. A prospective clinical trial comparing chiropractic manipulation and exercise therapy vs. chiropractic mobilization and exercise therarpy for treatment of patients suffering from adhesive capsulitis/frozen shoulder. J Am Chiroprac Assoc 2008;12–28.

62. Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I. Stabilizing training compared with manual treatment in subacute and chronic low-back pain. Man Ther 2003;8(4): 233–41.

63. Ritvanen T, Zaproudina N, Nissen M, Leinonen V, Hanninen O. Dynamic surface electromyographic responses in chronic low back pain treated by traditional bone setting and conventional physical therapy. J Manipulative Physiol Ther 2007;30(1):31–37.

64. Roy RA, Boucher JP, Comtois AS. Heart rate variability modulation after manipulation in pain-free patients vs patients in pain. J Manipulative Physiol Ther 2009;32(4):277–86.

65. Rupert RL, McKinzie CL, Morter MT, Jr., Daniel DM. Treatment of chronic nonresponsive patients with a nonforce technique. J Manipulative Physiol Ther 2005;28(4): 259–64.

66. Schellingerhout JM, Verhagen AP, Heymans MW, Pool JJ, Vonk F, Koes BW, et al. Which subgroups of patients with non-specific neck pain are more likely to benefit from spinal manipulation therapy, physiotherapy, or usual care? Pain 2008;139(3):670–680.

67. Schenk P, Laeubli T, Klipstein A. Validity of pressure pain thresholds in female workers with and without recurrent low back pain. Eur Spine J 2007;16(2):267–75.

68. Schimmel JJ, de KM, Horsting PP, Spruit M, Jacobs WC, van LJ. No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy. E Spine J 2009;18(12):1843–50.

69. Schneider MJ, Brach J, Irrgang JJ, Abbott KV, Wisniewski SR, Delitto A. Mechanical vs manual manipulation for low back pain: an observational cohort study. J Manipulative Physiol Ther 2010;33(3):193–200.

70. Sheahan PA, Seaton TL. Alternative therapy for low back pain. Journal of Family Practice 1999;48(1): 10–11.

71. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med 1992;117(7):590–598.

72. Shekelle PG, Markovich M, Louie R. Factors associated with choosing a chiropractor for episodes of back pain care. Med Care 1995;33(8):842–50.

73. Sherman kJ, Cherkin DC, Connelly MT, Erro J, Savetsky JB, Davis RB, et al. Complementary and alternative medical therapies for chronic low back pain: What treatments are patients willing to try? BMC Complement Altern Med 2004;49.

74. Simon T. A randomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints: subgroup analysis and relationship between outcome measures. J Manipulative Physiol Ther 1994;17(2):128.

75. Skillgate E, Bohman T, Holm LW, Vingard E, Alfredsson L. The long-term effects of naprapathic manual therapy on back and neck pain - results from a pragmatic randomized controlled trial. BMC Musculoskelet Disord 2010;11:26.26.

76. Skillgate E, Vingard E, Alfredsson L. Naprapathic manual therapy or evidence-based care for back and neck pain: a randomized, controlled trial. Clin J Pain 2007;23(5):431–39.

77. Slater MA, Weickgenant AL, Greenberg MA, Wahlgren DR, Williams RA, Carter C, et al. Preventing progression to chronicity in first onset, subacute low back pain: an exploratory study. Arch Phys Med Rehabil 2009;90(4):545–52.

78. Smith DL, Dainoff MJ, Smith JP. The effect of chiropractic adjustments on movement time: a pilot study using Fitts Law. J Manipulative Physiol Ther 2006;29(4):257–66.

79. Snyder BJ, Zhang J. Toftness system of chiropractic adjusting on pain syndromes: a pilot study in a multicenter setting. J Chiropr Med 2007;6(1):15–19.

80. Stern PJ, Cote P, Cassidy JD. A series of consecutive cases of low back pain with radiating leg pain treated by chiropractors. J Manipulative Physiol Ther 1995;18(6):335–42.

81. Tepe, R, Zhang, J, and Enix, D. A randomized controlled trial of the effects of instrument–applied cervical manipulative therapy on cervical range of motion. J Chiropr Edu 20[1], 104. 2006.

82. Triano J, Schultz AB. Loads transmitted during lumbosacral spinal manipulative therapy. Spine (Phila Pa 1976) 1997;22(17):1955–64.

83. Underwood M, O’Meara S, Harvey E. The acceptability to primary care staff of a multidisciplinary training package on acute back pain guidelines. Fam Pract 2002;19(5):511–15.

84. Westrom KK, Maiers MJ, Evans RL, Bronfort G. Individualized chiropractic and integrative care for low back pain: the design of a randomized clinical trial using a mixed–methods approach. Trials 2010;11:24.24.

85. Zaproudina N, Hietikko T, Hanninen OO, Airaksinen O. Effectiveness of traditional bone setting in treating chronic low back pain: a randomised pilot trial. Complement Ther Med 2009;17(1):23–28.

86. Zhang J, Dean D, Nosco D, Strathopulos D, Floros M. Effect of chiropractic care on heart rate variability and pain in a multisite clinical study. J Manipulative Physiol Ther 2006; 29(4):267–74.



References:

  • Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.
    Spinal manipulative therapy for low back pain.
    A meta-analysis of effectiveness relative to other therapies.
    Ann Int Med 2003;138(11):871–81.

  • Bombardier C, Hayden J, Beaton DE.
    Minimal clinically important difference. Low back pain: outcome measures.
    J Rheumatol 2001;28(2):431–8.

  • Bronfort G, Evans R, Maiers M, Anderson AF.
    Spinal Manipulation, Epidural Injections, and Self-care for Sciatica:
    A Pilot Study for a Randomized Clinical Trial

    J Manipulative Physiol Ther. 2004 (Oct); 27 (8): 503–508

  • Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S.
    Evidence-informed management of chronic low back pain with
    spinal manipulation and mobilization.
    Spine J 2008;8(1):213–25.

  • Bronfort G, Haas M, Evans R, Leininger B, Triano J.
    Effectiveness of Manual Therapies: The UK Evidence Report
    Chiropractic & Osteopathy 2010 (Feb 25); 18 (1): 3

  • 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 Synthesis

    Spine J (N American Spine Soc) 2004 (May); 4 (3): 335–356

  • Carey TS, Freburger J K, Holmes G M, Castel L, Darter J, Agans R, et al.
    A long way to go: practice patterns and evidence in chronic low back pain care.
    Spine (Phila Pa 1976) 2009;34(7):718–24.

  • Chou R, Qaseem A, Snow V, Casey Jr D, Shekelle Jr P, et al.
    Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline
    from the American College of Physicians and
    the American Pain Society

    Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491

  • Christensen MG, Kollasch MW, Martin W, Hyland JK.
    Practice Analysis of Chiropractic 2010:
    A project report, survey analysis, and summary of chiropractic practice
    in the United States (2010); 2010.
    Greenley (CO): National Board of Chiropractic Examiners.

  • Dagenais S, Caro J, Haldeman S.
    A systematic review of low back pain cost of illness studies
    in the United States and internationally.
    Spine J 2008;8(1):8–20.

  • Dagenais S, Tricco AC, Haldeman S.
    Synthesis of Recommendations for the Assessment and Management of
    Low Back Pain from Recent Clinical Practice Guidelines

    Spine J. 2010 (Jun); 10 (6): 514–529

  • Deyo RA, Cherkin D, Conrad D.
    The back pain outcome assessment team.
    Health Serv Res 1990;25(5):733–7.

  • Deyo RA, Mirza SK, Martin BI.
    Back pain prevalence and visit rates: estimates from US national surveys, 2002.
    Spine (Phila Pa 1976) 2006;31(23):2724–7.

  • Evans DW.
    Why do spinal manipulation techniques take the form they do?
    Towards a general model of spinal manipulation.
    Manual Ther 2010;15(3):212–9.

  • Evans DW, Lucas N.
    What is ‘manipulation’? A reappraisal.
    Manual Ther 2010;15(3):286–91.

  • Fairbank JC, Couper J, Davies JB, O’Brien JP.
    The Oswestry low back pain disability questionnaire.
    Physiotherapy 1980;66(8):271–3.

  • Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG.
    Efficacy of spinal manipulative therapy for low back pain of less than three months’ duration.
    J Manipulative Physiol Ther 2003;26(9):593–601.

  • Furlan A, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L, et al.
    Complementary and alternative therapies for back pain II. Evidence report/
    technology assessment no. 194 (prepared by the University of Ottawa
    Evidence-based practice center under contract no. 290–2007–10059–I (EPCIII)).
    AHRQ publication no. 10(11)E007 [October 2010]; 2010.
    Rockville (MD): Agency for Healthcare Research and Quality.

  • Gershon RC, Rothrock N, Hanrahan R, Bass M, Cella D.
    The use of PROMIS and assessment center to deliver patient-reported
    outcome measures in clinical research.
    J Appl Meas 2010;11(3):304–14.

  • Hagg O, Fritzell P, Nordwall A.
    The clinical importance of changes in outcome scores after treatment for chronic low back pain.
    Eur Spine J 2003;12(1):12–20.

  • Herzog W.
    The Mechanical neuromuscular, and physiologic effects produced by spinal manipulation.
    In: Herzong W, editor. Clinical biomechanics of spinal manipulation.
    New York: Churchill Livingstone; 2000. p. 191–207.

  • Higgins JPT, Green S.
    Cochrane handbook for systematic reviews of interventions version 5.0.2.9-1-2009.
    The Cochrane Collaboration; 2009.

  • Hurwitz EL.
    Commentary: exercise and spinal manipulative therapy for chronic low back pain:
    time to call for a moratorium on future randomized trials?
    Spine J 2011;11(7):599–600.

  • Jaeschke R, Singer J, Guyatt GH.
    Measurement of health status. Ascertaining the minimal clinically important difference.
    Control Clin Trials 1989;10(4): 407–15.

  • Khorsan R, Coulter ID, Hawk C, Choate CG.
    Measures in chiropractic research: choosing patient-based outcome assessments.
    J Manipulative Physiol Ther 2008;31(5):355–75.

  • Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM.
    Spinal manipulation for low back pain.
    An updated systematic review of randomized clinical trials.
    Spine (Phila Pa 1976) 1996;21(24):2860–71.

  • Koes BW, van TM, Lin CW, Macedo LG, McAuley J, Maher C.
    An Updated Overview of Clinical Guidelines for the Management of
    Non-specific Low Back Pain in Primary Care

    Eur Spine J. 2010 (Dec); 19 (12): 2075–2094

  • Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR, Haas M, et al.
    Chiropractic Management of Low Back Pain and Low Back-Related
    Leg Complaints: A Literature Synthesis

    J Manipulative Physiol Ther 2008 (Nov); 31 (9): 659–674

  • Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ et al.
    CONSORT 2010 explanation and elaboration:
    updated guidelines for reporting parallel group randomised trials.
    BMJ 2010;340–869.

  • Ostelo RW, De Vet HC.
    Clinically important outcomes in low back pain.
    Best Pract Res Clin Rheumatol 2005;19(4):593–607.

  • Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von KM, et al.
    Interpreting change scores for pain and functional status in low back pain:
    towards international consensus regarding minimal important change.
    Spine (Phila Pa 1976) 2008;33(1):90–4.

  • Pengel HM, Maher CG, Refshauge KM.
    Systematic review of conservative interventions for subacute low back pain.
    Clin Rehabilit 2002;16(8): 811–20.

  • Pransky G, Borkan JM, Young AE, Cherkin DC.
    Are we making progress? The tenth international forum for primary care
    research on low back pain.
    Spine (Phila Pa 1976) 2011;36(19):1608–14.

  • Riddle DL, Stratford PW, Binkley JM.
    Sensitivity to change of the Roland-Morris back pain questionnaire: Part 2.
    Phys Ther 1998;78(11):1197–207.

  • Roland M, Fairbank J.
    The Roland-Morris disability questionnaire and the Oswestry disability questionnaire.
    Spine 2000;25(24):3115–24.

  • Rubinstein SM, van MM, Assendelft WJ, de Boer MR, van Tulder MW.
    Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review.
    Spine (Phila Pa 1976) 2011;36(13):E825–46.

  • Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al.
    Scientific monograph of the Quebec Task Force on Whiplash-Associated
    Disorders: redefining ‘‘whiplash’’ and its management

    Spine (Phila Pa 1976) 1995; 20(8 Suppl.): 1S–73S.

  • Stratford PW, Binkley JM, Riddle DL.
    Development and initial validation of the back pain functional scale.
    Spine 2000;25(16):2095–102.

  • Triano JJ.
    The mechanics of spinal manipulation.
    In: Herzog W, editor. Clinical biomechanics of spinal manipulation.
    New York: Churchill Livingstone; 2000. p. 92–190.

  • Triano JJ, Bougie J, Rogers C, Scaringe J, Sorrels K, Skogsbergh D, et al.
    Procedural skills in spinal manipulation: do prerequisites matter?
    Spine J 2004;4(5): 557–63.

  • van der Roer N, Ostelo RW, Bekkering GE, van Tulder MW, de Vet HC.
    Minimal clinically important change for pain intensity, functional status,
    and general health status in patients with nonspecific low back pain.
    Spine (Phila Pa 1976) 2006;31(5):578–82.

  • van Tulder MW, Assendelft WJ, Koes BW, Bouter LM.
    Method guidelines for systematic reviews in the Cochrane collaboration back review
    group for spinal disorders.
    Spine (Phila Pa 1976) 1997;22(20):2323–30.

  • van Tulder MW, Furlan AD, Gagnier JJ.
    Complementary and alternative therapies for low back pain.
    Best Pract Res Clin Rheumatol 2005;19(4):639–54.

  • van Tulder MW, Koes B.
    Chronic low back pain.
    Am Family Phys 2006;74(9):1577–9.

  • Vela LI, Haladay DE, Denegar C.
    Clinical assessment of low-back-pain treatment outcomes in athletes.
    J Sport Rehabil 2011;20(1):74–88.

  • Walker BF.
    The prevalence of low back pain: a systematic review of the literature from 1966 to 1998.
    J Spinal Disord 2000;13(3):205–17.

  • Walker BF, French SD, Grant W, Green S.
    Combined chiropractic interventions for low-back pain.
    Cochrane Database Syst Rev 2010(4):CD005427.



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