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PTH 662 Literature Review Grace Blankenhagen

Lower Back Pain and Spinal Manipulations vs. Therapeutic Exercise

Low back pain (LBP) can be an enigma in the world of medicine. Sometimes the cause

is mechanical or anatomical, which can be addressed, or other times there can be no

identifiable cause. There are many ways to treat low back pain from a medical standpoint,

including medications and possible surgery, but a more conservative approach would be to get

physical therapy. Over 1/3 of the $50 billion spent annually on lower back pain in the medical

field is attributed to physical therapy visits1, making it a common and reliable source of

treatment for LBP. Treatment in these sessions can involve flexibility training, strengthening,

education, and massage. Another technique that can be used by many health practitioners,

including physical therapists, is the use of manipulations to help combat the pain patients

experience in their lower back. In typical physical therapy practice, manipulations are followed

by exercises to restore any possible imbalance that may have led to the need for a manipulation

in the first place. The question set out to be answered by this literature review is what is the

typical success rate for improving different types of low back pain using manipulative therapy?

Before performing manipulations on the lumbar spine, it is advised to quickly run through

some clinical predictive rules (CPRs) to determine likelihood of success in manipulation for that

patient and that technique. In a case series conducted by Cleland et al1, 12 patients referred to

physical therapy for low back pain were referred to the study. This study was performed to

evaluate the effectiveness of clinical predictive rules for performing an alternative side-lying

lumbar spine manipulation. Of the 12 patients who participated, 11 experienced a successful

(50% reduction in pain) outcome from side-lying lumbar spine manipulations paired with

posterior pelvic tilt exercises. From this study, it was determined the current CPRs do not

universally coincide with every lumbar spine manipulative technique; however it does not mean

they dont still have a high success rate.

PTH 662 Literature Review Grace Blankenhagen

In a study performed by Childs et al2, 130 adult patients complaining of low back pain

were randomly assigned to either an exercise only or exercise plus manipulation group. No

patients exhibited signs of non-musculoskeletal involvement for their pain. The exercises given

to both groups focused on trunk strengthening and low-intensity aerobic training. The

manipulation group began these exercises at the 3rd visit, as the first 2 visits consisted of a

manipulative thrust and range of motion exercises. The results displayed after 4 weeks, 11% of

the non-manipulative group experienced continued disability as evidenced by the Oswestry

scale, compared to only 3% of the manipulative group. According to Childs et al, patients

with LBP who received only exercise without manipulation were eight times more likely to

experience a worsening in disability after 1 week than patients who received manipulation2.

Also stated by Childs et al2, it is important to individualize the treatment to each patient case.

From this study, it would appear combining therapeutic exercise with lumbar spine manipulative

thrusts has the most positive results compared to therapeutic exercise alone.

In a case study performed by Brenner3, he performed regional manipulations for a 22

year old male patient with right sided hemisacralization at L5-S1 level. The patient experienced

low back pain while ruck marching for more than 20 minutes, with forward bending, and sitting

for more than 20 minutes. His pain was relieved through assuming supine position for 15

minutes. Brenner performed a right sided lumbosacral manipulation in sidelying. Brenner

combined his manipulative therapy with a home exercise program focusing on flexibility. The

patient was seen for 4 visits over the course of 15 days, where an Oswestry scale was

performed at each session. Objectively after each manipulative thrust, the patient gained

multiple degrees of forward bending and experienced less pain. After a 4 week follow up, the

patient reported no pain with forward bending and road marching. In conclusion, Brenner

believes combining lumbosacral manipulation and therapeutic exercise shows great benefit for

patients with type IIA lumbosacral transitional vertebrae.

PTH 662 Literature Review Grace Blankenhagen

Although manipulations with exercise have proven benefits, there are also cases where

manipulation alone has worked to reduce pain just as effectively. Bronfort et al4 performed a

systematic review analyzing the effects of spinal manipulation on neck and low back pain

compared to modalities, different therapies, and between professions. Acute low back pain

responded well to manipulation therapy, showing quicker results than exercises. For chronic low

back pain, it was found that manipulation plus strengthening exercises had a similar effect on

pain as NSAID treatment for short and long term relief. For subacute back pain, manipulations

worked just as well as medical treatment for long and short term decreases in pain levels. In

general, it was concluded for acute and subacute back pain, manipulations alone may be

beneficial for pain relief. However, in contrast, patients with chronic low back pain would benefit

from both manipulation and therapeutic exercise for long term relief.

From these studies, it has been determined the most successful intervention for multiple

types of low back pain has been introducing a manipulative thrust plus multiple exercises. The

manipulation resets the barrier, and the exercises help with maintenance. Although the main

question of whether or not lumbar spinal manipulations can be used universally in low back pain

has been answered, there is another underlying theme that must be addressed to achieve full

success in treatment: the treatment must be individualized to the patient for best results. Childs

et al2 experienced overall success, but there were still one or two patients who did not benefit

from manipulative thrusts. Similar to Cleland et al1, who did not experience 100% success, but

had a certain percent that did not benefit from that particular technique. Treatment must depend

on the patient. For future research, it would be recommended to investigate the relationship

between specific lumbar spine dysfunction plus manipulation and specific exercises related to

the dysfunction- is one exercise combination superior to another? Overall in conclusion,

manipulative thrusts for low back pain exhibit the best results when paired with therapeutic

exercise and with individualized treatment.

PTH 662 Literature Review Grace Blankenhagen

Works Cited

1. Cleland JA, Fritz JM, Whitman JM, Childs JD, Palmer JA. The use of a lumbar spine

manipulation technique by physical therapists in patients who satisfy a clinical prediction

rule: A case series. JOSPT. 2006; 36(4): 209-214. Available at

2. Childs JD, Flynn TW, Fritz JM. A perspective for considering the risks and benefits of

spinal manipulation in patients with low back pain. Man Ther. 2006; 11:316-320. doi:


3. Brenner AK. Use of lumbosacral region manipulation and therapeutic exercises for a

patient with a lumbosacral transitional vertebra and low back pain. JOSPT. 2005;35(6):

368-376. Available at

4. 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. The Spine Jour. 2004;4:335-356. doi: 10.1016/j.spinee.2003.06.002.