The Effectiveness and Safety of Manual

Therapy on Pain and Disability in Older

Persons With Chronic Low Back Pain:
A Systematic Review
Katie E. de Luca, MChiro, PhD, a Sheng Hung Fang, BChiroSc, b Justin Ong, BChiroSc, b
Ki-Soo Shin, BChiroSc, b Samuel Woods, BChiroSc, b and Peter J. Tuchin, GradDC, DipOHS, PhD b

ABSTRACT

Objectives: The aim of this study was to perform a systematic review of the literature of the effectiveness and safety
of manual therapy interventions on pain and disability in older persons with chronic low back pain (LBP).
Methods: A literature search of 4 electronic databases was performed (PubMed, EMBASE, OVID, and CINAHL).
Inclusion criteria included randomized controlled trials of manual therapy interventions on older persons who had
chronic LBP. Effectiveness was determined by extracting and examining outcomes for pain and disability, with safety
determined by the report of adverse events. The PEDro scale was used for quality assessment of eligible studies.
Results: The search identified 405 articles, and 38 full-text articles were assessed. Four studies met the inclusion
criteria. All trials were of good methodologic quality and had a low risk of bias. The included studies provided
moderate evidence supporting the use of manual therapy to reduce pain levels and alleviate disability.
Conclusions: A limited number of studies have investigated the effectiveness and safety of manual therapy in the
management of older people with chronic LBP. The current evidence to make firm clinical recommendations is
limited. Research with appropriately designed trials to investigate the effectiveness and safety of manual therapy
interventions in older persons with chronic LBP is required. (J Manipulative Physiol Ther 2017;xx:1-8)
Key Indexing Terms: Pain; Low Back Pain; Chronic Pain; Review; Aging; Musculoskeletal Manipulations; Safety

INTRODUCTION people who retire early because of LBP have substantially

less total wealth and income-producing assets, about 87%
Low back pain (LBP) is the leading cause of years lived
less than those who remain in full-time employment. 6 In the
with disability in both developed and developing countries and
United States, more than 25% of older persons with back pain
sixth in terms of overall disease burden (disability adjusted
already had chronic back pain when they entered the retirement
life-years). 1 It is a common condition that has a profound
age. 7 From this study, in 2006-2007, Baby Boomers (born
socioeconomic impact on individuals, families, and societies.
between 1946 and 1964) accounted for 51% of total chronic
In older persons, the World Health Organization has identified
back pain costs, costing over $10 billion on ambulatory
LBP as the major disabling condition. 2 In Australia, older
services (services provided during outpatient, office-based, or
people have greater physical disability as a consequence emergency department settings, including purchased pre-
of their LBP compared with younger people. 3 Old age is
scribed medicines in those encounters). 7 In developed nations,
significantly associated with nonrecovery and poor outcome. 4
the population of older people will increase dramatically. In
LBP is a common reason forcing people to retire, 5 and older
Australia, it is estimated that by 2042, 25% of the population,
a or 6.2 million people, will be aged over 65 years. 8 Among
Private Practice, South West Rocks, NSW, Australia.
b
Macquarie University, Department of Chiropractic, Sydney,
older persons living in developed countries, the 1-month
NSW, Australia. prevalence of LBP is estimated to be between 18% and 29%. 9
Corresponding author: Katie E. de Luca, MChiro, PhD, 24 Over the next few decades, the number of older people living
Salmon Circuit, South West Rocks, NSW, Australia, 2431. Tel.: with LBP will increase substantially, and the costs incurred by
+61 412 431 931. (e-mail: chirokatie@live.com.au). the individual and government will also continue to grow.
Paper submitted April 11, 2017; in revised form June 12, 2017;
Although LBP is common in older persons, there is a
accepted June 16, 2017.
0161-4754 very limited understanding of how to manage the condition.
© 2017 by National University of Health Sciences. A 2011 Cochrane review that assessed the effectiveness of
https://doi.org/10.1016/j.jmpt.2017.06.008 combined chiropractic interventions for LBP reported
2 de Luca et al Journal of Manipulative and Physiological Therapeutics
Low Back Pain in Older People Month 2017

Table 1. Eligibility Criteria for Including Studies in the Review

Topic Inclusion Criteria
Participants Adults aged 55 years and over
Study population must have a classification of chronic low back pain (N3 months)
Study population could have low back pain with or without radiating symptoms

Intervention A manual therapy intervention

Comparison No-intervention or control group; sham manual therapy; another type of manual therapy;
or manual therapy combined with other therapy versus other therapy alone

Outcome Primary outcomes of interest—pain and disability

Design Randomized controlled trial

Exclusion Criteria
Participants Study participants who had postpartum low back pain; pain unrelated to the lumbar spine (eg, coccydynia);
and postoperative back pain or “failed back syndrome”

Comparison Single treatment intervention without further follow-up

Studies examining an intervention focused on a specific pathology

Outcome No measure of primary outcomes

limited evidence to support or refute the clinical meaningful
difference for pain and disability. 10 Six of the 12 studies
explicitly excluded participants over 60 years of age.
Another 2011 Cochrane review assessed nonoperative
treatment for chronic LBP, and while spinal manipulation
therapy (SPM) had small, statistically significant improve-
ments in pain and functional status in the short term
compared with other interventions. 11 Again, older adults
were commonly excluded from the trials. The clinical
presentation of LBP is complex, and there are distinct
patterns in which subgroups of a large number of patients do
not become pain-free. 12,13 There is a substantial knowledge
gap as a result of the exclusion of older persons from studies of
interventions and management of care. An important question
is whether manual therapy is effective and safe for older
persons who suffer chronic LBP. Therefore, the aim of this
study was to perform a systematic review of the literature on
the effectiveness and safety of manual therapy interventions on
pain and disability in older persons with chronic LBP.
METHODS
Reporting of this systematic review is guided by the
Preferred Reporting Items for Systematic Reviews and
Meta-Analysis (PRISMA) checklist. 14
“osteopathic,” “physiotherapy,” “orthopedics,” “spinal,”
“manipulation,” “adjustment,” “manual therapy,” “massage,”
and “mobilisation.” Details of individual database searches
are presented in Appendix A. The search was limited to
studies published in English.
Screening of Eligible Studies
The search of titles relevant to the aim of this study was
undertaken by 4 reviewers (H.F., J.O., K.S., S.W.). If there
was uncertainty regarding the eligibility of a study title, the
abstract was obtained and added into the next phase of the
review for further clarification. Abstracts were then
screened for eligibility by using a screening tool with 4
key headings: (1) randomized controlled trial, (2) eligible
participants, (3) manual therapy interventions, and (4)
primary outcomes. Eligible abstracts were included in
full-text retrieval stage of the review if they met all 4 criteria
on the screening tool. If clarification was needed on any of
the eligibility criteria, the reviewers consulted with a
designated reviewer (K.D.). Full-text manuscripts were
then screened for eligibility, as determined by inclusion and
exclusion criteria (Table 1). This then yielded a final
number of eligible studies for the data extraction phase. If
there was any uncertainty or disagreement on eligibility, 2
designated reviewers (K.D., P.T.) were consulted.

Literature Search Strategy

A computerized electronic literature search of PubMed,
EMBASE, OVID, and CINAHL (from January 2006 to March
2016), was undertaken by 4 reviewers (H.F., J.O., K.S., S.W.).
The search string consisted of combinations of the following
keywords and Medical Subject Headings (MeSH): “elderly,”
“geriatric,” “seniors,” “older,” “low back pain,” “chiropractic,”
Data Extraction
The effectiveness of manual therapy was determined
through self-reported outcomes for pain and disability. A data
extraction tool was developed by 1 reviewer (K.D.) based on the
Cochrane Handbook for Systematic Reviews of Interventions 15
and peer-reviewed articles. 16,17 Data extracted from the studies
Journal of Manipulative and Physiological Therapeutics
Volume xx, Number
405 study titles identified through
Identification
database searching
380 study abstracts were screened
Screening
for eligibility with an abstract
screening tool
38 full text studies were assessed for
eligibility in reference to the inclusion
Eligibility
and exclusion criteria
4 studies met the inclusion criteria
and were included in this systematic
Included
review
Fig 1. PRISMA 2009 flow diagram. RCT, randomized controlled trial.
included authors’ names and affiliations, study year, study
design, setting, sample size, randomization, participant charac-
teristics, diagnosis and duration of LBP, type and timing of
interventions, primary outcomes, treatment effects, and key
findings of the study. Data extraction was undertaken by 4
reviewers (H.F., J.O., K.S., S.W.). One reviewer (K.S.)
formatted a merged data extraction document and 2 other
reviewers (K.D., P.T.) checked the level of agreement.
RESULTS
A PRISMA flowchart of the literature search is shown in
Figure 1. Eighteen studies were excluded because they failed to
meet the inclusion criteria. A total of 4 articles were included,
and their study characteristics and key findings are presented in
Table 2. 18-22 The results of the quality assessment of each
study on the PEDro scale are presented in Table 3. The 4 trials
were of good methodologic quality and had a low risk of bias,
with scores ranging from 6 to 8 on the PEDro scale. Outcomes
measures used by studies included in the review comprise
self-reported tools: the Visual Analog Scale (VAS), Numeric
Pain Rating Scale, 21-Box Questionnaire, Short Form of
McGill Pain Questionnaire, Present Pain Index, Oswestry
de Luca et al 3
Low Back Pain in Older People
Duplicate studies
removed
(n = 25)
Studies excluded
(n = 342)
Studies excluded
(n = 34)
Not an RCT = 13
Not including manual therapy = 18
Not geriatric population = 1
Not in English = 1
Not chronic low back pain = 1
Disability Index (ODI), Roland Morris Disability Question-
naire, Short-Form Health Survey-36, Time to Up and Go, and
Fear-Avoidance and Belief Questionnaire.
Pain
The first placebo-controlled trial utilizing a sham
intervention evaluating the effect of SPM in older adult
veterans 18 measured pain using the VAS 23 and the pain
subscale of the Short-Form Health Survey-36. 24 SPM did
not produce a significantly greater reduction in pain
compared with the sham intervention group at either the
5th-week or the 12th-week follow-up. There was a
significant reduction in the pain scores from baseline to
follow-up in both the SPM and the sham intervention
groups, suggesting a general “nonspecific therapeutic
effect.” Similarly, in an earlier study, 21 when comparing
the effects of thrust manipulation and nonthrust manipula-
tion on a sample of older subjects with LBP, there were no
between-group differences between older subjects receiv-
ing thrust manipulation and those receiving non-thrust
manipulation, but both forms of manual therapy produced
similar, significant outcomes. This study used an 11-point
ordinal Numeric Pain Rating Scale to measure pain.
4 de Luca et al Journal of Manipulative and Physiological Therapeutics
Low Back Pain in Older People Month 2017

Table 2. Characteristics and Key Findings of the 4 Studies Included in the Review
Sample Size Primary
(n); Study Outcomes of
Population Duration of Pain and
Inclusion Age LBP (Mean Disability
Study (Year) Study Intervention Trial Design (Mean: [SD]) [SD]) Within Study Key Findings of Study
Learman et al TM: commonly side-lying Pragmatic RCT: 49; ≥55 years Not reported; NPRS, ODI Statistically significant
(2013)21 rotational manipulation and Intervention (mean: 64.5 22.2 weeks reductions in pain (P b .001)
the supine anterior superior received on 2 [8.9]) (40.6) and improvements in disability
iliac spine; vs NTM: passive, occasions (P b .001) in both TM and
low-velocity oscillatory (range 1-4 days) NTM across both time periods;
movements no statistically significant
Both groups prescribed a between group differences
standardized home in pain or disability
exercise program
Sritoomma Control intervention: TTM RCT: both 140; ≥60 years LBP lasting VAS, MPQ, Statistically significant
et al delivered through clothing intervention for N12 weeks; ODI reductions in pain (P b .001)
(2014)22 with no oil; vs treatment groups received not reported and improvements in disability
intervention received SMGO a 30-min (P b .001) in both SMGO
(2% essential ginger oil massage and TTM across the 3 time
with Jojoba oil) ×2/week periods; SMGO was more
for 5 weeks effective than TTM in reducing
pain (P = .04) and improving
disability (P = .041).
Dougherty Treatment intervention: SMT RCT: both 136; ≥65 years LBP pain VAS, pain Statistically significant
et al (HVLA-SM, and/or flexion groups received (mean 76.9 ≥3 months and physical reductions in pain (VAS
(2014)18 distraction therapy and/or intervention [6.77]) subscale of P b .001; SF-36 Pain Scale
mobilization); vs sham ×2/week the SF-36, P b .001) and improvements
intervention: detuned for 4 weeks ODI in disability (P b .001;
ultrasound applied over the SF-36 physical function
lumbar spine for 11 minutes subscale P b .01) in both
SMT and sham groups from
baseline to 12 weeks’
follow-up. No statistically
significant between group
difference in pain at week 5
or week 12. No statistically
significant between group
difference in disability at
week 5; however, there was
a statistically significantly
improvement in disability in
the SMT compared with the
sham group at week 12
(P b .001)
Enix et al Chiropractic care: any RCT: both 118; LBP at least 21-point Statistically significant
(2015)19 combination of HVLA-SM, groups received 60–85 years 12 weeks Box Scale reductions in pain in both
LVVA-SM, flexion distraction, intervention ×2 duration chiropractic care and physical
drop table manipulation, passive to ×3/week for therapy treatment groups
mobilization, PNF, PIR, massage 6 weeks at week 6 and at week 12;
or stretching; vs physical therapy: no statistically significant
any combination of neuromuscular between group differences
re-education, muscle endurance in pain
and strength training exercises,
flexibility stretches, interferential
electrical stimulation, ultrasound,
postural education, home exercise
FABQ, Fear Avoidance Beliefs Questionnaire; HVLA-SM, high-velocity, low amplitude spinal manipulation; LBP, low back pain; LVVA-SM,
low-velocity, variable amplitude spinal manipulation; MCMC, minimal conservative medical care; MPQ, McGill Pain Questionnaire; NPRS, numerical
pain rating scale; NTM, non-thrust manipulation; ODI, Oswestry Disability Index; PIR, post-isometric exercise relaxation; PNF, proprioceptive
neuromuscular facilitation; RCT, randomized controlled trial; RMD, Roland Morris Disability; SD, standard deviation; SF-36, 36-Item Short-Form
Health Survey; SMGO, Swedish massage with aromatic ginger oil; SMT, spinal manipulation therapy; TM, thrust manipulation; TTM, traditional Thai
massage; VAS, Visual Analog Scale.
Journal of Manipulative and Physiological Therapeutics de Luca et al 5
Volume xx, Number Low Back Pain in Older People

Table 3. Methodological Quality Assessment of the 4 Studies Included in This Review Using PEDro
Learman et al Sritoomma et al Dougherty et al Enix et al
(2013)21 (2014)22 (2014)18 (2015)19
1. Eligibility criteria were specified. Y Y Y Y

2. Subjects were randomly allocated to groups. Y Y Y Y

3. Allocation was concealed. Y Y Y Y

4. The groups were similar at baseline with regard to Y Y Y Y

the most important prognostic indicators.

5. There was blinding of all subjects. N N N N

6. There was blinding of all therapists who administered the therapy. N N N N

7. There was blinding of all assessors who measured at least 1 outcome. N N Y Y

8. Measures of at least 1 key outcome were obtained Y Y Y Y

from N85% of the subjects initially allocated to groups.

9. All subjects for whom outcome measures were available N Y Y Y

received the treatment or control condition as allocated or,
where this was not the case, data for at least 1 key outcome
was analyzed by “intention to treat.”

10. The results of between–group statistical comparisons are Y Y Y Y

reported for at least 1 key outcome.

11. The study provides both point measures and measures of Y Y Y Y

variability for at least 1 key outcome.

12. PEDro score 7 7 8 8

N, no; Y, yes.

Another study 19 reported statistically significant reductions
in pain for interventions of chiropractic and physiotherapy
for older patients with balance problems, with or without
chronic LBP. There was, again, no significant between-
group effect. This study used a 21-point Box Scale
self-reported pain questionnaire to measure pain. Both
Swedish massage with aromatic ginger oil and traditional
Thai massage led to significant reductions in pain level
across the 3 periods of assessment (immediate, 6th-week
assessment, and 15th-week assessment). There were no
significant differences between the group receiving Swed-
ish massage with aromatic ginger oil and the one receiving
traditional Thai massage immediately after the massage;
however, the Swedish massage group showed a better
outcome at the 6th-week and 15th-week follow-up. This
study used the VAS and McGill Pain Questionnaire (Thai
version) to measure pain.
intervention group. Another study by Learman et al 21 did
not report any significant differences between the 2
intervention groups (thrust manipulation vs nonthrust
manipulation) in alleviation of disability. In this study, the
2 intervention groups were combined and stratified for age
to determine if there were any differences in outcomes
based on age. Learman et al found that age had an impact
on ODI scores. 21 These authors concluded that their lower
success rate of achieving a 50% reduction of ODI,
compared with earlier studies, 25 could be attributed to the
sample subjects being older and having a longer duration of
symptoms. A clinical trial by Sritoomma et al 22 found that
both Swedish massage with aromatic ginger oil and
traditional Thai massage significantly improved partici-
pants’ disability ratings; however, the Swedish massage
with aromatic ginger oil was more effective at the 6th-week
and 15th-week follow-up. Disability was measured by
using the ODI (Thai version 1.0).

Disability
A study by Dougherty et al 18 reported that the SPM Safety and Adverse Events
group had statistically significant improvement with regard Only the study by Dougherty et al 18 provided a
to disability at week 12 compared with the sham comprehensive and explicit report of adverse events
6 de Luca et al
Low Back Pain in Older People
(AEs). This study measured AEs at each treatment visit
and at the 5th-week and 12th-week follow-up. AEs were
clinically judged as mild, moderate, or severe, and a
serious AE (SAE) was defined as any AE occurring
during the study or within 30 days of conclusion of study
participation, resulting in any one of the following
outcomes: death, life-threatening persistent or significant
disability/incapacity, or hospitalization. A total of 250
AEs were reported; there were no differences in the
frequency or severity of the AEs between the PM and
sham intervention groups; most AEs were mild to moderate
musculoskeletal soreness, and only 10% of the AEs were
judged to be definitely related to the study. There were 6
SAEs reported after the start of the treatment; however, none
of the SAEs was associated with study interventions. The
remaining 3 studies reported that there were no
intervention-related AEs recorded during the course of their
studies.
DISCUSSION
The aim of this systematic review was to determine the
effectiveness and safety of manual therapy on pain and
disability in older persons with chronic LBP. There is
moderate evidence to support the effectiveness of manual
therapy in reducing pain levels in older persons with
chronic LBP. A consistent finding from the studies was that
manual therapy was effective in reducing pain; however, in
most cases, there was no significant difference between the
intervention groups that were compared, suggesting
different forms of manual therapy did not lead to different
outcomes in older persons with chronic LBP. In the study
by Dougherty et al, manual therapy was compared with
placebo, and although both interventions showed a
reduction in pain level, no statistically significant differ-
ences were observed. This finding implies the presence of a
nonspecific therapeutic effect, possibly associated with the
doctor–patient encounter. 26
There is also moderate evidence showing the effective-
ness of manual therapy on disability in older persons with
chronic LBP. Three of the 4 studies included measures of
disability within their outcomes, 18,21,22 with 2 studies
finding small, but significant, differences between the
intervention groups. 18,22 In an RCT that was excluded from
this review (the study population included patients with
subacute and chronic back pain, of whom 14 reported LBP
of ≤2 weeks’ duration and 6 participants reported LBP of 4
weeks’ duration), 2 types of spinal manipulation and
minimal conservative medical care for LBP were compared
in adults 55 years and older. 20 In alleviating disability, low
velocity-variable amplitude spinal manipulation was supe-
rior to minimally conservative medical care at all end
points (3, 6, 12, and 24 weeks), with high velocity-low
amplitude spinal manipulation being superior to mini-
Journal of Manipulative and Physiological Therapeutics
Month 2017
mally conservative medical care at week 3. 20 The finding
of this study concurs with those of 2 of the included
studies in this review and further supports a mild treatment
effect of spinal manipulation compared with other available
therapies. 27,28
Two studies compared different forms of manual
therapy, and no significant between-group differences in
pain or disability were reported in both. 19,21 The study by
Learman et al 21 had an intervention design in which
clinicians used either a thrust technique or a nonthrust
technique to best benefit the patient. Similarly, the study
by Enix et al 19 decided on a hybrid pragmatic study
design after comparing a physical therapy intervention
with chiropractic care. In trying to reflect clinical practice,
Enix et al included interventions that had similar
modalities (Table 2), and the commonalities between
groups probably explain the lack of between–group
treatment effect.
Although chiropractic is commonly used in older adults,
studies that evaluate the effectiveness and safety of
chiropractic care, specifically for older people, are lacking.
Dougherty et al 18 provided a comprehensive and explicit
report of AEs, with no differences in the frequency or
severity of AEs between the SPM and sham intervention
groups. The other 3 studies reported that no intervention-
related AEs were observed during the course of their
studies. 19,21,22 Although the reporting in these 3 studies was
not as comprehensive as that by Dougherty et al, 18 this does
suggest that older people receiving manual therapy
experience very few AEs. A recent consensus process that
determined the best practice for chiropractic care for older
adults 29 recommended that manual procedures take into
consideration patient size and frailty; biomechanical force
should be modified and may often be contraindicated in
older people. This reflects the literature that suggests that it
is important to tailor manual therapy to the clinical
presentation and preferences of patients 30 and that low
velocity, variable amplitude techniques, such as instrument-
assisted procedures, pelvic blocking, mechanized or
non-mechanized table-assisted procedures, and other
low-force techniques are appropriate. 30,31
Limitations
The main limitation of this review was that only 4
randomized controlled trials met the eligibility criteria, and
lack of available research data prevented making any
clinical recommendations. Studies included in this review
may be limited by their study population exclusion criteria;
many older participants are excluded from research if they
have existing comorbidities. This possibly introduces
selection bias and minimizes the generalizability of findings
because many older patients often have multiple comor-
bidities. A further limitation is that because of the nature of
the treatment performed, certain patients and practitioners
Journal of Manipulative and Physiological Therapeutics
Volume xx, Number
could not be blinded through the course of the trials.
Additionally, of the studies that compared different
treatments, some did not publish results comparing the
treatment interventions. Only one of the included studies
had a control group. Further studies should investigate the
placebo effect by adding control groups to improve study
quality and identify the true effect of manual therapy as a
treatment for LBP in older people.
CONCLUSIONS
A limited number of studies have investigated the
effectiveness and safety of manual therapy in the manage-
ment of older people with chronic LBP. Four studies
identified by this review demonstrated moderate evidence
supporting the use of manual therapy to reduce pain levels
and alleviate disability. Current evidence limits the ability
to make firm clinical recommendations. Considering that
chronic LBP is one of the major disabling musculoskeletal
conditions in older people, specific research with appropri-
ately designed trials to investigate the effectiveness of
manual therapy interventions in older persons with chronic
LBP is urgently required.
FUNDING SOURCES AND CONFLICTS OF INTEREST
There are no funding sources, and the authors report no
conflicts of interest for this study.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
K.D., P.T.
Design (planned the methods to generate the results):
K.D., P.T., S.F., J.O., K.S., S.W.
Supervision (provided oversight, responsible for orga-
nization and implementation, writing of the manuscript):
K.D., P.T.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data): K.D.,
P.T., S.F., J.O., K.S., S.W.
Analysis/interpretation (responsible for statistical analy-
sis, evaluation, and presentation of the results): K.D., S.F.,
J.O., K.S., S.W.
Literature search (performed the literature search): K.D.,
S.F., J.O., K.S., S.W.
Writing (responsible for writing a substantive part of the
manuscript): K.D., P.T., S.F., J.O., K.S., S.W.
Critical review (revised manuscript for intellectual
content, this does not relate to spelling and grammar
checking): K.D., P.T., S.F., J.O., K.S., S.W.
de Luca et al 7
Low Back Pain in Older People
Practical Applications
• Older people are typically excluded from
randomized controlled trials, which has
created a large gap in the literature on the
effectiveness and safety of manual therapy in
this population.
• Four studies explicitly investigated manual
therapy for chronic LBP in older persons, and
although there is moderate evidence to
support the use of manual therapy to improve
pain and disability, current evidence limits
the ability to make clinical recommendations.
• Studies have reported significant improve-
ments over time in pain and level of disability;
however, minimal significant differences were
observed between interventions.
• Better study designs are recommended for
future trials. The commonalities between
interventions probably explain the lack of
between–group treatment effects. A prag-
matic approach is recommended to reflect
clinical practice.
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APPENDIX A. FULL SEARCH TERMS, AND YIELD, FOR EACH OF THE 4 ELECTRONIC DATABASES
Database Search Yield
CINAHL Geriatric OR elderly 22
Back pain OR low back pain OR chronic
Manip* OR chiropract* OR osteopath*

EMBASE Elderly OR senior OR geriatric OR older 15

Low back pain OR Lower back pain OR LBP
Chiropract* OR Osteopath* OR Physio* OR Orthopaedic OR
Orthopedic OR Manipulat* OR Adjustment OR Manual therapy
OR Manual treatment OR Massage OR Mobilisation OR Mobilization
#1 AND #2 AND #3

OVID geriatric 8
elderly
back pain
low back pain
chronic
manip* OR chiropract* OR osteopath*

PUBMED Elderly OR senior OR geriatric OR older 212

Low back pain OR Lower back pain OR LBP
Chiropract* OR Osteopath* OR Physio* OR Orthopaedic OR
Orthopedic OR Manipulat* OR Adjustment OR Manual therapy OR
Manual treatment OR Massage OR Mobilisation OR Mobilization
#1 AND #2 AND #3