Low back pain

Lumbar Spine Manipulation

I (Steve) thought I would discuss the clinical prediction rule for manipulation of the lumbar spine. Although an old study, it had a significant influence on how manipulation is practiced and the clinical decision making behind the intervention. It has also been scrutinized and misinterpreted frequently over the last decade.

First a little background. In 2002, Tim Flynn took 71 patients with low back pain (LBP) and prospectively tested them on a number of variables from both the history and the clinical examination. He then treated all patients with two sessions of lumbar spinal manipulative therapy (SMT) over a one week period. The treatment effect was dichotomized as success or non-success based on a 50% reduction in Oswestry Disability Index (ODI) score. Those patients considered a success were further analyzed to determine common factors the patients shared from the history and the clinical examination. Noteworthy is that 45% of all patients who received lumbar SMT demonstrated the 50% improvement. In addition no adverse events were reported.

Factors associated with success included:

  • Pain lasting less than 16 days
  • No symptoms distal to the knee
  • FABQ score less than 19
  • Internal Rotation of greater than 35 degrees for at least one hip
  • Hypomobility of a least one level of the lumbar spine

Having 4/5 of these variables positive increased the likelihood of dramatic success to 95%. Interestingly, Tim Flynn was a highly touted manual therapist and fully believed in a biomechanical model and thought that this study would provide evidence for this form of clinical reasoning. Tim now refers to himself as a recovering biomechanist!

John Childs then prospectively tested the rule in a randomized controlled trial with four groups: 1) patients positive on the CPR who received two manipulations and three sessions of stability exercises, (2) patients positive on the rule who received five sessions of exercise based therapy, (3) patients negative on the rule and received manipulation and stabilization exercises, and (4) patients negative on the rule and received five sessions of exercise based therapy.

Those patients positive on the rule who received manipulation demonstrated dramatic improvements compared to those positive on the rule who only received the exercise based therapy. It is worth noting that these effects were not only dramatic but also long lasting. At six month follow-up as demonstrated by the graph below:

Furthermore, the benefits were not limited to just improvement in ODI scores; at six month follow-up, those patients receiving manipulation demonstrated a reduction in the use of medication, utilization of treatment, and lost time from work. Again, no adverse events were reported.

Although the CPR is helpful at identifying a sub-group of responders to lumbar SMT, isn’t there a faster maybe more pragmatic screening exam? Well Fritz. et al examined the variables that were predictive of success with lumbar SMT. The authors took the 71 subjects used to develop the CPR (1) and the 70 subjects randomized to receive the manipulation intervention taken from the validation study (2) and found that with the two criteria present - acute low back pain (less than 16 days) and no symptoms distal to the knee - yielded a positive likelihood ratio of 7 (95% CI: 3.2-16.1) (3). That is, patients were 7 times more likely to have a favorable response (a 50% reduction in the ODI score) to lumbar SMT if these two criteria were present.

For those positive on the rule, spinal manipulation appears to have a “Slam dunk” effect and is perhaps considered negligent to potentially withhold the intervention.

For those positive on the rule, spinal manipulation appears to have a “Slam dunk” effect and is perhaps considered negligent to potentially withhold the intervention. If we look more closely at the data, patients in the manipulation group demonstrated significantly better results in outcomes at six weeks irrespective of status on the prediction rule when compared to those only receiving exercise - although the effect size was not as dramatic. On this basis, perhaps our clinical question should not be “Who should we manipulate” but rather “Who shouldn’t we manipulate”.

I hope this provides stimulus for thought and I encourage you to review these two studies and reflect about how the information should effect your practice. 

Happy Reading!


Childs, John D., 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." 141.12 (2004): 920-928.


Flynn, Timothy, et al. "A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation."Spine 27.24 (2002): 2835-2843.


Fritz, Julie, et al. Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention. “BMC Family Practice. (2005) 6:29.


Imaging And The Lumbar Spine, What Does It Tell Us?

By Sean Overin BHK, MPT, DPT & Steve Young BA, BHSc PT, DPT

Traditionally, a pathoanatomical approach has been used in medicine in order to guide treatment intervention; a specific pathology is identified and based on this disease a specific treatment intervention is implemented. It has been estimated that 65-80% of the population will experience at least one episode of low back pain (LBP)1, and unfortunately, there is evidence we are unable to accurately identify the specific cause for the vast majority of these patients2.

In a classic study published in the New England Journal of Medicine, 98 asymptomatic individuals had magnetic resonance imaging (MRI) of their lumbar spine and over 60% presented with some type of abnormality according to the reading radiologist3. In another study, a prospective cohort of patients without LBP were given an MRI and a multitude of self-report questionnaires then followed for three years to determine factors associated with the development of LBP4. Similar incidences of asymptomatic findings were found on MRI as was seen in the New England Journal of Medicine study. The only anatomical finding that approached clinical significance was a frank disk herniation, while depression was the only factor that was actually found to be a significant predictor of future episodes of LBP.

Even though there is evidence that asymptomatic findings are the norm with imaging and may not be predictive in the development or prognosis of LBP, could there be any dangers with imaging above and beyond the cost and potential exposure to radiation? A number of studies have identified that, all other things being equal, patients receiving imaging for LBP show no difference or even worse outcomes than those randomized to not receive imaging. For example, studies consistently show associations between increased use of imaging and higher rate of spinal surgeries and injections, consequently putting patients at risk for prolonged disability and complications including death5,6. Another study found that patients randomized to receive their MRI results had worse health perceptions compared to patients not given their results7.

lumbar spine image

Current evidence-based clinical practice guidelines advise clinicians to avoid routine imaging for non-specific LBP, except to rule out serious pathology (1-2%) and patients with progressive neurological deficits8. In a meta-analysis reviewing randomized controlled trials of early imaging for non-specific LBP, there were no identified red flag conditions that were missed secondary to not imaging patients9. Future directions should look to provide specific protocols for lumbar imaging, similar to the well established Canadian Cervical Spine Rules10. Until then, evidence from large population based studies advocates for early physiotherapy intervention as this has been associated with improved patient outcomes when compared to patients who receive delayed referral for physiotherapy services11, 12. Furthermore, early physiotherapy also translated into a reduction in overall healthcare costs, opiate based medication usage and invasive procedures that carry greater risk of significant side-effects.

Clinical Bottom Line: Patients presenting with non-specific LBP should not receive routine medical imaging. These patients may benefit from early physiotherapy that includes active based treatment and reassurance of a favourable prognosis.






1. Lawrence RC, Helmick CG, Arnett FC. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis & Rheumatism 1998; 41:778-799.

2. Casazza, BA. (15 February 2012). "Diagnosis and treatment of acute low back pain". American family physician 85 (4): 343–50

3. Jensen, Maureen C., et al. "Magnetic resonance imaging of the lumbar spine in people without back pain." New England Journal of Medicine 331.2 (1994): 69-73.

4. Jarvik, Jeffrey G., et al. "Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors." Spine 30.13 (2005): 1541-1548.

5. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289:2810-2818.

6. Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine 2003; 28: 616–20

7. Ash, L. M., et al. "Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain." American Journal of Neuroradiology 29.6 (2008): 1098-1103.

8. Chou, Roger et al. 2007. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society.

9. Flynn, Timothy W., Britt Smith, and Roger Chou. "Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good." journal of orthopaedic & sports physical therapy 41.11 (2011): 838-846.

10. Stiell, Ian G., et al. "The Canadian C-spine rule for radiography in alert and stable trauma patients." Jama 286.15 (2001): 1841-1848.

11. Gellhorn, Alfred Campbell, et al. "Management patterns in acute low back pain: the role of physical therapy." Spine 37.9 (2012): 775.

12. Fritz, Julie M., et al. "Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs." Spine 37.25 (2012): 2114-2121.