Just in the news: Guidelines for Cholesterol has changed.  Think statin prescribing clinicians see this and may change practice patterns?  Most likely.  It seems in musculoskeletal care, we don’t.  Let’s look at a few guidelines.

Spinal Manipulation Therapy (SMT) is a common intervention for back pain. It has more robust evidence for acute low back pain compared to subacute and chronic.  However, I do think it’s utilization in physical therapy is lacking. A recent survey of DPT students at ODU who took Dr. Eric Jorde and myself’s introduction to SMT class showed this:


And the 65% of CI’s who performed SMT is better than what was studied by Boissonnault in 2005 (56%).

If we want to be evidence-based, or as I call it evidence-informed in our practices; we need to get on board. But as you will see in post below, no informed data here, this is evidence-based at its best in regards to musculoskeletal care. Level 1 evidence… Practice Guidelines and Systematic Reviews. Not just your level 5 expert opinion.


Yes, I know in 2013, Rubeinstein and his colleagues found:

SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies. Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation.

Maybe we should change our ways and stop manipulating acute low back pain.  I won’t change my patterns from one Cochrane Review personally. But to be fair, it needs to be shown.  Before we run off on this review, let’s look at multiple guidelines and systematic review.

European: NICE Guidelines.
National Institute for Health and Care Excellence. Early management of persistent non-specific low back pain. May 2009.

Considering offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to twelve weeks.

American: Family Physician Guidelines
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Chou et al. Annals of Internal Medicine. 2007;147(7):148-91.

“Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence)

Orthopaedic Section of the APTA: Guidelines for Low Back Pain

Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association.  J Orthop Sports Phys Ther. 2012:42(4):A1-A57

INTERVENTIONS – MANUAL THERAPY: Clinicians should consider utilizing thrust manipulative procedures to reduce pain and disability in patients with mobility deficits and acute low back and back-related buttock or thigh pain. Thrust manipulative and nonthrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with subacute and chronic low back and back-related lower extremity pain. (Recommendation based on strong evidence.)

Systematic Review of the Literature

Conclusions from:
John J. Kuczynski, SPT, Braun Schwieterman, SPT, […], and Chad E. Cook, PT, PhD, MBA, FAAOMPT
Int J Sports Phys Ther. 2012 December. 7(6): 647-662.

Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain.

Now is SMT the end-all, be-all treatment? NO. But, until we can understand low back disorders more; let’s get away from our corework bandwagon from the ’90s and actually hit the nail on the head.  Sometimes spinal manipulation is that hammer and sometimes not.  Why not bring this intervention to the table and see what happens?


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