Journal of Electromyography and Kinesiology 22 (2012) 670–691
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Journal of Electromyography and Kinesiology
journal homepage: www.elsevier .com/locate / je lek in
Review
Patient-centered outcomes of high-velocity, low-amplitude spinal manipulationfor low back pain: A systematic review
C.M. Goertz a,⇑, K.A. Pohlman a, R.D. Vining a, J.W. Brantingham b, C.R. Long a
a Palmer College of Chiropractic, Davenport, IA, 741 Brady St. United Statesb Private Practice, 3180 Willow Ln 20 Thousand Oaks, CA, United States
a r t i c l e i n f o
Keywords:Spinal manipulation
Low back painPatient-centered outcomes1050-6411/$ - see front matter � 2012 Published byhttp://dx.doi.org/10.1016/j.jelekin.2012.03.006
⇑ Corresponding author. Address: 741 Brady St., DStates. Tel.: +1 563 884 5150.
E-mail address: [email protected] (C.M
a b s t r a c t
Low back pain (LBP) is a well-recognized public health problem with no clear gold standard medicalapproach 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. Theprimary objective of this paper was to describe the current literature on patient-centered outcomes fol-lowing a specific type of commonly used SM, high-velocity low-amplitude (HVLA), in patients with LBP. Asystematic search strategy was used to capture all LBP clinical trials of HVLA using our predefinedpatient-centered outcomes: visual analogue scale, numerical pain rating scale, Roland-Morris DisabilityQuestionnaire, and the Oswestry Low Back Pain Disability Index. Of the 1294 articles identified by oursearch, 38 met our eligibility criteria. Like previous SM for LBP systematic reviews, this review showsa 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 drawdefinitive conclusions. Future SM studies for LBP would benefit if some of these issues were addressed bythe scientific community before further research in this area is conducted.
� 2012 Published by Elsevier Ltd.
1. Introduction
Low back pain (LBP) is a well-recognized public health problemwith lifetime prevalence ranging from 11% to 84% and median costper quality-adjusted life year of $13,015 (Dagenais et al., 2008;Walker, 2000). Point prevalence within the last 3 months is esti-mated at 17% (Deyo et al., 2006). At the most recent meeting ofthe Tenth International Forum for Primary Care Research on LowBack Pain participants concluded that ‘‘the LBP epidemic remainsa 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 uti-lization patterns in patients with chronic LBP (Carey et al., 2009).They found high health care utilization in this group, with an aver-age of 21 visits to 2.7 provider-types annually. Many of the testsand treatments used did not conform to evidence-based practice.The authors concluded that (1) care utilization for chronic LBP isvery high, including high use rates for advanced imaging, narcotics,and physical treatments; (2) use of evidence-based treatments arelow when compared with current best evidence; and (3) manytreatments are over-utilized. A recent review of clinical practice
Elsevier Ltd.
avenport, IA 52803, United
. Goertz).
guidelines for the treatment of LBP found that acute LBP manage-ment recommendations included three interventions: patient edu-cation, acetaminophen or nonsteroidal anti-inflammatory andspinal manipulation (Dagenais et al., 2010).
Spinal manipulation (SM) is commonly used to treat low backpain (LBP). SM is the therapeutic application of a load (force) tospecific body tissues (usually vertebral joints). Load delivery varieswith respect to velocity, amplitude, frequency, choice of lever, anddirection of force application (Herzog, 2000; Triano, 2000).
Because little is understood about the pathophysiology of mostLBP, and the exact mechanism(s) of action of SM’s effect on LBP islargely unknown, clinical trials have primarily depended upon pa-tient-perceived outcomes such as pain level and functional healthstatus (Bronfort et al., 2008; Lawrence et al., 2008). These have tra-ditionally been considered ‘‘soft’’ outcomes by the scientific com-munity. However, the recent creation of the Patient-CenteredOutcomes Research Institute (PCORI) in Washington, DC withinthe 2010 Patient Protection and Affordable Care Act by the US Con-gress has brought more focus and a growing acceptance of patient-perceived or ‘‘patient-centered’’ outcomes, at least in the context ofcomparative effectiveness research. While this has been a recentphenomenon, a patient-centered perspective has always been theprimary focus of SM research because of a lack of other availableoutcomes. A recent article found that the most commonly used pa-tient-based outcome assessments in chiropractic SM research were
1294 of records identifed through
database searching and hand-checked reference lists of
relevant studies(Including duplicate records)
1040of records excluded
254of abstracts screened for
selection criteria
85of records excluded:
(Table 1)14 No LBP14 No SM
57 Not a RCT
169of full-text articles assessed
for eligibility
131of full-text articles
excluded:(Table 2)28 Data
28 Outcomes26 Secondary Paper
26 No SM16 Not a RCT
7 No LBP
38of studies included
(Table 3)
Fig. 1. Literature retrieval process flow chart.
C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691 671
a mix of both pain and functional health status measures, includingthe Visual Analogue Scale (VAS), the Numerical Rating Scale (NRS),the Roland Morris Disability Questionnaire (RM), the Oswestry LowBack Pain Disability Index (OSW) and the Short Form-36 (SF-36)(Khorsan et al., 2008).
Numerous systematic reviews evaluating the effects of variousSM techniques for low back pain have been conducted over thepast 10 years (Assendelft et al., 2003; Bronfort et al., 2010; Ferreiraet 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 con-veys a modest but consistent benefit for patients with LBP at leastas large as commonly used alternative treatments. This is despitemarked heterogeneity in study design and quality.
Our review is unique in that only studies comparing high-veloc-ity, low-amplitude (HVLA) SM are included – because HVLA SM iscommonly used both in clinical trials and in the clinical setting(Christensen et al., 2010). We also present these data in a way thatallows us to separately consider the data from specific patient-cen-tered outcome instruments. In this paper we present tables show-ing the two most commonly used pain rating scales (NRS and VAS)and the two most commonly used patient-reported measures oflow back function (RM and OSW) in order to discern both similar-ities and differences in use and meaning. Included studies were re-stricted to those whose primary or secondary outcome was VAS,NRS, RM, and/or OSW. This allowed us to concentrate on studiesthat had similar outcome measures, decreasing heterogeneitywhile still including the most recent studies available. The primaryobjective of this paper was to describe the current literature on pa-tient-centered outcomes in randomized controlled trials of HVLASM in patients with low back pain.
2. Methods
2.1. Sources of information
The relevant studies were identified using the following dat-abases: PubMED (an index to Medline), the Cochrane Library, andIndex to Chiropractic Literature (ICL). All databases were searchedfrom inception through April 2011.
2.2. 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 ICLdatabase was searched using ‘‘low back pain’’ OR ‘‘back’’ OR ‘‘backpain’’ OR ‘‘back injuries’’ OR ‘‘sciatica’’ OR ‘‘LBP.’’ All searches werelimited to those studies written in English and involving humansubjects.
2.3. Search strategy
As shown in Fig. 1, a systematic search strategy was used tocapture all LBP clinical trials of SM using our predefined patient-centered outcomes. First, the sources of information were searchedusing the search terms and delimiters. We then cross referencedour findings with MESH headings and hand-checked reference listsof relevant studies to identify cited articles not captured by elec-tronic searches. Two independent reviewers screened all of the po-tential relevant studies for selection criteria. Discrepancies weresettled by a third independent reviewer (KAP). Second, abstractswere screened for absolute exclusionary criteria by an independentreviewer with any discrepancies resolved by at least three other
reviewers. The final step was a full-text review for selection criteriaconducted as a group by at least four of the authors.
2.4. Selection criteria
Articles were included if they met the following criteria: 1 –English language; 2 – non-specific low back pain as identified bythe author; 3 – involved adult human subjects, 18 years of ageor older; 4 – included HVLA as a category of spinal manipulativetherapy; however, studies of SM under anesthesia were ex-cluded; 5 – a randomized clinical trial that included a separateand distinct control or comparative treatment group; 6 – articlesthat used intention-to-treat analysis and had extractable data; 7– use of one or more of the following patient-centered out-comes: VAS, NRS, RM, and OSW. SF-36 data were not includedin this review because the majority of studies reviewed providedSF-36 data only when describing baseline characteristics. Studiesincluding other forms of SM (e.g. mobilization techniques) thatdid not have an HVLA arm were not included. Mechanistic andbasic science trials conducted on human participants were ex-cluded as were studies where the only comparative group wasanother SM method.
2.5. Operational definitions
For purposes of this review, SM was defined as a manuallydelivered high-velocity low-amplitude force or thrust applied toa vertebral or pelvic joint with the intent of creating a momentaryseparation of joint surfaces and cavitation. Components of SM,such as velocity and amplitude, have variable ranges of implemen-tation. Most definitions of SM refer to a thrust or an increasingmagnitude of force that peaks over a finite period of time (Evans,2010; Evans and Lucas, 2010). Cavitation alone is not considereda necessary component, though it is often considered one of thegoals of this procedure. Manual contacts over the intended verte-bral or pelvic joint (short lever) or over distant sites (long lever)were considered under our definition of spinal manipulation.
672 C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691
For this review, patient-centered outcomes have been given theoperational definition: patient self-report questionnaires related topain and physical/emotional/social functioning.
Currently few methods exist to reliably confirm a specific diag-nosis for the cluster of symptoms categorized as non-specific oridiopathic LBP. However, identifying specific patient characteristicsof LBP can demarcate similarities and differences between studypopulations. We found that symptom duration varied widelyamong the included study population and therefore added a classi-fication to each study based upon guideline definitions by the 2007American College of Physicians and American Pain Society: acutepain (0–4 wks), subacute pain (4–12 wks), and chronic pain (12or more wks) (Chou et al., 2007). Study populations were furtherclassified according to the Quebec Task Force (QTF) classificationsystem (Fig. 2) (Spitzer et al., 1995).
The timing of the primary endpoint for each study is presentedin the tables. For those studies reporting outcomes at durations be-yond the primary endpoint, we included the longest term follow-up available, up to 1 year.
2.6. Data extraction
For each article we extracted means, standard deviations (SD)and confidence intervals (CI) from the tables and text, but not fromfigures. We converted VAS scores reported in cm to mm and OSWscores reported on a 50-point scale to a 100-point scale. For articleswhere median and interquartile ranges were reported, we assumedthe median was equivalent to the mean and the interquartile rangewas equivalent to 1.35 times the standard deviation (Higgins andGreen, 2009).
Within each group, we extracted mean changes betweenbaseline and follow-up with confidence intervals directly fromthe article when possible. When only the means for baseline andfollow-up were given, we calculated the difference between meansrecognizing that the actual mean change could differ due to miss-ing data. When the SD of a change was given, we used it to esti-mate the standard error (SE) and calculate a 95% CI. When the SDof the change variable was not reported, but the SD of both thebaseline and follow-up variables were, we conservatively assumedthere was no correlation between baseline and follow-up measuresto estimate the SD of the change variable. We then used this SD toestimate the SE and calculate a 95% CI.
Between-groups, we extracted mean differences and CIs di-rectly from the article when possible. Some articles reported differ-ences in mean changes and some reported differences in follow-upmeans adjusted for the baseline outcome variable. Some articlesadjusted for covariates and others did not. We have not distin-guished between these different methods. When between-groupdifferences were not reported, we calculated them by using the re-ported group means. If group means were not given, we used thewithin-group means calculated as described above. When be-
Quebec Task Force classification1. LBP without radiation2. LBP + radiation to extremity, proximally3. LBP + radiation to extremity, distally4. LBP + radiation to limb with presence of neurologic signs5. Presumptive compression of a spinal nerve root 6. Compression of a nerve root confirmed by specific imaging techniques7. Spinal Stenosis8. Post surgical status < 6 months9. Post surgical status > 6 months10. Chronic pain syndrome11. Other diagnoses
Fig. 2. Quebec task force (QTF) classification system.
tween-group CIs were not reported, we calculated a pooled esti-mate of the SDs using the reported within-group SDs or thoseestimated as described above when within-group SDs were not re-ported. The pooled estimate of the SDs was then used to estimatethe standard error of the differences between means to calculate a95% CI.
2.7. Risk of bias
Independent quality rating went beyond the scope of this study.However, we reviewed and combined quality ratings from 2 Coch-rane 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.
3. Results
Of the 1294 articles identified by our initial search, 38 articlesmet the selection criteria (Fig. 1). The first three tables show stud-ies that were: (1) excluded based on abstract (Table 1); (2) ex-cluded based on full article assessment (Table 2); and (3)included (Table 3). Tables 4–7 give with-in group mean changesand between-group mean differences with 95% CIs of the VAS,NRS, RM and OSW, respectively, for the studies included in this re-view. Below is a description of each patient-centered outcomemeasure with a brief summary of our findings.
The visual analogue scale is a 100-mm line. The ends of theline are anchored with response categories, which are generally‘‘no pain’’ at the 0 mm end of the line and a descriptor suchas ‘‘unbearable pain’’ or ‘‘worst pain possible’’ at the 100 mmend of the line. The minimum clinically important difference(MCID) is defined as the smallest difference in the outcome per-ceived by patients as beneficial (Jaeschke et al., 1989). The MCIDfor VAS has been reported to range from 20 to 35 mm, with thesmaller difference typically for subacute and chronic LBP pa-tients and the larger difference for acute LBP patients (Hagget al., 2003; Ostelo and de Vet, 2005; Vela et al., 2011). Meanchange scores were similar at both short and long term follow-ups (Table 4).
The numerical pain rating scale asks participants to rate theirlevel of pain on an ordinal 11 point scale, anchored with responsecategories in which 0 represents ‘‘no pain’’ and 10 represents‘‘unbearable pain’’ or ‘‘worst pain possible’’ (Table 5). The MCIDis considered to be a change of 2.5 points (van der Roer et al.,2006). Between-group treatment effects tended to favor SM, butthe differences were not clinically or statistically significant.
The modified Roland-Morris Disability Questionnaire assessesLBP-related disability and has a MCID estimated at 2–3.5 points(Bombardier et al., 2001; Ostelo and de Vet, 2005). The RM is a1-page questionnaire and has shown both good reliability andvalidity (Roland and Fairbank, 2000) and is sensitive to clinicalchange in patients with LBP (Deyo et al., 1990; Riddle et al.,1998; Stratford et al., 2000). Within-group changes were higherin studies focused on acute LBP when compared to chronic LBP(Table 5). Between-group differences were inconsistent. With rareexceptions, long-term outcomes were similar to short-termoutcomes.
The Oswestry Low Back Pain Disability Index consists of 10questions assessing pain intensity and limitations in various activ-ities (Fairbank et al., 1980). Scores range from 0 to 50 points andare transformed into a percentage score, or score out of 100 points.The MCID is 6%, with recent discussion suggesting that the MCIDshould be 10% (Ostelo et al., 2008; Vela et al., 2011). Long-termoutcomes, when available, were similar to short-term outcomes(Table 6).
Table 1Excluded articles based on abstract screening.
Authors Year Journal Reason
Aleksiev A 1995 J Orthopaedic Med Not a RCTApeldoorn et al. 2010 BMC Musculoskelet Disord Not a RCTAxen et al. 2005 J Manipulative Physiol Ther Not a RCTAxen et al. 2005 J Manipulative Physiol Ther Not a RCTAxen et al. 2002 J Manipulative Physiol Ther Not a RCTBennell et al. 2010 BMC Musculoskelet Disord No LBPBoesler et al. 1993 J Am Osteopath Assoc No LBPBrealey et al. 2003 BMC Health Serv Res Not a RCTBreen A 1990 BMJ Not a RCTBrooks K 1988 Aust J Physiother Not a RCTCarey et al. 1995 NEJM Not a RCTCherkin et al. 1999 ACP Journal Club Not a RCTChiradejnant et al. 2002 Physiother Theory PraNot a RCT Not a RCTCibulka et al. 1988 Phys Ther Not a RCTCleland et al. 2006 BMC Musculoskelet Disord Not a RCTCooperstein et al. 2001 J Manipulative Physiol Ther Not a RCTCox JM 2009 J Manipulative Physiol Ther Not a RCTCramer et al. 2002 Spine No LBPCramer et al. 2000 J Manipulative Physiol Ther No LBPDescarreaux et al. 2004 J Manipulative Physiol Ther Not a RCTDogan et al. 2008 Clin Rheumatol No SMEvans et al. 2005 BMC Musculoskelet Disord Not a RCTFlynn et al. 2002 Spine Not a RCTFrench et al. 2000 J Manipulative Physiol Ther Not a RCTFritz et al. 2004 Phys Ther Not a RCTGemmell HA 1992 Chiropr J Aust Not a RCTGeisser et al. 2005 Clin J Pain No SMGunby P 1983 JAMA Not a RCTHaas et al. 2005 J Manipulative Physiol Ther Not a RCTHaas et al. 2004 J Manipulative Physiol Ther Not a RCTHancock et al. 2005 BMC Musculoskelet Disord Not a RCTHarvey et al. 2003 Man Ther Not a RCTHawk et al. 1999 J Manipulative Physiol Ther No LBPHemmila et al. 2002 J Manipulative Physiol Ther No SMHemmila et al. 1997 Arch Phys Med Rehabil No SMHenchoz et al. 2010 Spine No SMHeymans et al. 2006 Nat Clin PraNot a RCT Rheumatol Not a RCTHildebrandt et al. 1997 Spine Not a RCTHoskins and Pollard 2010 BMC Musculoskelet Disord No LBPJayson et al. 1981 Spine Not a RCTKane et al. 1974 Lancet Not a RCTKoes et al. 1990 Aust J Physiother Not a RCTKoes et al. 1991 J Manipulative Physiol Ther Not a RCTKohlbeck et al. 2005 J Manipulative Physiol Ther Not a RCTKokjohn et al. 1992 J Manipulative Physiol Ther No LBPLaird and Hughes 1988 Aust J Physiother Not a RCTLeboeuf-Yde et al. 2005 J Manipulative Physiol Ther Not a RCTLeboeuf-Yde et al. 2005 J Manipulative Physiol Ther Not a RCTLeboeuf-Yde et al. 2004 J Manipulative Physiol Ther Not a RCTLicciardone et al. 2010 Am J Obstet Gynecol No LBPMaiers et al. 2007 BMC Musculoskelet Disord Not a RCTMartin et al. 1986 Int Rehabil Med No SMMayer et al. 2004 Spine No SMMeade TW 1991 J Manipulative Physiol Ther Not a RCTMoffett and Frost 2000 Physiotherapy Not a RCTMooney V 2004 Spine Not a RCTNo authors listed 1990 Lancet Not a RCTNyiendo et al. 2000 J Manipulative Physiol Ther Not a RCTRainbow et al. 2008 JACA Online No LBPRasmussen-Barr
et al.2003 Manual Therapy No SM
Ritvanen et al. 2007 J Manipulative Physiol Ther No SMRoy et al. 2009 J Manipulative Physiol Ther No LBPRupert et al. 1985 ICA Rev Not a RCTSchellingerhout et al. 2008 Pain No LBPSchenk et al. 2007 Eur Spine J Not a RCTSchimmel et al. 2009 Eur Spine J No SMSchneider et al. 2010 J Manipulative Physiol Ther Not a RCTSheahan and Seaton 1999 J Fam Prac Not a RCTShekelle et al. 1992 Ann Intern Med Not a RCTShekelle et al. 1995 Med Care Not a RCTSherman et al. 2004 BMC Complement Altern Med Not a RCTSimon T 1994 J Manipulative Physiol Ther Not a RCTSkillgate et al. 2010 BMC Musculoskelet Disord No SMSkillgate et al. 2007 Clin J Pain No SMSlater et al. 2009 Arch Phys Med Rehabil No SM
Table 1 (continued)
Authors Year Journal Reason
Smith et al. 2006 J Manipulative Physiol Ther No LBPSnyder and Zhang 2007 J Chiropr Med Not a RCTStern et al. 1995 J Manipulative Physiol Ther Not a RCTTepe et al. 2006 J Chiropr Edu No LBPTriano and Schultz 1997 Spine Not a RCTUK BEAM trial team 2003 BMC Health Serv Res Not a RCTUnderwood et al. 2002 Fam PraNot a RCT Not a RCTWestrom et al. 2010 Trials Not a RCTZaproudina et al. 2009 Complement Ther Med No SMZhang et al. 2006 J Manipulative Physiol Ther No LBP
Abbreviations: No LBP – did not define participants was diagnosised with non-specific low back pain; No SM – did not have HVLA as the primary SM; Not a RCT –was not a randomized clinical trial.
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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 scoreswithin-groups and differences of mean change scores between-groups (Table 8). A wide range of mean change scores were foundboth within and between-groups across all measures. Within-group SM + scores were slightly higher. However, this was not truebetween-groups. The vast majority of comparison groups were ac-tive. There are too few sham control groups to draw any conclu-sions regarding effect sizes of active versus sham study designs.
In Table 9 we present quality ratings for the 20 articles includedin this review that were evaluated for quality in one or more of 3other reviews (Furlan et al., 2010; Rubinstein et al., 2011; Walkeret al., 2010). Overall, ratings for the majority of papers showedimportant gaps in quality markers for RCT study design, especiallyrelated to risk of bias, influence of co-intervention, and compliancewith interventions.
4. Discussion
Although this review specifically focused on studies with HVLASM as the primary treatment of interest, our findings are consistentwith those found in the latest reviews of SM for LBP that incorpo-rate the most recently published trials (Assendelft et al., 2003;Bronfort et al., 2010; Ferreira et al., 2003; Furlan et al., 2010; Koeset al., 2010; Pengel et al., 2002; Rubinstein et al., 2011; van Tulderet al., 2005; van Tulder, 2006; Walker et al., 2010). We agree withprevious conclusions that, although the data are generally insuffi-cient to make strong recommendations, SM appears to be one ofseveral effective treatment options for both acute and chronicLBP (Assendelft et al., 2003; Bronfort et al., 2004a; Koes et al.,1996; van Tulder et al., 1997; van Tulder, 2006). We also share con-cerns over the highly variable quality of extant trials, small effectsizes and large variation in outcomes (Assendelft et al., 2003;Bronfort et al., 2004b; Rubinstein et al., 2011) and agree that thevariation is most likely due to a combination of deficient trialmethodology, inadequate execution and reporting, the large andnon-quantified variation in the SM, and the unknown heterogene-ity of LBP patients (Furlan et al., 2010; Hurwitz, 2011; Rubinsteinet al., 2011).
The majority of studies included both pain and function as pri-mary and/or secondary outcomes. For pain, either the VAS or NRSwas used, while function was measured using either the RM or theOSW. VAS was more widely used than NRS (20 used VAS vs. 8 usedNRS), while use of RM and OSW were about equally divided (20 RMvs. 16 OSW). Two studies used both RM and OSW. In the majorityof studies, authors did not present a rationale for why one partic-ular pain or function measure was chosen over others. RM wasmore often used when the provider type was either a DO or aDC, while those studies with a PT provider used either RM or OSW.
Table 2Excluded articles based on full-text review.
Author Year Journal Reason
Arkuszewski Z 1986 Manual Med OutcomesAtkinson MJ 2002 Eur J Chiropr Not a RCTBeyerman et al. 2006 J Manipulative Physiol Ther DataBialosky et al. 2009 Phys Ther Not a RCTBialosky et al. 2008 J Orthop Sports Phys Ther Not a RCTBeira et al. 1998 JNMS DataBlomberg et al. 1992 Scand J Prim Health Care Secondary PaperBlomberg et al. 1994 Spine Secondary PaperBlomberg et al. 1993 Scand J Prim Health Care Secondary PaperBlomberg et al. 1994 Eur Spine J DataBlomberg and Tibblin 1993 Clin Rehabil Secondary PaperBoesler et al. 1993 J Am Osteopath Assoc OutcomesBogefeldt et al. 2008 Clin Rehabil OutcomesBronfort G. 1990 J Manipulative Physiol Ther OutcomesBronfort et al. 2000 J Manipulative Physiol Ther DataBronfort et al. 2004 J Manipulative Physiol Ther DataCambron et al. 2006 Chiropr & Osteopat OutcomesCambron et al. 2006 J Altern Complement Med No SMChilds et al. 2004 J Manipulative Physiol Ther DataChilds et al. 2006 Man Ther DataChiradejnant et al. 2003 Aust J Physiother No SMCleland et al. 2009 J Orthop Sports Phys Ther Secondary PaperCote et al. 1994 J Manipulative Physiol Ther OutcomesCoxhead CE 1974 Physiotherapy OutcomesCoxhead CE 1981 Lancet OutcomesCoyer and Curwen 1955 Br Med J OutcomesDavis and Kotowski 2005 Technol Health Care Not a RCTDegenhardt et al. 2007 J Am Osteopath Assoc Not a RCTDelitto et al. 1993 Phys Ther DataDoran and Newell 1975 Br Med J OutcomesEisenberg et al. 2007 Spine No SMEllestad et al. 1988 J Am Osteopath Assoc Not a RCTErhard et al. 1994 Phys Ther DataEvans et al. 1978 Rheumatol Rehabil OutcomesFarrell and Twomey 1982 Med J Aust DataFarrin et al. 2005 Clin Trials Secondary PaperFisk JW 1979 N Z Med J Not a RCTFlynn et al. 2006 J Manipulative Physiol Ther DataFroud et al. 2009 BMC Med Res Methodol Secondary PaperGarratt et al. 2003 Spine Not a RCTGemmell and Jacobson 1995 J Manipulative Physiol Ther Not a RCTGemmel and Jacobson 1998 Chiropr Tech No SMGlover et al. 1974 Br J Ind Med OutcomesGodfrey et al. 1984 Spine DataGoldstein et al. 2002 Spine J Secondary PaperGoldby et al. 2006 Spine No SMGoodsell et al. 2000 J Manipulative Physiol Ther No SMGudavalli et al. 2006 Eur Spine J No SMGudavalli et al. 2004 J Chiropr Educ No SMHaas et al. 2004 The Spine Journal Not a RCTHadler et al. 1987 SpIne DataHancock et al. 2008 European Spine Journal Secondary PaperHancock et al. 2007 Lancet DataHanrahan et al. 2005 J Athl Train No SMHarvey et al. 2004 Educ Prim Care Secondary PaperHawk et al. 1999 J Manipulative Physiol Ther DataHawk et al. 2005 J Altern Complement Med No SMHertzman-Miller et al. 2002 Am J Public Health Secondary PaperHerzog et al. 1991 J Manipulative Physiol Ther DataHoehler et al. 1981 JAMA DataHoiriis et al. 2000 J Chiropr Educ Secondary PaperHoiriis et al. 1999 J Chiropr Educ Not a RCTHurley et al. 2004 Spine No SMHurley et al. 2005 Man Ther No SMHurwitz et al. 2006 Spine Secondary PaperHurwitz et al. 2005 Am J Public Health Secondary PaperHurwitz et al. 2002 J Manipulative Physiol Ther Secondary PaperHurwitz et al. 2003 J Clin Epidemiol Secondary PaperHurwitz et al. 2005 Spine Secondary PaperKeller and Colloca 2000 J Manipulative Physiol Ther OutcomesKinalski et al. 1989 J Manual Medicine OutcomesKirk et al. 2005 Int J Osteopath Med DataKlaber et al. 2009 Disabil Rehabil Secondary PaperKoes et al. 1992 Spine No LBP
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Table 2 (continued)
Author Year Journal Reason
Koes et al. 1992 BMJ No LBPKoes et al. 1993 J Manipulative Physiol Ther No LBPKoes et al. 1992 J Manipulative Physiol Ther No LBPKominski et al. 2005 Med Care Secondary PaperKonstantinou et al. 2007 J Manipulative Physiol Ther No SMLalanne et al. 2009 J Manipulative Physiol Ther OutcomesLearman et al. 2009 J Manipulative Physiol Ther DataLewis et al. 2005 Spine No SMLicciardone et al. 2003 Spine DataMacDonald et al. 1990 Spine OutcomesMathews et al. 1987 Br J Rheumatol OutcomesMathews et al. 1988 Physiotherapy PraNot a RCTice OutcomesMeade et al. 1986 J Epidemiol Community Health DataMeade et al. 1995 BMJ Secondary PaperMeade et al. 1991 J Orthop Sports Phys Ther Secondary PaperMellin et al. 1989 Scand J Rehab Med DataMueller and Giles 2005 J Manipulative Physiol Ther Secondary PaperMurphy et al. 2006 BMC Musculoskelet Disord Not a RCTNiemisto et al. 2003 Spine No SMNiemisto et al. 2004 J Rehabil Med No SMNiemisto et al. 2005 Spine No SMNwuga 1982 Am J Phys Med Not a RCTPalmieri and Smoyak 2002 J Manipulative Physiol Ther No SMPetty NJ 1995 Man Ther No SMPope et al. 1994 Spine Secondary PaperPostacchini et al. 1988 Neuro-Orthopedics OutcomesPowers et al. 2008 Phys Ther No SMRasmussen-Barr et al. 2003 Man Ther No SMRasmussen GG 1979 Manual Med OutcomesRiipinen et al. 2005 J Rehabil Med No SMRitvanen et al. 2007 J Manipulative Physiol Ther No SMRupert et al. 2005 J Manipulative Physiol Ther No SMSanders et al. 1990 J Manipulative Physiol Ther OutcomesSantilli et al. 2006 Spine J DataSchenk et al. 2003 J Man Manip Ther No SMSeferlis et al. 2000 Scand J Prim Health Care OutcomesShearar et al. 2005 J Manipulative Physiol Ther Not a RCTShekelle et al. 1995 Spine OutcomesSims-Williams et al. 1979 Br Med J OutcomesSims-Williams et al. 1978 Br Med J OutcomesSkargren and Oberg 1998 Pain DataSkargren et al. 1998 Spine DataSnyder BJ 1996 Chiropr Tech No LBPSutlive et al. 2009 Mil Med Not a RCTTimm KE 1994 J Orthop Sports Phys Ther No LBPTriano et al. 1995 Spine DataUK Beam 2004 BMJ Secondary PaperUnderwood et al. 2006 Rheumatology Secondary PaperUnderwood et al. 2007 Rheumatology Secondary PaperWaagen et al. 1986 Man Med DataWaterworth and Hunter 1985 N Z Med J OutcomesWilliams et al. 2003 Fam PraNot a RCT No LBPWilliams et al. 1989 Chiropr Res J OutcomesWreje et al. 1992 Scand J Prim Health Care DataZaproudina et al. 2009 Compl Therap Med No SMZhang et al. 2008 J Chiro Med Not a RCTZylbergold et al. 1981 Arch Phys Med Rehabil Outcomes
Abbreviations: Data- articles utilized intention to treat analysis or data was not extractable; No LBP- Did not define participants was diagnosised with non-specific low backpain; No SM- Did not have HVLA as the primary SM; Not a RCT- Was not a randomized clinical trial; Outcomes- did not report at on VAS, NRS, RM, or Oswestry; SecondaryPaper- Was a second paper to one that was already reported in this article.
C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691 675
While formal assessment of article quality was not specificallyincluded as part of this review effort, we did observe several issuesrelated to quality that potentially impact our ability to derive use-ful conclusions from this and similar systematic reviews. For in-stance, we believe that the wide ranges found in pain changescores between studies are more likely to represent differencesin how the data were collected rather than real differences in treat-ment effect. Specifics regarding VAS anchors were provided in onlyslightly more than half the studies and, when presented, descrip-tors varied widely, from ‘‘no pain’’ to ‘‘worst pain,’’ ‘‘pain as badas it could be,’’ ‘‘max pain,’’ ‘‘worst pain you have ever felt,’’
‘‘unbearable pain’’ or ‘‘worst imaginable pain/symptoms.’’ The timeframe within which participants were asked to rate their pain alsovaried widely, ranging from ‘‘current’’ to ‘‘within the past 14 days.’’It is equally difficult to evaluate NRS scores due to lack of consis-tency in both anchor descriptors and time frame in which the par-ticipant was asked to assess his or her pain. Time frames rangedfrom ‘‘current pain’’ to ‘‘pain over the past 2 weeks,’’ while anchorsranged from ‘‘no pain’’ to either ‘‘worst pain possible’’ or ‘‘worstpain imaginable.’’ In 5 out of 8 studies that used the NRS as a pri-mary or secondary outcome, the anchor descriptors were notspecified.
Tabl
e3
Art
icle
sIn
clud
ed.
Au
thor
Yea
r,Jo
urn
alIn
clu
sion
Cri
teri
a:Q
TFca
tego
ryD
ura
tion
⁄in
dica
tes
not
clea
rly
spec
ified
SMFr
equ
ency
Endp
oin
ts#
ofgr
oups
SMEx
pG
rou
pPr
ovid
erTy
peC
ompa
riso
nin
terv
enti
on(s
)N
n=
Ou
tcom
em
easu
res
Not
es
An
ders
son
etal
.19
99,N
Engl
JM
edQ
TF1-
2A
cute
,Su
bacu
te,C
hro
nic
max
of8
trts
over
3m
os(n
opa
inth
anap
pts.
stop
ped)
12w
ks2
SM+
MT
DO
Prim
ary
Med
ical
Car
e17
8SM
=83
MD
=82
Prim
ary:
VA
SR
MD
QO
SW
⁄N
otin
ten
tion
totr
eat.
INC
LUC
EDD
RO
POU
TSIN
FIN
AL
AN
ALY
SIS.
Prag
mat
icTr
ial
Au
reet
al.
2003
,Spi
ne
QTF
1-3
Suba
cute
,Ch
ron
ic16
trts
/8w
ks4
wks
.6m
os,1
2m
os2
SM+
MT
PTEx
erci
seTh
erap
y49
SM=2
2Ex
erci
se=2
7Pr
imar
y:V
AS
OSW
Bic
alh
oet
al.
2010
,Man
Ther
QTF
1-2
Ch
ron
ic1
trt
Pre
and
Post
2SM
only
DO
Sham
Trea
tmen
t40
SM=2
0Sh
am=2
0Se
con
dary
:V
AS
Bis
hop
etal
.20
10,S
pin
eJ
QTF
1-2
Acu
te2-
3tr
ts/4
wks
16,2
4w
ks2
SM+
Exer
cise
DC
Prim
ary
Med
ical
Car
e88
SM=4
3M
D=4
5Pr
imar
y:R
MD
QSe
con
dary
:SF
-36
Lum
bar
spin
eon
ly
Bro
nfo
rtet
al.
1996
,JM
anip
ula
tive
Phys
iol
Ther
QTF
1-2
Suba
cute
,Ch
ron
ic10
trts
/5w
ks11
wks
3SM
+st
ren
gth
exer
cise
DC
1)SM
+St
retc
hin
gEx
erci
se2)
Prim
ary
Med
ical
Car
e17
4R
ando
miz
ed/A
nal
ysis
SM+S
tren
gth
=71/
56SM
+Str
etch
=52/
40M
D=5
1/36
Prim
ary:
RM
DQ
NR
S
Bro
nfo
rtet
al.
2011
,Th
eSp
ine
J.Q
TF1-
3⁄
Suba
cute
,Ch
ron
ic1-
2tr
ts/w
kfo
r12
wks
4,12
,26,
52w
ks3
SMon
lyD
C1)
Supe
rvis
edEx
erci
se2)
Hom
eEx
erci
sean
dA
dvic
e30
1R
ando
miz
ed/4
wk/
12w
k/26
wk/
52w
kSM
=100
/100
/99/
88/8
2H
ome
Exer
cise
=101
/96/
91/8
3/81
Supe
rvis
edEx
erci
se=1
00/
94/9
2/89
/82
Prim
ary:
NR
SSe
con
dary
:M
odifi
edR
DM
QSF
-36
Bu
rton
etal
.20
00,E
ur
Spin
eJ
QTF
6C
hro
nic⁄
Not
repo
rted
2,6
wks
and
12m
os2
SM+
MT
DO
1)Pr
imar
yM
edic
alC
are
+C
hem
onu
cleo
lysi
s40
Bas
elin
e/2w
k/6w
k/12
mo
SM=2
0/20
/19/
15M
D=2
0/20
/18/
15
Prim
ary:
RM
DQ
Prim
ary
auth
orw
astr
eati
ng
clin
icia
n.
Scia
tica
and
Lum
bar
disc
her
nat
ion
spt
.
Cec
chi
etal
.20
10,C
lin
Reh
abil
QTF
1-2
Ch
ron
ic4-
6tr
ts/w
kfo
r4-
6w
ks4
or6
wks
(Dis
char
ge),
3m
os,6
mos
,12
mos
3SM
+M
TM
D1)
Bac
ksc
hoo
l2)
PT20
5en
roll
ed/a
nal
yzed
SM=
70/6
9B
ackS
choo
l=70
/68
PT=7
0/68
Prim
ary:
RM
DQ
Prag
mat
icTr
ial
No
corr
ecti
onfo
rm
ult
iple
com
pari
son
s.
Ch
erki
net
al.
1998
,NEn
glJ
Med
QTF
1-3⁄
Acu
te,S
uba
cute
,Ch
ron
ic⁄
up
to9
trts
/4w
ks1
wk,
4w
ks,1
2w
ks,5
2w
ks,1
04w
ks3
SMon
lyD
C1)
PT2)
Edu
cati
onal
book
let
321
base
lin
e/4w
k/6w
kSM
=122
/118
/118
Boo
klet
=66/
60/6
3PT
=133
/129
/117
Prim
ary:
RM
DQ
Ch
ilds
etal
.20
04,A
nn
Inte
rnM
edQ
TF1-
3A
cute
,Su
bacu
te,C
hro
nic⁄
5tr
ts/4
wks
Bas
elin
e,1w
k,4w
k&
6m
os2
SM+
exer
cise
PTEx
erci
se13
1ba
seli
ne/
1wk/
4wk/
6mo
SM=7
0/70
/70/
52Ex
=61/
61/6
0/40
Prim
ary:
OSW
Ch
own
etal
.20
08,P
hys
ioth
erap
yQ
TF1-
2C
hro
nic
5tr
ts/3
mos
6w
ks3
SM+
Oth
erD
O1)
Gro
up
Exer
cise
2)PT
239
base
lin
e/6w
k/12
wk
DO
=80/
39/2
8PT
=80/
35/2
4Ex
=80/
24/1
3
Prim
ary:
OSW
Hig
hdr
opou
tra
tew
hic
hre
sult
edin
no
stai
stic
alpo
wer
.PT
grou
ppo
ten
tial
lyin
clu
ded
mob
iliz
atio
n.
Cle
lan
det
al.
2009
,Spi
ne
QTF
1-3
Acu
te,S
uba
cute
,Ch
ron
ic⁄
5tr
ts/4
wks
1wk,
4wks
,6m
os3
SM+
Exer
cise
PT1)
Supi
ne
+Ex
erci
se2)
Non
-Th
rust
+Ex
erci
se11
2ba
seli
ne/
1wk/
4wk/
6mo
SM-s
upi
ne=
37/3
6/33
/33
SM-s
ide=
38/3
6/33
/32
Ex=3
7/36
/36/
33
Not
Spec
ified
:O
SWN
RS
Add
itio
nal
Ref
eren
ces:
Cle
lan
d20
09
Cra
mer
etal
.19
93,J
Man
ipu
lati
vePh
ysio
lTh
erQ
TF1-
3A
cute
3-5
trt/
10da
ys10
days
2SM
only
DC
1)U
ltra
sou
nd,
cold
pack
and
gen
tle
mas
sage
21B
asel
ine/
10da
ysSM
=17/
17C
ontr
ol=1
9/18
Not
Spec
ified
:O
SWV
AS
SMto
L3-S
1on
ly
Ferr
eira
etal
.20
07,P
ain
QTF
1-3
Ch
ron
ic12
trts
/8w
ks8
wks
,6m
os,1
2m
os3
SM+
MT
PT1)
Gen
eral
Exer
cise
2)M
otor
Con
trol
Exer
cise
240
base
lin
e/8w
k/6m
o/12
mo
SM=8
0/77
/72/
73M
C=8
0/73
/68/
65G
en=8
0/74
/71/
73
Seco
nda
ry:
NR
SR
MD
Q
Gib
son
etal
.19
85,T
he
Lan
cet
QTF
1-3
Suba
cute
,Ch
ron
ic3
trts
/wk
for
4w
ks2,
4,12
wks
3SM
+M
TD
O1)
Shor
t-w
ave
Dia
ther
my
2)D
etu
ned
Dia
ther
my
109
SM=4
1D
ia=3
4Sh
am=3
4
Not
Spec
ified
:V
AS
The
sham
grou
p’s
base
lin
epa
insc
ores
wer
eh
igh
erth
anth
eot
her
2gr
oups
.
Gil
eset
al.
2003
,Spi
ne
QTF
1-2
Ch
ron
ic2
trts
/wk
for
9w
ks2,
5,9
wks
3SM
only
DC
1)Pr
imar
yM
edic
alC
are
2)N
eedl
eA
cupu
nct
ure
115
MD
=40
Acu
=34
SM=3
5
Not
Spec
ified
:O
SWV
AS
Incl
ude
dba
ckan
dn
eck
pain
.A
ddit
ion
alR
efer
ence
s:M
uel
ler
and
Gil
es
Gil
eset
al.
1999
,JM
anip
ula
tive
Phys
iol
Ther
QTF
1-2
Ch
ron
ic6
trts
ina
3-4
wks
4w
ks3
SMon
lyD
C1)
Prim
ary
Med
ical
Car
e2)
Acu
pun
ctu
rew
/lo
wvo
lte-
stim
77M
D=2
1A
cu=2
0SM
=36
Prim
ary:
OSW
VA
S
Inte
nti
onto
Trea
tA
nal
ysis
un
clea
r;Pr
oble
ms
wit
h‘‘d
rop
outs
’’
Gru
nn
esjo
etal
.20
04,J
Man
ipu
lati
vePh
ysio
lTh
erQ
TF1-
3A
cute
,Su
bacu
te10
wks
(#of
trts
not
spec
ified
)5
&10
wks
2SM
+M
D+
oth
erM
D,P
T‘‘S
tay-
acti
ve’’
+Pr
imar
yM
edic
alC
are
+Ex
erci
se16
0SM
=88
Con
trol
=72
Prim
ary:
VA
STr
ain
ing
for
SMpr
ovid
erw
asa
12da
ytr
ain
ing
sess
ion
.
Hal
legr
aeff
etal
.20
09,P
erce
ptM
otSk
ills
QTF
1-2
Acu
te4
trts
/2.5
wks
4w
ks2
SM+
PTPT
PT64
SM=3
1PT
=33
Prim
ary:
VA
SO
SW
SMre
stri
cted
lum
bosa
cral
join
ts,s
acro
ilia
cjo
ints
,or
both
.
Hoi
riis
etal
.20
04,J
Man
ipu
lati
vePh
ysio
lTh
erQ
TF1-
3⁄
Acu
te,S
uba
cute
3tr
ts/2
wks
2,4
wks
3SM
+M
D(p
lace
bo)
DC
1)M
usc
leR
elax
ants
and
Sham
Trea
tmen
ts2)
Med
ical
Plac
ebo
and
Sham
Trea
tmen
ts
192
SM=5
0M
D=5
3C
ontr
ol=5
3
Prim
ary:
VA
SO
SW
Add
itio
nal
Ref
eren
ce:
Hoi
riis
etal
.
Hon
dras
etal
.20
09,J
Man
ipu
lati
vePh
ysio
lTh
erQ
TF1-
3Su
bacu
te,C
hro
nic
Max
12tr
ts/6
wks
3,6,
12,2
4w
ks3
SMon
lyD
C1)
Flex
ion
-Dis
trac
tion
(F/D
)2)
Min
imal
Con
serv
ativ
eM
edic
alC
are
(MC
MC
)
240
enro
ll/a
nal
yzed
SM=9
6/94
LVV
A=9
5/91
MD
=49/
40
Prim
ary:
RM
DQ
Seco
nda
ry:
VA
SSF
-36
SMre
stri
cted
toT1
2-L5
676 C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691
Hou
ghet
al.
2007
,BM
CM
usc
ulo
skel
etD
isor
dQ
TF1-
3Su
bacu
te,C
hro
nic
8tr
ts/4
wks
4w
ks2
SM+
MT
+ex
erci
sePT
Act
ive
Reh
abil
itat
ion
39SM
=20
Reh
ab=1
9N
otSp
ecifi
ed:
RM
DQ
VA
SH
sieh
etal
.20
02,S
pin
eQ
TF1-
3Su
bacu
te,C
hro
nic
3tr
ts/3
wks
3w
ks,6
mos
4SM
+PT
DC
1)C
ombi
ned
SMan
dM
yofa
scia
lTh
erap
y2)
‘‘Bac
kto
Sch
ool
3)M
yofa
scia
lTh
erap
y
200
base
lin
e/3w
k/6m
oSM
=48/
45/4
0M
yo=5
1/49
/47
Bac
kSch
ool=
48/4
2/42
Com
bin
ed=5
2/48
/48
Prim
ary:
VA
SR
MD
Q
Lum
bar
and/
orsa
crol
ilac
regi
ons
Hsi
ehet
al.
1992
,JM
anip
ula
tive
Phys
iol
Ther
QTF
1-2
Suba
cute
,Ch
ron
ic3
trts
/3w
ks3
wks
4SM
+PT
DC
1)M
assa
ge2)
Cor
set
3)Tr
ansc
uta
neo
us
Mu
scu
lar
Stim
ula
tion
(TM
S)
63SM
=26
Mas
=15
Cor
set=
12TM
S=10
Prim
ary:
OSW
RM
DQ
Add
itio
nal
refe
ren
ces:
Pope
etal
.
Hu
rwti
zet
al.
2002
,Spi
ne
QTF
1-3⁄
Acu
te,S
uba
cute
,Ch
ron
icA
veSM
3.2
trts
DC
+mod
3.7
trts
(1.7
)2,
6,26
wks
,12
mos
,18
mos
4SM
+Ex
erci
seD
C,M
D,P
T1)
SM+
Exer
cise
+PT
2)Pr
imar
yM
edic
alC
are
3)Pr
imar
yM
edic
alC
are
+PT
681
base
lin
e/2w
k/6w
k/26
wk
SM=1
69/1
69/1
69/1
65SM
+PT=
172/
171/
169/
163
MD
=170
/170
/169
/165
MD
+PT=
170/
169/
168/
159
Prim
ary:
NR
SR
MD
Q
Prag
mat
icTr
ial
Add
itio
nal
Ref
eren
ces:
Hu
rwit
zet
al.,
2002
,200
3,20
05,2
005,
2006
;H
ertz
man
-Mil
ler
etal
.,G
olds
tein
etal
.,K
omin
iski
etal
.
Jun
iet
al.
2008
,An
nR
heu
mD
isQ
TF1-
2A
cute
5tr
ts/2
wks
Day
142
SM+
MT
+M
DD
C,D
O,D
VPr
imar
yM
edic
alC
are
104
allo
cati
on/d
ay14
/6m
osSM
=52
/48/
50M
D=
52/
49/5
1jb
Prim
ary:
NR
SSe
con
dary
:R
MD
Q
Inte
nti
onto
Trea
tA
nal
ysis
incl
ude
dal
lsu
bjec
ts
Man
dara
etal
.20
08,I
nt
JO
steo
path
Med
QTF
un
repo
rted
Ch
ron
ic⁄
Not
spec
ifei
dN
otsp
ecifi
ed2
SM+
MD
DO
Sham
Trea
tmen
ts94
SM=4
4Sh
am=5
0Pr
imar
y:O
SWV
AS
McM
orla
nd
etal
.20
10,J
Man
ipu
lati
vePh
ysio
lTh
erQ
TF6
Ch
ron
ic2-
3tr
ts-
1st
4w
k;1-
2tr
ts/w
kn
ext
3-4
wks
;at
8w
ksw
ith
trt
PRN
3,6,
12,2
4,52
wks
2SM
+PT
DC
Surg
ical
Mic
rodi
sket
omie
s40
SM=2
0M
D=2
0N
otSp
ecifi
ed:
SF-3
6R
MD
Q
Pth
adle
g-do
min
ant
sym
ptom
s.Pr
agm
atic
Tria
l
Mea
deet
al.
1990
,BM
JU
nre
port
edM
axof
10tr
tsw
ith
in3
mos
to1
yr6
wks
,6m
os,1
yr,2
yrs,
3yr
s2
SMon
lyD
CPr
imar
yM
edic
alC
are
741
base
lin
e/6w
k/6m
o/1y
r/2y
rs/3
yrs
SM=3
84/3
57/3
24/3
14/
285/
290
MD
=357
/309
/282
/265
/25
6/23
9
Prim
ary:
OSW
Prag
mat
icTr
ial
Add
itio
nal
Ref
eren
ces:
Mea
deet
al.1
991
&19
95
Moh
sen
i-B
andp
eiet
al.
2006
,Ph
ysio
ther
apy
QTF
1-3⁄
Ch
ron
ic1-
2tr
ts/w
kfo
r6
mos
end
oftr
eat
&6
mos
2SM
+Ex
erci
sePT
Ult
raso
un
dan
dEx
erci
se12
0ba
seli
ne/
end
oftr
eatm
ent
SM=6
0/56
US=
60/5
6
Prim
ary:
OSW
VA
SM
orto
nJE
1999
,JM
anip
ula
tive
Phys
iol
Ther
QTF
1A
cute
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C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691 677
Table 4VAS outcomes summary.
Author/year VAS descriptors Endpoints Primary/end of treatment Long-term
Mean change 95% CI Mean change 95% CI
Andersson et al. 1 12 wks SM + MT 32.0 26.9, 37.1 NS NS1999 MD 26.3 20.6, 32.0 NS NS
SM + vs MD 5.7 �1.8, 13.2 NS NSAure et al.* 1, 2 4 wks SM + MT 33.0 23.1, 42.9 34.0 28.6, 39.42003 52 wks Exercise 15.0 3.0, 27.0 19.0 5.6, 32.4
SM + vs exercise 18.0 15.1, 20.9 15.0 12.1, 17.9Bicalho et al.* 3 1 trt SM 11.0 7.6, 14.3 NS Ns2010 Sham �2.2 0.6, 5.0 NS NS
SM vs Sham 13.2 9.0, 17.3 NS NSCramer et al.* 99 1 trt SM 33.2 19.7, 46.7 NS NS1993 Ultrasound + other 30.0 14.1, 45.9 NS NS
SM vs Ultrasound+ 3.2 �17.0, 23.4 NS NSGibson et al.a, * 4 4 wks SM + MT 17.0 11.6, 22.5 20.0 14.8, 25.31985 12 wks Diathermy 14.0 9.5, 18.6 22.0 17.5, 26.6
Placebo Diathermy 21.0 15.8, 26.2 42.0 36.5, 47.5SM + vs diathermy 3.0 �2.4, 8.4 �2.0 �7.2, 3.2SM + vs placebo diathermy �4.0 �9.5, 1.5 �20.0 �27.6, �16.4
Giles et al.* 1 9 wks SM 30.0 26.9, 33.1 NS NS2003 MD 0.0 �0.5, 0.5 NS NS
Acupuncture 20.0 19.5, 20.5 NS NSSM vs MD 30.0 21.2, 38.8 NS NSSM vs acupuncture 10.0 7.1, 12.9 NS NS
Giles et al.a, * 1 4 wks SM 25.0 7.2, 42.8 NS NS1999 MD �3.0 �19.1, 13.5 NS NS
Acupuncture �8.0 �3.7, 2.1 NS NSSM vs MD 28.0 11.0, 45.0 NS NSSM vs acupuncture 33.0 15.6, 50.3 NS NS
Grunnesjo et al.* 1, 6 5 wks SM + MD + other 24.5 17.8, 31.2 34.0 27.5, 40.52004 10 wks MD + other 18.4 10.9, 25.9 27.0 19.7, 34.3
SM + vs MD+ 6.1 1.2, 13.4 7.0 0.1, 13.91, 5 SM + MD + other 33.9 27.0, 40.8 38.5 31.9, 49.1
MD + other 22.5 13.2, 31.8 31.1 22.7, 39.5SM + vs MD+ 11.4 3.6, 19.2 7.4 0.9, 13.9
Hallegraeff et al.* 1, 5 4 wks SM + PT 23.7 22.9, 24.5 NS NS2009 PT only 29.2 28.4, 30.0 NS NS
SM + vs PT only �5.5 �6.9, �4.1 NS NSHoiriis et al. * 99 2 wks SM + placebo MD 20.8 19.1, 22.5 28.1 26.5, 29.72004 4 wks MD + Sham SM 11.6 9.9, 13.3 16.5 14.8, 18.2
Placebo MD + Sham SM 6.6 5.1, 8.1 16.3 15.0, 17.6SM + vs MD + Sham SM 9.2 7.0, 11.4 11.6 8.8, 14.4SM + vs Placebo MD+ 14.2 10.9, 17.5 11.8 9.0, 14.6
Hondras et al.** 1, 6 6 wks SM 7.8 7.4, 8.2 NS NS2009 Mobilization 6.1 5.7, 6.5 NS NS
MD 7.5 6.9, 8.0 NS NSSM vs mobilization 0.2 �6.3, 6.7 NS NSSM vs MD �4.3 �13.6, 5.0 NS NS
Hough et al. 99 4 wks SM + MT + exercise 18.3 7.3, 29.3 NS NS2007 Rehabilitation 3.3 �9.4, 16.0 NS NS
SM + vs rehabilitation 15.0 �1.1, 31.2 NS NSHsieh et al. * 99 3 wks SM 10.8 9.6, 12.0 12.6 11.1, 14.12002 26 wks SM + Myofascial 17.1 16.1, 18.1 15.1 13.9, 16.3
Back School 20.1 19.0, 21.2 18.5 17.2, 19.8Myofascial 12.7 11.6, 13.8 10.6 9.3, 11.9SM vs SM+ �6.3 �13.0, 0.4 �2.5 �11.6, 6.6SM vs back school �9.3 �16.2, �2.4 �5.9 �15.4, 3.6SM vs Myofascial �1.9 �8.5, 4.7 2.0 �7.2, 11.2
Mandara et al. * 7 NS SM + MD �2.8 �4.2, �1.4 NS NS2008 Sham 1.4 �0.9, 0.9 NS NS
SM + vs Sham �4.2 �5.1, �3.3 NS NSMohseni-Bandpei et al. 1, 8 End of trts SM + exercise 41.6 34.2, 49.6 37.9 27.7, 48.12006 26 wks Ultrasound + exercise 25.1 17.7, 32.5 22.8 12.4, 33.2
SM + vs ultrasound+ 16.4 6.1, 26.8 1.4 0.1, 2.7Morton JE* 99 4 wks SM + exercise 47.3 43.9, 50.7 49.7 46.0, 52.71999 12 wks Exercise only 21.1 16.4, 25.9 33.0 28.9, 37.1
SM + vs exercise only 26.2 16.5, 35.9 16.7 10.5, 23.0Paatelma et al. * 1, 8 12 wks SM 17.0 15.9, 18.1 24.0 22.8, 25.22008 52 wks McKenzie 22.0 21.2, 22.9 24.0 23.1, 24.9
Advice 20.0 18.6, 21.4 21.0 19.4, 22.6SM vs McKenzie �5.0 �6.0, �4.0 0.0 �5.0, 5.0SM vs advice �3.0 �3.67, �2.33 3.0 14.1, 19.3
Senna and Machaly* 1, 8 4 wks Maintained SM 13.4 7.0, 19.8 19.3 11.7, 26.82011 43 wks Nonmaintained SM 12.4 5.1, 19.6 3.3 �6.3, 12.8
Sham SM 8.0 2.0, 14.1 2.9 �6.1, 11.9
678 C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691
Table 4 (continued)
Author/year VAS descriptors Endpoints Primary/end of treatment Long-term
Mean change 95% CI Mean change 95% CI
Maintained SM vs Sham SM 5.3 2.0, 8.7 16.3 10.3, 22.3Nonmaintained SM vs Sham SM 4.3 1.0, 7.6 0.4 �5.5, 6.3
Wand et al. * 9 6 wks SM + MT + exercise + other 34.0 32.6, 35.4 37.0 35.4, 38.62004 26 wks Advice only 19.0 17.6, 20.4 28.0 26.3, 29.7
SM + vs advice 15.0 11.9, 18.1 9.0 7.1, 10.9
VAS descriptors:99 – No specifics given.1 – Anchors noted as: ‘‘no pain’’ or ‘‘no pain/symptoms’’ to ‘‘worst pain’’ or ‘‘pain as bad as it could be’’ or ‘‘max pain’’ or ‘‘worst pain you have ever felt’’ or ‘‘unbearable pain’’ or‘‘worst imaginable pain/symptoms’’.2 – Mean of: pain at the moment, worst pain past 14 days, and mean pain past 14 days.3 – Perceived pain intensity.4 – Pain during the day.5 – Pain past 24 h.6 – Pain past/last week.7 – Overall back pain.8 – Current.9 – Usual pain intensity.* calculated.
a Median changed to mean.** Contacted author; mos – months; MD – Primary Medical Care; MT – Manual Therapy; NS – Not Specified; PT – Physical Therapy; SM – Spinal Manipulation; trts –treatments; yr – year.
C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691 679
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 tri-als of HVLA SM for LBP. For this reason we chose not to conduct ameta-analysis or formally synthesize the results. ‘‘Industry stan-dards’’ for measuring both pain and physical functioning in pa-tients with low back pain would make comparisons between SMstudies more relevant. It has recently been suggested that assess-ing the functional capacity of patients may be of greater clinical va-lue than assessing reported pain levels (Pransky et al., 2011). Also,the National Institutes of Health-funded PROMIS initiative has fos-tered the creation of new measures of both pain and physical func-tioning that may be useful in the study of LBP (Gershon et al.,2010). These are issues that warrant further discussion amongSM investigators.
In our review of these papers, we became aware of other oppor-tunities for standardization. Adherence to the recently updatedCONSORT standards (Moher et al., 2010) by SM investigatorswould help with this effort. Specifically, we recommend (1) provid-ing clear descriptions of intervention groups, including SM, in suf-ficient detail to allow for replication and (2) describing eligibilitycriteria in detail. Adoption of standard classifications to better de-scribe the nature of LBP studied in a particular trial would also beuseful. While diagnostic code classifications such as ICD-9 or ICD-10 are theoretically more specific, current differences in diagnosticapproaches between provider types limit their usefulness in re-search studies. However, describing LBP according to the QuebecTask Force classifications would be an improvement over currentreporting efforts. Also, while the majority of studies we reviewedreported on whether participants had acute, sub-acute or chronicLBP, definitions for these terms were not consistent.
Future studies of SM for LBP would also benefit from the adop-tion of reporting standards regarding SM intervention delivery. Inthis review, it was difficult to find consistent information regardingthe frequency and/or timing of SM and other treatment visits, orthe number of procedures delivered at each visit. Given the com-plexity of and skill level required for the delivery of SM techniquessuch as HVLA (Triano et al., 2004), articles would also benefit frominclusion of both the credentials of the clinicians delivering SM orrelated procedures and their level of expertise (e.g. years in clinicalpractice, experience with the SM procedure under evaluation).
5. Conclusion
We found that HVLA SM for LBP appears to convey a small butconsistent treatment effect at least as large as that seen in otherconservative methods of care. This finding is similar to that inother systematic reviews of SM of LBP. The heterogeneity andinconsistency in reporting within the studies reviewed makes itdifficult to draw definitive conclusions or adequately summarizepatient-centered outcomes for clinical trials of HVLA SM for LBP.These are issues that should be addressed by the scientific commu-nity before future SM studies for LBP are conducted.
Acknowledgments
We gratefully acknowledge the contributions of: clinical re-search fellows James Boysen, Christopher Woslanger, Julie Kumar,Christopher Roecker, Amin Neekomand, and Connie Mitchell; sum-mer intern Laura Macko; Ying Cao; Leah Cafer; and Paige Morgen-thal for help in literature searching, data extraction andmanuscript preparation. We also thank Dana Lawrence and JoelPickar for their critical review of the manuscript.
Appendix A. Thirty-eight articles that met eligibility criteria
1. United Kingdom back pain exercise and manipulation (UKBEAM) randomised trial: effectiveness of physical treat-ments 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 manipulationwith standard care for patients with low back pain. NEJM1999;341(19):1426–31.
3. Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercisetherapy in patients with chronic low back pain: a random-ized, controlled trial with 1-year follow-up. Spine (Phila Pa1976) 2003;28(6):525–31.
4. Bicalho E, Setti JA, Macagnan J, Cano JL, Manffra EF. Immedi-ate effects of a high-velocity spine manipulation in paraspi-nal muscles activity of nonspecific chronic low-back painsubjects. Man Ther 2010;15(5):469–75.
Table 5NRS outcomes summary.
Author NRS descriptors Endpoints Primary/end of treatment Long-term
Mean change 95% CI Mean change 95% CI
Bronfort et al. 2 11 wks SM + strength exercise 2.7 2.2, 3.2 NS NS1996 SM + stretch exercise 3.3 2.5, 4.1 NS NS
MD 3.5 2.8, 4.2 NS NSSM/strength vs SM/stretch 0.6 �0.2, 1.4 NS NSSM/strength vs MD 0.8 �0.0, 1.6 NS NS
Bronfort et al.* 1, 3 12 wks SM 2.5 1.9, 3.1 2.1 1.5, 2.72011 52 wks Supervised exercise 2.5 1.9, 3.1 2.3 1.6, 3.0
Home exercise + advice 2.0 1.4, 2.6 2.4 1.8, 3.0SM vs supervised exercise 0.1 �0.6, 0.8 0.3 �0.5, 1.1SM vs home exercise+ �0.6 �1.4, 0.1 0.0 �0.8, 0.8
Cleland et al. 1, 4 4 wks SM + exercise NS NS NS NS2009 26 wks Supine + exercise NS NS NS NS
Non-thrust + exercise NS NS NS NSSM + vs supine+ �0.5 �1.5, 0.6 �0.2 �1.0, 0.6SM + vs non-thrust+ 1.3 0.5, 2.2 0.4 �0.3, 1.1
Ferreira et al.* 1, 5 8 wks SM 2.1 2.0, 2.2 1.3 1.2, 1.42007 52 wks General exercise 1.7 1.6, 1.8 1.3 1.2, 1.4
Motor control exercise 2.3 2.2, 2.4 1.4 1.3, 1.5SM vs general 0.6 �0.1, 1.4 0.2 �0.6, 1.1SM vs motor control 0.2 �0.6, 1.0 0.1 �0.8, 1.0
Hurwitz et al. 6 6 wks SM 1.0 0.7, 1.4 NS NS2002 (JMPT & Spine) 52 wks SM + PT 1.4 1.1, 1.7 NS NS
MD NS NS NS NSMD + PT NS NS NS NSSM vs MD 0.2 �0.2, 0.7 0.2 �0.4, 0.8SM vs SM/PT �0.3 �0.7, 0.1 �0.6 �1.1, 0.0
Juni et al. 99 2 wks SM + MT + MD NS NS NS NS2008 MD NS NS NS NS
SM + vs MD 0.6 �0.1, 1.3 NS NSRasmussen et al.a 7 4 wks SM + exercise 2.0 1.8, 2.2 3.0 2.8, 3.22008 52 wks Exercise only 2.0 0.8, 3.2 3.0 2.9, 3.1
SM + vs exercise 0.0 NS 0.0 NSWilkey et al. 8 8 wks SM 1.4 0.9, 1.9 NS NS2004 Pain clinic �0.4 �0.8, 0.1 NS NS
SM vs pain clinic 1.7 0.3, 3.2 NS NS
SM – Spinal Manipulation; trts – treatments; yr – year.NRS descriptors:99 – No specifics given.1 – Anchors noted as: ‘‘no pain’’ to ‘‘worst pain possible’’ or ‘‘worst pain imaginable.2 – Weekly LBP severity.3 – Pain over the past week.4 – Mean of: current, best past 24 h, and worst past 24 h.5 – Ave pain intensity over the last week.6 – Ave LBP intensity past week.7 – Worst pain within the last 48 h for both leg and LB.8 – Current pain and average pain over preceding 2 weeks.�� – Contacted author; mos – months; MD – Primary Medical Care; MT – Manual Therapy; NS – Not Specified; PT – Physical Therapy;* Calculated.
a Median changed to mean.
680 C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691
5. Bishop PB, Quon JA, Fisher CG, Dvorak MF. The ChiropracticHospital-based Interventions Research Outcomes (CHIRO)study: a randomized controlled trial on the effectiveness ofclinical practice guidelines in the medical and chiropracticmanagement of patients with acute mechanical low backpain. Spine J 2010;10(12):1055–64.
6. Bronfort G, Goldsmith CH, Nelson CF, Boline PD, AndersonAV. Trunk exercise combined with spinal manipulative orNSAID therapy for chronic low back pain: a randomized,observer-blinded clinical trial. J Manipulative Physiol Ther1996;19(9):570–582.
7. Bronfort G, Maiers MJ, Evans RL, Schulz CA, Bracha Y, Svend-sen KH, et al. Supervised exercise, spinal manipulation, andhome exercise for chronic low back pain: a randomized clin-ical trial. Spine J 2011;11(7):585–98.
8. Burton AK, Tillotson KM, Cleary J. Single-blind randomisedcontrolled trial of chemonucleolysis and manipulation inthe treatment of symptomatic lumbar disc herniation. Euro-pean Spine Journal 2000;9(3):202–7.
9. Cecchi F, Molino-Lova R, Chiti M, Pasquini G, Paperini A, ContiAA, et al. Spinal manipulation compared with back school andwith individually delivered physiotherapy for the treatmentof chronic low back pain: a randomized trial with one-yearfollow-up. Clinical Rehabilitation 2010;24(1):26–36.
10. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A compar-ison of physical therapy, chiropractic manipulation, and pro-vision of an educational booklet for the treatment of patientswith low back pain. New England Journal of Medicine1998;339(15):1021–29.
11. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK,Majkowski GR, et al. A clinical prediction rule to identifypatients with low back pain most likely to benefit fromspinal manipulation: a validation study. Annals of InternalMedicine 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 ran-domised to group exercise, physiotherapy or osteopathy.Physiotherapy 2008;9421–28.
Table 6RM outcomes summary.
Author Endpoints Primary/end of treatment Long-term
Mean change 95% CI Mean change 95% CI
UK Beam Trial Team 12 wks SM + MD 5.1 NS 5.2 NS2004 52 wks SM + MD + exercise 4.8 NS 4.7 NS
MD 6.7 NS 6.1 NSExercise + MD 5.5 NS 5.7 NSSM/MD vs MD 1.6 0.8, 2.3 1.0 0.2, 1.8SM/MD vs exercise/MD 1.9 1.2, 2.6 1.3 0.5, 2.1
Andersson et al. 12 wks SM + MT 5.0 NS NS NS1999 MD 5.0 NS NS NS
SM + vs MD 1.0 NS NS NSBishop et al. 16 wks SM + exercise 2.5 �3.8, �1.2 2.5 �3.8, �1.22010 24 wks MD 0.0 �1.3, 1.4 �0.1 �1.3, 1.4
SM + vs MD 2.5 0.9, 4.2 2.6 1.4, 5.3Bronfort et al.* 11 wks SM + strength exercise 15.1 10.4, 19.8 NS NS1996 SM + stretch exercise 18.4 12.6, 24.2 NS NS
MD 20.9 15.5, 26.3 NS NSSM/strength vs SM/stretch 3.3 �3.6, 10.2 NS NSSM/strength vs MD 5.8 �1.1, 12.7 NS NS
Bronfort et al. 12 wks SM 4.4 3.1, 5.7 4.6 3.3, 5.92011 52 wks Supervised exercise 3.8 2.6, 5.0 3.6 2.4, 4.8
Home exercise + advice 4.5 3.2, 5.8 4.6 3.3, 5.9SM vs supervised exercise 0.5 �0.9, 2.0 1.3 �0.4, 2.9SM vs home exercise+ �0.3 �1.8, 1.1 �0.4 �2.0, 1.2
Burton et al. * 6 wks SM 4.1 3.2, 5.0 6.0 5.0, 7.02000 52 wks MD + other 1.0 0.1, 1.8 4.7 3.6, 5.8
SM vs MD+ 3.2 2.1, 4.2 1.4 0.9, 1.8Cecchi et al. * Discharge SM 6.8 5.6, 8.0 5.9 4.6, 7.22010 52 wks PT 4.4 2.6, 6.2 4.0 2.2, 5.8
Back school 3.6 2.0, 5.2 4.2 2.6, 5.8SM vs PT 2.4 0.9, 3.9 1.9 0.4, 3.4SM vs back school 3.2 1.7, 4.7 1.7 0.2, 3.2
Cherkin et al. * 4 wks SM 8.4 7.2, 9.6 9.0 7.7, 10.31998 12 wks PT 8.1 7.0, 9.2 8.1 7.0, 9.2
Booklet 6.8 5.4, 8.2 7.4 5.9, 8.9SM vs PT 0.4 0.4, 0.5 1.0 0.9, 1.1SM vs booklet 1.2 1.0, 1.4 1.2 1.0, 1.4
Ferreira et al. * 8 wks SM 4.5 2.6, 6.4 3.2 1.2, 5.22007 52 wks General exercise 4.4 2.5, 6.3 4.5 2.4, 6.6
Motor control exercise 6.1 4.3, 7.9 5.2 3.1, 7.3SM vs general 0.1 �1.8, 2.0 �1.3 �3.5, 0.9SM vs motor control �1.6 �3.5, �0.3 �2.0 �0.2, 4.2
Hondras et al. ** 6 wks SM 1.0 0.9, 1.1 0.6 0.5, 0.62009 24 wks Mobilization 0.9 0.9, 1.0 0.9 0.8, 1.0
MD 4.7 3.7, 5.9 1.1 1.0, 1.2SM vs mobilization 0.2 �0.7, 1.1 0.6 �0.7, 1.9SM vs MD �1.2 �2.5, 0.1 �1.3 �2.9, 0.6
Hough et al. 4 wks SM + MT + exercise 4.2 2.1, 6.3 NS NS2007 Rehabilitation 0.6 �0.9, 2.1 NS NS
SM + vs rehabilitation 3.6 1.1, 6.2 NS NSHsieh et al. * 3 wks SM 4.0 3.6, 4.3 5.1 4.8, 5.42002 26 wks SM + myofascial 3.9 3.7, 4.1 4.1 3.8, 4.3
Back school 3.7 3.4, 3.9 4.4 4.2, 4.7Myofascial 2.6 2.3, 2.8 3.3 3.0, 3.6SM vs SM+ 0.1 �1.7, 1.9 1.0 �0.7, 2.8SM vs back school 0.3 �0.4, 3.2 0.7 �1.2, 2.5SM vs myofascial 1.4 �0.4, 3.2 1.8 0.0, 3.6
Hsieh et al. * 3 wks SM 22.7 20.7, 24.7 NS NS1992 Massage 8.2 2.5, 13.9 NS NS
Corset 18.8 13.9, 23.7 NS NSTMS 9.4 2.5, 16.4 NS NSSM vs massage 14.6 9.8, 19.3 NS NSSM vs corset 3.9 2.6, 5.3 NS NSSM vs TMS 13.3 8.4, 18.3 NS NS
Hurwtiz et al. 6 wks SM 3.2 2.5, 3.9 NS NS2002 (JMPT & Spine) 52 wks SM + PT 3.2 2.5, 3.9 NS NS
MD NS NS NS NSMD + PT NS NS NS NSSM vs MD �0.1 �0.6, 0.4 0.8 �0.3, 1.8SM vs SM/PT 0.0 �1.0, 1.0 0.8 �0.3, 1.8
Juni et al. * 2 wks SM + MT + MD 7.0 6.9, 7.1 NS NS2008 MD 9.1 9.0, 9.2 NS NS
SM + vs MD 0.8 �1.5, 3.2 NS NSMcMorland et al. * 3 wks SM 1.5 0.7, 2.3 3.0 2.1, 3.92010 12 wks Surgery �2.1 �3.0, �1.2 2.9 2.0, 3.8
(continued on next page)
C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691 681
Table 6 (continued)
Author Endpoints Primary/end of treatment Long-term
Mean change 95% CI Mean change 95% CI
SM vs surgery 3.6 2.5, 4.7 0.1 0.1, 0.1Morton JE* 4 wks SM + exercise 8.7 7.8, 9.5 10.3 9.5, 11.01999 12 wks Exercise only 4.1 2.8, 5.3 6.4 5.4, 7.5
SM + vs exercise only 4.6 2.9, 6.3 3.8 2.4, 5.37Paatelma et al. * 12 wks SM 7.0 6.8, 7.2 9.0 8.8, 9.22008 52 wks McKenzie 8.0 7.8, 8.2 8.0 7.9, 8.1
Advice 8.0 7.8, 8.2 8.0 7.8, 8.2SM vs McKenzie �1.0 �1.2, �0.8 1.0 0.8, 1.2SM vs advice �1.0 �1.2, �0.8 0.0 �1.0, 1.0
Wand et al. * 6 wks SM + MT + exercise + other 8.2 7.9, 8.6 8.8 8.4, 9.22004 26 wks Advice only 3.8 3.5, 4.1 5.7 5.3, 6.1
SM + vs advice 4.4 3.5, 5.3 3.1 2.5, 3.7Wilkey et al. 8 wks SM 5.9 3.1, 8.7 NS NS2008 Pain clinic 0.4 �1.2, 1.9 NS NS
SM vs pain clinic 5.5 2.0, 9.0 NS NS
^ – Median changed to mean.* Calculated.
** Contacted author; mos – months; MD – Primary Medical Care; MT – Manual Therapy; NS – Not Specified; PT – Physical Therapy; SM – Spinal Manipulation; trts –treatments; yr – year.
682 C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691
13. Cleland J, Fritz J, Kulig K, Davenport TE, Eberhart S, Magel JS,et al. Comparison of the effectiveness of 3 manual physicaltherapy techniques in a subgroup of patients with low backpain who satisfy a clinical prediction rule: a randomizedclinical trial. Journal of Orthopaedic and Sports PhysicalTherapy 2009;39(1):A16.
14. Cramer GD, Humphreys CR, Hondras MA, McGregor M, TrianoJJ. The Hmax/Mmax ratio as an outcome measure for acutelow 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, motorcontrol exercise and spinal manipulative therapy for chroniclow 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 treatmentwith osteopathic treatment in non-specific low back pain.Lancet 1985;1(8440):1258–61.
17. Giles LG, Muller R. Chronic spinal pain syndromes: a clinicalpilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. J ManipulativePhysiol Ther 1999;22(6):376–81.
18. Giles LG, Muller R. Chronic spinal pain: a randomizedclinical trial comparing medication, acupuncture, andspinal manipulation. Spine (Phila Pa 1976) 2003;28(14):1490–1502.
19. Grunnesjo MI, Bogefeldt JP, Svardsudd KF, Blomberg SI. Arandomized controlled clinical trial of stay-active care ver-sus manual therapy in addition to stay-active care: func-tional variables and pain. J Manipulative Physiol Ther2004;27(7):431–41.
20. Hallegraeff JM, de GM, Winters JC, Lucas C. Manipulativetherapy and clinical prediction criteria in treatment of acutenonspecific 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 chiro-practic adjustments to muscle relaxants for subacute lowback pain. J Manipulative Physiol Ther 2004;27(6):388–98.
22. Hondras MA, Long CR, Cao Y, Rowell RM, Meeker WC. A ran-domized controlled trial comparing 2 types of spinal manip-ulation and minimal conservative medical care for adults55 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 manualtherapy and active rehabilitation in the treatment of nonspecific low back pain with particular reference to apatient’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 suba-cute low back pain: a randomized clinical trial. Spine (PhilaPa 1976) 2002;27(11):1142–48.
25. Hsieh CY, Phillips RB, Adams AH, Pope MH. Functional out-comes of low back pain: comparison of four treatmentgroups in a randomized controlled trial. J Manipulative Phys-iol Ther 1992;15(1):4–9.
26. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, BelinTR, Yu F, et al. A randomized trial of medical care withand without physical therapy and chiropractic care withand without physical modalities for patients with low backpain: 6-month follow-up outcomes from the UCLA lowback 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 manipulativetherapy in acute low back pain. Annals of the Rheumatic Dis-eases 2009;68(9):1420–1427.
28. Mandara, A, Fusaro, A, Musicco, M, and Bado, F. A random-ised controlled trial on the effectiveness of ostopathicmanipulative treatment of chronic low back pain. Int J Oste-opath Med 11[4], 156. 2008.
29. McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ.Manipulation or microdiskectomy for sciatica? A prospec-tive randomized clinical study. J Manipulative Physiol Ther2010;33(8):576–84.
30. Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Lowback pain of mechanical origin: randomised comparison ofchiropractic and hospital outpatient treatment. BMJ1990;300(6737):1431–37.
31. Mohseni-Bandpei MA, Critchley J, Staunton T, Richardson B.A prospective randomised controlled trial of spinal manipu-lation and utlrasound in the treatment of chronic low backpain. Physio 2006;9234–42.
32. Morton JE. Manipulation in the treatment of acute low backpain. The Journal of Manual and Manipulative Therapy1999;7(4):182–89.
Table 7OSW outcomes summary.
Author Endpoints Primary/end of treatment Long-term
Mean change 95% CI Mean change 95% CI
Andersson et al.* 12 wks SM + MT 27.2 21.4, 33.0 NS NS1999 MD 15.8 19.6, 32.0 NS NS
SM + vs MD 1.4 �7.0, 10.0 NS NSAure et al. * 4 wks SM + MT 21.0 13.9, 28.1 22.0 14.9, 29.12003 52 wks Exercise 9.0 0.5, 17.5 13.0 4.5, 21.5
SM + vs exercise 12.0 9.5, 14.5 9.0 5.6, 12.4Childs et al. 4 wks SM + exercise NS NS NS NS2004 26 wks Exercise NS NS NS NS
SM + vs exercise 8.3 2.4, 14.2 10.1 4.3, 15.9Chown et al. 6 wks SM 5.0 1.6, 8.4 NS NS2008 PT 4.1 1.4, 6.9 NS NS
Group exercise 4.5 0.9, 8.0 NS NSSM vs PT 0.9 �3.3, 5.1 NS NSSM vs group exercise 0.5 �5.2, 4.2 NS NS
Cleland et al. 4 wks SM + exercise NS NS NS NS2009 26 wks Supine + exercise NS NS NS NS
Non-thrust + exercise NS NS NS NSSM + vs supine+ �1.5 �7.01, 4.1 0.9 �3.8, 5.5SM + vs non-thrust+ 12.7 7.5, 18.0 6.8 2.3, 11.4
Cramer et al. * 1 trt SM 10.2 6.4, 14.1 NS NS1993 Ultrasound + other 6.8 5.8, 7.9 NS NS
SM vs ultrasound+ 3.4 �1.6, 8.4 NS NSGiles et al.a, * 9 wks SM 10.0 7.8, 12.2 NS NS2003 MD 0.0 �2.7, 2.7 NS NS
Acupuncture 6.0 4.0, 8.0 NS NSSM vs MD 10.0 7.1, 12.9 NS NSSM vs acupuncture 4.0 2.8, 5.2 NS NS
Giles et al.a, * 4 wks SM 8.5 0.3, 16.7 NS NS1999 MD 0.0 �8.8, 8.8 NS NS
Acupuncture �0.50 �10.6, 9.6 NS NSSM vs MD 8.5 2.7, 14.3 NS NSSM vs acupuncture 9.0 2.8, 15.2 NS NS
Hallegraeff et al. * 4 wks SM + PT 10.0 8.4, 11.6 NS NS2009 PT only 12.0 11.0, 13.0 NS NS
SM + vs PT only �2.0 �2.5, �1.5 NS NSHoiriis et al. * 2 wks SM + placebo MD 7.8 7.0, 8.5 12.8 12.1, 13.62004 4 wks MD + Sham SM 5.8 5.0, 6.5 6.7 5.8, 7.6
Placebo MD + Sham SM 5.5 4.7, 6.2 8.5 7.8, 9.3SM vs MD + Sham SM 2.0 1.6, 2.4 6.1 4.9, 7.4SM vs placebo MD+ 2.3 1.8, 2.7 4.3 3.4, 5.2
Hsieh et al. * 3 wks SM 20.0 18.6, 21.4 NS NS1992 Massage 9.1 5.9, 12.4 NS NS
Corset 7.7 4.9, 10.5 NS NSTMS 16.0 10.9, 21.1 NS NSSM vs massage 10.9 7.4, 14.4 NS NSSM vs corset 12.3 8.3, 16.3 NS NSSM vs TMS 4.0 2.5, 5.5 NS NS
Mandara et al. * NS SM + MD �8.4 �16.9, 0.1 NS NS2008 Sham 0.3 �6.9, 7.5 NS NS
SM + vs Sham �8.8 �10.6, �7.0 NS NSMeade et al. 6 wks SM NS NS NS NS1990 52 wks MD NS NS NS NS
SM vs MD �1.7 �4.1, 0.7 �2.0 �5.3, 1.1Mohseni-Bandpei et al. (2006) End of trts SM + exercise 17.9 14.0, 21.8 16.7 11.1, 22.3
26 wks Ultrasound + exercise 10.1 6.2, 13.9 11.5 5.6, 17.3SM + vs ultrasound+ 7.8 2.4, 13.2 7.4 0.1, 13.8
Senna and Machaly* 4 wks Maintained SM 15.0 8.5, 21.4 19.0 11.9, 26.02011 43 wks Nonmaintained SM 14.6 7.2, 22.0 3.8 �5.6, 13.2
Sham SM 5.6 �1.1, 12.2 0.7 �7.9, 9.2Maintained SM vs Sham SM 9.4 4.0, 14.8 18.3 12.3, 24.3Nonmaintained SM vs Sham SM 9.1 3.7, 14.4 3.1 �2.8, 9.0
Skargren et al. End of trts SM + MT + other NS NS NS NS1997 26 wks Mobilization + other NS NS NS NS
SM + vs mobilization+ �2.5 �4.2, 10.8 3.3 �4.2, 10.8
�� – Contacted author; mos – months; MD – Primary Medical Care; MT – Manual Therapy; NS – Not Specified; PT – Physical Therapy.SM – Spinal Manipulation; trts – treatments; yr – year.* Calculated.
a Median changed to mean.
C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691 683
33. Paatelma M, Kilpikoski S, Simonen R, Heinonen A, Alen M,Videman T. Orthopaedic manual therapy, McKenzie methodor advice only for low back pain in working adults: a ran-domized controlled trial with one year follow-up. J RehabilMed 2008;40(10):858–63.
34. Rasmussen J, Laetgaard J, Lindecrona AL, Qvistgaard E, Blid-dal H. Manipulation does not add to the effect of extensionexercises in chronic low-back pain (LBP). A randomized, con-trolled, double blind study. Joint Bone Spine 2008;75(6):708–13.
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35. Senna MK, Machaly SA. Does maintained spinal manipula-
tion therapy for chronic nonspecific low back pain result inbetter long-term outcome? Spine (Phila Pa 1976)2011;36(18):1427–37.36. Skargren EI, Oberg BE, Carlsson PG, Gade M. Cost and effec-tiveness analysis of chiropractic and physiotherapy treat-ment 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, DeSouza LH. Early intervention for the management of acutelow back pain: a single-blind randomized controlled trialof 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 comparisonbetween chiropractic management and pain clinic manage-ment for chronic low-back pain in a national health serviceoutpatient clinic. J Altern Complement Med 2008;14(5):465–73.
Appendix B. Eighty-five articles that were excluded based onabstract
1. Chiropracters and low back pain. Lancet 1990;336(8709):220.
2. Aleksiev A. Longitudinal comparative study on the out-come of inpatient treatment of low back pain with manualtherapy vs physical therapy. J Orthopaed Med 1995;17(1):10–14.
3. Apeldoorn AT, Ostelo RW, van HH, Fritz JM, de Vet HC, vanTulder MW. The cost-effectiveness of a treatment-basedclassification system for low back pain: design of a random-ised controlled trial and economic evaluation. BMC Muscul-oskelet Disord 2010;11:58.58.
4. Axen I, Jones JJ, Rosenbaum A, Lovgren PW, Halasz L, LarsenK, et al. The Nordic Back Pain Subpopulation Program: vali-dation and improvement of a predictive model for treatmentoutcome in patients with low back pain receiving chiroprac-tic treatment. J Manipulative Physiol Ther 2005a;28(6):381–85.
5. Axen I, Rosenbaum A, Robech R, Larsen K, Leboeuf-Yde C. TheNordic back pain subpopulation program: can patient reac-tions to the first chiropractic treatment predict early favor-able treatment outcome in nonpersistent low back pain? JManipulative 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 treatmentpredict early favorable treatment outcome in persistentlow back pain? J Manipulative Physiol Ther 2002;25(7):450–454.
7. Bennell KL, Matthews B, Greig A, Briggs A, Kelly A, SherburnM, et al. Effects of an exercise and manual therapy programon physical impairments, function and quality-of-life in peo-ple with osteoporotic vertebral fracture: a randomised, sin-gle-blind controlled pilot trial. BMC Musculoskelet Disord2010;1136.
8. Boesler D, Warner M, Alpers A, Finnerty EP, Kilmore MA. Effi-cacy of high-velocity low-amplitude manipulative techniquein 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 forback pain in primary care: objectives, design and interven-tions [ISRCTN32683578]. BMC Health Serv Res 2003a;3(1):16.
hy and Kinesiology 22 (2012) 670–691
Tabl
e9
Sum
mar
yof
qual
ity
rati
ngs.
C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691 685
686 C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691
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 forback pain in primary care: objectives, design and interven-tions [ISRCTN32683578]. BMC Health Serv Res 2003b;3(1):16.
11. Breen A. Low back pain: comparison of chiropractic and hos-pital outpatient treatment. BMJ 1990;301341.
12. Brooks K. Effects of rotational mobilization versus shammobilization of patients suffering acute low back pain. AustJ Physio 1988;35(1):60.
13. Brooks K. Effects of rotational mobilization versus shammobilization of patients suffering acute low back pain. AustJ Physio 1989;35(1):60.
14. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smuc-ker DR. The outcomes and costs of care for acute low backpain among patients seen by primary care practitioners, chi-ropractors, and orthopedic surgeons. The North CarolinaBack Pain Project. NEJM 1995;333(14):913–17.
15. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. Chiro-practic manipulation and McKenzie physiotherapy werenot effective for low back pain. ACP Journal Club 1999;42.
16. Chiradejnants A. Does the choice of spinal level treated dur-ing posteroanterior (PA) mobilization affect treatmentoutcome? Physiotherapy Theroy and Practice 2002;18(4):165–74.
17. Cibulka MT, Delitto A, Koldehoff RM. Changes in innominatetilt after manipulation of the sacroiliac joint in patients withlow back pain. An experimental study. Phys Ther1988;68(9):1359–63.
18. Cleland JA, Fritz JM, Childs JD, Kulig K. Comparison of theeffectiveness of three manual physical therapy techniquesin a subgroup of patients with low back pain who satisfy aclinical prediction rule: study protocol of a randomized clin-ical trial [NCT00257998]. BMC Musculoskelet Disord2006;7:11.11.
19. Cooperstein R, Perle SM, Gatterman MI, Lantz C, SchneiderMJ. Chiropractic technique procedures for specific low backconditions: characterizing the literature. J ManipulativePhysiol Ther 2001;24(6):407–24.
20. Cox JM. A randomized controlled trial comparing 2 typesof spinal manipulation and minimal conservative medicalcare for adults 55 years and older with subacute or chroniclow back pain. J Manipulative Physiol Ther 2009;32(7):601.
21. Cramer GD, Gregerson DM, Knudsen JT, Hubbard BB, UstasLM, Cantu JA. The effects of side-posture positioning andspinal adjusting on the lumbar Z joints: a randomized con-trolled 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 andside-posture adjusting on the lumbar zygapophysial jointsas evaluated by magnetic resonance imaging: a before andafter study with randomization. J Manipulative Physiol Ther2000;23(6):380–394.
23. Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teas-dale N. Efficacy of preventive spinal manipulation forchronic low-back pain and related disabilities: a preliminarystudy. J Manipulative Physiol Ther 2004;27(8):509–14.
24. Evans DW, Foster NE, Underwood M, Vogel S, Breen AC, Pin-cus T. Testing the effectiveness of an innovative informationpackage on practitioner reported behavior and beliefs: theUK Chiropractors, Osteopaths and Musculoskeletal Physio-therapists 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 withlow back pain who demonstrate short-term improvementwith spinal manipulation. Spine (Phila Pa 1976)2002;27(24):2835–43.
26. French SD, Green S, Forbes A. Reliability of chiropracticmethods commonly used to detect manipulable lesions inpatients with chronic low-back pain. J Manipulative PhysiolTher 2000;23(4):231–38.
27. Fritz JM, Whitman JM, Flynn TW, Wainner RS, Childs JD. Fac-tors related to the inability of individuals with low back painto improve with a spinal manipulation. Phys Ther2004;84(2):173–90.
28. Geisser ME, Wiggert EA, Haig AJ, Colwell MO. A randomized,controlled trial of manual therapy and specific adjuvantexercise for chronic low back pain. Clin J Pain2005;21(6):463–70.
29. Gemmell HA. Treatment of chronic low-back pain withlow force manipulation. Chiroprac J Aust 1992;22(2):54–60.
30. Gunby P. Study to evaluate manipulation therapy. JAMA1983;249(23):3148–50.
31. Haas M, Goldberg B, Aickin M, Ganger B, Attwood M. A prac-tice-based study of patients with acute and chronic low backpain attending primary care and chiropractic physicians: 2-week to 48-month follow-up. J Manipulative Physiol Ther2004;27(3):160–169.
32. Haas M, Sharma R, Stano M. Cost-effectiveness of medicaland chiropractic care for acute and chronic low back pain. JManipulative 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 acutelow back pain: design of a randomized controlled trial [ACT-RN012605000036617]. BMC Musculoskelet Disord 2005;657.
34. Harvey E, Burton AK, Moffett JK, Breen A. Spinal manipula-tion for low-back pain: a treatment package agreed to bythe UK chiropractic, osteopathy and physiotherapy profes-sional associations. Man Ther 2003;8(1):46–51.
35. Hawk C, Phongphua C, Bleecker J, Swank L, Lopez D, RubleyT. Preliminary study of the reliability of assessment proce-dures for indications for chiropractic adjustments of thelumbar spine. J Manipulative Physiol Ther 1999;22(6):382–89.
36. Hemmila HM, Keinanen-Kiukaanniemi SM, Levoska S, PuskaP. Does folk medicine work? A randomized clinical trial onpatients with prolonged back pain. Arch Phys Med Rehabil1997;78(6):571–77.
37. Hemmila HM, Keinanen-Kiukaanniemi SM, Levoska S, PuskaP. Long-term effectiveness of bone-setting, light exercisetherapy, and physiotherapy for prolonged back pain: a ran-domized controlled trial. J Manipulative Physiol Ther2002;25(2):99–104.
38. Henchoz Y, de GP, Norberg M, Paillex R, So AK. Role ofphysical exercise in low back pain rehabilitation: a ran-domized controlled trial of a three-month exercise pro-gram in patients who have completed multidisciplinaryrehabilitation. Spine (Phila Pa 1976) 2010;35(12):1192–99.
39. Heymans MW, Anema JR, de Vet HC, van MW. Does flexion-distraction help treat chronic low back pain? Nat Clin PractRheumatol 2006;2(7):360–361.
40. Hildebrandt J, Pfingsten M, Saur P, Jansen J. Prediction ofsuccess from a multidisciplinary treatment program forchronic low back pain. Spine (Phila Pa 1976) 1997;22(9):990–1001.
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46. Kohlbeck FJ, Haldeman S, Hurwitz EL, Dagenais S. Supplemen-tal care with medication-assisted manipulation versus spinalmanipulation therapy alone for patients with chronic lowback pain. J Manipulative Physiol Ther 2005;28(4):245–52.
47. Kokjohn K, Schmid DM, Triano JJ, Brennan PC. The effect ofspinal manipulation on pain and prostaglandin levels inwomen with primary dysmenorrhea. J Manipulative PhysiolTher 1992;15(5):279–85.
48. Koldas DS, Sonel TB, Kurtais Y, Atay MB. Comparison of threedifferent approaches in the treatment of chronic low backpain. Clin Rheumatol 2008;27(7):873–81.
49. Laird R, Hughes P. Manipulative therapy and back care edu-cation: a comparative trial of two treatment methods. Aust JPhysio 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 backpain treated by chiropractors in Sweden. J ManipulativePhysiol 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 pro-gram: demographic and clinical predictors for outcome inpatients receiving chiropractic treatment for persistent lowback pain. J Manipulative Physiol Ther 2004;27(8):493–502.
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64. Roy RA, Boucher JP, Comtois AS. Heart rate variabilitymodulation after manipulation in pain-free patients vspatients in pain. J Manipulative Physiol Ther2009;32(4):277–86.
65. Rupert RL, McKinzie CL, Morter MT, Jr., Daniel DM. Treat-ment of chronic nonresponsive patients with a nonforcetechnique. 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 withnon-specific neck pain are more likely to benefit from spinalmanipulation therapy, physiotherapy, or usual care? Pain2008;139(3):670–680.
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Appendix C. One hundred thirty-one articles that were excludedbased on full article assessment
1. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.Spinal manipulative therapy for low back pain. A meta-anal-ysis of effectiveness relative to other therapies. Annals ofInternal Medicine 2003;138(11):871–81.
2. Bombardier C, Hayden J, Beaton DE. Minimal clinicallyimportant difference. Low back pain: outcome measures. JRheumatol 2001;28(2):431–38.
3. Bronfort G, Evans RL, Maiers M, Anderson AV. Spinal manip-ulation, epidural injections, and self-care for sciatica: a pilotstudy for a randomized clinical trial. J Manipulative PhysiolTher 2004a;27(8):503–8.
4. Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evi-dence-informed management of chronic low back pain withspinal manipulation and mobilization. Spine J 2008;8(1):213–25.
5. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effective-ness of manual therapies: the UK evidence report. ChiroprOsteopat 2010;183.
6. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinalmanipulation and mobilization for low back pain and neckpain: a systematic review and best evidence synthesis. SpineJ 2004b;4(3):335–56.
7. Carey TS, Freburger JK, Holmes GM, Castel L, Darter J, AgansR, et al. A long way to go: practice patterns and evidence inchronic low back pain care. Spine (Phila Pa 1976)2009;34(7):718–24.
8. Chou R, Qaseem A, Snow V, Casey D, Cross JT, Jr., Shekelle P,et al. Diagnosis and treatment of low back pain: a joint clin-ical practice guideline from the American College of Physi-cians and the American Pain Society. Annals of InternalMedicine 2007;147(7):478–91.
9. Christensen, MG, Kollasch, MW, Martin, W, and Hyland JK.Practice Analysis of Chiropractic 2010: A project report, sur-vy analysis, and summary of chiropractic practic in the Uni-ted States. 2010. Greenley, CO, National Board ofChiropractic Examiners.
10. Dagenais S, Caro J, Haldeman S. A systematic review of lowback pain cost of illness studies in the United States andinternationally. Spine J 2008;8(1):8–20.
11. Dagenais S, Tricco AC, Haldeman S. Synthesis of recommen-dations for the assessment and management of low backpain from recent clinical practice guidelines. Spine J2010;10(6):514–29.
12. Deyo RA, Cherkin D, Conrad D. The Back Pain OutcomeAssessment Team. Health Services Research 1990;25(5):733–37.
13. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visitrates: estimates from U.S. national surveys, 2002. Spine(Phila Pa 1976) 2006;31(23):2724–27.
14. Evans DW. Why do spinal manipulation techniques take theform they do? Towards a general model of spinal manipula-tion. Man Ther 2010;15(3):212–19.
15. Evans DW, Lucas N. What is ‘manipulation’? A reappraisal.Man Ther 2010;15(3):286–91.
16. Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry lowback pain disability questionnaire. Physiotherapy 1980;66(8):271–73.
17. Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG. Effi-cacy of spinal manipulative therapy for low back pain of lessthan three months’ duration. J Manipulative Physiol Ther2003;26(9):593–601.
18. Furlan, A, Yazdi, F, Tsertsvadze, A, Gross, A, Van Tulder, M, San-taguida L, Cherkin D, Gagnier J, Ammendolia C, Ansari M, Oster-mann T, Dryden T, Doucette S, Skidmore B, Daniel R, Tsouros S,Weeks L, and Galipeau J. Complementary and Alternative Ther-apies for Back Pain II. Evidence Report/Technology AssessmentNo. 194 (Prepared by the University of Ottawa Evidence-basedPractice Center under Contract No. 290–2007-10059-I (EPCIII).AHRQ Publication No.10(11)E007 [October 2010]. 2010. Rock-ville, MD, Agency for Healthcare Research and Quality.
19. Gershon RC, Rothrock N, Hanrahan R, Bass M, Cella D. Theuse of PROMIS and assessment center to deliver patient-reported outcome measures in clinical research. J Appl Meas2010;11(3):304–14.
20. Hagg O, Fritzell P, Nordwall A. The clinical importance ofchanges in outcome scores after treatment for chronic lowback pain. Eur Spine J 2003;12(1):12–20.
C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691 689
21. Herzog W. The Mechanical Neuromuscular, and PhysiologicEffects Produced by Spinal Manipulation. In: Herzong W,editor. Clinical Biomechanics of Spinal Manipulation. NewYork: Churchill Livingstone, 2000: 191–207.
22. Higgins JPT and Green S. Cochrane Handbook for SystematicReviews of Interventions Version 5.0.2. 9–1-2009. The Coch-rane Collaboration, 2009.
23. Hurwitz EL. Commentary: Exercise and spinal manipulativetherapy for chronic low back pain: time to call for a morato-rium on future randomized trials? Spine J 2011;11(7):599–600.
24. Jaeschke R, Singer J, Guyatt GH. Measurement of health sta-tus. Ascertaining the minimal clinically important differ-ence. Control Clin Trials 1989;10(4):407–15.
25. Khorsan R, Coulter ID, Hawk C, Choate CG. Measures in chi-ropractic research: choosing patient-based outcome assess-ments. J Manipulative Physiol Ther 2008;31(5):355–75.
26. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM.Spinal manipulation for low back pain. An updated system-atic review of randomized clinical trials. Spine (Phila Pa1976) 1996;21(24):2860–2871.
27. Koes BW, van TM, Lin CW, Macedo LG, McAuley J, Maher C.An updated overview of clinical guidelines for the manage-ment of non-specific low back pain in primary care. EurSpine J 2010;19(12):2075–94.
28. Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR,Haas M, et al. Chiropractic management of low back painand low back-related leg complaints: a literature synthesis.J Manipulative Physiol Ther 2008;31(9):659–74.
29. Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC,Devereaux PJ, et al. CONSORT 2010 explanation and elabora-tion: updated guidelines for reporting parallel group ran-domised trials. BMJ 2010;340c869.
30. Ostelo RW, de Vet HC. Clinically important outcomes in lowback pain. Best Pract Res Clin Rheumatol 2005;19(4):593–607.
31. Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von KM,et al. Interpreting change scores for pain and functional sta-tus in low back pain: towards international consensusregarding minimal important change. Spine (Phila Pa 1976)2008;33(1):90–94.
32. Pengel HM, Maher CG, Refshauge KM. Systematic review ofconservative interventions for subacute low back pain. Clin-ical Rehabilitation 2002;16(8):811–20.
33. Pransky G, Borkan JM, Young AE, Cherkin DC. Are we makingprogress?: the tenth international forum for primary careresearch on low back pain. Spine (Phila Pa 1976)2011;36(19):1608–14.
34. Riddle DL, Stratford PW, Binkley JM. Sensitivity to change ofthe Roland-Morris Back Pain Questionnaire: part 2. PhysicalTherapy 1998;78(11):1197–207.
35. Roland M, Fairbank J. The Roland-Morris Disability Ques-tionnaire and the Oswestry Disability Questionnaire. Spine2000;25(24):3115–24.
36. Rubinstein SM, van MM, Assendelft WJ, de Boer MR, van Tul-der MW. Spinal manipulative therapy for chronic low-backpain: an update of a Cochrane review. Spine (Phila Pa1976) 2011;36(13):E825-E846.
37. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J,Suissa S, et al. Scientific monograph of the Quebec Task Forceon Whiplash-Associated Disorders: redefining ‘‘whiplash’’and its management. Spine (Phila Pa 1976) 1995;20(8 Sup-pl):1S-73S.
38. Stratford PW, Binkley JM, Riddle DL. Development and initialvalidation of the back pain functional scale. Spine2000;25(16):2095–102.
39. Triano JJ. The Mechanics of Spinal Manipulation. In: HerzogW, editor. Clinical Biomechanics of Spinal Manipulation.New York: Churchill Livingstone, 2000: 92–190.
40. Triano JJ, Bougie J, Rogers C, Scaringe J, Sorrels K, SkogsberghD, et al. Procedural skills in spinal manipulation: do prereq-uisites matter? Spine J 2004;4(5):557–63.
41. van der Roer N, Ostelo RW, Bekkering GE, van Tulder MW, deVet HC. Minimal clinically important change for pain inten-sity, functional status, and general health status in patientswith nonspecific low back pain. Spine (Phila Pa 1976)2006;31(5):578–82.
42. van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Methodguidelines for systematic reviews in the Cochrane Collabora-tion Back Review Group for Spinal Disorders. Spine (Phila Pa1976) 1997;22(20):2323–30.
43. van Tulder MW, Furlan AD, Gagnier JJ. Complementary andalternative therapies for low back pain. Best Pract Res ClinRheumatol 2005;19(4):639–54.
44. van Tulder MW, Koes B. Chronic low back pain. AmericanFamily Physician 2006;74(9):1577–79.
45. Vela Li, Haladay DE, Denegar C. Clinical assessment of low-back-pain treatment outcomes in athletes. J Sport Rehabil2011;20(1):74–88.
46. Walker BF. The prevalence of low back pain: a systematicreview of the literature from 1966 to 1998. J Spinal Disord2000;13(3):205–17.
47. Walker BF, French SD, Grant W, Green S. Combined chiro-practic interventions for low-back pain. Cochrane DatabaseSyst Rev 2010;(4):CD005427.
References
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Bombardier C, Hayden J, Beaton DE. Minimal clinically important difference. Lowback pain: outcome measures. J Rheumatol 2001;28(2):431–8.
Bronfort G, Evans RL, Maiers M, Anderson AV. Spinal manipulation, epiduralinjections, and self-care for sciatica: a pilot study for a randomized clinical trial.J Manipulative Physiol Ther 2004a;27(8):503–8.
Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informedmanagement of chronic low back pain with spinal manipulation andmobilization. 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. Chiropr Osteopat 2010:183.
Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation andmobilization for low back pain and neck pain: a systematic review and bestevidence synthesis. Spine J 2004b;4(3):335–56.
Carey TS, Freburger J K, Holmes G M, Castel L, Darter J, Agans R, et al. A long way togo: practice patterns and evidence in chronic low back pain care. Spine (Phila Pa1976) 2009;34(7):718–24.
Chou R, Qaseem A, Snow V, Casey Jr D, Shekelle Jr P, et al. Diagnosis andtreatment of low back pain: a joint clinical practice guideline from theAmerican College of Physicians and the American Pain Society. Ann IntMed 2007;147(7):478–91.
Christensen MG, Kollasch MW, Martin W, Hyland JK. Practice Analysis ofChiropractic 2010: A project report, survey analysis, and summary ofchiropractic 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 illnessstudies in the United States and internationally. Spine J 2008;8(1):8–20.
Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for theassessment and management of low back pain from recent clinical practiceguidelines. Spine J 2010;10(6):514–29.
Deyo RA, Cherkin D, Conrad D. The back pain outcome assessment team. HealthServ Res 1990;25(5):733–7.
Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates fromUS national surveys, 2002. Spine (Phila Pa 1976) 2006;31(23):2724–7.
Evans DW. Why do spinal manipulation techniques take the form they do? Towardsa general model of spinal manipulation. Manual Ther 2010;15(3):212–9.
Evans DW, Lucas N. What is ‘manipulation’? A reappraisal. Manual Ther2010;15(3):286–91.
Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry low back pain disabilityquestionnaire. Physiotherapy 1980;66(8):271–3.
690 C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691
Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG. Efficacy of spinalmanipulative therapy for low back pain of less than three months’ duration. JManipulative 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)). AHRQpublication no. 10(11)E007 [October 2010]; 2010. Rockville (MD): Agency forHealthcare Research and Quality.
Gershon RC, Rothrock N, Hanrahan R, Bass M, Cella D. The use of PROMIS andassessment center to deliver patient-reported outcome measures in clinicalresearch. J Appl Meas 2010;11(3):304–14.
Hagg O, Fritzell P, Nordwall A. The clinical importance of changes in outcomescores after treatment for chronic low back pain. Eur Spine J2003;12(1):12–20.
Herzog W. The Mechanical neuromuscular, and physiologic effects produced byspinal manipulation. In: Herzong W, editor. Clinical biomechanics of spinalmanipulation. New York: Churchill Livingstone; 2000. p. 191–207.
Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventionsversion 5.0.2.9–1-2009. The Cochrane Collaboration; 2009.
Hurwitz EL. Commentary: exercise and spinal manipulative therapy for chronic lowback pain: time to call for a moratorium on future randomized trials? Spine J2011;11(7):599–600.
Jaeschke R, Singer J, Guyatt GH. Measurement of health status. Ascertainingthe 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 Ther2008;31(5):355–75.
Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM. Spinal manipulation for lowback 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 ofclinical guidelines for the management of non-specific low back pain in primarycare. Eur Spine J 2010;19(12):2075–94.
Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR, Haas M, et al. Chiropracticmanagement of low back pain and low back-related leg complaints: a literaturesynthesis. J Manipulative Physiol Ther 2008;31(9):659–74.
Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ et al.CONSORT 2010 explanation and elaboration: updated guidelines for reportingparallel group randomised trials. BMJ 2010;340–869.
Ostelo RW, De Vet HC. Clinically important outcomes in low back pain. Best PractRes Clin Rheumatol 2005;19(4):593–607.
Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von KM, et al. Interpretingchange scores for pain and functional status in low back pain: towardsinternational consensus regarding minimal important change. Spine (Phila Pa1976) 2008;33(1):90–4.
Pengel HM, Maher CG, Refshauge KM. Systematic review of conservativeinterventions 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 tenthinternational forum for primary care research on low back pain. Spine (Phila Pa1976) 2011;36(19):1608–14.
Riddle DL, Stratford PW, Binkley JM. Sensitivity to change of the Roland-Morris backpain questionnaire: Part 2. Phys Ther 1998;78(11):1197–207.
Roland M, Fairbank J. The Roland-Morris disability questionnaire and the Oswestrydisability questionnaire. Spine 2000;25(24):3115–24.
Rubinstein SM, van MM, Assendelft WJ, de Boer MR, van Tulder MW. Spinalmanipulative therapy for chronic low-back pain: an update of a Cochranereview. Spine (Phila Pa 1976) 2011;36(13):E825–46.
Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientificmonograph of the Quebec Task Force on Whiplash-Associated Disorders:redefining ‘‘whiplash’’ and its management. Spine (Phila Pa 1976) 1995;20(8Suppl.):1S–73S.
Stratford PW, Binkley JM, Riddle DL. Development and initial validation of the backpain functional scale. Spine 2000;25(16):2095–102.
Triano JJ. The mechanics of spinal manipulation. In: Herzog W, editor. Clinicalbiomechanics of spinal manipulation. New York: Churchill Livingstone; 2000. p.92–190.
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Christine M. Goertz, D.C., Ph.D. is Vice Chancellor ofResearch and Health Policy at Palmer College of Chiro-practic and currently serves on the Board of Governorsfor the Patient Centered Outcomes Research Institute, isa member of the American Medical Association PCPIMeasurement, Instrumentation and Evaluation Com-mittee and Chair of the American Chiropractic Associa-tion Performance Measurement Task Force. She receivedher Doctor of Chiropractic (D.C.) degree from North-western Health Sciences University and her Ph.D. inHealth Services Research, Policy and Administrationfrom the University of Minnesota.She came to Palmer in January, 2007, with more than
15 years of experience as a scientist and in science administration. She has extensiveexperience in the administration of Federal grants, as a PI and as a NIH ProgramOfficial. Prior to joining the PCCR, she spent 4 years as an independent scientist and in
research administration positions of increasing responsibility at the Samueli Insti-tute. Before joining the Institute, she was a Program Officer at the National Center forComplementary and Alternative Medicine (NCCAM), National Institutes of Health(NIH), managing a $50 million portfolio focused on musculoskeletal disease, pain, andhealth services research. Prior to the NIH, she was Vice-President of Research andPolicy at the American Chiropractic Association and an NIH-funded post-doctoralfellow at the University of Minnesota. Her research interests have focused on CAMtreatments for cardiovascular disease and pain.Cynthia R. Long is professor and director of research atPalmer College of Chiropractic in Davenport, IA. Shewas awarded an M.S. in statistics from Iowa StateUniversity in 1989 and a Ph.D. in biostatistics from theUniversity of Iowa in 1995. She directs the Office ofData Management and Biostatistics at the PalmerCenter for Chiropractic Research and the M.S. in Clini-cal Research Program at Palmer College.
James W. Brantingham graduated from SouthernCalifornia University of Health Sciences with his DC in1983. In 2000 he became a senior lecturer in the Pro-gramme of Chiropractic at the University of Surrey inGuildford, England where in 2005 he earned his PhD.From 2005 until 2011he was the director of research atCleveland Chiropractic College, Los Angeles. Currentlyhe is a Research Consultant in the areas of spinal andextremity manipulation.
Robert D. Vining is assistant professor and directorof the research clinic at the Palmer Center for Chi-ropractic Research. He earned his Doctor of Chiro-practic from Logan College of Chiropractic in 1989.Prior to joining Palmer, he was Clinic Director at theLogan College of Chiropractic Southroads HealthCenter and Staff Physician at the VA Medical Center(Jefferson Barracks Division), both in St. Louis, Mis-souri. He has more than 14 years of experience inprivate practice. His research interests are in theareas of musculoskeletal diagnosis, radiographicfindings as they relate to clinical decision-making formanual therapy providers, and understanding mech-
anisms associated with spinal manipulative procedures.
C.M. Goertz et al. / Journal of Electromyography and Kinesiology 22 (2012) 670–691 691
Katherine A. Pohlman is a clinical project manager atthe Palmer Center for Chiropractic Research. Sheearned her Doctor of Chiropractic and MS in ClinicalResearch from the Palmer College of Chiropractic and isa PhD candidate at the University of Alberta. Herresearch interests include the safety and effectivenessof spinal manipulative therapy.
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