Research Review by Dr. Shawn Thistle©


June 2006

Study Title:

The use of a lumbar spine manipulation technique by physical therapists in patients who satisfy a clinical prediction rule: A case series


Cleland JA et al.

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2006; 36: 209-214.


The health care costs associated with low back pain in the United States is comparable to other severe health problems such as depression, heart disease, and diabetes. Of this cost, an estimated 37% is a direct result of physical therapy services. A common intervention utilized by physical therapists and chiropractors to treat low back pain is spinal manipulation.

Research on spinal manipulation for low back pain to this point has been generally supportive, but clouded by poor study design and standardization, and until recently, the inability to homogenize patient groups so they can be properly studied.

The latter issue has been well addressed by a group of physical therapists in the United States (Julie Fritz, Timothy Flynn, Joshua Cleland, John Childs, and others), who over the last 7-8 years have developed a validated a clinical prediction rule (CPR) to identify patients most likely to benefit from spinal manipulation, and other commonly used physical therapy interventions for low back pain.

The CPR involves pen and paper outcome measure, historical, and physical examination components (for complete information on the CPR, feel free to email me or simply do a literature search for any of the authors listed above). Patients who satisfy a certain number of criteria from the CPR have been shown to respond favourably to spinal manipulation.

It should be mentioned that the manipulation technique used in the development and validation of the CPR was a patient-supine technique utilizing the upper extremities to create a torque through the lumbar spine.

The purpose of this case series was to determine the outcomes of low back pain patients who satisfy the CPR if an alternative type of manipulation was used (i.e. not the technique used in the development of the CPR). A total of 12 patients participated in the case series (average age 39, 7 males, and 5 females). Each patient underwent two treatments within one week involving a side-posture manipulation technique. This technique would be familiar to chiropractors as a Bonyun-type adjustment.

The manipulation was followed by a simple range of motion exercise for all patients. The Oswestry Disability Index was used as the primary outcome, with a significant improvement defined as a 50% reduction of the initial score (which had to be at least 30).

Pertinent Results:

  • 92% of the patients treated with the side-lying manipulation technique demonstrated a successful outcome within one week

Conclusions & Practical Application:

I don't normally review case studies or case series on my website, but I feel this small case series presents an interesting extension from the original work that has contributed to the formation of this clinical prediction rule. Patients in this case series had successful outcomes with a different type of lumbar manipulation.

This supports previous research that has shown that low back pain patients respond similarly to a randomly selected mobilization technique as a specifically selected one. Further, it suggests that using the CPR could effectively select patients likely to respond to ANY type of manipulation, which would certainly expand the applicability of this line of research.

This small case series sets up future studies investigating the long term outcomes associated with different lumbar spine manipulation techniques. I feel this line of investigation is very useful as it directly addresses one of the shortcomings of low back pain research - being able to ensure a homogenous patient population.

If we know which patients are most likely to benefit from a treatment intervention, it will be easier to fairly compare treatments, which in the long term will benefit patients.