Manipulation of the Lumbar Spine

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Introduction[edit | edit source]

Manipulation techniques are widely used by health professionals such as chiropractors, osteopathic physicians and physiotherapists, and are applied to different aspects of the body to provide pain relief. As widely used and acceptable as these techniques may be, it is important to analyse and review their effectiveness on commonly affected joints like the lumbar spine and sacroiliac joint that are prone to causing low back pain (LBP). The mechanisms underlying the effectiveness of the procedures, their efficacy, safety and contraindications are also important to be explored.

What is Manipulation?[edit | edit source]

Manipulation is a technique where a therapist passively applies a directed thrust to a joint at the end of physiological range of movement, causing an audible sound to be created by the joint[1]. This differs from mobilisation where passive movement is carried out within available range of motion and then gradually increased to a larger range as the patient feels more comfortable[1].

The Use of Manipulations[edit | edit source]

Lower back pain, according to a 2017 report, is the most common musculoskeletal problem globally with a prevalence of 7.5% across all age groups in the world and in the United States, life-time prevalence may reportedly be as high as 84%[2][3]. Manipulation techniques as part of manual therapy to improve an individual’s movement potential is within a physiotherapist's scope of practice [4]. They are often used for patients with chronic non-specific low back pain as it has been shown to be effective in their management[5].

How to Use Lumbar Manipulation[edit | edit source]

See the physiopedia page: Spinal Manipulation to learn more how lumbar manipulation can be used and its contraindications.

Example of a Lumbar Manipulation[edit | edit source]

Below is an example of a lumbar manipulation technique


Mechanisms[edit | edit source]

The exact mechanism by which spinal manipulation works has not been established but an array of biomechanical, muscular reflexogenic and neurophysiological responses have been reported[7][8] to support its effects such as: pain relief[7], reduction of spinal stifness[9]. A number of these mechanisms are as discussed below:

Mechanical gapping of the facet joint is reported as an effect of spinal manipulation (SM) although its clinical significance is unclear. SM is also thought to evoke spinal stretch reflexes resulting in a brief muscle contraction possibly followed by a period of reduced muscle activity, and to bring about pain relieving effects[8].

Motor Neurone Excitability  [edit | edit source]

Hyper-excitability of the A motor neuron leads to increased muscle activity, spinal manipulation has been thought to relax hyperactive muscles through modulating the A motor neuron activity.  

Muscle Activity[edit | edit source]

Individuals with LBP experience greater amount of spinal muscle hyperactivity in static postures than healthy participants.

The pain-spasm cycle suggests that pain causes muscular hyperactivity (spasm) and this spasm can cause further pain.  

Pain -> Hyperactivity (spasm) -> Pain  

The mechanical stimulation of spinal manipulation is thought to cause the sensory receptors to inhibit muscle activity - disrupting the pain-spasm-model.

Activation of Descending Pain Modulation  [edit | edit source]

Spinal manipulation is thought to activate the descending pain modulation circuit, specifically, the serotonin and noradrenaline pathways.

Segmental Inhibition[edit | edit source]

This theory proposes that nociceptive (small-diameter) A-δ and C sensory fibers carry the pain stimuli to the dorsal horn and “open” the substantia gelatinosa layer, whereas non-nociceptive (large-diameter) A-β fibers inhibit the transmission of pain signals by blocking the entry of A-δ and C fibers. Because mechanical stimulus applied during spinal manipulation may alter peripheral sensory input from paraspinal tissues, it has been presumed that manipulation may influence the gate closing mechanism by stimulating the A-β fibers from muscle spindles and facet joint mechanoreceptors.

Temporal Summation[edit | edit source]

Temporal summation is an increased perception of pain caused by repetitive nociceptive stimuli – it's related to aspects of central sensitization. Lumbar spine manipulation has been shown to reduce temporal summation of pain.

Endocrine Response  [edit | edit source]

Manipulations at the thoracolumbar segment of the spine could result in excitation of the preganglionic sympathetic cells and subsequent stimulation of mechanoreceptors. These inputs would then travel to several regions of the brain stem and lead to opioid-independent analgesia by influencing the hypothalamus and periaqueductal gray (PAG) in the midbrain. The hypothalamic release of corticotropin-releasing factor would then occur to modulate the SNS and HPA axis response. The neuroendocrine (SNS–HPA axis) system would then release its end products (catecholamines and glucocorticoids) to initiate anti-inflammatory and tissue-healing actions. However, there is a lack of research to support with only one study looking at SNS and HPA.

Non-Specific Responses  [edit | edit source]

The relevance of non-specific variables, for example expectations or psychosocial factors. It is not well understood how physiologically these factors effect various factors such as pain or psychological outcome measures, only that the evidence shows that manipulations of the lower back improve these factors.

Efficacy of Lumbar Manipulations[edit | edit source]

Effectiveness as a sole treatment[edit | edit source]

Spinal manipulation can either be used alongside other forms of treatment or alone as an individual intervention. Its effectiveness as a sole treatment approach is discussed below.

A 2016 systematic review and meta-analysis compared SM with sham manipulation for non-specific LBP showed that a greater reduction in pain scores was present in SM in comparison to those receiving a placebo[10]

A RCT compared the effectiveness of spinal manipulation and a functional MT technique involving breathing on improving pain, disability, quality of life and fear of movement. Over a short-term period, SM only reduced disability in patients with chronic LBP and the other outcomes weren’t improved. The small sample size (n=62) may be a reason why improvements in disability weren’t clinically significant; it was concluded that SM didn’t result in clinically meaningful short-term benefits[11].  

A RCT comparing the effectiveness of region specific and non-region-specific spinal manipulation for improving pain intensity within chronic LBP patients found that both groups experienced immediate decrease in pain intensity[12].

Required treatment Sessions  [edit | edit source]

A study comparing a variety of spinal manipulation treatment sessions found that 12 sessions over a 6-week period yielded the greatest improvement in pain and functional disability. This quantity of treatment saw improvements in pain and functional disability in both the short term (12 weeks) and long term (52 weeks)[13].

Effectiveness as an Adjunct to Exercise[edit | edit source]

Nice guidelines state that for patients with lower back pain manual therapies including manipulation should be considered as a package of treatment including exercise with/ without psychological therapy[14]. Manipulations are commonly used alongside other therapies, and this has been shown to yield a statistically significantly better outcome in pain and function after 1 month of intervention[15].

In a randomised control trial,[16] the use of manual therapies followed by exercises for patients with chronic nonspecific lower back pain was analysed. This study found that manual therapies (including manipulations) followed by exercises provided a statistically significant reduction in pain and disability compared with a sham therapy followed by exercises. This study was conducted on adults (20-65) with chronic nonspecific lower back pain without co-morbidities so may not be generalisable to all populations. Another randomised trial on adolescent (12-18) patients with non-specific lower back pain showed that spinal manipulations alongside exercise is more effective than exercise alone for lower back pain[17].

Manipulations as adjuncts to other treatments for lower back pain such as myofascial release and kinesio taping have been found to produce no significant benefit compared with manipulations alone[18][19] .

Chronic vs acute  [edit | edit source]

Due to the different mechanisms of pain between acute and chronic pain it is important to analyse the effectiveness of treatments between these two patient groups[20]. The manipulations for chronic lower back pain have been found to be effective in multiple studies[5][13].  

A randomised control trial found that manipulations are significantly effective in reducing pain for chronic and sub-acute lower back pain with radiculopathy and improving range of motion[21]. However, all participants to the study were given pain killers (paracetamol and gabapentin) which may have had an effect in reducing pain.  

For patients with acute lower back pain spinal manipulations may not be effective for many of these patients who will recover quickly with or without intervention[22]. Furthermore, a randomised control trial found that patients with acute lower back pain do not recover more quickly with the addition of manipulation to first line care[22]. A Cochrane review[23] found low to very low-quality evidence suggesting that spinal manipulation was no more effective than other recommended therapies for acute lower back pain.

Safety of Spinal Manipulations[edit | edit source]

Safety[edit | edit source]

The research around safety and adverse events in lumbar manipulation is limited by the amount of good quality research. A review [24] looked at spinal manipulation as a whole and show stroke (1 in 20,000–2,000,000 manipulations) or Vertebrobasilar accident (1 in 228,050–1,000,000 manipulations) as the most common serious adverse events. However, these events are caused by cervical manipulations and in the sole study looking at lumbar manipulation, the adverse event caused was lumbar disc hernia which the risk was assessed at 1 in 3.8m. The review was inconclusive about the overall safety of spinal manipulation as 46% conclude it was safe, 13% unsafe and 42% unclear. Further research needs to be done, especially into Lumbar manipulation safety as the anatomy would suggest it to be safer than cervical or thoracic, with most common adverse event being mild soreness, however there is a lack of research in to the area.

Swait and Finch also conducted a review[25] in 2017 on the risks of manual techniques on the spine. 250 articles were included in the review, including observational studies, randomised studies and systematic reviews. Swait and Finch’s findings are in agreement with the findings of Neilson et al 2017[24]. Benign adverse advents are commonplace in both adolescence and adults:

• Benign adverse events are common, affecting 23–83% of adult patients.

• These are mostly mild-moderate, transient (usually resolve within 24 h) and commonly include musculoskeletal pain, stiff-ness and headache.

• Dizziness, tiredness, feeling faint/lightheaded or tingling in the arms might also be experienced following neck treatment.

Serious adverse events appear to be rare and, as a result, estimates of the level of risk are problematic.

• However, cases of serious adverse events, including serious spinal or neurological problems as well as strokes affecting arteries in the neck, have been reported.

• Serious adverse events could result from pre-existing pathologies, therefore assessment for signs or symptoms of these is important.

• Where a serious adverse event is thought to have occurred following manual spinal intervention, use of a patient safety incident reporting system enables dissemination of accurate case details.

Safety of Lumbar Manipulation in Different populations[edit | edit source]

Under 18[edit | edit source]

A review done between 1990 to 2019 looked at the safety of spinal manipulation in children under 10 years old[26].

Most adverse events found were mild (crying or soreness) but once case described a rib fracture to 3-week-old. The incidence of mild adverse events ranges from 0.3% (95% CI: 0.06, 1.82) to 22.22% (95% CI: 6.32, 54.74)

It was inconclusive as to whether spinal manipulative therapy was safe in under 10s. However, had poor study quality and quantity and may have had a conflicting interest as they were mandated by the College of Chiropractors of British Columbia to review the evidence which was the published in a chiropractic journal.

RCTs carried out [27] [28] looked at exercise and manual therapy in adolescents and both concluded there were no adverse reactions to the manipulations but also no benefit reported vs exercise alone.

Age 18-65[edit | edit source]

The review by Rubinstein et al (2019)[15] of patients aged 35-60, found One study powered enough to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT.

Over 65[edit | edit source]

In a systematic review [29] which looked at effectiveness and safety of manipulations in the elderly, they found no conclusive result due the lack of studies investigating the area and the quality of those studies as well as a need for a standardised adverse event reporting system. They also found no difference in the number of adverse events in the ‘sham’ manipulation group vs the intervention group.

References  [edit | edit source]

  1. 1.0 1.1 Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low‐back pain. Cochrane Database of Systematic Reviews. 2011(2).
  2. Wu A, March L, Zheng X, Huang J, Wang X, Zhao J, Blyth FM, Smith E, Buchbinder R, Hoy D. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Annals of translational medicine. 2020 Mar;8(6).
  3. Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. The lancet. 2012 Feb 4;379(9814):482-91.
  4. Chartered Society of Physiotherapy (CSP), 2020 CSP Accreditation of Qualifying Programmes in Physiotherapy quality assurance processes. Available at: [Accessed 22 May 2021].
  5. 5.0 5.1 Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Booth MS, Herman PM. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. The Spine Journal. 2018 May 1;18(5):866-79.
  6. John Gibbons. Spinal Manipulation (HVT or grade 5) of the Lumbar Spine (L4/5). Available from: 5EwC55PuU90 [last accessed 17/8/20]
  7. 7.0 7.1 Gyer G, Michael J, Inklebarger J, Tedla JS. Spinal manipulation therapy: Is it all about the brain? A current review of the neurophysiological effects of manipulation. J Integr Med. 2019 Sep;17(5):328-337. doi: 10.1016/j.joim.2019.05.004.
  8. 8.0 8.1 Potter L, McCARTHY CH, Oldham J. Physiological effects of spinal manipulation: a review of proposed theories. Physical therapy reviews. 2005 Sep 1;10(3):163-70.
  9. Jun P, Pagé I, Vette A, Kawchuk G. Potential mechanisms for lumbar spinal stiffness change following spinal manipulative therapy: a scoping review. Chiropractic & manual therapies. 2020 Dec;28(1):1-3.
  10. Ruddock JK, Sallis H, Ness A, Perry RE. Spinal manipulation vs sham manipulation for nonspecific low back pain: a systematic review and meta-analysis. Journal of chiropractic medicine. 2016 Sep 1;15(3):165-83.
  11. Castro-Sánchez AM, Lara-Palomo IC, Matarán-Peñarrocha GA, Fernández-De-Las-Peñas C, Saavedra-Hernández M, Cleland J, Aguilar-Ferrándiz ME. Short-term effectiveness of spinal manipulative therapy versus functional technique in patients with chronic nonspecific low back pain: a pragmatic randomized controlled trial. The Spine Journal. 2016 Mar 1;16(3):302-12.
  12. de Oliveira RF, Liebano RE, Costa LD, Rissato LL, Costa LO. Immediate effects of region-specific and non–region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Physical therapy. 2013 Jun 1;93(6):748-56.
  13. 13.0 13.1 Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MB. Dose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial. The Spine Journal. 2014 Jul 1;14(7):1106-16.
  14. National GC. Low Back Pain and Sciatica in Over 16s: Assessment and Management. Available from:
  15. 15.0 15.1 Rubinstein SM, De Zoete A, Van Middelkoop M, Assendelft WJ, De Boer MR, Van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. bmj. 2019 Mar 13;364.
  16. Balthazard P, de Goumoens P, Rivier G, Demeulenaere P, Ballabeni P, Dériaz O. Manual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: a randomized controlled trial. BMC musculoskeletal disorders. 2012 Dec;13(1):1-1.
  17. Evans R, Haas M, Schulz C, Leininger B, Hanson L, Bronfort G. Spinal manipulation and exercise for low back pain in adolescents: a randomized trial. Pain. 2018 Jul;159(7):1297.
  18. Kamali F, Sinaei E, Taherkhani E. Comparing spinal manipulation with and without Kinesio Taping® in the treatment of chronic low back pain. Journal of bodywork and movement therapies. 2018 Apr 1;22(2):540-5.
  19. Boff TA, Pasinato F, Ben ÂJ, Bosmans JE, van Tulder M, Carregaro RL. Effectiveness of spinal manipulation and myofascial release compared with spinal manipulation alone on health-related outcomes in individuals with non-specific low back pain: randomized controlled trial. Physiotherapy. 2020 Jun 1;107:71-80.
  20. Crofford LJ. Chronic pain: where the body meets the brain. Transactions of the American Clinical and Climatological Association. 2015;126:167.
  21. Ghasabmahaleh SH, Rezasoltani Z, Dadarkhah A, Hamidipanah S, Mofrad RK, Najafi S. Spinal Manipulation for Subacute and Chronic Lumbar Radiculopathy: A Randomized Controlled Trial. The American Journal of Medicine. 2021 Jan 1;134(1):135-41.
  22. 22.0 22.1 Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO, Spindler MF, McAuley JH. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. The Lancet. 2007 Nov 10;370(9599):1638-43.
  23. Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low‐back pain. Cochrane Database of Systematic Reviews. 2012(9).
  24. 24.0 24.1 Nielsen SM, Tarp S, Christensen R, Bliddal H, Klokker L, Henriksen M. The risk associated with spinal manipulation: an overview of reviews. Systematic reviews. 2017 Dec;6(1):1-9.
  25. Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropractic & manual therapies. 2017 Dec;25(1):1-5.
  26. Corso M, Cancelliere C, Mior S, Taylor-Vaisey A, Côté P. The safety of spinal manipulative therapy in children under 10 years: a rapid review. Chiropractic & manual therapies. 2020 Dec;28(1):1-8.
  27. Selhorst M, Selhorst B. Lumbar manipulation and exercise for the treatment of acute low back pain in adolescents: a randomized controlled trial. Journal of Manual & Manipulative Therapy. 2015 Sep 1;23(4):226-33.
  28. Walston Z, Yake D. Lumbar thrust manipulation and exercise for the treatment of mechanical low back pain in adolescents: a case series. journal of orthopaedic & sports physical therapy. 2016 May;46(5):391-8.
  29. de Luca KE, Fang SH, Ong J, Shin KS, Woods S, Tuchin PJ. The effectiveness and safety of manual therapy on pain and disability in older persons with chronic low Back pain: a systematic review. Journal of manipulative and physiological therapeutics. 2017 Sep 1;40(7):527-34.