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ARTICLE

A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study

John D. Childs, PhD, PTMaj; Julie M. Fritz, PhD, PT; Timothy W. Flynn, PhD, PT; James J. Irrgang, PhD, PT; Kevin K. Johnson, Maj; Guy R. Majkowski, Maj; and Anthony Delitto, PhD, PT

21 December 2004 | Volume 141 Issue 12 | Pages 920-928

Background: Conflicting evidence exists about the effectiveness of spinal manipulation.

Objective: To validate a manipulation clinical prediction rule.

Design: Multicenter randomized, controlled trial.

Setting: Physical therapy clinics.

Patients: 131 consecutive patients with low back pain, 18 to 60 years of age, who were referred to physical therapy.

Intervention: Patients were randomly assigned to receive manipulation plus exercise or exercise alone by a physical therapist for 4 weeks.

Measurements: Patients were examined according to the clinical prediction rule criteria (symptom duration, symptom location, fear–avoidance beliefs, lumbar mobility, and hip rotation range of motion). Disability and pain at 1 and 4 weeks and 6 months were assessed.

Results: Outcome from spinal manipulation depends on a patient's status on the prediction rule. Treatment effects are greatest for the subgroup of patients who were positive on the rule (at least 4 of 5 criteria met); health care utilization among this subgroup was decreased at 6 months. Compared with patients who were negative on the rule and received exercise, the odds of a successful outcome among patients who were positive on the rule and received manipulation were 60.8 (95% CI, 5.2 to 704.7). The odds were 2.4 (CI, 0.83 to 6.9) among patients who were negative on the rule and received manipulation and 1.0 (CI, 0.28 to 3.6) among patients who were positive on the rule and received exercise. A patient who was positive on the rule and received manipulation has a 92% chance of a successful outcome, with an associated number needed to treat for benefit at 4 weeks of 1.9 (CI, 1.4 to 3.5).

Limitations: The response rate for the 6-month follow-up resulted in inadequate power to detect statistically significant differences for some comparisons.

Conclusions: The spinal manipulation clinical prediction rule can be used to improve decision making for patients with low back pain.

Editors' Notes Context In this randomized, controlled trial, spinal manipulation plus exercise produced outcomes for low back pain similar to those produced by exercise alone. Yet, some patients did respond to spinal manipulation, and it would be helpful for doctors to be able to identify such patients. Contribution Patients were most likely to benefit from spinal manipulation if they met 4 of 5 of the following criteria: symptom duration less than 16 days, no symptoms distal to knee, score less than 19 on a fear-avoidance measure, at least 1 hypomobile lumbar segment, and at least 1 hip with more than 35 degrees of internal rotation. Implications Clinicians may be able to use these criteria to identify patients with low back pain who are good candidates for spinal manipulation. –The Editors

 

Author and Article Information

From Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas; University of Pittsburgh, Pittsburgh, Pennsylvania; U.S. Army–Baylor University Graduate Program in Physical Therapy, Fort Sam Houston, Texas; Hill Air Force Base Medical Clinic, Ogden, Utah; and Luke Air Force Base Medical Clinic, Phoenix, Arizona.

The trial will be registered in Current Controlled Trials (http://www.controlled-trials.com) in the near future.

Disclaimer: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force or Department of Defense.

Acknowledgments: The authors thank the physical therapy staff at the following sites for their assistance with data collection: Wilford Hall Medical Center, Lackland Air Force Base (AFB); Malcolm Grow Medical Center, Andrews AFB; Wright-Patterson Medical Center, Wright-Patterson AFB; Eglin Hospital, Eglin AFB; Luke Medical Clinic, Luke AFB; Hill Medical Clinic, Hill AFB; F.E. Warren Medical Clinic, F.E. Warren AFB; and University of Pittsburgh Medical Center Health System's Centers for Rehab Services.

Grant Support: By the Foundation for Physical Therapy, Inc., and Wilford Hall Medical Center Commander's Intramural Research Funding Program.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Maj John D. Childs, PhD, PT, 508 Thurber Drive, Schertz, TX 78154-1146; e-mail, childsjd{at}sbcglobal.net.

Current Author Addresses: Dr. Childs: 508 Thurber Drive, Schertz, TX 78154.

Dr. Fritz: Department of Physical Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT 84108.

Dr. Flynn: Department of Physical Therapy, Regis University, 3333 Regis Boulevard, G-4, Denver, CO 80221-1099.

Drs. Irrgang and Delitto: Department of Physical Therapy, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260.

Mr. Majkowski: Physical Therapy Service, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234.

Mr. Johnson: 2602 Blue Rock Drive, Beavercreek, OH 45434.

Author Contributions: Conception and design: J.D. Childs, J.M. Fritz, T.W. Flynn, J.J. Irrgang, A. Delitto. Administrative, technical, or logistic support: K.K. Johnson, G.R. Majkowski.

Collection and assembly of data: J.D. Childs, K.K. Johnson, G.R. Majkowski.

Analysis and interpretation of the data: J.D. Childs, J.M. Fritz, T.W. Flynn, J.J. Irrgang.

Drafting of the article: J.D. Childs, J.M. Fritz, A. Delitto.

Critical revision of the article for important intellectual content: J.D. Childs, J.M. Fritz, T.W. Flynn, K.K. Johnson, A. Delitto.

Final approval of the article: J.D. Childs, J.M. Fritz, T.W. Flynn, J.J. Irrgang, K.K. Johnson, G.R. Majkowski, A. Delitto.

Provision of study materials or patients: K.K. Johnson, G.R. Majkowski.

Statistical expertise: J.J. Irrgang.

Obtaining of funding: J.D. Childs, J.M. Fritz.

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