GROUND-BREAKING NEW STUDY… Mobilization and Manipulation are EQUALLY EFFECTIVE and produce the SAME OUTCOMES in Mechanical LBP

By: Chris Showalter PT, OCS, COMT, FAAOMPT
Full Disclosure: This month’s Research Commentary discusses a peer reviewed research article co-authored by MAPS Research Consultant Chad Cook and MAPS Senior Faculty Members Ken Learman, Chris Showalter, Vincent Kabbaz and Bryan O’Halloran. The synopsis and link to Manual Therapy are found below. The full article will be available in an upcoming issue of Manual Therapy
Prior studies have proclaimed the early use of Thrust Manipulation (TM) in Acute Low Back Pain (LBP) as TM has been suggested to improved outcomes and provide quicker recovery. To our knowledge only two prior studies have directly compared TM to Mobilization, also known as Non Thrust Manipulation (NTM) (Hadler et al, 1987 and Cleland et al, 2009). These studies both concluded that TM was superior to NTM.
Contrary to the Hadler and Cleland studies, our results find NO DIFFERENCES between TM and NTM. We discuss potential reasons for these different results in detail in the complete article…

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All Comments

  • Nice post Joe. Chris Showalter offered me my first position when I was interested in coming to NYC but things fortunately (and unfortunately) did not work out. Too many clinicians get hooked on the whole cavitation bit and oftentimes it’s better to go most conservative to least conservative. Look forward to reading the full article when it’s published. WIll try to see if the epub is already online…thanks for sharing!!!

    Chris Johnson October 10, 2012 3:54 pm Reply
  • Thanks for the early share, Joe. Great info.

    Nick Nordtvedt, PT (@nicktnpt) October 10, 2012 4:26 pm Reply
  • I agree with Chris. I focus on soft tissue, and address weak and tight structures through therex and stretches with grade 1-3 mobs to start. If hypomobile segment does not respond I can always manip later but that rarely is necessary – my experience.
    Looking forward to the article to come out for full read. This is a favorite topic of research for Cook

    David Gerstel October 11, 2012 10:10 am Reply
  • Thanks for sharing tis Joe. Looking forward to reading the article. I like how it was a pragmatic design. I do perform both Thrust and Non thrust and I truly believe your outcomes will depend on the presentation in front of you. I hope to get the article from my current intern (as I don’t have access to Manual Therapy) and write a tidbit on my blog.

    Harrison Vaughan October 11, 2012 11:49 am Reply
  • The title of this post seems a bit misleading…without more info. Current evidence would suggest acute mechanical LBP is a homgenous enitity. As many on this forum probably know, TM has been advocated by some for a specific subgroup of patients with acute low back pain, a la the CPR. Based on the abstract, it does not appear that the subjects presented positive on the CPR for low back pain. If this is the case, this is a different group of subjects than in the Cleland study (2009). If the subjects did meet the CPR, this article would surely be ground-breaking (given the significant interest in the CPR for low back pain since 2004). If not, TM may be more effective than NTM for those who meet the CPR for low back pain (Cleland 2009). Certainly, there was a methodological issue with the Cleland study in comparing a central posterior to anterior NTM to a sidelying-rotational thrust manipulation…Perhaps Chris or someone with access to the in press article could enlighten? Excited to get my hands on this study.

    Travis Gunderson October 12, 2012 12:40 am Reply
    • Hi Travis
      You are correct, it is inappropriate to compare outcomes in two different trials that have two very different designs. Indeed our study (Cook et al.) and the Cleland et al., (and Hadler’s for that matter) are very dissimilar. We did capture whether or not one met the CPR was associated with an outcome within our study. Our recent paper published in PTJ discusses the outcomes for those who met the CPR, regardless if they received manip or mob, and in all cases, those who met the rule were more likely to improve. This suggests the rule is partly prognostic (which it is; others have identified that) and it is certainly prescriptive when compared to the use of benign exercises or the type of mob that was used prescriptively in Josh’s study. We hope to publish these results in the future; but are certain we’ll encounter some challenges along the way. We’ve reported on this at the recent OPTA conference and discusses this as well at IFOMPT. When mob was used pragmatically (similar to how clinicians use it in actual clinical practice) there was no difference for those who met the CPR. This does not seem to be a surprise to very skilled clinicians who use both effectively in clinical practice but it is a surprise to many; some of whom have had a visceral response to the finding. It might be worth discussing in this blog why our findings are different. I think there are many reasons.

      Chad Cook October 16, 2012 8:09 pm
    • Thanks for the reply, Chad. Very interesting, indeed, that patients improved with “pragmatic” use of mob, or manip when meeting the CPR. Without reading the entire study, it would mostly be uneducated guessing as to why the findings were different. Ill give some thoughts anyway though. Controlling for provider (and patient) bias with regard to treatment technique of choice is a novel concept in OMPT research (oh, to be able to double blind in manual therapy…sigh). Given the researchers’ background, Cleland’s study may have been subject to this sort of bias, impacting the results. Im assuming that the “pragmatic” approach refers to the Maitland concept of clinical reasoning…these therapists were allowed to use the subjective examination, and re-assessment to influence treatment technique? (if so this seems like a very difficult design to undertake). As you say, this lends to a bit more external validity compared to the other studies. Perhaps having the ability to judge concepts such as irritability are important when performing mobilization…having this latitude could result in a better outcome, as opposed to a standardized mob.
      (correction, lbp is a heterogenous entity**)

      Travis Gunderson October 18, 2012 11:29 pm
    • Travis
      I agree with you. Our design was similar in nature to Leaver et al’s pragmatic trial that compared neck mob to manip (Archives). We were actually motivated to perform a LB trial using a similar design since we wanted to see whether mobs did as poorly as Cleland et al., found when clinicians were allowed to use a mob they did in clinical practice. We powered the study under the assumption that manip would beat mob (effect size of 0.30) but did not find this to be the case. All the clinicians used the same philosophy during the care process thus we measured this “process” versus a prescriptive use of techniques. We state this in the paper too. Consequently, the process of applying a non-thrust procedure was similar to the process of applying a thrust procedure. Also, other interventions were allowed after 2 visits (again simulating clinical practice). The design is very different than Josh’s. His has greater internal validity, ours has better external validity. We can’t say a particular technique is better because that’s not what our study investigated.

      Chad Cook October 19, 2012 10:13 am
  • I think this study and the current “CPR’s” in PT illustrate more about prognosis and mechanisms of our treatment interventions than WHAT treatment a patient should receive. Manual therapy, as Jason Silvernail has stated, is a process, not a product. Our mechanism’s are not nearly as specific as we once postulated, likely do no permanently change connective tissue in any meaningful way, and are almost exclusively neuro-physiologic mediated (which includes psychosocial variables like placebo, expectation, novelty). Know your biomechanics, but recognize the MASSIVE limitations of that model. Apply your manual therapy in a specific, hypotheses oriented fashion, but recognize that the treatment targets and affects/effects are not specific.
    Our words are important conceptually, and maybe more so, in what we tell our patients.
    Will studies like this finally push us to pursue a deeper model of understanding and treatment? That seeks to truly understand the complex and multi multi multi factorial pain experience?

    kridgeway October 18, 2012 1:01 am Reply
    • Am I reading you wrong here, Kyle? Outcomes-based RCT’s really dont illustrate mechanisms of effect. To the contrary, they illustrate WHAT treatment a patient COULD receive.
      Overall agree with the rest, I nor any manual therapist has ever changed any CT with our hands.
      Research in OMPT seems a bit backwards…On one hand our profession is developing research methods (CPR’s, linear regressions) that are relatively evloved in terms of clinical medicine (think CDR for MI, OAR/OKR etc), which essentially use a computer to do part of the reasoning in developing a treatment (or diagnosis)…and on the other hand we have relatively little idea as to why these same treatments may work.

      Travis Gunderson October 18, 2012 11:49 pm
    • Travis,
      Thanks for inquiry, and pushing me to clarify myself! You are absolutely correct Travis, RCT’s can never truly inform us about mechanisms, but they can provide some insight on potential mechanisms. Also, with a better understanding to the most plausible mechanisms, these trials make more sense. In my opinion, research that is done without a very focused effort to construct a realistic deep model and theory is potential dangerous for our profession, especially in manual therapy. Knowing how non-specific the effects of manual therapy are, comparing two separate techniques or interventions alone (while from a research construction stand point makes sense) does not appear to be the best approach. We need to focus on process validation not comparisons of products vs products.
      Knowing this, would we ever expect one manual therapy technique to be found truly and robustly superior to another? Or, is the success more dependent on the process that the specific technique is applied within as well as boat loads of other messy concepts like placebo effects, patient and practitioner expectation, environment, context, patient-therapist interaction, and therapeutic alliance? That is why this trial is important. Not for the results, but for the how it was constructed. It was not merely the application of techniques for comparison.
      It is a sticky situation, because we are designing RCT’s based on other RCT’s based on clinical expertise that is usually absent of a true deep model of treatment effect, and maybe more importantly the multi-factorial nature of the individual pain experience. I think if we dig into the practice and research of thrust joint manipulation, we can see this quite clearly.
      Science Based Medicine puts it best….
      “Good science is the best and only way to determine which treatments and products are truly safe and effective. That idea is already formalized in a movement known as evidence-based medicine (EBM). EBM is a vital and positive influence on the practice of medicine, but it has limitations and problems in practice: it often overemphasizes the value of evidence from clinical trials alone, with some unintended consequences, such as taxpayer dollars spent on “more research” of questionable value. The idea of SBM is not to compete with EBM, but a call to enhance it with a broader view: to answer the question “what works?” we must give more importance to our cumulative scientific knowledge from all relevant disciplines.”
      I think it was actually Chad Cook that once stated “Remember, the evidence hierarchy is sorted by rigor, not relevance.” Your point about OMPT research being backwards is spot on. The more we investigate mechanisms of treatment and sharpen our understanding of pain, the more we realize that it is not the method that is the trick. (
      It a CPR or CDR came out that identified a priori patient’s that had a positive outcome when treated with Reiki or Craniosacral Therapy would you be inclined to use these treatments or constructs or refer patients who met a certain criteria to those specific practioners?
      Clinical prediction rules or decision rules are likely better served in aiding in essential diagnoses and treatment of essential diagnoses, especially in populations and diagnoses that are exceedingly complex, and exceedingly prone to human cognitive biases in the diagnostic process. Nominal, non-specific, or even non-existent diagnoses are the norm of the PT, outpatient, and pain world. While CPR’s may prove relevant in the guidance of treatment or determination of prognosis, they are probably better utilized in medical screening and differential diagnosis.

      kridgeway October 19, 2012 12:29 am
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  • I posted this as a comment to a student a while back, but thought it would also be applicable here:
    Randomized control trials do not need to the basis of your entire practice!! But, your practice should be based on the philosophy of science including concepts of prior plausibility and strong logic. Thus, when RCT’s exist, are well designed, and in line with good logic we should absolutely implement their results within the broader context of physiology, basic science, and other published literature. However, RCT’s are tough in such a multi-modal profession such as physical therapy. In addition, RCT’s for the non-pharmacologic treatment of painful problems can be difficult to truly analyze given the effects of patient expectation, PT expectation, placebo response, and the difficulty in designing a realistic comparison group. True scientific “control” is difficulty, if not impossible. A study examining the effect of spinal manipulation on pressure pain thresholds/hypoalgesia in healthy volunteers is an interesting example of this:
    I quote “A significant increase in pain perception occurred following SMT in the low back of participants receiving negative expectation suggesting a potential influence of expectation on SMT induced hypoalgesia in the body area to which the expectation is directed.”
    If an RCT illustrated that craniosacral therapy was more effective than nothing (or “placebo”) in treating neck pain should we utilize craniosacral therapy in practice? NO, because the THEORY of application and assessment makes no sense. What does that hypothetical RCT REALLY tell us? That gently touching patients in pain and telling them a not true story may be beneficial. This post explains that concept in more detail:
    So, where does that leave us? We must be guided by a strong understanding of logic, cognitive biases, and a DEEP model of the mechanisms of our client’s complaints (many times involves pain) as well as our techniques or approaches. Essentially, strong scientific, inquiring, SKEPTICAL minds. Jason Silvernail does an excellent job discussing some of these issues in his post EBP, Deep Models, and Scientific Reasoning over at the Evidence in Motion Blog:
    Lastly, although not directly about physical therapy the blog Science Based Medicine has some fantastic resources and discussions surrounding this issue: I would suggest starting with:

    Kyle Ridgeway (@Dr_Ridge_DPT) December 21, 2012 12:52 am Reply
    Which prognostic factors for low back pain are generic predictors of outcome across a range of recovery domains?
    Meeting the clinical prediction rule for manipulation was prognostic in all 4 models utilized in the study. Thus, as mentioned above, meeting the CPR does not necessarily mean that person NEEDS manipulation, but rather they likely have an excellent prognosis.

    kridgeway February 15, 2013 9:56 am Reply
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