A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study.
BACKGROUND
Conflicting evidence exists about the effectiveness of spinal manipulation.


OBJECTIVE
To validate a manipulation clinical prediction rule.


METHODS
Multicenter randomized, controlled trial.


METHODS
Physical therapy clinics.


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


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


METHODS
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).


CONCLUSIONS
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.
Childs
John D
JD
Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas, USA. childsjd@sbcglobal.net
Fritz
Julie M
JM
Flynn
Timothy W
TW
Irrgang
James J
JJ
Johnson
Kevin K
KK
Majkowski
Guy R
GR
Delitto
Anthony
A
D000293:Adolescent; D000328:Adult; D003131:Combined Modality Therapy; D004185:Disability Evaluation; D005081:Exercise Therapy; D005260:Female; D006801:Humans; D017116:Low Back Pain / Q000145:classification* / Q000628:therapy*; D008297:Male; D020393:Manipulation, Spinal; D008875:Middle Aged; D013223:Statistics as Topic; D011795:Surveys and Questionnaires