title: Dose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial.
abstract: BACKGROUND
  There have been no full-scale trials of the optimal number of visits for the care of any condition with spinal manipulation.
  
  
  OBJECTIVE
  To identify the dose-response relationship between visits to a chiropractor for spinal manipulation and chronic low back pain (cLBP) outcomes and to determine the efficacy of manipulation by comparison with a light massage control.
  
  
  METHODS
  Practice-based randomized controlled trial.
  
  
  METHODS
  Four hundred participants with cLBP.
  
  
  METHODS
  The primary cLBP outcomes were the 100-point modified Von Korff pain intensity and functional disability scales evaluated at the 12- and 24-week primary end points. Secondary outcomes included days with pain and functional disability, pain unpleasantness, global perceived improvement, medication use, and general health status.
  
  
  METHODS
  One hundred participants with cLBP were randomized to each of four dose levels of care: 0, 6, 12, or 18 sessions of spinal manipulation from a chiropractor. Participants were treated three times per week for 6 weeks. At sessions when manipulation was not assigned, they received a focused light massage control. Covariate-adjusted linear dose effects and comparisons with the no-manipulation control group were evaluated at 6, 12, 18, 24, 39, and 52 weeks.
  
  
  RESULTS
  For the primary outcomes, mean pain and disability improvement in the manipulation groups were 20 points by 12 weeks and sustainable to 52 weeks. Linear dose-response effects were small, reaching about two points per six manipulation sessions at 12 and 52 weeks for both variables (p<.025). At 12 weeks, the greatest differences from the no-manipulation control were found for 12 sessions (8.6 pain and 7.6 disability points, p<.025); at 24 weeks, differences were negligible; and at 52 weeks, the greatest group differences were seen for 18 visits (5.9 pain and 8.8 disability points, p<.025).
  
  
  CONCLUSIONS
  The number of spinal manipulation visits had modest effects on cLBP outcomes above those of 18 hands-on visits to a chiropractor. Overall, 12 visits yielded the most favorable results but was not well distinguished from other dose levels.
authors.affiliation: Center for Outcomes Studies, University of Western States, 2700 NE 132nd Ave., Portland, OR 97230, USA. Electronic address: haasmitch@comcast.net.
authors.forename: Mitchell
authors.initials: M
authors.lastname: Haas
authors.affiliation: Center for Outcomes Studies, University of Western States, 2700 NE 132nd Ave., Portland, OR 97230, USA.
authors.forename: Darcy
authors.initials: D
authors.lastname: Vavrek
authors.affiliation: Division of Chiropractic Sciences, University of Western States, 2700 NE 132nd Ave., Portland, OR 97230, USA.
authors.forename: David
authors.initials: D
authors.lastname: Peterson
authors.affiliation: The Mountain-Whisper-Light Statistics, 1827 23rd Ave. E., Seattle, WA 98122, USA.
authors.forename: Nayak
authors.initials: N
authors.lastname: Polissar
authors.affiliation: The Mountain-Whisper-Light Statistics, 1827 23rd Ave. E., Seattle, WA 98122, USA.
authors.forename: Moni B
authors.initials: MB
authors.lastname: Neradilek
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D017116:Low Back Pain / Q000628:therapy*; D008297:Male; D020393:Manipulation, Spinal / Q000379:methods*; D008875:Middle Aged; D016896:Treatment Outcome
keywords: Chiropractic; Chronic low back pain; Dose-response; Randomized controlled trial; Spinal manipulation