Clinical Scenarios for Which Spinal Mobilization and Manipulation Are Considered by an Expert Panel to Be Inappropriate (and Appropriate) for Patients With Chronic Low Back Pain

Published in: Medical Care, Volume 57, Issue 5, pages 391-398 (May 2019). doi: 10.1097/MLR.0000000000001108

Posted on on June 10, 2019

by Patricia M. Herman, Eric Hurwitz, Paul G. Shekelle, Margaret D. Whitley, Ian D. Coulter

Read More

Access further information on this document at Medical Care

This article was published outside of RAND. The full text of the article can be found at the link above.


Spinal mobilization and manipulation are 2 therapies found to be generally safe and effective for chronic low back pain (CLBP). However, the question remains whether they are appropriate for all CLBP patients.

Research Design

An expert panel used a well-validated approach, including an evidence synthesis and clinical acumen, to develop and then rate the appropriateness of the use of spinal mobilization and manipulation across an exhaustive list of clinical scenarios which could present for CLBP. Decision tree analysis (DTA) was used to identify the key patient characteristics that affected the ratings.


Nine hundred clinical scenarios were defined and then rated by a 9-member expert panel as to the appropriateness of spinal mobilization and manipulation. Across clinical scenarios more were rated appropriate than inappropriate. However, the number patients presenting with each scenario is not yet known. Nevertheless, DTA indicates that all clinical scenarios that included major neurological findings, and some others involving imaging findings of central herniated nucleus pulposus, spinal stenosis, or free fragments, were rated as inappropriate for both spinal mobilization and manipulation. DTA also identified the absence of these imaging findings and no previous laminectomy as the most important patient characteristics in predicting ratings of appropriate.


A well-validated expert panel-based approach was used to develop and then rate the appropriateness of the use of spinal mobilization and manipulation across the clinical scenarios which could present for CLBP. Information on the clinical scenarios for which these therapies are inappropriate should be added to clinical guidelines for CLBP.

Research conducted by

This report is part of the RAND Corporation External publication series. Many RAND studies are published in peer-reviewed scholarly journals, as chapters in commercial books, or as documents published by other organizations.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.