Determining the Appropriateness of Spinal Manipulation and Mobilization for Chronic Low Back Pain

Indications and Ratings by a Multidisciplinary Expert Panel

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

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Research Questions

  1. What is the methodology of the process used to obtain appropriateness ratings?
  2. What is the list of actual indications used in this study?
  3. Did ratings of appropriateness change between rounds? Did agreement or disagreement go up after panelists met face to face?
  4. What were the final ratings of the appropriateness of manipulation and mobilization?

The approach developed by researchers at the RAND Corporation for assessing the appropriateness of health care makes it feasible to take the best of what is known from research and apply it — using the expertise of experienced clinicians — over the wide range of patients and health problems seen in real-world clinical practice. The major limitation of the RAND approach is that it utilizes a limited definition of appropriateness that relies heavily on safety, efficacy, and effectiveness. This report, which focuses on appropriateness of indications for spinal manipulation and mobilization for chronic low back pain, presents results from one part of a broader study designed to develop a methodology to integrate patient-reported outcomes, patient preferences, and costs into the appropriateness panel process. It describes the results and methodology of convened panels of back pain experts who met to discuss and rate appropriateness of 450 indications for spinal manipulation and mobilization for chronic low back pain. It serves four objectives: (1) Describe the methodology of the process of obtaining appropriateness ratings that can be used later to calculate rates of appropriate care and can be replicated by other studies; (2) provide the list of actual indications used in this study so that future studies can use them or adapt them without going through the extensive and costly process we did; (3) provide further data on the modified Delphi process for generating consensus by exploring whether ratings of appropriateness changed between rounds and whether agreement or disagreement went up after panelists met face to face; and (4) present final ratings of the appropriateness of manipulation and mobilization for low back pain for 450 indications.

Key Findings

The methodology involved a literature review and panel assessments.

  • To determine the appropriateness of manipulation and mobilization for chronic low back pain, we convened a nine-member modified-Delphi panel of clinicians.
  • The initial ratings of appropriateness were made individually and without group discussion.
  • The second-round ratings followed a structured face-to-face method that was based on procedures often used to bring people closer to consensus or agreement.
  • The project staff compiled the initial indications list using a literature review, the advice of chiropractors and an internist, and a list of indications created for an earlier study on manipulation for low back pain.

The panel rated 450 indications to assess the appropriateness of manipulation and mobilization for chronic low back pain.

  • There was agreement among the panelists for 17.8 percent to 29.8 percent of indications.
  • The average median appropriateness ratings ranged from 5.2 to 5.5 on a nine-point scale, and 15.3 percent to 24.3 percent of indications were rated appropriate.
  • Appropriateness ratings for mobilization were higher than the ratings for manipulation.
  • Appropriateness ratings for either treatment were higher assuming nonmanipulative conservative care has failed than when no other adequate conservative care has been given.
  • Most findings were equivocal; i.e., raters were split on the appropriateness of the measures described.
  • Rates of agreement increased after panelists met to discuss the issues.

Table of Contents

  • Chapter One


  • Chapter Two


  • Chapter Three


  • Chapter Four


  • Appendix A

    Definitions Provided to Panelists

  • Appendix B

    Final Panel Ratings of Indications, by Chapter

The research described in this report was funded by by a cooperative agreement from the National Center for Complementary and Integrative Health and conducted through a joint undertaking of RAND Health; the University of California, Los Angeles; and the Samueli Institute.

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