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The Agency for Health Care Policy and Research Clinical Practice Guideline for Low Back Problems concludes: Manipulation can be helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms. When findings suggest progressive or severe neurologic deficits, an appropriate diagnostic assessment to rule out serious neurologic conditions is indicated before beginning manipulation therapy. There is insufficient evidence to recommend manipulation for patients with radiculopathy. A trial of manipulation in patients without radiculopathy with symptoms longer than a month is probably safe, but efficacy is unproven.If manipulation has not resulted in symptomatic improvement that allows increased function after 1 month of treatment, manipulation therapy should be stopped and the patient reevaluated. This is based on the following types of data: (also see the recent NEJM study and editorial.)

Manipulation and mobilization of the cervical spine. A systematic review of the literature. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG, Spine 1996 Aug 1;21(15):1746-1759
RAND, Santa Monica, CA, USA.
STUDY DESIGN: Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present. OBJECTIVES: To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache. SUMMARY OF BACKGROUND DATA: Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache. METHODS: A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients' pain status. RESULTS: Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations. CONCLUSIONS: Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death.

Spinal manipulation for low-back pain. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH, Ann Intern Med 1992 Oct 1;117(7):590-598 RAND, Santa Monica, CA 90406-2138. PURPOSE: To review the use, complications, and efficacy of spinal manipulation as a treatment for low-back pain. DATA IDENTIFICATION: Articles were identified through a MEDLINE search, review of articles' bibliographies, and advice from expert orthopedists and chiropractors. STUDY SELECTION: All studies reporting use and complications of spinal manipulation and all controlled trials of the efficacy of spinal manipulation were analyzed. Fifty-eight articles, including 25 controlled trials, were retrieved. DATA ANALYSIS: Data on the use and complications of spinal manipulation were summarized. Controlled trials of efficacy were critically appraised for study quality. Data from nine studies were combined using the confidence profile method of meta-analysis to estimate the effect of spinal manipulation on patients' pain and functional outcomes. RESULTS OF DATA SYNTHESIS: Chiropractors provide most of the manipulative therapy used in the United States for patients with low-back pain. Serious complications of lumbar manipulation, including paraplegia and death, have been reported. Although the occurrence rate of these complications is unknown, it is probably low. For patients with uncomplicated, acute low-back pain, the difference in probability of recovery at 3 weeks favoring treatment with spinal manipulation is 0.17(for example, increase in recovery from 50% to 67%; 95% probability limits of estimate, 0.07 to 0.28). For patients with low-back pain and sciatic nerve irritation, the difference in probabilities of recovery at 4 weeks is 0.098 (probability limits, -0.016 to 0.209). CONCLUSIONS: Spinal manipulation is of short-term benefit in some patients, particularly those with uncomplicated, acute low-back pain. Data are insufficient concerning the efficacy of spinal manipulation for chronic low-back pain.