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Panel findings and recommendations: 
 -   Manipulation can be helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms. (Strength of Evidence = B.) 
 -   When findings suggest progressive or severe neurologic deficits, an appropriate diagnostic assessment to rule out serious neurologic conditions is indicated before beginning manipulation therapy. (Strength of Evidence = D.) 
 -   There is insufficient evidence to recommend manipulation for patients with radiculopathy.  (Strength of Evidence = C.) 
 -   A trial of manipulation in patients without radiculopathy with symptoms longer than a month is probably safe, but efficacy is unproven. (Strength of Evidence = C.) 
 -   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. (Strength of Evidence = D.)  
  Spinal manipulation includes many different techniques.  For this guideline, manipulation is defined as manual therapy in which loads are applied to the spine using short or long lever methods.  The selected jointis moved to its end range of voluntary motion, followed by application of an impulse loading.  The therapeutic objectives of manipulation include symptomatic relief and functional improvement.   
Spinal Manipulation 
Literature Reviewed     Evidence on Efficacy   Potential Harms and Costs      Summary of Findings     Author's Example 
Spinal Manipulation 
  Literature Reviewed.  Of the 112 articles screened for this topic, 13 reporting on 12 RCTs met criteria for review.72, 85, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140 
  The panel also considered recent meta-analyses and cost analyses141, 142, 143, 144  In addition, the panel used information from articles that did not meet selection criteria.145,146,147,148,149 
  Evidence on Efficacy.    The meta-analysis by Shekelle, Adams, Chassin, et al. 144 was based on 29 controlled trials of manipulation for low back problems.  Nine of the studies used in the meta-analysis focused on patients with acute low back problems and tested the effect of manipulation against sham manipulation136 or various other conservative treatments.72, 132, 135, 137,138,140, 145,149 
  Of those RCTs that evaluated manipulation in patients with acute low back pain, the two highest quality studies used similar research designs. 136, 137  Both these studies randomly assigned patients to either a group receiving manipulation or a nontreatment control group, with patients stratified by whether symptoms had lasted less than 14 days, 14 to 28 days, or over 28 days in one study.137  For patients with 14 to 28 days of symptoms, both studies found the manipulation groups had statistically significant improvement in pain relief and functioning compared with the control groups.  However, this effect was only seen within the first 2 weks after starting treatment.  For patients with symptoms of less than 14 days or over 28 days, no differences in improvement were found between the manipulation and control groups for any followup times. 
  A meta-analysis of the remaining seven studies also showed statistically significant short-term effects of manipulation in hastening recovery from low back problems. 144  Another meta-analysis, based on 23 randomized controlled trials of manipulation or mobilization, came to a similar conclusion.141  This analysis indicated that, in patients with acute low back problems without radiculopathy, manipulation reduces pain and has positive short-term impact on daily functioning.  Most studies have concentrated upon outcomes assessed within the first month of care. 
  The meta-analysis by Shekelle, Adams, Chassin, et al.144 analyzed,in addition, studies of spinal manipulation in patient groups who had predominantly chronic low back problems, a mix of acute and chronic low back problems, or pain of undetermined duration.  Studies of manipulation in these groups had conflicting results concerning the efficacy of manipulation. 
  Shekelle, Adams, Chassin, et al.141 also analyzed three studies on the use of spinal manipulation for patients with low back problems who had radiculopathy, but concluded that the evidence was insufficient to 
demonstrate efficacy. 132, 146, 148 
  Potential Harms and Costs.  Shekelle, Adams, Chassin, et al.144 described published case reports of patients presenting with sciatica who had increasing neurologic deterioration following manipulation, but estimated that the risk of serious complications from lumbar spinal manipulation is small and may vary with the clinical condition with which the patient presents.  No systematic report of frequency of complications from spinal manipulative therapy has been published.  Mandell, Lipton, Bernstein, et al.147 listed autonomic disturbances such as faintness, perspiration, and hyperventilation as common short-term reactions to manipulation.  The total cost of manipulative therapy is determined by the frequency and duration of care. 
  Summary of Findings.  The evidence for effectiveness of manipulation varies depending on the duration and nature of the patient's presenting symptoms.  For patients with low back symptoms without radiculopathy, the scientific evidence suggests spinal manipulation is effective in reducing pain and perhaps speeding recovery within the first month of symptoms.  For patients whose low back problems persist beyond 1 month, the scientific evidence on effectiveness of manipulation was found to be inconclusive.  For patients with radiculopathy, the scientific evidence was also inconclusive about either the effectiveness or the potential harms of manipulation.  Finally, the panel offered the opinion that, for patients with low back problems and findings of possible progressive or severe neurologic deficits, assessment to rule out serious neurologic conditions is indicated before initiating manipulation therapy. 
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