Current issues of ACP Journal Club are published in Annals of Internal Medicine


Chiropractic manipulation and McKenzie physiotherapy were not effective for low back pain

ACP J Club. 1999 Mar-April;130:42. doi:10.7326/ACPJC-1999-130-2-042

Source Citation

Cherkin DC, Deyo RA, BattiƩ M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998 Oct 8;339:1021-9.



In patients with low back pain (LBP), what are the relative effectiveness and cost of physical therapy, chiropractic manipulation, and education?


Randomized controlled trial with 2-year follow-up.


2 primary care clinics in Seattle, Washington, USA.


321 patients (mean age 41 y, 52% men) with LBP who were between 20 and 64 years of age and had sought care from their primary physician. Exclusion criteria were minimal pain or dysfunction within 7 days of seeing the physician, history of back surgery, sciatica, osteoporosis, vertebral fracture or dislocation, or spondylolisthesis; concurrent illness; steroid therapy; pregnancy; involvement in claims or litigation; and current physical therapy or chiropractic or osteopathic treatment. Follow-up was between 89% and 96%.


122 patients were allocated to chiropractic manipulation from 4 experienced chiropractors; manipulation included stretching and strengthening but not extension exercises. 133 patients were allocated to treatment by McKenzie Institute faculty-trained physiotherapists, were taught exercises, and received McKenzie's Treat Your Own Back book and a lumbar roll. Patients in both groups began treatment within 4 days of randomization and were allowed a maximum of 9 visits. The other 66 patients were given an educational booklet that included advice about promoting recovery and preventing recurrence.

Main outcome measures

Short-term (1-, 4-, and 12-wk) outcomes included symptoms, level of function, and disability. Long-term (1- to 2-y) outcomes included recurrence of pain and use of back-related health care. Costs of care included visits to therapists, radiography, the lumbar roll, and printed educational material.

Main results

At 4 weeks, the chiropractic group had less severe symptoms than the education groups (P = 0.02). The groups did not differ for symptoms at 12 weeks, days of reduced activity, missed work, need for bed rest, or recurrence of LBP. The 2-year cumulative costs were U.S. $437, $429, and $153 for the physical therapy, chiropractic, and education groups, respectively.


Except for differences in the extent of bothersome symptoms at 4 weeks, chiropractic manipulation and the McKenzie physical therapy approach did not reduce short- or long-term pain or improve function in patients with low back pain. Both treatments were more expensive than an education intervention.

Source of funding: U.S. Agency for Health Care Policy and Research.

For correspondence: Dr. D.C. Cherkin, Group Health Center for Health Studies, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, USA. FAX 206-287-2871.


LBP is among the most common musculoskeletal conditions. Although many patients use self-care for episodes of acute pain, others seek professional attention for symptom relief, pain control, and more rapid return to function. In North America, chiropractors and physical therapists offer the main alternatives to physician-based care, and doctors of osteopathy provide another option. In this well-designed, randomized trial, Cherkin and colleagues compared the relative effectiveness and costs of the McKenzie method of physical therapy, chiropractic manipulation, and an educational booklet. The management approaches used in the study were appropriate. Heat, cold, ultrasonography, electrical stimulation, and other common methods of largely unproven effectiveness (other than transient relief ) (1) were not included in either regimen.

The findings of minimal differences among the 3 groups can guide patient management by clinicians and health care systems. This research does not support manual or physical therapy as preferred primary interventions for acute LBP. However, neither approach seems to be harmful (and may result in improved general satisfaction) in patients who actively seek such care. The minimal benefit accruing to manual therapy in this paper is consistent with the results of previous clinical trials and cohort studies (2, 3). Even meta-analyses have shown only modest benefits (4).

The question for insurers is, of course, whether to offer manual or physical therapy as part of a preferred disease management approach or as a covered service option for acute LBP. Is improved satisfaction worth an additional several hundred dollars per patient? Are resources better spent on patients with spinal disease who might receive more benefit? The answers to these questions may depend on society's ability to financially support our open-ended health care system.

Timothy S. Carey, MD, MPH
University of North CarolinaChapel Hill, North Carolina, USA


1. Agency for Health Care Policy and Research. Acute Low Back Pain in Adults. Clinical Practice Guideline #14. U.S. Dept. of Health and Human Services. 1994. AHCPR Publication No. 95-0642.

2. Koes BW, Bouter LM, van Mameren H, et al. The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints. A randomized clinical trial. Spine. 1992;17:28-35.

3. Carey TS, Garrett J, Jackman A, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. N Engl J Med. 1995;333:913-7.

4. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low back pain. Ann Intern Med. 1992;117:590-8.