JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015

www.jmscr.igmpublication.org Impact Factor 3.79

ISSN (e)-2347-176x

Efficacy of Spinal Manipulation as a Part of Physical Therapy Program in

Patients with Lumbar Disc Herniation: A Randomized Controlled Trial
Authors
Neveen Abdel Latif Abdel Raoof , Nevein Mohammed Mohammed Gharib2
1

Sahar Mohammed Adel1

1
Department of Basic Science, Faculty of Physical Therapy, Cairo University, Giza, Egypt
2
Physical Therapy Department for Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy,
Cairo University, Giza, Egypt
Corresponding Author
Sahar Mohammed Adel
Department of Basic Science, Faculty of Physical Therapy, Cairo University, Giza, Egypt
Email: smadel@pnu.edu.sa
Abstract
Objective: To investigate the effect of a combined spinal manipulation plus physical therapy program on pain
intensity, physical function and asymmetry of lumbar facet angles in patients with lumbar disc herniation.
Methods: This was a single blinded randomized controlled study design. Thirty patients with lumbar disc
herniation from both sexes and aged between 20 – 45 years participated in the study. They were randomly
divided into two groups of equal number; experimental and control groups. Patients in the experimental group
received a designed physical therapy program in addition to lumbar manipulation techniques applied to L4-L5
level. Those in the control group received the same physical therapy program only. Treatment was given three
days/ week for continuous four weeks. Assessment was performed before and after treatment using Visual
analogue scale (VAS), Modified Oswestry low back pain disability questionnaire (ODQ) and facet joint angle
asymmetry.
Results: Patients in the experimental group showed a significant improvement as compared with those in the
control group. Pain intensity was 3.6±0.91 for the experimental group and 4.9±1.33 for the control group
(P=0.002). Physical function measured by Oswestry disability questionnaire was 28.76±7.3 for the
experimental group and 35.48±9.2 for the control group (p=0.007). There was a significant improvement in the
asymmetry of facet angles between both sides in both groups (in favour of the experimental group).
Conclusions: Spinal manipulation combined with proper physiotherapy program has an objective effect on
pain, physical function and asymmetry of lumbar facet angles in patients with lumbar disc herniation.
Keywords: Lumbar disc herniation; Spinal manipulation; Pain; Physical function; Facet angles asymmetry.

Introduction and/or leg pain[1]. The prevalence of symptomatic

Lumbar disc herniation (LDH) is one of most lumbar herniated discs ranges from 1% to 3%
common diseases that produces low back pain along lifetime[2], although LDH is anatomically

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5768
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
evident in 20% to 40% of imaging tests among Therefore, the purpose of this study was to
[3]
asymptomatic persons . The highest prevalence investigate the benefit, if any, of additional spinal
is among those aged between 30 and 50 years but manipulation as opposed to traditional physical
[4]
can also occur in adolescents and older people . therapy program in patients with symptomatic
Several studies reported that patients with LDH LDH, expressed in terms of pain intensity,
also exhibited signs of asymmetry of facet joint physical function and asymmetry of facet angles
angles (facet tropism)[5,6]. This combination is also at L4-L5 level.
considered as a common radiological feature of
herniation of the lumbar discs[7]. Facet tropism Subjects and methods
increases shear forces, making it a potential risk Subjects
factor for early degeneration and herniation of the Thirty patients, 17 females and 13 males with
corresponding disc[8]. lumbar disc herniation at L4-L5 level were
Many therapeutic interventions are used for recruited from the neurological physical therapy
management of LDH but the results are outpatient clinic of the faculty of Physical
conflicting[9]. Spinal manipulations are commonly Therapy, Cairo University, Egypt after research
used for treatment of LDH[10]. The benefits and ethics board (REB) approval from the Faculty of
hazards of this intervention are not known; Physical Therapy. Their ages ranged between 20
however, some researchers recommended its use and 45 years and their body mass index ranged
in cases of LDH, even after failure of other from 20-25 Kg/m². Their CT or MRI confirmed
modalities[11,12]. The current body of evidence the diagnosis.
suggests spinal manipulation as a method of To be eligible for inclusion; each participant had
improving pain, range of motion[13], loosening of to report chronic low back pain of at least 3
adhesive fibrosis around the prolapsed discs or months’ duration; with or without radicular pain
facet joints and entrapped synovial folds, in the lower limb and to be currently seeking care
adjusting disc displacement, inhibiting nociceptive for low back pain. The exclusion criteria were: 1)
impulses and relaxing spasmodic muscles spinal pathology (e.g., spondylolisthesis, tumor,
[9]
.However, there are no studies that have infection, fracture), 2) pregnancy, diabetic
evaluated the efficacy of spinal manipulation on neuropathy, previous spinal surgery, 3) herniated
facet joint asymmetry with respect to cases of disc classified as extrusion or sequestration, 4)
LDH. Some studies reported that spinal history of osteoporosis and metabolic disease
manipulation can cause disc herniations and cauda causing osteopenia, 5) previous treatment with
equina syndrome[14,15]. Results are also conflicting spinal manipulation to exclude possible blinding
for chronic spinal pain[16-17]. These contradictory failure and 6) refusal to give written informed
results might be partially attributed to variation in consent.
[18]
study design and poor methodological quality .

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5769
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
The patients were randomly assigned into two having an affective radiating area of 5.0cm2. Gel
equal groups; experimental and control groups was used as a coupling medium.
with 15 patients in each by using computer
generated lists[9]. Patients in both groups received Procedures
traditional physical therapy program for three The study was a single blind randomized
days/week for successive four weeks which controlled trial with two measures; pre treatment
consisted of the application of infrared radiation, and post treatment (after four weeks from the start
therapeutic ultrasound and a designed exercise of the treatment program).
program for lumbar spine. Patients in the
experimental group received additional lumbar Outcome measures
manipulation techniques applied to L4-L5 level Pain intensity was assessed by using visual
for three days/week for successive four weeks[19]. analogue scale (VAS). Self report of physical
After explaining the experimental protocol to the function was assessed by using modified
participants, those participants who volunteered to Oswestry low back pain disability questionnaire
be in the study signed informed consents prior to (ODQ) and the asymmetry of lumbar facet angle
beginning data collection. at L4-L5 level was evaluated by CT.
- Visual analogue scale (VAS) was used to
Instrumentations measure pain intensity pre and post treatment for
For assessment: The asymmetry of facet angle in each patient. VAS is a self reported pain
lumbar spine (facet joint tropism) at L4-L5 level assessment tool that requires the subject to place
was evaluated by computerized axial tomography an X on a 10 cm long straight line with stops on
(CT) of lumbar spine. It is the method of choice each end. The left stop corresponds to ‘‘no pain’’,
for evaluation of lumbar region dysfunctions and and the right stop to ‘‘unbearable pain’’ [21].
it can easily measure the asymmetry of facet angle Modified Oswestry low back pain disability
[20]
in this region . questionnaire (ODQ): This questionnaire gives
information as to how back or leg pain is affecting
For treatment: the ability to manage in everyday life. The
- Infra red radiation (IRR) device: Non-luminous questionnaire consists of 10 items addressing
infrared generators, emitting long IRR around different aspects of function including pain
3000-4000 nm. intensity, personal care, lifting, walking, sitting,
- Ultrasound (US) Device: Enraf Nonius- standing, sleeping, social life, travelling and
Sonoplus 590 is a microprocessor controlled unit employment/ Homemaking. Each item is scored
for continuous and pulsed US therapy. This from 0 to 5, with higher values representing
apparatus allows 1MHz frequency with transducer greater disability. Each patient was instructed to
choose the most suitable answer that represents

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5770
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
his/her level of function. If the first statement is facets. The midsagittal line passed through the
marked, the section score = zero. If the last centre of the disc (O) and the centre of the base of
statement is marked the section score = 5. ODQ the spinous process. The angle between the facet
was reported to be reliable and had sufficient line and the midsagittal line was measured for
width scale to detect the progression or regression each side of the spine. The difference of the right
in most subjects with low back pain. The total and left facet angles (a-b) of each patient was then
score is multiplied by 2 and expressed as a calculated.
[22]
percentage .
Treatment Procedures:
Measuring procedures of facet joint angle by All patients in both groups received traditional
CT: physical therapy program in the form of infrared
The lumbar facet angles at L4-L5 level were radiation (for 20 minutes) followed by ultrasound
[7]
measured using the method of Karacan et al by therapy. For each patient, ultrasound was applied
an independent radiologist who did not know the at the lower back with a frequency of 1 MHz, in a
aim of the study. A line was drawn between the continuous mode and 0.5 W/cm² for five minutes
two edges of each of the superior articular facets. using moving head technique. This was followed
A mid-sagittal line was drawn passing through the by exercise program in the form of massage,
centre of the disc and the centre of the base of the stretching exercises for back muscles to improve
spinous process. The facet joint angle was defined mobility and decrease muscle spasm and to
as the angle between the facet line and the mid- hamstrings to decrease posterior pelvic tilt, and
sagittal line and it was measured bilaterally and back exercises in the form of static, bridging and
the difference between the two sides was then active exercises from standing and prone
[24]
calculated (Fig. 1). It was reported that this positions. Finally, core stabilization exercises
method of measurement has good intra observer were also given in the form of quadruped, bridge
[23]
and inter observer reliability . and plank (side and prone) progressions aiming to
activation of transverses abdominus and multifidi
coordinated with hip musculature. The exercise
program was applied for 45 minutes within the
pain free range.
Patients in the experimental group received
additional lumbar manipulation techniques in the
form of: indirect rotation, postro-anterior central

Fig. 1: Measurement of facet tropism, quoted pressure and transverse vertebral pressure

from Lee et al [23]

. A line was drawn between the techniques.

two margins of each of the superior articular

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5771
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
1- Indirect rotation technique the arms by his/her side or hanging over the sides
Patient position: side lying with the head rested of the couch and the head turned conformably to
on a pillow. The lower shoulder is pulled forward one side.
by grasping the arm at the elbow and gently but Therapist position: Standing facing the patient at
firmly rotating the spine. The uppermost arm rests the level of lumbosacral spine. The manipulating
on the lateral wall of the chest. The uppermost leg hand was positioned with the heel of the hand
is flexed at the hip (to about 50° to 60°) and the (pisiform bone) placed over the spinous process.
knee flexed to a right angle. The foot rests behind The therapist’s trunk was aligned directly over the
the knee of the lower leg. A pillow was given to spine, so the manipulating force is directed
the patient to hold and act as a physical barrier. downward and not at an angle.
Therapist position: standing facing the patient at Technique: The manipulation force was directed
the waist level with one hand was used to push the to produce anterior glide in the form of sudden
trochanteric area of the hip forwards and the other small amplitude pressure to the spinous process of
to force the front of the shoulder downwards and the involved vertebra that produces a sudden
backwards so that the patient's trunk was rotated movement of a small range [26,27].
in the opposite direction. The finger tips of the
proximal and distal hands were placed on the 3- Transverse vertebral pressure technique:
above and below spinous processes to monitor Positions of the patient and the therapist were the
motion. same as in the postro-anterior central vertebral
Technique: the patient’s trunk was passively pressure technique, but the pad of the left thumb
rotated backward to “take up the slack” and the of the therapist was placed against the right lateral
forearm of the therapist was rested on the patient’s surface of the spinous process of the vertebrae
torso. Steady rotational movement was applied being treated, and the right thumb was used for
until a full stretch was reached to both shoulder reinforcement by placing the pad of the right
and hip. Maintaining sustained pressure for one to thumb over the nail of the left thumb. The fingers
two seconds at the end of the range and a sharp of both hands were spread out over the patient
rotational thrust was applied to the hip through the back for more stabilization.
distal forearm by pulling the patient’s lower trunk Technique: The thumbs were positioned to fit
toward the therapist’s body [25,26]. deeply into the groove beside the spine in a
relaxed manner. Lateral pressure over the spinous
2- Postro-anterior central vertebral pressure processes of L4 and L5 vertebrae was carried out
technique: in an appropriate thrusting force from right to the
Patient position: Prone with a pillow placed left and vice versa. The pressure was exerted from
under the abdominal region for patient comfort the side of the spinous process [28].
and to provide a neutral lumbosacral curve; with

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5772
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
Data analysis and statistical design Results
All analyses were conducted using the SPSS For this study, 51 patients were identified as
statistical package, version 16.00. Descriptive potential participants (Fig. 2). Of these, 13
statistics were used in the form of means and (25.4%) were excluded because they failed to
standard deviations for all variables. The paired fulfill the inclusion criteria, 5 patients (9.8%)
and unpaired t-tests were used to compare the pre- refused to participate in the study and 3 patients
and post-treatment values of the measured (5.8%) did not return the consent form. Thus, of
parameters within the group and between the two the original pool, 30 patients (58.8%) with chronic
groups (experimental and control groups) low back accompanied with disc herniation were
respectively. The outcome measures were VAS, included in the study: 17 females and 13 males.
ODQ and facet angle asymmetry. The alpha was They were randomly assigned into two equal
set at p ≤ 0.05. groups; experimental and control groups. The
demographic characteristics of the two groups are
listed in table 1. There were non-significant
differences in the demographic characteristics
between the experimental and the control groups.

Assessed for eligibility

(n=51) Excluded (n=21)

Enrollment Not meeting inclusion criteria (n=13)

Refused to participate (n=5)

Randomized Consent form not returned (n=3)

Spinal manipulation + Physiotherapy Physiotherapy programme (control group)

programme (experimental group)
Allocated to intervention (n=15)
Allocated to intervention (n=15)
Received to intervention (n=15)
Received to intervention (n=15)

Analyzed (n=15) Analyzed (n=15)

Fig 2. Participants flow through the study.

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5773
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
Table 1. Demographic characteristics of patients in both groups
Experimental
Control group
group t-value p-value
(n=15)
(n=15)
Age (year) 34.46±6.9 34.6±6.91 0.95 0.05
Weight (Kg) 68.0±5.68 67.86±5.46 0.94 0.06
Height (cm) 168.8±8.17 168.2±7.23 0.83 0.21
Values are mean ± SD. *Significant at p<0.05.

The results of the present study showed a tested in both the experimental and control groups
statistically non-significant difference in the mean showed statistically significant differences.
values of pre data of all variables including VAS, Additionally, there was a significant difference
ODQ and asymmetry of facet angles between both between the two groups post-treatment in the
sides at L4-L5 level. Comparison between pre and mean values of all variables being tested. The
post treatment mean values of all variables being changes in the mean values of all variables tested
are presented in Table 2.

Table 2. Changes in outcome measures in the experimental and control groups at baseline and following
treatment.

Baseline Post-treatment t-value

VAS
Experimental (N=15) 7.0±1.2 3.6±0.91 11.5
Control (N=15) 7.36±0.84 4.9±1.33 5.73
P value 0.24 0.002*
ODQ
Experimental (N=15) 52.0±6.55 28.76±7.3 8.64
Control (N=15) 54.13±6.99 35.48±9.2 6.19
P value 0.43 0.007*
Asymmetry of facet angle
between both sides
Experimental (N=15) 7.11±0.34 2.54±0.15 12.4
Control (N=15) 7.0±0.33 5.9±0.18 11.9
P value 0.27 0.0001*

Values are mean ± SD. VAS: Visual analogue scale.

ODQ: Modified Oswestry low back pain disability questionnaire.
*Significant at p<0.05.

Discussion intensity scores, disability scores and asymmetry

The results of the present study demonstrated that of lumbar facet angles (in favour of the
patients in both the experimental and control experimental group). The significant improvement
groups showed significant improvement in pain in the experimental group as compared to the

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5774
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
control group in all outcome measures might be hypomobility can lead to dysafferentation which
attributed to the combined effect of both is described as reduced activity of mechanorec-
manipulation and the training exercise program. It eptors and increased excitation of the nociceptive
was reported that spinal manipulation, combined system which is produced by joint hypomobility
[32]
with spinal stabilization and manual therapy . Therefore, when improving spinal
treatment to the soft-tissues supporting the spine intersegmental movement, pain can be improved.
can achieve a greater level of improvement and This comes in agreement with Patterson[33] who
minimize the recurrence. Moreover, spinal reported that spinal manipulation can reduce
manipulation as a single therapy is not sufficient motion restrictions, increase proper fluid infusion,
to lengthen muscles that are chronically shortened and restore mechanoreceptive input to the CNS
or rehabilitate degenerated or deconditioned and subsequently reduce nociceptive inputs to the
[29]
structures . Therefore, spinal manipulation spinal cord.
should be combined with exercise program to gain
3) The ability of spinal manipulation to create
good results.
negative pressure which reduces compression on
The significant reduction of pain intensity scores
any nerve root or other innervated paraspinal
measured by VAS in the experimental group as
tissues [31].
compared to the control group might be attributed
Regarding the results obtained for disability
to the additional effect of lumbar manipulation in
scores measured by ODQ, patients in the
the experimental group as a result of several
experimental group showed a significant
mechanisms:
improvement of ODQ as compared to the control
1) The direct effect of spinal manipulation on pain
group. This can be justified by the fact that
itself. Spinal manipulation can increase pain
chronic spinal joint hypomobility, and the
tolerance or its threshold through its ability to
resulting pain, can lead to deconditioning
alter central sensory processing by removing
syndrome and reduced physical activity, which
subthreshold mechanical or chemical stimuli from
[30]
further promotes decline in a patient’s physical
paraspinal tissues . Additionally, spinal
condition and subsequently increased disability.
manipulation might reduce pain by means of its
Deconditioning syndrome is characterized by
effects on the inflow of sensory information to the
specific clinical findings including decreased
central nervous system. The mechanical input may
strength, endurance, flexibility, cardiovascular
ultimately reduce nociceptive input from receptive [34]
[31]
fitness and proprioception . Therefore, the
nerve endings in innervated paraspinal tissues .
effect of spinal manipulation on improvement of
2) The effect of spinal manipulation on spinal
intersegmental hypomobility and pain will
mobility. Spinal manipulation can improve spinal
promote more improvement in functional
intersegmental hypomobility. Abnormal
disability. These results were in line with other
intersegmental spinal range of motion and
studies reported that manipulation was effective in

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5775
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
the treatment of symptomatic LDH and resulted in were all suffering from chronic LBP. Further
improvement of pain and functional disabilities study into the value of manipulation at a more
[16,18,35]
. On the other hand, the findings of the acute stage is warranted to compare the effect of
current study disagreed with the findings of manipulation on both acute and chronic LBP. The
[36]
Ferreira et al who indicated that there was no lack of follow-up for the patients in both the
improvement in pain and function after lumbar experimental and control groups might be
manipulation. The different results might be considered another limitation of the study. The
attributed to the selection criteria of the patients lumbar manipulation techniques conducted in this
that participated in the previous study. study were done as a complete regimen performed
The significant improvement of the asymmetry of on the patient, thus the effect of every single
facet angles at the level of (L4-L5) in the manipulation technique was not demonstrated but
experimental group more than the control group the improvement reported was attributed to the
might be explained by the additional effect of entire regimen. Therefore, future studies are
lumbar manipulation in the experimental group. suggested to evaluate the effect of each technique
The biomechanical changes caused by spinal and to determine the technique of the best effect in
manipulation are thought to have very essential this group of patients.
role in the correction and realignment of the facet
joints. In the available literatures, there were no Conclusion
studies disagreed with the results of the present Within the limitations of this study the following
study about the significant improvement of the conclusion was warranted, the lumbar
asymmetry of lumbar facet angles at L4-L5 in manipulation techniques proved to have high
response to lumbar manipulation techniques. significant effects on improving pain, degree of
Some points were considered during the disability and asymmetry of lumbar facet angles in
conduction of this study to avoid any potential patients with LDH. This can provide evidence that
source of bias such as only one examiner took the spinal manipulation, in conjunction with
measurement pre and post treatment and the same therapeutic exercises can produce a greater level
therapist was allowed to apply the manipulation of recovery and improved outcomes.
techniques for all patients. Ethical approval: All procedures were approved
There are some limitations to the present trial. The by the Research Ethics Committee of the Faculty
small number of patients might limit the of Physical Therapy, Cairo University, Egypt.
generalization of the results. The age of all
participants ranged between 20 and 45 years. Competing interests
Future studies are required to target different ages The authors declare that they have no competing
to enable comparisons of the results across various interests.
age groups. The patients included in this study

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5776
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
Authors’ contributions 4. Weber H. The natural history of disc
Authors’ NALAR NMMG SMA herniation and the influence of
contributions
intervention. Spine 1994; 19: 2234-38.
Research concept and √ √ √
design 5. Kunakornsawat S, Ngamlamaidt K,
Collection and/or √ √ √ Tungsiripat R, Prasartritha T. The
assembly of data
Data analysis and √ √ √ relationship of facet tropism to lumbar disc
interpretation herniation. J Med Assoc Thai 2007; 90(7):
Writing the article √ √ √
Critical revision of the √ √ √ 1337–41.
article 6. Kong M H, He W, Tsai YD, Chen NF,
Final approval of √ √ √
article Keorochana G, Do DH, Wang JC.
Statistical analysis √ √ √ Relationship of facet tropism with
degeneration and stability of functional
Acknowledgment
spinal unit. Yonsei Med J 2009; 50(5):
The authors would like to express their
624–29.
appreciation to all patients who participated in this
7. Karacan I, Aydin T, Sahin Z, Cidem M,
study with all content and cooperation.
Koyuncu H, Aktas I, et al. Facet angles in
lumbar disc herniation: their relation to
References
anthropometric features. Spine 2004;
1. Han L, Zhao P, Guo W, Wei J, Wang F,
29:1132-6.
Fan Y, et al. Short-term study on risk-
8. Do DH, Taghavi CE, Fong W, Kong MH,
benefit outcomes of two spinal
Morishita Y, Wang JC. The relationship
manipulative therapies in the treatment of
between degree of facet tropism and
acute radiculopathy caused by lumbar disc
amount of dynamic disc bulge in lumbar
herniation: study protocol for a
spine of patients symptomatic for low back
randomized controlled trial. Trials 2015;
pain. Eur Spine J 2011; 20:71–78.
16(1):122-30.
9. Santilli V, Beghi E, Finucci S.
2. Crawford CM, Hannon RF. Management
Chiropractic manipulation in the treatment
of acute lumbar disc herniation initially
of acute back pain and sciatica with disc
presenting as mechanical low back pain. J
protrusion: a randomized double- blind
Manipulative Physiol Ther 1999; 22: 235-
clinical trial of active and simulated spinal
44.
manipulations. Spine J 2006; 6: 131–37.
3. Deyo RA, Rainville J, Kent DL. What can
10. Meeker WC, Haldeman S. Chiropractic: a
the history and physical examination tell
profession at the crossroads of mainstream
us about low back pain? JAMA 1992; 268:
and alternative medicine. Ann Intern Med
760-65.
2002; 136:216–27.

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5777
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
11. Bergman TF, Jongward BV. Manipulative 18. Koes BW, Bouter LM, van der Heijden
therapy in lower back pain with leg pain GJ. Methodological quality of randomized
and neurological deficit. J Manipulative clinical trials on treatment efficacy in low
Physiol Ther 1998; 21: 288-94. back pain. Spine 1995; 20: 228–35.
12. Cramer GD, Tuck NR, Knudsen JT, Fonda 19. Burton AK, Tillotson KM, Cleary I.
SD, Schlieser JS, Fournier JT, et al. Single-blind randomized controlled trial of
Effects of side-posture adjusting on the chemonucleolysis and manipulation in the
lumbar zygapophyseal joints as evaluated treatment of symptomatic lumbar disc
by MRI: a before and after study with herniation. Eur Spine J 2000; 9: 202-7.
randomization. J Manipulative Physiol 20. Kim HS, Heller JG, Hudgins PA, Fountain
Ther 2000; 23: 380-94. JA. The accuracy of computed tomogram-
13. Oliphant D. Safety of spinal manipulation phy in assessing cervical pedicle screw
in the treatment of lumbar disk placement. Spine 2003; 28(21):2441-6.
herniations: a systematic review and risk 21. Boonstra AM, Schiphorst Preuper HR,
assessment. J Manipulative Physiol Ther Reneman MF, Posthumus JB, Stewart RE.
2004; 27:197-210. Reliability and validity of the visual
14. Rivett D, Milburn P. Complications analogue scale for disability in patients
arising from spinal manipulative therapy in with chronic musculoskeletal pain. Int J
New Zealand. Physio 1997; 83: 626-32. Rehabil Res 2008; 31(2): 165-9.
15. Rydell N, Raf L. Spinal manipulation– 22. Fritz JM, Irrgang JJ. A Comparison of a
treatment associated with a high risk of Modified Oswestry Low Back Pain
complications. Lakartidningen 1999; 96: Disability Questionnaire and the Quebec
3536-40. Back Pain Disability Scale. Phys Ther
16. Assendelft WJJ, Morton SC, Yu EI, 2001; 81:776-88.
Suttorp MJ, Shekelle PG. Spinal 23. Lee DY, Ahn Y, Lee SH. The influence of
manipulative therapy for low back pain: a facet tropism on herniation of the lumbar
meta-analysis of effectiveness relative to disc in adolescents and adults. J Bone Joint
other therapies. Ann Intern Med 2003; Surg [Br] 2006; 88-B: 520-3.
138: 871–81. 24. Delitto A, George SZ, Van Dillen LR,
17. Muller R, Giles LG. Long-term follow-up Whitman JM, Sowa G, Shekelle P, et al.
of a randomized clinical trial assessing the Low back pain: Clinical guidelines linked
efficacy of medication, acupuncture, and to the international classification of
spinal manipulation for chronic functioning, disability, and health from the
mechanical spinal pain syndromes. J orthopaedic section of the American
Manipulative Physiol Ther 2005; 28: 3–11.

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5778
JMSCR Volume||03||Issue||05||Page 5768-5779||May 2015
Physical Therapy Association. J Orthop dysfunction; a look at likely mechanisms
Sports Phys Ther. 2012; 42(4): A1-A57. of symptom generation. J Manip Physiol
25. Nwuga VC. Relative therapeutic efficacy Ther 1998; 21: 267-80.
of vertebral manipulation and conventional 33. Patterson M. The spinal cord: participant
treatment in back pain management. Am J in disorder. Spinal Manipulation 1993; 9:
Phys Med 1982; 61(6): 273-78. 2-11.
26. Kisner C, Colby LA. Therapeutic exercise: 34. Carpenter N. Low back strengthening for
Foundation and techniques, sixth edition. the prevention & treatment of low back
Philadelphia: F.A. Davis Company, 2012. pain. Med Sci Sports Exerc 1999; 31:18-
27. Jordan A, Bendix T, Nielsen H, Winkel A. 24.
Intensive training physiotherapy or 35. Mohseni-Bandpei MA, Critchley J,
manipulation for patient with chronic neck Staunton T, Richardson B. A prospective
pain. Spine 1992; 23(3): 311-19. randomised controlled trial of spinal
28. Kenna CJ, Murtagh JE. Back pain and manipulation and ultrasound in the
spinal manipulation: a practical guide, treatment of chronic low back pain.
second edition. Butterworth-Heinemann, Physiotherapy 2006; 92: 34-42.
1997 36. Ferreira M, Ferreira P, Latimer J, Herbert
29. Globe GA, Morris CE, Whalen WM, R, Hodges P, Jennings M, et al.
Farabaugh RJ, Hawk C. Chiropractic Comparison of general exercise, motor
management of low back disorders: report control exercise and spinal manipulative
from a consensus process. J Manip Physiol therapy for chronic low back pain: A
Ther 2008; 31: 651-58. randomized trial. Pain 2007; 131: 31-7.
30. Pickar JG. Neurophysiological effects of
spinal manipulation. Spine 2002; 2: 357-
71.
31. Bronfort G, Haas M, Evans R, Kawchuk
G, Dagcnais S. Evidence-informed
management of chronic low back pain
with spinal manipulation and mobilization.
Spine J. 2008; 8 (1): 213-25.
32. Seaman DR. Dysafferentation: a novel
term to describe the neuropatho-
physiological effects of joint complex

Neveen Abdel Latif Abdel Raoof et al JMSCR Volume 03 Issue 05 May Page 5779