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Eur Spine J. 2019 Feb;28(2):259-269. doi: 10.1007/s00586-018-5851-2. Epub 2019 Jan 2.

Differential patient responses to spinal manipulative therapy and their relation to spinal degeneration and post-treatment changes in disc diffusion.

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Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada.
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, SAR, China.
Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada.
Department of Radiology, University of Alberta, Edmonton, AB, Canada.
Department of Mathematical and Statistical Sciences, University of Alberta Hospital, Edmonton, AB, Canada.
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.



Our prior study revealed that people with non-specific low back pain (LBP) who self-reported a > 30% improvement in disability after SMT demonstrated significant post-treatment improvements in spinal stiffness, dynamic muscle thickness and disc diffusion, while those not having self-reported improvement did not have these objective changes. The mechanism underlying this differential post-SMT response remains unknown. This exploratory secondary analysis aimed to determine whether persons with non-specific LBP who respond to spinal SMT have unique lumbar magnetic resonance imaging (MRI) findings compared to SMT non-responders.


Thirty-two participants with non-specific LBP received lumbar MRI before and after SMT on Day 1. Resulting images were assessed for facet degeneration, disc degeneration, Modic changes and apparent diffusion coefficient (ADC). SMT was provided again on Day 4 without imaging. SMT responders were classified as having a ≥ 30% reduction in their modified Oswestry disability index at Day 7. Baseline MRI findings between responders and non-responders were compared. The associations between SMT responder status and the presence/absence of post-SMT increases in ADC values of discs associated with painful/non-painful segments as determined by palpation were calculated. In this secondary analysis, a statistical trend was considered as a P value between 0.05 and 0.10.


Although there was no significant between-group difference in all spinal degenerative features (e.g. Modic changes), SMT responders tended to have a lower prevalence of severely degenerated facets (P = 0.05) and higher baseline ADC values at the L4-5 disc when compared to SMT non-responders (P = 0.09). Post hoc analyses revealed that 180 patients per group should have been recruited to find significant between-group differences in the two features. SMT responders were also characterized by significant increases in post-SMT ADC values at discs associated with painful segments identified by palpation (P < 0.01).


The current secondary analysis suggests that the spines of SMT responders appear to differ from non-responders with respect to degeneration changes in posterior joints and disc diffusion. Although this analysis was preliminary, it provides a new direction to investigate the mechanisms underlying SMT and the existence of discrete forms of treatment-specific LBP. These slides can be retrieved under Electronic Supplementary Material.


Apparent diffusion coefficient; Degeneration; Facet joint; Low back pain; Spinal manipulative therapy


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