SAMPLE PROTOCOL – LUMBAR FACET SYNDROME
Management Soft Tissue
- Manipulation – Lumbar and Sacral
Phase I Exercises
Phase II Exercises
- Since the medial branch of the dorsal ramus does not cross the mid line, facet pain generally presents in an ipsilateral fashion with peak intensity over the affected joint.
- While scleratogenous referral to the thigh is likely, true radicular complaints suggest an alternate pathology.
- Seven factors associated with the diagnosis of facet joint pain include: an older patient (over 65), with recurrent low back pain, not extending beyond the knee, which is maximally exacerbated with extension from a fully flexed position.
- Guidelines suggest “imaging only for patients who have severe or progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition”.
- MRI, should be reserved for patients with radicular complaints who are potential candidates for surgery or injections and only when the results of the test are likely to affect clinic decision making.
“Lumbar facet syndrome” describes acute or chronic inflammation of a lumbar zygapophyseal joint. The facet joint is thought to be the source of pain in 15-45% of patients with chronic low back pain. (1-6) The literature is mottled with various explanations for the genesis of facet syndrome, including: capsular sprain, joint hypomobility, synovial cysts and degeneration. (7-9) The term “facet syndrome” shares many common characteristics with intersegmental joint dysfunction, to the point that some clinicians characterize facet syndrome as the medical equivalent of intersegmental joint dysfunction.
The lumbar facet joints are motion-restricting joints. The sagittal orientation of the upper lumbar facet joints help to limit rotation, while the more frontal orientation of the lower lumbar facet joints resist forward displacement. (10) The facet joints and adjacent soft tissues are richly innervated by the medial branches of the dorsal rami. (7,11-15) The facet capsule contains low-threshold mechanoreceptors and nociceptors that fire when the facet is compressed or its capsule is stretched. (17,18) Nociceptors can be hypersensitized by an inflammatory process. (19)
Repetitive capsular stress or other cumulative low-level trauma is the most common origin of facetogenic pain. (20) Excessive compression and extension of the lumbar spine (especially in the presence of degeneration) cause the “inferior articular process to pivot about the pars and stretch the joint capsule.” (7) Acute or repetitive trauma leads to inflammation and joint dysfunction, including intra-articular adhesions with subsequent degenerative changes of the facet joint. (21) The biomechanical three-joint model suggests that dysfunction involving any portion of the segmental tripod will lead to a cycle of self-perpetuating changes, including degeneration, in the remaining components.
Nociceptive stimulation of the facet joint has been shown to cause back and/or leg pain. (22-25) Not surprisingly, the most frequent complaint associated with facet syndrome is lower back pain radiating toward the flank, hip, and thigh. (20) While scleratogenous referral to the thigh is likely, true radicular complaints suggest an alternate pathology. (26,27) Since the medial branch of the dorsal ramus does not cross the mid line, facet pain generally presents in an ipsilateral fashion with peak intensity over the affected joint. (28-31) A complaint of stiffness or morning stiffness may be associated with degenerative change of the facet joint. (32-35) Symptoms of facetogenic pain may present following an acute injury but are more commonly the result of cumulative trauma.
The “1988 Volvo award in clinical sciences” study identified seven factors associated with the diagnosis of facet joint pain: an older patient (over 65), with recurrent low back pain, not extending beyond the knee, which is maximally exacerbated with extension from a fully flexed position. Clinical findings demonstrate normal gait, with the absence of muscle spasm, and a negative Valsalva. (36) Other researchers have identified “relief with recumbancy” as another criteria for the diagnosis of facetogenic pain. (37-38) Predisposing factors for the development of facet syndrome include a history of trauma, overuse, osteoarthritis, systemic arthropathy, and being overweight. (39)
Clinical evaluation should demonstrate localized tenderness to palpation of the facet joint. (32,40,41) Muscle guarding may emerge as a protective response. (42) Range of motion testing will likely elicit pain in extension, as this causes compressive loading of the facets. (28,32,36,44) Extension combined with lateral flexion or rotation generates maximal compression of the facet joint and is even more likely to reproduce symptoms. (32,36,45) Facet syndrome is often accompanied by postural imbalances, including hyperlordosis and/or lower crossed syndrome.
While conditions like disc lesions and sacroiliac joint dysfunction have reliable orthopedic diagnostic tests, the diagnosis of lumbar facet syndrome lacks orthopedic evaluation with high sensitivity or specificity. (46) Application of a manual “springing” pressure over the affected zygapophyseal joint (Spring test) will likely provoke symptoms. (43) Spinal percussion and the Segmental rotation test may be useful in the diagnosis of facet syndrome. (43) Orthopedic evaluation of benign lower back pain most frequently demonstrates positive Kemp’s and Yeoman tests. (47) Neurologic testing is characteristically normal. Confirmatory medical diagnostic procedures include facet joint injection and flouroscopically-guided nerve blocks. (32, 48-58) Diagnostic nerve blocks (with pain relief post-injection) are thought to be the most reliable diagnostic tool for lumbar facet pain. (58,59)
Evidence-based recommendations from the American College of Physicians (ACP) and the American Pain Society (APS) suggest that routine spinal imaging of benign lower back pain may be unnecessary. There are no radiographic findings that can identify the lumbar facet joints as the source of the patient’s symptoms. (59) Furthermore, radiographic findings do not correlate with facet-generated symptoms. (32,60- 63) Guidelines suggest “imaging only for patients who have severe or progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition” (64). Radiographs are appropriate for patients with “red flags” including a history of: cancer, unexplained recent weight loss, bone disease, systemic disease, inflammatory arthropathy (particularly ankylosing spondylitis), steroid use, immune suppression, fever, nocturnal pain, prior lumbar surgery, in patients with suspected congenital deficit or instability, and in those whose pain is usually severe, progressive, prolonged or unaffected by position. Radiographs may be needed to rule out suspicion of vertebral compression fracture or spondylolisis/ spondylolisthesis.
Likewise, advanced imaging is unable to predict lumbar facet joint pain. (65) Advanced imaging, including MRI, should be reserved for patients with radicular complaints who are potential candidates for surgery or injections and only when the results of the test are likely to affect clinic decision making. Advanced imaging would be appropriate for patients with a history of major trauma, severe neurologic compromise, or suspicion of vertebral infection (64). CT scanning has no value in the diagnosis of lumbar facet pain. (66)
Differential diagnostic considerations for lumbar facet syndrome include: intersegmental joint dysfunction, myofascial pain, spondylolysis, spondylolisthesis, sprain/strain, disc lesion, fracture, compression fracture, DJD/DDD, stenosis, neoplasm, infection, inflammatory arthropathy, sacroiliac joint dysfunction, hip pathology/ osteoarthritis, abdominal aortic aneurysm and referred pain, particularly from the gastrointestinal or genitourinary systems.
Treatment progresses from pain relief through mobility and eventually functional stabilization. There is significant data to suggest that spinal manipulation (SMT) is an effective treatment for LBP (67-71). Spinal manipulation produces zygapophyseal joint gapping with subsequent break up of intra-articular adhesions. (72-75) Elimination of zygapophyseal joint adhesions help to reestablish “normal” function and may slow the degenerative process. (76-79) Spinal manipulation does not stress the facet capsule beyond its physiologic range and is thought to be safe. (104) The only dose-response efficacy study of SMT for LBP suggested that 12 visits over 6 weeks provided the most favorable outcomes. (80) Research has demonstrated that SMT is superior to alternate options including: traditional medical management (muscle relaxants, pain meds, anti-inflammatories), physical therapy, pain management, exercise, acupuncture, bed rest and massage (81-95).
Fritz identified five criteria that predict the success of spinal manipulation for lower back pain. These include pain lasting less than 16 days, no symptoms distal to the knee, low fear avoidance beliefs (FABQ score of less than 19), hip internal rotation greater than 35 degrees, and hypomobility of at least one lumbar segment (96). Related research suggests the first two factors are most significant (97).
SMT should address restrictions in the thoracic, lumbar, sacroiliac, and pelvic regions. Clinicians should be alert to the possibility of structural or functional instability, which may present in a very similar fashion to facet syndrome. Patients with micro- or macroinstability will benefit from spinal stabilization rather than manipulation, although facet syndrome and global instability are not always mutually exclusive.
Myofascial release techniques or IASTM may be appropriate for lesions in the lumbar erectors, quadratus lumborum, hip flexors, hip rotators, gluteal muscles, piriformis, and hamstrings as well as the iliolumbar ligament. Flexibility exercises may include a knee to chest stretch and hamstring stretch. Rehab of facet syndrome should focus on helping the patient find and maintain a neutral spine posture. (98) The addition of spinal stabilization exercises may help to reduce pain, disability, medication intake as well as future episodes of lower back pain. Stability exercises may include: side bridge, bird dog, dead bug and hip abductor strengthening (99). Postural correction may be necessary for lower crossed syndrome, and breathing exercises are appropriate for those with dysfunctional respiration.
Heat, ice, ultrasound, and e-stim may help relax muscles and provide short-term palliative relief in the early phases of facet syndrome treatment. (100) Patients may need to limit heavy physical activity but should avoid bed rest. (101) Lifestyle modifications should include removal of the activity that induces pain. Patients should be counseled on lifting mechanics, work activities, sleep positions and shoe wear. Educational counseling regarding predictable exacerbating activities for lumbar, lumbosacral, and hip trigger points is warranted. This may include minimization of prolonged sitting and sedentary hobbies. Yoga has been shown to be an effective treatment for simple mechanical low back pain (102). The addition of NSAIDS may help reduce pain and inflammation initially.
Medical management of facet syndrome includes fluoroscopically-guided intra-articular zygapophyseal joint steroid injections and radiofrequency abalation of the medial branch to (temporarily) eliminate all sensory input from the facet joint. (103) van Kleef (20) states “currently, the gold standard for (allopathically) treating facetogenic pain is radio frequency treatment. The evidence supporting intra-articular corticosteroids is limited: hence, this should be reserved for those individuals who do not respond to radio frequency treatment.”
1. Ray CD. Percutaneous Radiofrequency Facet Nerve Blocks: Treatment of the Mechanical Low Back Syndrome. Radionics Procedure Technique Series. Burlington, Mass: Radionics Inc; 1982. 2. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N: Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994, 19:1132-1137. 3. Manchikanti L, Singh V, Pampati V, Damron K, Barnhill R, Beyer C, Cash K: Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 2001, 4:308-316. 4. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287–333 5. van Kleef M, Vanelderen P, Cohen SP, Lataster A, Van Zundert J, Mekhail N. 12. Pain originating from the lumbar facet joints. Pain Pract 2010;10:459-69. 6. Bogduk N: International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part 1: Zygapophyseal joint blocks. Clin J Pain 1997, 13:285-302 7. Malanga GA et al. Lumbosacral Facet Syndrome MedScape www.emedicine.medscape.com/article/94871-overview. Accessed 2/15/14. 8. Ghormley RK. Low back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933;101:1773-7. 9. Harris RI, Macnab I. Structural changes in the lumbar intervertebral discs; their relationship to low back pain and sciatica. J Bone Joint Surg Br. May 1954;36-B(2):304-22 10. Bogart BI, Ort VH. Elsevier’s Integrated Anatomy and Embryology. Elsevier (2007) ISBN:9781416031659 11 Bogduk N: The clinical anatomy of the cervical dorsal rami. Spine 1982, 7:35-45. 12. Chua WH, Bogduk N: The surgical anatomy of thoracic facet denervation. Acta Neurochir (Wien) 1995, 136:140-144. 13. Bogduk N, Wilson AS, Tynan W: The human lumbar dorsal rami. J Anat 1982, 134:383-397. 14. Stilwell DL: The nerve supply of the vertebral column and its associated structures in the monkey. Anat Rec 1956, 125:139-169. 15. Cavanaugh JM, Ozaktay AC, Yamashita HT, King AI: Lumbar facet pain: Biomechanics, neuroanatomy, and neurophysiology. J Biomech 1996, 29:1117-1129 17. Cavanaugh JM, Ozaktay AC, Yamashita HT, King AI: Lumbar facet pain: Biomechanics, neuroanatomy and neurophysiology. J Biomechanics 1996; 29: 1117–29 18. Stillwell DL: The nerve supply of the vertebral column and its associated structures in the monkey. Anat Rec 1956; 125:136–69 19. Cavanaugh JM, Lu Y, Chen C, Kallakuri S. Pain Generation in Lumbar and Cervical Facet Joints The Journal of Bone and Joint Surgery (American) April 2006;88:63-67. 20. van Kleef M, Vanelderen P, Cohen SP, Lataster A, Van Zundert J, Mekhail N. 12. Pain originating from the lumbar facet joints. Pain Pract 2010;10:459-69. 21. Cramer GD, Fournier JT, Henderson CN, Wolcott CC. Degenerative changes following spinal fixation in a small animal model. J Manipulative Physiol Ther 2004;27:141-54. 22. Hirsch C, Ingelmark BE, Miller M: The anatomical basis for low back pain: Studies on the presence of sensory nerve endings in ligamentous, capsular and intervertebral disc structures in the human lumbar spine. Acta Orthop Scand 1963; 33:1–17 23. Marks RC, Houston T, Thulbourne T: Facet joint injection and facet nerve block: A randomized comparison in 86 patients with chronic low back pain. Pain 1992; 49:325–8 24. Mooney V, Robertson J: The facet syndrome. Clin Orthop Relat Res 1976; 115:149–56 25. McCall IW, Park WM, O’Brien JP: Induced pain referral from posterior lumbar elements in normal subjects. Spine 1979; 4:441–6 26. Marks R. Distribution of pain provoked from lumbar facet joints and related structures during diagnostic spinal infiltration. Pain. 1989;39 :37– 40. 27. Fukui S, Ohseto K, Shiotani M, et al. Distribution of referred pain from the lumbar zygapophyseal joints and dorsal rami. Clin J Pain. 1997;13 :303– 307. 28. Cavanaugh JM, Ozaktay AC, Yamashita HT, King AI. Lumbar facet pain: biomechanics, neuroanatomy and neurophysiology. J Biomech. 1996;29 :1117– 1129. 29. Bogduk N. The innervation of the lumbar spine. Spine. 1983;8 :286– 293. 30. Jackson H, Winkelmann R, Bickel W. Nerve endings in the human lumbar spinal column and related structures. J Bone Joint Surg Am. 1966;48 :1272– 1281. 31. McCall I, Park W, O’Brien J. Induced pain referral from posterior lumbar elements in normal subjects. Spine. 1979;4 :441– 446. 32. Wilde VE, Ford JJ, McMeeken JM. Indicators of lumbar zygapophyseal joint pain: survey of an expert panel with the Delphi technique. Phys Ther. 2007;87 :1348– 1361. 33. Eisenstein S, Parry C. The lumbar facet arthrosis syndrome: clinical presentation and articular surface changes. J Bone Joint Surg Br. 1987;69 :3– 7. 34. Igarashi A, Kikuchi S, Konno S, Olmarker K. Inflammatory cytokines released from the facet joint tissue in degenerative lumbar spinal disorders. Spine. 2004;29 :2091– 2095. 35. Tournade A, Patay Z, Krupa P, et al. A comparative study of the anatomical, radiological and therapeutic features of the lumbar facet joints. Neuroradiology. 1992;24 :257-261 36. Jackson RP, Jacobs RR, Montesano PX. 1988 Volvo award in clinical sciences. Facet joint injection in low-back pain. A prospective statistical study. Spine. Sep 1988;13(9):966-71 37. Revel M, Poiraudeau S, Auleley GR, et al. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine. 1998;23:1972–1976. doi: 10.1097/00007632-199809150-00011. 38. Revel ME, Listrat VM, Chevalier XJ, et al. Facet joint block for low back pain: identifying predictors of a good response. Arch Phys Med Rehabil. 1992;73:824–828. 39. National Spine and Pain Center. www.treatingpain.com/conditions/facet-syndrome. Accessed 2/15/14 40. Fritz J, Piva S. Physical impairment index: reliability, validity and responsiveness in patients with acute low back pain. Spine. 2003;28 :1189– 1194. 41. May S, Littlewood C, Bishop A. Reliability of procedures used in the physical examination of non-specific low back pain: a systematic review. Aust J Physiother. 2006;52 :91– 113. 41. 42. Strender L, Sjoblom A, Sundell K, et al. Interexaminer reliability in physical examination of patients with low back pain. Spine. 1997;22 :814 43. Mainka T. Association between clinical signs assessed by manual segmental examination and findings of the lumbar facet joints on magnetic resonance scans in subjects with and without current low back pain: A prospective, single-blind study. PAIN 154 (2013) 1886–1895 44. Adams MA, Hutton WC. The mechanical function of the lumbar apophyseal joints. Spine. 1983;8 :327– 329. 45. Yang K, King A. Mechanism of facet load transmission as a hypothesis for low-back pain. Spine. 1984;21 :538 46. M. J. Hancock, 1 C. G. Maher,1 J. Latimer,1 M. F. Spindler,1 J. H. McAuley,1 M. Laslett,2 and N. Bogduk3 Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain . 47. Walsh MJ. Evaluation of orthopedic testing of the low back for nonspecific lower back pain. J Manipulative Physiol Ther. 1998 May;21(4):232-6 48. Bogduk N. International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part 1. Zygapophysial joint blocks. Clin J Pain. 1997;13 :285– 302. 49. Marks R, Houston T, Thulbourne T. Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain. Pain. 1992;49 :325– 328. CrossRefMedline 50. Dreyfuss PH, Dreyer SJ, Herring SA. Lumbar zygapophysial (facet) joint injections. Spine. 1995;20 :2040– 2047. Medline 51. Dreyfuss P, Schwarzer AC, Lau P, Bogduk N. Specificity of lumbar medial branch and L5 dorsal ramus blocks: a computed tomography study. Spine. 1997;22 :895– 902. CrossRefMedline 52. Kaplan M, Dreyfuss P, Halbrook B, Bogduk N. The ability of lumbar medial branch blocks to anesthetize the zygapophysial joint: a physiologic challenge. Spine. 1998;23 :1847– 1852. 53. Marks RC, Houston T, Thulbourne T. Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain. Pain 1992; 49:325-328 54. Bogduk N, Aprill C, Derby R. Lumbar zygapophyseal joint pain: diagnostic blocks and therapy. In: Wilson DJ, ed. Practical interventional radiology of the musculoskeletal system. Oxford, UK: University of Oxford Press, 1995:73-86 55. Carrera GF. Lumbar facet joint injection in low back pain and sciatica: preliminary results. Radiology 1980; 137:665-667 56. Lippitt AB. The facet joint and its role in spine pain: management with facet joint injections. Spine 1984; 9:746-750 57. Cohen SP, Hurley RW. The ability of diagnostic spinal injections to predict surgical outcomes.Analg. Dec 2007;105(6):1756-75 58. Saravanakumar K, Harvey A. Lumbar Zygapophyseal (Facet) Joint Pain British Journal of Pain September 2008 vol. 2 no. 1 8-13 59. Maus T. Imaging the back pain patient. Phys Med Rehabil Clin N Am. Nov 2010;21(4):725-66. 60. Koes B, van Tudler M, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006;332 :1430– 1434. 61. Murtagh F. Computed tomography and fluoroscopy guided anaesthesia and steroid injection in facet syndrome. Spine. 1988;13 :686– 689. 62. Schwarzer AC, Wang S, O’Driscoll D, et al. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine. 1995;20 :907– 912. 63. Igarashi A, Kikuchi S, Konno S, Olmarker K. Inflammatory cytokines released from the facet joint tissue in degenerative lumbar spinal disorders. Spine. 2004;29 :2091– 2095. 64. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463.-72 65. Shin CH, Calliet R. et al. Lumbar Facet Arthropathy emedicine.medscape.com/article/310069-overview. Accessed 2/15/14 66. Schwarzer AC, Wang SC, O’Driscoll D, et al. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine. Apr 15 1995;20(8):907-12. 67. Chou R, Qaseem A, Snow V, et al. (October 2007). “Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society”. Ann. Intern. Med. 147 (7): 478–91. 68. Haldeman S, Dagenais S. What we have learned about the evidence-informed management of chronic low back pain? The Spine Journal. 2008(8): 266-277 69. Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel*. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491. 70. Bigos S, Bowyer O, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, Number 14, Rockville, Maryland: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub. No. 95-0642, December 1994. 71. Shekelle PG, Adams A. et al. The Appropriateness of Spinal Manipulation for Low-Back Pain: Indications and Ratings by a Multidisciplinary Expert Panel. RAND Corporation, Santa Monica, California, 1991. 72. Janse J. In: Hildebrandt RW, editor. Principles and practice of chiropractic: an anthology. Wheaton: Kjellberg & Sons; 1976.p. 326. 73. Mooney V, Robertson J. The facet syndrome. Clin Orthop Res 1976;115:149-56. 74. Triano JJ. Interaction of spinal biomechanics and physiology. In: Haldeman S, editor. Principles and practice of chiropractic. 2nd ed. East Norwalk, Conn: Appleton & Lange; 1992. p. 225-57. 75. Cramer G, Henderson C, Little J, Daley C, Grieve T. Zygapophysial joint adhesions following induced hypomobility. J Manipulative Physiol Ther 2010;33:508-18. 76. Cramer GD, Tuck NR, Knudsen JT, Fonda SD, Schliesser JS, Fournier JT, et al. Effects of side-posture positioning and side-posture adjusting on the lumbar zygapophysial joints as evaluated by magnetic resonance imaging: a before and after study with randomization. J Manipulative Physiol Ther 2000; 23:380-94. 77. Cramer GD, Gregerson DM, Knudsen JT, Hubbard BB, Ustas LM, Cantu JA. The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: a randomized controlled trial with sixty-four subjects. Spine 2002;27: 2459-66. 78. Cramer GD, Fournier JT, Henderson C. Zygapophysial joint changes following spinal fixation. International Conference on Spinal Manipulation; 2000 September 21-23; Minneapolis. Brookline: Foundation for Chiropractic Education and Research; 2000. p. 85-7 79. Cramer GD, Fournier JT, Henderson CN, Wolcott CC. Degenerative changes following spinal fixation in a small animal model. J Manipulative Physiol Ther 2004;27:141-54. 80. Haas M, Vavrek D, Peterson D, Polissar N, Neradilek M. Dose=response and efficacy of spinal manipulation for care of chronic low back pain: a randomized clinical trial. The Spine Journal (2013) 81. von Heymann WJ, Schloemer P, Timm J, Muehlbauer B. Spinal high-velocity low amplitude manipulation in acute nonspecific low back pain: a double-blinded randomized controlled trial in comparison with diclofenac and placebo. Spine (Phila Pa 1976). 2013 Apr 1;38(7):540-8. 82. Francesca Cecchi, Raffaello Molino-Lova , Massimiliano Chiti, Guido Pasquini, Anita Paperini, Andrea A Conti, Claudio Macchi Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Clinical Rehabilitation, Vol. 24, No. 1, 26-36 (2010) 83. Bronfort G, Haas M, Evans R, Bouter L. Efficacy of Spinal Manipulation and Mobilization for Lower Back Pain and Neck Pain: A Systematic Review and Best Evidence Synthesis, The Spine Journal, 2004 84. Simon Dagenais, DC, PhDa,b,*, Ralph E. Gay, DC, MDc, Andrea C. Tricco, PhDd, Michael D. Freeman, PhD, MPH, DCe, John M. Mayer, DC, PhDf. NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain. The Spine Journal 10 (2010) 918–940 85. Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM (October 2010). “NASS Contemporary Concepts in Spine Care: spinal manipulation therapy for acute low back pain”. Spine J 10 (10): 918–40 86. Giles L, Mueller R. A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation. Spine, Volume 28, Number 14, 2003, pp. 1490-1503 87. Meade TW, Dyer S, et al. “Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment.” British Medical Journal, Volume 300, Number 6737, June 2, 1990, Pages 1431-1437. 88. Meade TW, Dyer S, et al. “Randomised Comparison of Chiropractic and Hospital Outpatient Management for Low-Back Pain: Results from Extended Follow Up.” British Medical Journal, Volume 311, Number 7001, August 5, 1995, Pages 349-351. 89. Koes, BW, Bouter LM, et al. “Randomised Clinical Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up.” British Medical Journal, Volume 304, Number 6827, March 7, 1992, Pages 601-605. 90. van Tulder and Bouter et al. “Conservative Treatment of Acute and Chronic Nonspecific Low-Back Pain.” Spine, Vol. 22, Number 18, 1997, Pages 2128-2156. 91. von Heymann, Wolfgang J. Dr. med.; Schloemer, Patrick Dipl. math.; Timm, Juergen Prof. Dr. rer. nat. PhD; Muehlbauer, Bernd Prof. Dr. med. Spinal HVLA-Manipulation in Acute Non- specific LBP: A Double Blinded Randomized Controlled Trial in Comparison With Diclofenac and Placebo. Spine. Publish Ahead of Print, POST ACCEPTANCE, 28 September 2012 92. Bishop et al. The chiropractic hospital-based interventions research outcomes study: a random- ized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal 2010(10):1055-1064 93. Wilkey, et al. A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low Back Pain in a National Health Service Outpatient Clinic. Journal of Alternative & Complimentary Therapies: Volume 14, Number 5, 2008, pp.465-473. 94. Gregory F. Parkin-Smith, MTech(Chiro), MSc, DrHC, Ian J. Norman, BSc, MSc, PhD, Emma Briggs, BSc, PhD, RN, Elizabeth Angier, BSc, MSc(Chiro), Timothy G. Wood, BSc, MTech(Chiro), James W. Brantingham, DC, PhD A Structured Protocol of Evidence-Based Conservative Care Compared With Usual Care for Acute Nonspecific Low Back Pain: A Randomized Clinical Trial Arch Phys Med Rehabil Vol 93, January 2012 95. O. Aure, Nilsen, Vasseljen. Manual Therapy and Exercise Therapy in Patients with chronic Low Back Pain. Spine, Vol 28, Number 6, 2003, pp. 525-532. 96. Fritz, J, Cleland, J, Childs, JD, “Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy,” Journal of Orthop Sports Physical Therapy 37, no. 6 (June 2007): 290-302. 97. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27(24):2835-2843. 98. Malanga G. A., Chimes G. P., Memmo P.. Lumbosacrale Facet Syndrome: Treatment and medication. Medscape. 2008. 99. Hides J, Stanton W, McMahon S, Sims K, Richardson C. Effect of stabilization training on multifidus muscle cross-sectional area among young elite-cricketers with low back pain. J Orthop Sports Phys Ther 2008;38:101-108 100. Cloet N Vangindertael J Jughters A. Facet Joint Syndrome. www.physio-pedia.com/Facet_Joint_Syndrome. Accessed 2/15/14 101. Malanga G. A., Chimes G. P., Memmo P.. Lumbosacrale Facet Syndrome: Treatment and medication. Medscape. 2008. 102. Tilbrook HE, Cox H, Hewitt CE, et al. Yoga for chronic low back pain: a randomized trial. Ann Intern Med. Nov 1 2011;155(9):569-78. 103. Kroll HR, Kim D, Danic MJ, et al. A randomized, double-blind, prospective study comparing the efficacy of continuous versus pulsed radiofrequency in the treatment of lumbar facet syndrome. J Clin Anesth. Nov 2008;20(7):534-7. 104. Allyson Ianuzzi, Partap S. Khalsa Comparison of human lumbar facet joint capsule strains during simulated high-velocity, low-amplitude spinal manipulation versus physiological motions The Spine Journal Volume 5, Issue 3 , Pages 277-290, May 2005