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Chiropractic spinal manipulation has been one of the best-kept secrets for the conservative management of LBP… but that is changing.

In the past year, our profession has been helped by several other highly respected players including The American College of Physicians, JAMA, and the FDA. Most recently, 37 attorney’s general have endorsed chiropractic as a management tool for the opioid crisis and the Joint Commission has published new accreditation guidelines that will encourage hospitals to incorporate more conservative pain strategies, specifically chiropractic.

Yes, chiropractic spinal manipulation is receiving some well-deserved positive press. Chiropractors are very proud of their highly effective tool- but what happens when manipulation doesn’t resolve the patient’s complaint?

The most successful chiropractors use a simple predictive formula to know when manipulation is the best option and when something else is needed. This reproducible classification formula is outlined below.

Did you ever wonder why one LBP patient responded quickly to manipulation while a similar case failed? Or why some patients respond favorably to knee-to-chest exercises, while others prefer extension? While some like traction and others don’t?

Choosing the most appropriate treatment for any given LBP patient requires that your history and exam accomplish the following three criteria:

  1. Establish a structural diagnosis to identify the tissue of origin, i.e. facet syndrome, disc lesion, stenosis, etc.
  2. Identify the concurrent biomechanical dysfunctions that perpetuate these problems, i.e., foot hyperpronation, hip abductor weakness,
  3. Choose the most appropriate treatment based upon a classification .

Check out the following video to see this process in action.


This patient was a classic presentation for the diagnosis of extension biased lumbar disc lesion. Choosing manipulation as the only management tool would likely not have produced the same rapid positive outcome.

The most effective evidence-based chiropractors determine which treatment techniques are likely to produce the best results by classifying LBP presentations via the five following categories:

  • Manipulation
  • Extension-biased
  • Flexion-biased
  • Stability
  • Traction

Classification groups are not mutually exclusive; some patients, like our example, will require more than one category of treatment. The following chart outlines the typical history, exam findings, and structural diagnoses associated with each category of treatment.

Clearly, the classification process requires more than a 500-word blog and chart to fully appreciate, but hopefully, this discussion enhances your appetite to employ clinical prediction rules when selecting the most appropriate LBP management tools.

ChiroUp welcomes your feedback. More than anything, we are a knowledge-sharing resource for like-minded highly successful chiropractors. To learn more, please visit www.ChiroUp.com

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman


Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

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