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Spinal manipulation is reaching a tipping point in the United States as a well-accepted treatment for Low back pain and disability.  There are abundant studies demonstrating the benefit of SMT as a stand-alone treatment for LBP; however, manipulation, when combined with exercise has even better results. (1,2) To date, most studies have focused almost solely on adult populations.  There are very few studies analyzing the treatment of children or adolescents with LBP. (3) And for studies of adolescents, there have been no randomized trials utilizing manipulation as a potential strategy.  Many chiropractors treat adolescents with LBP pain on a daily basis.  So, is manipulation and exercise beneficial for adolescents?

Chiropractic treatment of adolescents with LBP is growing. In fact, twelve percent of children age 4-17 utilized complementary healthcare approaches.  SMT is strongly recommended in the treatment of LBP for adult populations.  However, management of children suffering from LBP does not have a widely accepted treatment algorithm.  There is an urgent need for non-pharmacologic LBP treatment options, especially in this young population.  Evans et al. set out to answer the problem in a multi-center randomized trial comparing 12 weeks of spinal manipulative therapy (SMT) combined with exercise therapy (ET) to exercise therapy alone.

“For adolescents with chronic LBP, spinal manipulation combined with exercise was more effective than exercise alone over a 1-year period, with the largest differences occurring at 6 months.” (4)

Participants included 185 adolescents aged 12-18 with chronic LBP. The primary outcome was LBP severity at 12, 26, and 52 weeks. Secondary outcomes included disability, quality of life, medication use, patient-rated and caregiver-rated improvement, and satisfaction. Adding SMT to ET resulted in a larger reduction in LBP severity over the course of one year. The group difference in LBP severity (0-10 scale) was small at the end of (12 weeks) treatment but was larger at weeks 26 and 52 weeks. At 26 weeks, SMT with ET performed better than ET alone for disability and improvement. The SMT with ET group reported significantly greater satisfaction with care at all time points. There were no serious treatment-related adverse events.


  • LBP severity is reduced in both the short-term and long-term
  • SMT decreases disability associated with chronic LBP
  • Patient satisfaction increases at all time points when treatment includes SMT and exercise

Adolescents should not have chronic pain.  Unfortunately, the increase in sports specialization and year-round training has led to an epidemic of children with LBP.  On the opposite end of the spectrum, there is a growing number of school-aged kids with a sedentary lifestyle.  Both extremes result in LBP and should be addressed.  Many patients with LBP benefit from SMT to restore motion to the lumbar spine and surrounding areas.  SMT is safe in adolescents and shows a more significant benefit than exercise alone.

Patient education is one of the most crucial aspects of care delivery for evidence-based chiropractors.  Often patients want to know what you are doing and why you are doing it.  With this new paper, we can be confident that adolescents with chronic LBP benefit more with manipulation and exercise. ChiroUp’s condition reports and exercise plans allow you to prescribe the right condition-specific rehab to the right patients while saving you time. By working together, we can make chiropractic the undeniable best choice for patients of all ages!

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  1. Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R,Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt E. Noninvasive treatments for low back pain. Rockville, MD: Agency for Healthcare Research and Quality (US), 2016.
  2. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev 2011;2:CD008112.
  3. Fanucchi GL, Stewart A, Jordaan R, Becker P. Exercise reduces the intensity and prevalence of low back pain in 12-13 year old children: a randomised trial. Aust J Physiother 2009;55:97–104.
  4. Roni Evans, Mitchell Haas, Craig Schulz, Brent Leininger, Linda Hanson, Gert Bronfort Spinal manipulation and exercise for low back pain in adolescents: a randomized trial PAIN 159 (2018) 1297–1307

About the Author

Dr. Brandon Steele

Dr. Brandon Steele


Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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