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



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.

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The authors would like to thank the Canadian Chiropractic Research Foundation and Alberta Innovates-Health Solutions Graduate Research Allowance for funding this project. Arnold Wong was supported by the Golden Key Graduate Scholar Award. The authors also thank Magnetic Imaging Consultants for providing scan services, and the River Valley Health Clinic for providing professional spinal manipulation and clinical space. The authors also express gratitude to Mr. Karl Brandt and Ms. Carolyn Berendt for assisting the coding and decoding of data files.

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Correspondence to Arnold Y. L. Wong.

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Appendix 1: Clinical prediction rule

Clinical characteristics of the clinical prediction rule for identifying people who benefit from spinal manipulative therapy

Clinical characteristics Definition of a positive finding
1. Duration of the current episode of low back pain Less than 16 days
2. Distal symptoms No symptoms distal to the knee
3. Fear avoidance beliefs questionnaire work subscale Less than 19 points
4. Lumbar stiffness At least one lumbar segment is determined to be hypomobile by the examiner using a manual posteroanterior spinal mobility test
5. Hip internal rotation range of motion At least one hip with 35° or greater as measured by an inclinometer in prone

Appendix 2: Spinal manipulative therapy procedure

The supine participant crossed and put his/her fingers behind the neck. The clinician stood opposite to the side to be manipulated and side bent the participant’s trunk towards the side of the pelvis to be manipulated, and rotated the trunk in the opposite direction. Then the clinician applied a high-velocity, low-amplitude thrust to the pelvis in a posteroinferior direction. The clinician delivered spinal manipulative therapy to each side at each given session. If the first attempt did not result in cavitation, a second spinal manipulation was allowed for each side. A maximum of two spinal manipulations would be given to each side within a session. In the current study, only two out of 64 sessions required a second spinal manipulation on the one side (one for responder and one for non-responder).

Appendix 3: Intra-observer reliability of the dichotomized degeneration variables

Magnetic resonance imaging findings Dichotomized category Kappa (CI)
Facet joint Normal (grade 0)
Abnormal (grade 1, 2 or 3)
0.84 (0.68–1.00)
Disc degeneration Normal (Pfirrmann grade 1);
Abnormal (Pfirrmann grade 2, 3, 4 or 5)
0.80 (0.62–0.98)
Modic changes Normal (no change)
Abnormal (types 1, 2, 3, mixed 1/2 or mixed 2/3)
0.81 (0.62–1.00)
  1. Cohen’s kappa coefficient was interpreted as poor (< 0.00), slight (0.00–0.20), fair (0.21–0.40), moderate (0.41–0.60), substantial (0.61–0.80) and almost perfect (0.81–1.0) agreement [52]
  2. CI confidence interval

Appendix 4: Intra-observer reliability of apparent diffusion coefficient measurement

Disc ICC3,1 (95% CI) Mean ADC (SD)a SEM MDC95 N
L1–2 0.98 (0.96–0.99) 2.181 (0.224) 0.032 0.089 15
L2–3 0.97 (0.94–0.99) 1.966 (0.136) 0.023 0.064 16
L3–4 0.99 (0.97–0.99) 2.010 (0.087) 0.009 0.025 16
L4–5 0.98 (0.95–0.99) 2.039 (0.111) 0.016 0.044 15
L5–S1 0.98 (0.96–0.99) 2.059 (0.246) 0.035 0.097 14
  1. CI confidence interval, ICC intra-class correlation coefficient, SD standard deviation, SEM standard error of measurement, MDC95 minimal detectable change at the 95% confidence interval, N number of disc
  2. aMean and standard deviation of apparent diffusion coefficient (ADC) values were expressed in units of 10−3 mm2/s

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Wong, A.Y.L., Parent, E.C., Dhillon, S.S. et al. Differential patient responses to spinal manipulative therapy and their relation to spinal degeneration and post-treatment changes in disc diffusion. Eur Spine J 28, 259–269 (2019). https://doi.org/10.1007/s00586-018-5851-2

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