Skip to main content

Cost-Effectiveness of Spinal Manipulation

Julie Fritz, PhD, PT, ATC, leads a team of investigators from the University of Utah and Intermountain Health Care investigating the effectiveness and cost-effectiveness of spinal manipulation for a sub-group of patients with low back pain. The Institute of Medicine has recognized low back pain as a top 15 priority condition, calling for health care organizations to develop new, evidence-based care processes. One intervention shown to be effective for at least some patients with low back pain is spinal manipulation, however not all patients will respond to this intervention.

Recent research by Dr. Fritz and colleagues has led to the development of a clinical prediction rule that identifies a subgroup of patients with LBP likely to experience rapid, pronounced, and sustained decreases in disability and pain with a brief manipulation and exercise intervention, suggesting it may be more cost-effective to manage this sub-group with early referral to physical therapy instead of a stepped care approach.(1,2) The integration of this prediction rule into routine clinical care is the focus of this research effort.

Current Projects

Cost-Effectiveness of Spinal Manipulation for Patients in Primary Care

We are examining the feasibility and clinical outcomes of integrating the clinical prediction rule into primary care management of patients with low back pain. The study is a collaborative effort between Dr. Fritz and Intermountain Health Care. The design is a randomized clinical trial, comparing management based on the prediction rule with the current clinical practice guidelines that recommend initial management of advice and education only for the first few weeks. Although the intervention will occur within the first few weeks of care, patients will be followed for 1 year. Outcomes will include measures of disability, pain, satisfaction, and direct medical costs. This study will permit an examination of the feasibility, costs, and effectiveness of integrating the clinical prediction rule into primary care.

Comparison of Different Manipulation Techniques

The clinical prediction rule developed for a sub-group of patients with low back pain examined only one manipulation technique. We encourage you to read the study "A Clinical Prediction Rule to Identify Patients with Low Back Pain Likely to Respond to Manipulation."

This study is a multi-center randomized clinical trial to compare the outcomes of three different manual therapy techniques in patients with low back pain who fit the clinical prediction rule. All patients will receive the same treatment protocol, and the only difference among the groups will be the specific manual therapy technique used. One group will receive the manipulation technique on which the prediction rule was based. Another group will receive an alternative lumbar manipulation technique, and another group will receive a mobilization technique.

Primary outcomes will be the patients perceived level of pain and disability assessed one- and four-weeks, and six-months after baseline. This study is a collaborative effort between Dr. Fritz and Intermountain Health Care, Rehabilitation Services of Concord Hospital in Concord, New Hampshire , Wilford Hall Air Force Base in San Antonio, Texas, and the Clinical Residency Program in Orthopedic Physical Therapy at the University of Southern California, Los Angeles California.


    • Gerard Brennan, PT, PhD
    • Director of Clinical Quality and Outcomes
    • Intermountain Health Care
    • Salt Lake City, Utah
    • John Childs, PT, PhD, MBA, OCS, FAAOMPT
    • Assistant Professor and Director of Research
    • US Army-Baylor University Doctoral Program in Physical Therapy
    • San Antonio, Texas
    • Josh Cleland, DPT, OCS
    • Assistant Professor
    • Franklin Pierce College
    • Concord, New Hampshire
    • Kornelia Kulig, PT, PhD
    • Associate Professor of Clinical Physical Therapy
    • University of Southern California
    • Los Angeles, California
    • Julie M. Whitman, PT, DSc, OCS, FAAOMPT
    • Assistant Professor
    • Regis University
    • Denver, Colorado

Key Publications

  1. 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; 27:2835-2843.
  2. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain who will benefit from spinal manipulation: A validation study. Ann Int Med. 2004;141: 920-928.
  3. Fritz JM, Delitto A, Erhard RE. Comparison of a classification-based approach to physical therapy and therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine. 2003; 28:1363-1371.
  4. Fritz JM, Whitman JM, Flynn TW, Wainner RM, Childs JD. Clinical factors related to the failure of individuals with low back pain to improve with a spinal manipulation. Phys Ther. 2004;84:173-190.
  5. Fritz JM, Brennan GP, Clifford SN, Hunter SJ, Thackeray A. An examination of the reliability of a classification algorithm for sub-grouping patients with low back pain. Spine. In press
  6. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying sub-groups of patients with acute/subacute "non-specific" low back pain: results of a randomized clinical trial. Spine. In Press

Contact Us

Charlie Hicks-Little, PhD

Phone: 801-581-4897 Email: