Best Evidence Topics
  • Send this BET as an Email
  • Make a Comment on this BET

Effectiveness of Manual Therapy in the Treatment of Acute Lumbar Disc Prolapse

Three Part Question

IN [adults presenting with acute lumbar disc prolapse] IS [manual therapy better than advice on back care & the stay active concept] AT [reducing pain & improving time to return to work & normal activity].

Clinical Scenario

"A 35 year old male presents to the physiotherapy department two weeks after an acute episode of low back pain with referred leg pain. You make a clinical diagnosis of acute lumbar disc prolpase. Evidence based national guidelines suggest it is effacious to give advice on back care education & the stay active concept, but you want to add in manual therapy as you feel this will further speed up his improvement.You decide to see if there is any evidence to support this."

Search Strategy

AMED on OVID interface 1985 - August 2006;PEDRO 1985 - August 2006: CINHAL on OVID interface 1982 - August 2006;
EMBASE 1974 - August 2006; COCHRANE via NELH; McKenzie Institute website; Eight other articles sourced from article references.
[Prolapse$. mp and and intervertebral. mp. and or ( and disk. mp. and {bulg$.mp. or burs$.mp. or extrus$.mp. or hernia$.mp. or sequest$.mp}) or (exp Radiculopathy/ and lumbar. mp.)] and [exp physical therapy modalities/ or exp exercise therapy/ or or physiotherapy$.mp. or manual thaerap$.mp. or physical therap$.mp. or manipulate$ therap$. mp. or exp bed rest/} limit to humans and English language

Search Outcome

Altogether 32 papers were found, of which 29 were irrelevant to the study question.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Grunnesjo et al
160 patients with acute or subacute LBP. Group 1- stay active concept & in some cases muscle stretching (5.6% had verified disc prolapse) Group 2 - Experimental group receiving manual therapy & in some cases steroid injections as well as the stay active concept (11.2% had verified disc prolapse)RCTPain score with VASFaster rate of decrease of pain in Group 2 after 5 weeks ( p=<0.05) NSS between groups at 10 weeksUse of multiple treatment approaches limits evaluation of a specific modality and makes the study difficult to replicate. Treatment was provided individually or in groups giving patients differing experiences for conditions with similar causes, having a detrimental effect on validity, reliability, & reproducibility.
15 item disability rating scoreGroup 2 had consistently lower disability levels than Group 1 for all variables at 5 & 10 weeks (p=<0.05)
Use of painkillers or NSAIDsNSS between groups
Cherkin D. et al
321 patients with LBP > seven days duration. Group 1 Physical Therapy Group where 92% were given a diagnosis of derangement. Group 2 Chiropractic treatment Group 3 minimal intervention (educational booklet)RCTBothersomeness of symptoms at 4 & 12 weeks, & 12 monthsNSS between groupsPatients with sciatica were excluded Only used the McKenzie approach in Physical Therapy Group and didn't consider other manual therapy techniques Not all subjects accounted for (8 missing) Use of single health care system therefore generalizability limited
Roland Disability Scale at 4 & 12 weeks & 12 monthsNSS between groups
Number of days of back related disability at 12 monthsNSS between groups
Reported recurrence of symptoms 2 years after initial treatmentNSS between groups
Patient satisfaction at 1 & 4 weeks75% of subjects in Groups 1 & 2 rated their treatment as
Fritz J. et al
78 patients with work related LBP < three weeks duration & of sufficient severity to necessitate modification of work, randomised to specific therapy groups. Group 1 - 37 patients following clinical guidelines (minimal intervention) Group 2 - Classification group (defined by Delitto)RCTModified OswestryGroup 2 better than Group 1 at 4 weeks (Oswestry 21.4 v 32.4) p= 0.023. NSS between groups at 12 months.Design of trial does not allow conclusions to be drawn over individual treatment effectiveness. Therapists gave the same number of appointments to both groups & this is not necessary according to clinical guidelines where Group 1 should receive minimal intervention, therefore potential for therapist influence cannot be discounted. Subgroups fit into a derangement pattern, but exact numbers of participants in these subgroups unclear. Up to 42% could potentially be drawn out as fitting into this category. Small sample size with no sample size estimate. Potential for therapist bias - same therapist trained in both methods & delivered both treatments. Examined only one patient population. Not all outcome measures reported on.
SF36 PCSGroup 2 better than Group 1 at 4 weeks. PCS 36.8 v 43.0 p =0.029. NSS between groups at 12 months.
SF36 MCSNSS between groups at 4 weeks & 12 months
Total medical costs over study periodGroup 1 $616, Group 2 $465.70
Work statusAt 4 weeks 21 in Group 1 & 34 in Group 2 had no work restrictions.
Additional days off work over 1 yearGroup 1 11 days, Group 2 6 days
Patient satisfaction (15 point scale)Group 2 higher median satisfaction than Group 1 p=0.006
Physical impairmentNSS between groups at 4 weeks & 12 months


There is some support for short-term benefits from the use of manual therapy in acute low back pain, notably in reduction of pain score, lower disability rating, & quicker return to work. In the papers reviewed it was difficult to identify patients with a specific diagnosis of acute lumbar disc prolapse. No papers were identified that answered the specific clinical question.

Clinical Bottom Line

At present there is no published research that provides conclusive evidence that manual therapy is more effective than back care advice, & the stay active concept in the treatment of patients with acute lumbar disc prolapse.


  1. Grunnesjo M. A randomized controlled clinical trial of stay active care versus manual therapy in addition to stay active care: functional variables and pain Journal of Manipulative & Physiologiacl Therapeutics Volume 27 Number 7 pp431-441 2004
  2. Cherkin D. A comparison of physical therapy, chiropractic manipulation, & provision of an educational booklet for the treatment of patients with low back pain New England Journal of Medicine Volume 339 pp 1021 - 1028 1998
  3. Fritz J. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain Spine Volume 28 Number 13 pp 1363 - 1372 2003