Manipulation Optimal Dosage

This addresses the question “How many treatments do I need.” My interpretation is that manipulation improved pain and health status. However, it reinforces my personal opinion that prolonged treatment yields little improvement and hence is often not indicated. See what you think!

Dose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial

Mitchell Haas et al2014


Background context

No previous trials for optimal number of visits for the care of any condition with spinal manipulation.


Identify the dose-response relationship between visits for spinal manipulation and chronic low back pain (cLBP) outcomes and to determine the efficacy of manipulation by comparison with a light massage control.

Study design/setting

Practice-based randomized controlled trial.

Patient sample

400 participants with cLBP.

Outcome measures

Primary cLBP outcomes were the 100-point modified Von Korff pain intensity and functional disability scales evaluated at the 12- and 24-week primary end points.

Secondary outcomes included days with pain and functional disability, pain unpleasantness, global perceived improvement, medication use, and general health status.


100 participants with cLBP were randomized tofour dose levels of care: 0, 6, 12, or 18 sessions of spinal manipulation. Participants were treated three times per week for 6 weeks. Covariate-adjusted linear dose effects and comparisons with the no-manipulation control group were evaluated at 6, 12, 18, 24, 39, and 52 weeks.


Primary outcomes, mean pain and disability improvement in the manipulation groups were 20 points by 12 weeks and sustainable to 52 weeks. Linear dose-response effects were small, reaching about two points per six manipulation sessions at 12 and 52 weeks for both variables (p<.025). At 12 weeks, the greatest differences from the no-manipulation control were found for 12 sessions (8.6 pain and 7.6 disability points, p<.025); at 24 weeks, differences were negligible; and at 52 weeks, the greatest group differences were seen for 18 visits (5.9 pain and 8.8 disability points, p<.025).


The number of spinal manipulation visits had modest effects on cLBP outcomes above those of 18 hands-on visits to a chiropractor. Overall, 12 visits yielded the most favourable results but was not well distinguished from other dose levels.

  • The Spine Journal, July 1, 2014 Volume 14, Issue 7, Pages 1106–1116