Who Responds Best To Spinal Manipulation?

side posturewho responds best to smt

Not every patient responds the same to Chiropractic adjustments or high velocity, low-amplitude (HVLA) spinal manipulation (SMT). That fact is obvious. However, there are some evidence-based patient characteristics that can predict who will respond better than others. Utilizing the research evidence on responsiveness characteristics to SMT can aid us in making better prognoses to our care.


Spinal Segmental Stiffness: Researchers have found that patients with at least one hypomobile vertebral segment, or spinal segmental stiffness beyond normal respond better to HVLA thrust manipulation. Further, the thrust SMT improved pre-SMT spinal segmental stiffness, while non-thrust manipulation did not. Interestingly, this included both global stiffness (stiffness of the underlying tissues throughout the measurement) and terminal stiffness (stiffness at the measurement end point).


Multifidus Activation:  Decreased activation and recruitment of the multifidi muscles is a common feature in spinal segmental dysfunction. Those patients with increased multifidus thickness and activation sustained over a one-week follow-up period after SMT have been shown to be good responders. SMT activates the Multifidus muscle with lasting effects in good responders.

The Multifidus is distinctive for the unusually high number of muscle spindles it contains. Muscle spindles are sensory receptors in muscles that detect changes in the length of the muscle and report this information back to the central nervous system. The central nervous system uses the information to calculate the body’s current position.

Atrophy of the multifidus muscle was found in patients with back pain, lumbar radiculopathy, and lumbar degenerative kyphosis. There is increased fat infiltration to the multifidus muscle in those patients with lumbar radiculopathy or lumbar degenerative kyphosis.


Minimal Facet Joint Degeneration: In lumbar spine back pain patients, SMT responders tended to have a lower prevalence of severely degenerated facets than non-responders according to a 2019 study. MR imaging studies also found that SMT responders were also characterized by significant increases in post-SMT apparent diffusion coefficient (ADC) values at discs associated with painful segments identified by palpation. Curiously, there was no significant difference in other spinal degenerative features found on MR imaging, such as Modic changes.


More Localized Symptoms: Patients with lumbar pain and no symptoms extending distal to the knee have been shown to be better responders to SMT. Patients with cervical pain with referral proximal to the shoulder or those with cervical spondylosis without radiculopathy have been shown to respond better to SMT.


Shorter Duration of Symptoms: Spinal pain symptom duration of less than 30 days for cervical, and 16 days for lumbar spine pain conditions have a better immediate response to SMT.


Early Symptomatic Response to SMT: Acute neck pain patients (<4 weeks symptoms) that reported improvement in 1 week have shown a 3X greater improvement at 3 months compared to those unimproved at 1 week. For patients with chronic pain (>12 weeks symptoms), those reporting improvement in 1 month had a 6X greater improvement at 3 months compared to unimproved at 1 week. Acute low back pain patients respond better than chronic low back pain patients. Low back pain patients respond better if at least 1 hip has more than 35 degrees of internal rotation. Predictors of improvement in Thoracic spine pain were a greater decrease in both pain intensity and tenderness.


Poor Responder Characteristics:

Patients who respond poorly to SMT most often have one or more factors as the reason: Inappropriate technique, poorly executed technique, unsuitable patient selected, the condition was not appropriate for the technique or treatment.


About The Author

Dr. David Graber is the chairperson of the ANJC Council on Technique and Clinical Excellence. He maintains a private practice in Parsippany, NJ. He can be reached at: DrDavidGraber@gmail.com.




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Originally published: New Jersey Chiropractor, Spring 2019


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