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Robert J. Fluegel, PT, COMT
MAPS Faculty, Fellow in Training, MAPS Orthopedic Manual Therapy Fellowship

Chris R. Showalter, PT, OCS, COMT, FAAOMPT, Fellowship Program Director

Mobilization combined with Stabilization is SUPERIOR compared to Stabilization alone in Non-Specific Mechanical Neck Pain (NSMNP)

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Mobilization and Manipulation are EQUALLY EFFECTIVE and produce the SAME OUTCOMES in Mechanical LBP

June 06, 2014


MAPS Groundbreaking 2012 study "Manipulation vs Mobilization for LBP" is in the Top 5% of articles EVER discussed online

MAPS landmark study "Early use of Thrust Manipulation versus Non-Thrust Manipulation: A Random Controlled Trial" has received significant interest around the world. The online attention this study received is in the top 5% of all articles EVER reviewed and discussed online, according to tracking data from the quality measurement tool Almetric.

MAPS Clinical Director, and Co-Author of the study, Chris Showalter PT, OCS, COMT, FAAOMPT, published a Research Commentary on this groundbreaking study on October 10, 2012. Find out what all the buzz is about. The research commentary can be found here:



Chris Showalter PT, OCS, COMT, FAAOMPT

MAPS Clinical Director

Full Disclosure: This month's Research Commentary discusses a peer reviewed research article co-authored by MAPS Research Consultant Chad Cook and MAPS Senior Faculty Members Ken Learman, Chris Showalter, Vincent Kabbaz and Bryan O'Halloran. The synopsis and link to Manual Therapy are found below. The full article will be available in an upcoming issue of Manual Therapy


Mobilization and Manipulation are EQUALLY EFFECTIVE and produce the SAME OUTCOMES in Mechanical LBP

Prior studies have proclaimed the early use of Thrust Manipulation (TM) in Acute Low Back Pain (LBP) as TM has been suggested to improved outcomes and provide quicker recovery. To our knowledge only two prior studies have directly compared TM to Mobilization, also known as Non Thrust Manipulation, (NTM) (Hadler et al, 1987 and Cleland et al, 2009). These studies both concluded that TM was superior to NTM. Contrary to the Hadler and Cleland studies, our results find NO DIFFERENCES between TM and NTM. We discuss potential reasons for these different results in detail in the complete article:

"Early use of thrust manipulation versus non-thrust manipulation: A randomized clinical trial"

Chad Cook, Kenneth Learman, Chris Showalter, Vincent Kabbaz, Bryan O'Halloran (E Pub, Manual Therapy)

There are three unique features incorporated into the design of this study, namely:

1)     Control for potential therapist bias

We performed pre-study evaluations of each treating therapist for "personal equipoise" regarding NTM and TM, and hence any pre-conceived therapist bias regarding the relative effectiveness of the interventions. To our knowledge, this is the FIRST STUDY to actively control for this potential for bias when investigating two manual therapy procedures.   

2)     Control for potential patient expectation bias

Patient expectations were also evaluated, prior to treatment, regarding the patient's perception of the most beneficial treatment approach (NTM or TM). To our knowledge, this is the FIRST STUDY to actively control for this potential for bias when investigating two manual therapy procedures.

3)     Pragmatic design reflects "actual clinical practice"

We designed our pragmatic trial to reflect actual clinical decision making processes involving manual therapy interventions. As such, our study reflects actual clinical practice in which physiotherapists were allowed to alter their treatment decision making based upon patient presentation. To our knowledge, this is only the FIRST STUDY to allow unfettered therapist clinical decision making when investigating two manual therapy procedures for LBP. Others (Leaver et al, 2010) have investigated NTM and TM in recent onset neck pain as a pragmatic trial (allowing therapists to modify their treatment). They also found no difference in the NTM or TM, in their study involving neck patients.

Background on Personal Equipoise AND Patient Expectations  

"Clinical and personal equipoise exists when a clinician has no good basis for a choice between two or more care options or when one is truly uncertain about the overall benefit or harm offered by the treatment to his/her patient. For most manual therapy trials, equipoise does not likely exist. Because of the nature of the intervention a lack of equipoise can lead to bias and may account for a portion of the ‘effect’ that has traditionally been assigned to the intervention. Although there are methodological mechanisms to reduce the risk of bias associated with a lack of equipoise, most of the manual therapy trials to date are likely guilty of this form of bias." (Cook and Sheets 2011)

It has been reported that if personal equipoise is biased toward one procedure, there is a danger that the trial will NOT be properly aimed at maximizing benefits to future patients (Alderson, 1996) 

Patient expectations may also be an influential component of clinical outcomes related to musculoskeletal pain (Bialosky et al 2010)


Study Methods

Patients were included if they were > 18 years of age and had mechanically reproducible LBP. 

After randomized allocation into the NTM and TM groups, therapists were allowed to determine which actual NTM or TM technique to use to implement the patients treatment for the first two treatment sessions. As treatment progressed, the therapists were allowed to modify treatment based upon their clinical reasoning and the patient's response to treatment.

We explored 5 different outcomes measures, namely:

  1. Oswestry Disability Index (ODI)

  2. Numeric Pain Rating Scale (NPRS)

  3. Reported of Rate of Recovery

  4. Total Visits and Days in Care

  5. FABQ (Work Subscale)                       

A two-way mixed model MANCOVA was used for statistical analysis.


Two important factors, Personal Equipoise and Patient Expectations, were controlled for in the study analysis and this is reflected in the subsequent results.


Study Results

N =149 patients completed the study

Average period of care was 35 days 


There were NO SIGNIFICANT DIFFERENCES between NTM and TM at the 2nd visit, or at discharge with ANY OF THE 5 OUTCOME MEASURES USED (ODI, NPRS, Reported Rate of Recovery, Total Visits and Days in Care, and FABQ)




1) This is the FIRST STUDY to show that Mobilization (NTM) and Manipulation (TM) are EQUALLY EFFECTIVE  in PRODUCING the SAME OUTCOMES in Mechanical LBP Patients


Within group changes were significant for both groups 

In other words...mobilization and manipulation produce the same outcomes in mechanical LBP Patients


2) This is the FIRST STUDY to control for personal equipoise AND patient expectations during the investigation of two manual therapy interventions...our control for equipoise and expectations results in substantially increased validity of our findings


In other words...prior studies that did not control for these significant factors may suffer from bias in terms of their results and conclusions


3) This is the FIRST LBP STUDY to reflect actual clinical practice in which physiotherapists were allowed to alter their treatment decision making based upon patient presentation (a pragmatic design)


In other words...when therapists who use mobilization and manipulation in clinical practice are allowed to mobilize and manipulate according to the patient's presentation...there is no difference between the two interventions


4) This is the FIRST STUDY to show that personal equipoise affects study outcome...personal equipoise was significantly associated with ODI and Pain (NPRS).


In other words...failure to control for equipoise (as is the case with prior manual therapy studies) may introduce bias into the study, the results and the subsequent conclusions.


Cheers and Enjoy

Chris R. Showalter PT, OCS, COMT, FAAOMPT 

© Chris R. Showalter and Maitland Australian Physiotherapy Seminars


Not to be reproduced, copied or retransmitted in any manner without author's express written permission

Directing others to the MAPS website ( is permissible.


Article Follows (with weblink to Manual Therapy)


Early use of thrust manipulation versus non-thrust manipulation: A randomized clinical trial

Chad Cook, Kenneth Learman, Chris Showalter, Vincent Kabbaz, Bryan O'Halloran



The purpose of this study was to investigate the comparative effectiveness of early use of thrust (TM) and non-thrust manipulation (NTM) in sample of patients with mechanical low back pain (LBP). The randomized controlled trial included patients with mechanically reproducible LBP, > age 18-years who were randomized into two treatment groups. The main outcome measures were the Oswestry Disability Index (ODI) and a Numeric Pain Rating Scale (NPRS), with secondary measures of Rate of Recovery, total visits and days in care, and the work subscale of the Fears Avoidance Beliefs Questionnaire work subscale (FABQ-w). A two-way mixed model MANCOVA was used to compare ODI and pain, at baseline, after visit 2, and at discharge and total visits, days in care, and rate of recovery (while controlling for patient expectations and clinical equipoise). A total of 149 subjects completed the trial and received care over an average of 35 days. There were no significant differences between TM and NTM at the second visit follow-up or at discharge with any of the outcomes categories. Personal equipoise was significantly associated with ODI and pain. The findings suggest that there is no difference between early use of TM or NTM, and secondarily, that personal equipoise affects study outcome. Within-groups changes were significant for both groups.


Where to find the Articles  


Hadler NM, Curtis P, Gillings DB, Stinnett S. A benefit of spinal manipulation as adjunctive therapy for acute low-back pain: a stratified controlled trial. Spine (Phila Pa 1976). 1987 Sep;12(7):702-6



Cleland JA, Fritz JM, Kulig K, Davenport TE, Eberhart S, Magel J, Childs JD. Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial. Spine (Phila Pa 1976). 2009 Dec 1;34(25):2720-9.



Leaver AM, Maher CG, Herbert RD, Latimer J, McAuley JH, Jull G, Refshauge KM. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil. 2010 Sep;91(9):1313-8.



Cook CE, Sheets C. Clinical equipoise and personal equipoise: two necessary ingredients for reducing bias in manual therapy trials. JMMT, Volume 19, Number 1, 2011, pp. 55-57(3)



Alderson P. Equipoise as a means of managing uncertainty: personal, communal and proxy. J Med Ethics. 1996 Jun;22(3):135-9.



 Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Phys Ther. 2010 Sep;90(9):1345-55.

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