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The methodology involved a literature review and panel assessments.

• To determine the appropriateness of manipulation and mobilization for chronic low back pain, we convened a nine-member modified-Delphi panel of clinicians.
• The initial ratings of appropriateness were made individually and without group discussion.
• The second-round ratings followed a structured face-to-face method that was based on procedures often used to bring people closer to consensus or agreement.
• The project staff compiled the initial indications list using a literature review, the advice of chiropractors and an internist, and a list of indications created for an earlier study on manipulation for low back pain.

The panel rated 450 indications to assess the appropriateness of manipulation and mobilization for chronic low back pain.

• There was agreement among the panelists for 17.8 percent to 29.8 percent of indications.
• The average median appropriateness ratings ranged from 5.2 to 5.5 on a nine-point scale, and 15.3 percent to 24.3 percent of indications were rated appropriate.
• Appropriateness ratings for mobilization were higher than the ratings for manipulation.
• Appropriateness ratings for either treatment were higher assuming nonmanipulative conservative care has failed than when no other adequate conservative care has been given.
• Most findings were equivocal; i.e., raters were split on the appropriateness of the measures described.
• Rates of agreement increased after panelists met to discuss the issues.