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Randomized controlled trial.To compare the effects of the McKenzie method performed by certified therapists with spinal manipulation performed by chiropractors when used adjunctive to information and advice.Recent guidelines recommend a structured exercise program tailored to the individual patient as well as manual therapy for the treatment of persistent low back pain. There is presently insufficient evidence to recommend the use of specific decision methods tailoring specific therapies to clinical subgroups of patients in primary care.A total of 350 patients suffering from low back pain with a duration of more than 6 weeks who presented with centralization or peripheralization of symptoms with or without signs of nerve root involvement, were enrolled in the trial. Main outcome was number of patients with treatment success defined as a reduction of at least 5 points or an absolute score below 5 points on the Roland Morris Questionnaire. Secondary outcomes were reduction in disability and pain, global perceived effect, general health, mental health, lost work time, and medical care utilization.Both treatment groups showed clinically meaningful improvements in this study. At 2 months follow-up, the McKenzie treatment was superior to manipulation with respect to the number of patients who reported success after treatment (71% and 59%, respectively) (odds ratio 0.58, 95% confidence interval [CI] 0.36 to 0.91, P = 0.018). The number needed to treat with the McKenzie method was 7 (95% CI 4 to 47). The McKenzie group showed improvement in level of disability compared to the manipulation group reaching a statistical significance at 2 and 12 months follow-up (mean difference 1.5, 95% CI 0.2 to 2.8, P = 0.022 and 1.5, 95% CI 0.2 to 2.9, P = 0.030, respectively). There was also a significant difference of 13% in number of patients reporting global perceived effect at end of treatment (P = 0.016). None of the other secondary outcomes showed statistically significant differences.In patients with low back pain for more than 6 weeks presenting with centralization or peripheralization of symptoms, we found the McKenzie method to be slightly more effective than manipulation when used adjunctive to information and advice.