EVIDENCE BASE

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Spinal manipulation therapy

~qqSpinal manipulation is an intervention performed on spinal articulations, synovial joints,
which is asserted to be therapeutic. These articulations in the spine that are amenable to spinal
manipulative therapy include the z-joints, the atlanto-occipital, atlanto-axial, lumbosacral,
sacroiliac, costotransverse and costovertebral joints.

 Spinal manipulation is also called spinal manipulative therapy. It’s a technique where

practitioners use their hands or a device to apply a controlled thrust (that is, a force of a specific
magnitude or degree in a specific direction) to a joint of your spine.
Spinal Manipulative Therapy (SMT) is effective for some individuals experiencing low back pain
(LBP); however, the mechanisms are not established regarding the role of placebo.
For our particular question on the effects of spinal manipulative therapy for neck pain we can take
advantage of the subject headings to specify Therapy as ‘stretching, mobilization, manipulation,
massage’ and Body Part as ‘head or neck’. Then we combine these search criteria with an AND by
checking the button at the bottom left of the screen, and we click on Start Search. PEDro returns 150
records. This is too many titles to scroll through, so we could select ‘systematic reviews’ under Method.
This returns 31 systematic reviews, most of which appear to be relevant to our question.12 We could
further narrow the search by specifying that the review must have been published since 2003, which
returns just three systematic reviews. One is a Cochrane systematic review, and that would be a good
place to start reading! This example illustrates one of the strengths of the Advanced Search , subject
headings can be used as a substitute for two or more synonyms. In fact you can combine any number of
subject headings and you can combine a subject heading with search terms entered as text. It is not
generally possible, in PEDro, to perform searches with combinations of ANDs and ORs. (Proficient users
of PEDro might like to consult Box 4.2 for some suggestions on how to trick PEDro into effectively
combining AND and OR searches.) A consequence is that, in PEDro at least, it is good policy to resist the
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temptation to use many search terms. Searches that employ many search terms will tend either to return
many irrelevant records (when OR is used), or no records at all (when AND is used). In general the best
search strategies have few search terms. It is often possible to use just one carefully selected search term,
and it is rarely necessary to use more than three.

Biomechanics
Spinal manipulation can be distinguished from other manual therapy interventions such as mobilization by
its biomechanics, both kinetics and kinematics.
While spinal manipulations may pose as a therapeutic effect in pain management, their efficacy in promoting
performance enhancement is inconclusive. The outcomes of individuals who undergo spinal manipulations
vary on a patient-to-patient basis

Providers
In North America, it is most commonly performed by physical therapists, osteopathic
physicians, occupational therapists, and chiropractors.
In Europe, physiotherapists, osteopaths and chiropractors are the majority providers, although the precise
figure varies between countries. In 1992, chiropractors were estimated to perform over 90% of all manipulative
treatments given for low back pain treatment.[45] A 2012 survey in the US found that 99% of the first-
professional physical therapy programs that responded were teaching some form of thrust joint manipulation
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Effectiveness
Back pain
A 2004 Cochrane review found that spinal manipulation
(SM) was no more or less effective than other commonly
used therapies such as pain medication, physical therapy,
exercises, back school or the care given by a general
practitioner. A 2010 systematic review found that most
studies suggest SM achieves equal or superior improvement
in pain and function when compared with other commonly
used interventions for short, intermediate, and long-term
follow-up. A 2019 systematic review concluded that SM
produced comparable results to recommended treatments for
chronic low back pain, while SM appeared to give improved
results over non-recommended therapies for short term
functional improvement

Neck pain
For neck pain, manipulation and
mobilization produce similar changes,
and manual therapy and exercise are
more effective than other strategies.
[12]
 A 2015 Cochrane systematic review
found that there is no high quality
evidence assessing the effectiveness of
spinal manipulation for treating neck
pain.[13] Moderate to low quality
evidence suggests that multiple spinal
manipulation sessions may provide
improved pain relief and an
improvement in function when
compared to certain medications.
[13]
 Due to the potential risks associated
with spinal manipulation, high quality
randomized controlled trials are needed to
determine the clinical role of spinal manipulation

Suggested mechanisms
The effects of spinal manipulation have been shown to include:
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 Temporary relief of musculoskeletal pain

 Shortened time to recover from acute back pain
 Temporary increase in passive range of motion (ROM)
 Physiological effects on the central nervous system (specifically the sympathetic nervous system)
 Altered sensorimotor integration.
 No alteration of the position of the sacroiliac joint
 Sham or placebo manipulation
Common side effects of spinal manipulation are characterized as mild to moderate and may include: local
discomfort, headache, tiredness, or radiating discomfort

References
1. ^ Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C (December 2010). "An
updated overview of clinical guidelines for the management of non-specific low back pain in primary
care".  European Spine Journal. 19 (12): 2075–94.  doi:10.1007/s00586-010-1502-
y.  PMC 2997201. PMID 20602122.
2. ^ Jump up to:a b Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004). Assendelft WJ
(ed.). "Spinal manipulative therapy for low back pain". The Cochrane Database of Systematic
Reviews. 2004 (1):
CD000447. doi:10.1002/14651858.CD000447.pub2.  PMID  14973958. (Retracted, see doi:10.1002/14
651858.cd000447.pub3. If this is an intentional citation to a retracted paper, please
replace  {{Retracted}}  with  {{Retracted|intentional=yes}} .)
3. ^ Jump up to:a b Gouveia LO, Castanho P, Ferreira JJ (May 2009).  "Safety of chiropractic
interventions: a systematic review"  (PDF). Spine. 34 (11): E405-
13.  doi:10.1097/BRS.0b013e3181a16d63. PMID 19444054.  Safety in chiropractic manipulation is far
from being achieved. Further investigations are urgent to assess definite conclusions regarding this
issue.  ... There is insufficient data to produce a robust conclusion on safety of chiropractic
interventions.
4.Assendelft WJJ, Morton SC, Yu EI et al 2003 Spinal manipulative therapy for low back pain: a
meta-analysis of effectiveness relative to other therapies. Annals of Internal Medicine 138:871–882

5. 7.chiller L 2001 Effectiveness of spinal manipulative therapy in the treatment of mechanical

thoracic spine pain: a pilot randomized clinical trial. Journal of Manipulative and Physiological
Therapeutics 24:394–401

6. 8.Ferreira ML, Ferreira PH, Latimer J et al 2003 Efficacy of spinal manipulative therapy for
low back pain of less than three months’ duration. Journal of Manipulative and Physiological
Therapeutics 26:593–601

7.^ Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM (October 2010). "NASS Contemporary
Concepts in Spine Care: spinal manipulation therapy for acute low back pain".  The Spine Journal.  10  (10):
918–40. doi:10.1016/j.spinee.2010.07.389.  PMID  20869008.

8. Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW (March
2019). "Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain:
systematic review and meta-analysis of randomised controlled trials". BMJ. 364:
l689.  doi:10.1136/bmj.l689. PMC  6396088.  PMID  30867144.
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