Poor sleep quality is a health concern in older adults, with low back pain (LBP) as a hypothesized risk factor. We aimed to synthesize evidence on the association between LBP and sleep quality among adults ≥ 60years. We conducted a systematic review, registered protocol (Open Science framework #u7bc4) and reported it according to PRISMA. We searched MEDLINE, Embase, CINAHL, and PsycINFO (inception to December 2025). We included cross-sectional, cohort, and case-control studies on LBP and sleep quality among adults ≥ 60years. We utilized a combination of OpenAI's ChatGPT and fluent members in our team to translate non-English studies after which we screened and assess their quality. We synthesized evidence from low and moderate risk of bias studies. Our search retrieved 2394 articles. After removing duplicates, we screened 2237 citations for eligibility, with 191 studies eligible for full-text screening. 13 studies were relevant and appraised. Our synthesis includes five studies of moderate to low risk of bias (three cross-sectional and two cohort studies). Although measures of LBP and sleep quality varied across the included studies, all demonstrated an overall positive small association between the two constructs. Chronic LBP is positively associated with poor sleep quality in aging adults. Our study highlights methodological limitations in existing research and calls for more rigorous epidemiological studies.

The back squat is a commonly prescribed exercise for developing lower body strength. The ability to squat can be affected by reduced ankle dorsiflexion range of motion (DF-ROM), leading to limited squat depth and dysfunctional compensatory movement patterns. To investigate the effect of high-velocity low-amplitude lower limb manipulations on 1 repetition maximum (1RM) back squat strength, sagittal plane ankle kinematics during a squat, and active DF-ROM in individuals with asymptomatic deficits in DF-ROM. Twenty-six enrolled; Twenty-four analysed resistance-trained participants with asymptomatic deficits in DF-ROM participated in this double-blind randomised sham-controlled cross-over trial. Interventions involved high-velocity low-amplitude joint manipulations targeting ankle DF-ROM, and a sham which mimicked the manipulations using a mechanical drop mechanism. The primary outcome was a change in back squat 1RM between baseline to post-intervention, with secondary outcomes being maximal ankle DF-ROM during the 1RM squat using 3D motion capture, and change in DF-ROM during the weightbearing lunge test. There was no statistically significant difference between interventions for back squat 1RM (p = 0.27). From baseline, the 1RM increased by 4.75kg (3.6%) following manipulation and 2.75kg (2.1%) following the sham. There were no statistically significant differences between interventions on maximal DF-ROM during the back squat (p = 0.24) and no statistically significant differences in ankle DF-ROM immediately following either intervention (p = 0.39). Based on these results a single session of high-velocity low-amplitude manipulations targeting ankle DF-ROM does not significantly improve 1RM back squat strength compared to sham, and does not influence short-term ankle DF-ROM. Trial registration The study was pre-registered with ANZCTR (ACTRN12622000811707).

Despite the availability of guidelines such as the Consolidated Standards of Reporting Trials (CONSORT) Harms extension, adverse event (AE) reporting in randomized controlled trials (RCTs) of spinal manipulative therapy (SMT) remains inconsistent and incomplete. Many trials fail to provide essential AE details hindering the accurate assessment of SMT-related risks. Mapping the current landscape of AE reporting and identifying deficiencies is critical to improving transparency and advancing patient safety in SMT research and practice. To provide a comprehensive overview of AE reporting in randomized controlled trials (RCTs) investigating high-velocity, low-amplitude SMT for spinal pain, including AE types, characteristics and reporting practices. Scoping review based on a previous systematic review. We searched PubMed and Epistemonikos for systematic reviews indexed up to February 2022 and conducted an updated systematic search in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Index to Chiropractic Literature from January 1, 2018, to September 12, 2023, with a final update on March 8, 2026. Eligible studies were RCTs involving SMT for spinal pain in adults, including multimodal SMT trials. Studies were included if published in English, Spanish, Portuguese, French, German, Norwegian, Swedish, or Danish. AE data were extracted in three steps: whether AEs were mentioned, collected, and reported. For studies reporting AEs, detailed data on type, severity, duration, onset, relatedness, and additional care were categorized into meaningful subgroups. Summary statistics and visualizations were used to describe reporting patterns. Of 253 included RCTs, 55% mentioned AEs, 53% collected them, and only 28% reported their occurrence. AE characteristics were inconsistently reported, with wide variation in terminology and classification. Pain-related AEs were most common, typically described as mild in severity. However, characteristics such as duration, onset, and additional care required were often omitted. Relatedness was also inconsistently assessed. AE reporting in SMT RCTs remains suboptimal and inconsistent with established standards. Improved adherence to standardized reporting frameworks, such as the CONSORT Harms extension, and a cultural shift toward treating AE monitoring as a core component of trial design are urgently needed to enhance transparency and strengthen patient safety.

Patellofemoral pain (PFP) is a common cause of anterior knee pain, particularly among physically active individuals. High-intensity laser therapy (HILT) has shown analgesic effects in several musculoskeletal conditions; however, its role in PFP remains unclear. To evaluate the effects of HILT in people with PFP. Randomized controlled trials (RCTs) evaluating HILT for PFP were identified through searches in PubMed, Scopus, Web of Science, CINAHL, MEDLINE, ScienceDirect, the Cochrane Library, and PEDro, with additional screening of reference lists and gray literature (last search: May 1, 2026). The primary outcome was pain intensity, while functional outcomes were considered secondary. Risk of bias was assessed using the Cochrane RoB 2 tool. Meta-analyses were conducted using standardized mean differences (SMDs) with 95% confidence intervals under a random-effects model. Certainty of evidence was evaluated using the GRADE framework. Four RCTs were included, with 77 participants allocated to HILT combined with exercise and 92 to control groups. The overall RoB was assessed as high across all included trials, primarily driven by concerns related to outcome measurement and selective reporting. All HILT protocols were delivered alongside therapeutic exercise (strengthening and/or stretching), and no included trial evaluated HILT as a standalone intervention. HILT resulted in a statistically significant reduction in pain at post-treatment (SMD = - 0.66; 95% CI - 0.98 to - 0.35; p < 0.01) and at follow-up (SMD = - 1.08; 95% CI - 1.89 to - 0.26; p < 0.01); however, the certainty of evidence was rated as very low due to high RoB across included trials, substantial heterogeneity (I2 > 50%), and imprecision related to small sample sizes. No significant between-group differences were observed for functional outcomes (Kujala scale), for which the certainty of evidence was also very low due to similar methodological limitations. HILT combined with therapeutic exercise may reduce pain in individuals with PFP; however, its independent effect cannot be determined. The very low certainty of the evidence limits confidence in these findings, and improvements in functional outcomes remain unclear. High-quality randomized controlled trials are required to clarify the role of HILT in PFP rehabilitation and to determine its potential contribution within multimodal treatment approaches. CRD42025631248 (PROSPERO) (December 24, 2024).

Percussive therapy (PT) is increasingly used for post-exercise recovery, but its effects and dose-related responses after exercise-induced muscle damage remain uncertain. This review evaluated the effects of PT on neuromuscular performance, muscle soreness, and biochemical markers after acute exercise. The study adhered to PRISMA guidelines. A comprehensive search was conducted across PubMed, Embase, Web of Science, the Cochrane Library, and CNKI for Randomized Controlled Trials (RCTs) published through November 26, 2025. Risk of bias, methodological quality, and certainty of evidence were assessed using RoB 2, PEDro, and GRADE. Data analysis was performed using Stata-MP 18.0 software. Twelve RCTs were included. PT improved countermovement jump recovery compared with control (k = 13, g = 0.78, 95% CI 0.26 to 1.29, p < 0.01; low certainty) and reduced creatine kinase levels (k = 7, g = - 0.87, 95% CI - 1.57 to - 0.17, p = 0.02; very low certainty). PT did not clearly improve maximum voluntary contraction recovery (k = 8, g = 0.12, 95% CI - 0.10 to 0.34, p = 0.28; moderate certainty) or delayed onset muscle soreness (k = 17, g = 0.14, 95% CI - 0.19 to 0.48, p = 0.40; very low certainty). Exploratory analyses suggested that longer treatment (> 5min per muscle group) was associated with larger countermovement jump effects, whereas 2.5-5min protocols at higher frequency (≥ 50Hz) were associated with creatine kinase reduction. Longer treatment was also associated with higher delayed onset muscle soreness scores. PT may improve explosive performance recovery and reduce early creatine kinase levels, but current evidence does not support clear benefits for maximum strength recovery or soreness relief. Dose-related findings are preliminary and should not be interpreted as prescriptive thresholds.

Low back pain (LBP) is the leading cause of years lived with disability globally and a major contributor to disease burden in Australia. Superficial heat is recognised as a non-pharmacological intervention for LBP. However, its clinical use among chiropractors and osteopaths remains unclear. To examine how chiropractors and osteopaths in Australia use superficial heat in the management of LBP, explore their perceptions of its role and effectiveness, and assess their awareness and application of clinical practice guidelines for LBP. A cross-sectional survey was conducted between June and October 2022 among registered chiropractors and osteopaths in Australia. The online 43-item questionnaire captured demographic, practice, and clinical data. This included frequency and method of superficial heat use, perceived effectiveness, and awareness of clinical practice guidelines for LBP. Descriptive statistics were used to summarise findings. A total of 341 practitioners completed the survey (78.3% chiropractors, 21.7% osteopaths). This represents approximately 3.5% of the total registered chiropractic and osteopathic workforce in Australia. Approximately half of all respondents (44.6%) reported using superficial heat for LBP in the preceding 12 months. Among those, chiropractors were more likely to use superficial heat for chronic LBP (44.6%) than for acute LBP (13.8%), whereas osteopaths were more likely to use it for acute LBP (20.3%). Superficial heat was acknowledged by 71.3% of respondents to have a role in LBP management, while 66.0% regarded it as an adjunct to spinal manipulation. In contrast, superficial heat was recommended for self-management by 34.1% of chiropractors and 28.4% of osteopaths. Awareness of LBP clinical guidelines was moderate, with 58.4% of practitioners reporting they knew how and where to access them. Chiropractors most commonly referred to the American College of Physicians (ACP) guidelines, whereas osteopaths more frequently used the UK NICE guidelines. Despite its recognised clinical value, the use of superficial heat for LBP was limited, with 44.6% of practitioners reporting its use in practice, and fewer chiropractors (34.1%) and osteopaths (28.4%) recommending it for patient self-management. These findings indicate a gap between awareness and guideline-concordant care, highlighting the need for targeted education and clearer clinical guidance to support its consistent integration within multimodal LBP management.

Lumbopelvic pain is highly prevalent in pregnant women and although exercises are part of the strategies used to manage pregnancy-related lumbopelvic pain (PLBPP), available evidence regarding their effectiveness is inconclusive. The primary objective of this pilot study was to assess the feasibility of implementing a motor control exercise program for pregnant women presenting with a history of, or currently experiencing lumbopelvic pain. The secondary objective of the study was to explore the preliminary effectiveness of the program. Women aged 18-40 years with a singleton pregnancy at gestational age ≤ 20 were eligible if they had a history of lumbopelvic pain or were currently experiencing their first PLBPP episode. Participants were randomly allocated to an intervention group (n = 16) or a control group (n = 16). The intervention group received standard prenatal care and participated in three 40-minute exercise sessions per week (one supervised and two unsupervised) from gestational age ≤ 20 weeks through 34-36. The control group received only standard prenatal care. Primary outcomes were recruitment, retention, and adherence rates, safety and acceptability of the intervention, whereas secondary outcomes included PLBPP frequency and intensity, PLBPP-related disability and several other PLBPP-related outcomes. Descriptive statistics were used to assess the feasibility and the preliminary effectiveness of the intervention. Over a 15-month period, 32 participants were recruited (April 2021 to July 2022). Of these, 26 (11 in the intervention group and 15 in the control group) attended the post-intervention visit, yielding an 81.3% retention rate. The adherence rates were similar for supervised and unsupervised exercise sessions; however, acceptability was higher for supervised sessions than for unsupervised sessions. No adverse events were reported. At pre-intervention, participants' characteristics were similar between both groups except for education levels (higher in the control group). Preliminary results showed no clear differences in PLBPP frequency, intensity or associated disability between groups. The motor control exercise program appears safe and feasible, with minor modifications. Optimization of recruitment strategies and participant adherence is warranted before proceeding to a full-scale randomized controlled trial. The study has been registered at the US National Institutes of Health Clinical trials registry (Clinicaltrials.gov) (05/02/2020) NCT04253717.

Headache disorders are among the leading causes of disability globally. In primary care, including chiropractic practice, clinicians often serve as the first point of contact for patients seeking evaluation and management of headache. Despite this, limited evidence exists regarding how Danish chiropractors assess, diagnose, and manage headache in routine practice. This study aimed to examine how Danish chiropractors adopt a profession-specific clinical care standard, conduct clinical assessments, apply the ICHD-3 diagnostic criteria, and manage patients presenting with headache. A cross-sectional, questionnaire-based study was conducted between May 2022 and August 2022 among Danish chiropractors. The Danish Headache Questionnaire was used covering aspects such as diagnostic knowledge, clinical assessments and management. Descriptive statistics were used to characterise respondents and their clinical practices. A predefined threshold of ≥ 70% was applied to indicate acceptable adherence to the clinical care standard and sufficient familiarity with the ICHD-3 criteria. A total of 100 chiropractors completed the questionnaire, corresponding to a response rate of 14.4%. Self-reported data indicated that a larger percentage of Danish chiropractors demonstrate adequate knowledge of and adhere well to the clinical care standard. However, a proportion of respondents reported modest familiarity with specific elements of the standard and knowledge of red flags was limited. Overall familiarity with, and use of, the ICHD-3 diagnostic criteria was high. Management approaches largely aligned with guideline-supported strategies, with most chiropractors reporting the use of manual therapy, exercise, and patient education. In contrast, structured monitoring tools - such as headache diaries - were seldom used. Respondents generally appear to follow the profession-specific clinical care standard, demonstrate good familiarity with ICHD-3 criteria, and deliver guideline-aligned management for patients with headache. These findings suggest that chiropractors may play a meaningful role in primary-care headache management and potentially help reduce the burden on other health-care providers, although the low response rate warrants caution in generalising these findings. Identified gaps in knowledge and practice indicate a need for targeted postgraduate education, enhanced implementation strategies to support consistent use of clinical care standards and guidelines, and policy initiatives that facilitate the integration of chiropractors into interdisciplinary headache care pathways.

Musculoskeletal (MSK) conditions remain a leading source of global disability, and manual therapy (MT) features in multimodal guideline concordant care; however, teaching in clinical programs that involve MT often remains technique-centric and insufficiently aligned with contemporary, person-centred teaching and practice. The present paper synthesizes literature and recent professional discourse to advance an educational framework that operationalizes modern clinical teaching across professions. To present a review-informed, consensus-driven, student centred framework for clinical education involving MT, designed to cultivate safe, effective, culturally responsive, and evidence-based graduates. Elements supporting a positive, student-centred learning experience were developed inductively by the lead author, then a narrative review of the literature was conducted on the elements, or pillars as they were designated. This was followed by iterative process to refine and further develop the ideas with a group of international educators, clinicians, and researchers across multiple professions. Consensus was achievedon the core elements of a modern clinical education framework. The framework is anchored in basic sciences and clinical skills, and articulated through six teachable pillars: self-awareness, communication, cultural respect, epistemic humility, intellectual curiosity, and professional identity, delivered via high engagement, student-centred teaching. It provides practical curriculum guidance (crossyear learning outcomes, assessment strategies, and implementation vignettes) to embed person-centred communication, bias mitigation, cultural safety, evidence-based practice competencies, lifestyle medicine integration, and interprofessional collaboration. Together, the six pillars offer a novel approach to student-centred learning. A six-pillar, multi-profession approach offers actionable guidance for modern clinical education involving MT and supports the development of graduates prepared for contemporary MSK care: technically competent, evidence-based communicators who are culturally responsive and collaborative across healthcare teams.

BackgroundSpinal pain and disorders are a major burden on our population and health systems. Previous research showed people with diabetes were 1.35 times and 1.24 times more likely to report low back pain and neck pain than people without diabetes respectively, but diabetes was not a predictor of future spinal pain. Here we update a previous systematic review to determine whether in an adult population, diabetes is associated with low back, neck, or spinal pain.MethodsThe search was performed in PUBMED, Medline, CINAHL and EMBASE. Studies between 2017–2025, of cross-sectional, case–control, twin-control, and cohort designs, assessing diabetes and low back, neck, or spinal pain in adult populations, were included. Excluded were single-case studies, spinal pathologies, multiple chronic diseases, additional pain sites, and gestational or pre-diabetes. Two independent reviewers extracted data on the incidence of pain and reported associations. Odds ratios (ORs) of the association between the exposure (diabetes) and outcome (back, neck, or spinal pain) were calculated using a random effects model. Systematic review registration: PROSPERO registration CRD42022333064.ResultsA total of 15 studies were included with 11 studies included in the meta-analysis. When compared to people without diabetes, people with diabetes had 1.44 times higher odds of reporting low back pain (n = 592,901; OR 1.44; 95% Confidence Interval (CI) 1.20- 1.74; p = 0.001), a 1.11 times higher odds of reporting neck pain (n = 465,130; OR 1.11; 95%CI 1.13–1.20; p = < 0.001) and a 1.42 times higher odds of reporting spinal pain (n = 1,335,999; OR 1.42; 95%CI 1.26–1.63; p = < 0.001). Diabetes was significantly associated with 1.27 times higher odds of developing spinal pain (n = 35,435; OR 1.27; 95%CI 1.08–1.50; p = 0.004) and 1.44 higher odds of developing neck pain (n = 15,075; OR 1.44; 95%CI 1.09 -1.90; p = 0.010). There was no significant association between diabetes and developing low back pain (n = 21,215; OR 1.11; 95%CI 0.88–1.41, p = 0.388).ConclusionsWith the inclusion of fifteen additional studies providing an overall sample size five and a half times larger than the previous review, diabetes was associated with prevalent neck, low back and spinal pain, as well as incident neck and neck and spinal pain. Clinicians must be adept at identifying co-morbid conditions and risk factors, understanding the interplay between them and creating well managed networks to address these complex presentations.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12998-026-00650-2.