Spinal Manipulation Research Articles

Assessment of chiropractic intervention influence on pain and life quality in cervicogenic headache afflicted office workers: a review

Cervicogenic headache, characterized by referred pain perceived in the head but originating from the cervical spine, is a prevalent non-migraine headache impacting a significant proportion of the global population, particularly office workers. Recent studies have identified a co-occurrence of cervicogenic headaches with neck pain, often exacerbated by long hours of stationary sitting and computer use common in desk jobs. Despite the growing evidence supporting the effectiveness of chiropractic treatment in mitigating head and neck pain, a distinct gap persists in the literature concerning chiropractic interventions specifically targeting office workers suffering from cervicogenic headaches. This review aims to scrutinize the current literature on the effectiveness of chiropractic interventions on pain management and life quality improvement for office workers afflicted with cervicogenic headaches. Specifically, the review will delve into high-velocity, low-amplitude (HVLA) thrust maneuvers, a widely employed strategy in spinal manipulative therapy, an extension of chiropractic treatment. In the context of cervicogenic headaches, the link between the Rectus Capitis Posterior Minor (RCPM) muscle and the Dura Mater, and how neck strains affecting this connection can instigate headaches, will be explored. Through the comprehensive evaluation of existing literature and studies, this review seeks not only to elucidate the potential of chiropractic treatment in improving the life quality of office workers suffering from cervicogenic headaches, but also to stimulate further research in this essential yet under-explored area of study.

A case report of Spontaneous Spinal Epidural Hematoma in Elderly Patient with Surgical Decompression

Spontaneous spinal epidural hematoma (SSEH), uncommon disorder with potentially devastating consequences as high morbidity. Incidence around 0.1 in 100,000 per/year, male- female ratio is approximately 1.4:1, most cases in 4th-5th decades. The etiology was associated with lumbar puncture and myelography, arteriovenous malformations, bleeding disorders, pregnancy, spinal manipulation. Anticoagulation is also a risk factor for spontaneous spinal epidural hematomas, warfarin is the most common related with SSEH. SSEH present clinically as a cord compression syndrome, acute onset pain and neurological deficit such as progressive motor or sensory symptoms, sphincter dysfunction, ultimately leads to complete/incomplete motor deficit caused by spinal cord/nerve root compression or cauda equina. The symptoms depending on the location of the hematoma. The worst prognostic factors are thoracic location, anticoagulation, severe neurologic deficits on admission, sphincter dysfunction, rapid progression. Magnetic resonance imaging (MRI) is the gold standard technique to diagnose SSEH. Once the diagnosis is established with clinical and imaging results, early surgical intervention should be considered. Currently, appropriate management is emergence decompression laminectomy and hematoma evacuation. We present the case of 87-year-old female, on warfarin for atrial fibrillation. Without recent trauma events. Presented sudden thoracic and lumbar pain, paresthesias with irradiation to legs. Progression with sudden paraplegic and anesthesia in lower extremities. Thoracolumbar MRI revealed a posterior SSEH extended from T9-T12. Was released a laminectomy and SSEH aspiration within 6 hours from the symptom’s onset. The patient was discharged one week after the surgery, symptoms improved during the follow-up.

Treatment and Response Factors in Muscle Activation during Spinal Manipulation.

The forces applied during a spinal manipulation produce a neuromuscular response in the paraspinal muscles. A systematic evaluation of the factors involved in producing this muscle activity provides a clinical insight. The purpose of this study is to quantify the effect of treatment factors (manipulation sequence and manipulation site) and response factors (muscle layer, muscle location, and muscle side) on the neuromuscular response to spinal manipulation. The surface and indwelling electromyographies of 8 muscle sites were recorded during lumbar side-lying manipulations in 20 asymptomatic participants. The effects of the factors on the number of muscle responses and the muscle activity onset delays were compared using mixed-model linear regressions, effect sizes, and equivalence testing. The treatment factors did not reveal statistical differences between the manipulation sequences (first or second) or manipulation sites (L3 or SI) in the number of muscle responses (p = 0.11, p = 0.28, respectively), or in muscle activity onset delays (p = 0.35 p = 0.35, respectively). There were significantly shorter muscle activity onset delays in the multifidi compared to the superficial muscles (p = 0.02). A small effect size of side (d = 0.44) was observed with significantly greater number of responses (p = 0.02) and shorter muscle activity onset delays (p < 0.001) in the muscles on the left side compared to the right. The location, layer, and side of the neuromuscular responses revealed trends of decreasing muscle response rates and increasing muscle activity onset delays as the distance from the manipulation site increased. These results build on the body of work suggesting that the specificity of manipulation site may not play a role in the neuromuscular response to spinal manipulation-at least within the lumbar spine. In addition, these results demonstrate that multiple manipulations performed in similar areas (L3 and S1) do not change the response significantly, as well as contribute to the clinical understanding that the muscle response rate is higher and with a shorter delay, the closer it is to the manipulation.

Translaminar Full Endoscopic Technique with Tom Shidi Needles for Highly- and Dorsally-Migrated Lumbar Disc Herniations

Thirty years have passed since Kambin's first clinical series of lumbar disc herniations (LDH) treated by arthroscopic microdiscectomy. Despite several advances in this interim, sequestrated LDHs over the dorsal aspect of the dura, and high-grade up- or downward disc migration have been a relative limitation of the transforaminal endoscopic technique. The interlaminar window was the next step to deal with such highly migrated LDHs. Favorable outcomes were obtained in 70-90% of the patients in the long-term, but recurrence rates remained high (approximately 12%), and the approach could be limited by the size of the interlaminar window. Few relevant studies have addressed the role of translaminar full endoscopic technique for migrated LDHs. To describe an innovative modification of the translaminar full endoscopic approach with Tom Shidi needles. This technical modification is presented in a detailed fashion for treating these challenging LDHs and illustrated through a clinical case. The patient underwent successful translaminar full endoscopic technique with complete pain resolution postoperatively. The postprocedural course was uneventful. A follow-up imaging showed no evidence of residual LDHs fragments. Translaminar full endoscopic technique with Tom Shidi needles is a promising modification of the previously presented interlaminar and translaminar endoscopic routes in the treatment of migrated LDHs to fasten surgical procedures and increase the safety of spinal canal manipulation.

Socioeconomic differences in the utilization of diagnostic imaging and non-pharmaceutical conservative therapies for spinal diseases

BackgroundA different utilization of health care services due to socioeconomic status on the same health plan contradicts the principle of equal treatment. We investigated the presence and magnitude of socioeconomic differences in utilization of diagnostic imaging and non-pharmaceutical conservative therapies for patients with spinal diseases.MethodsThe cohort study based on routine healthcare data from Germany with 11.7 million patient-years between 2012 and 2016 for patients with physician-confirmed spinal diseases (ICD-10: M40-M54), occupation and age 20 to 64 years. A Poisson model estimated the effects of the socioeconomic status (school education, professional education and occupational position) for the risk ratio of receiving diagnostic imaging (radiography, computed tomography, magnetic resonance imaging) and non-pharmaceutical conservative therapies (physical therapy including exercise therapy, manual therapy and massage, spinal manipulative therapy, acupuncture).ResultsPatients received diagnostic imaging in 26%, physical therapy in 32%, spinal manipulative therapy in 25%, and acupuncture in 4% of all patient-years. Similar to previous survey-based studies higher rates of utilization were associated with higher socioeconomic status. These differences were most pronounced for manual therapy, exercise therapy, and magnetic resonance imaging.ConclusionsThe observed differences in health care utilization were highly related to socioeconomic status. Socioeconomic differences were higher for more expensive health services. Further research is necessary to identify barriers to equitable access to health services and to take appropriate action to decrease existing social disparities.

Decompressive laminectomy with vertebral stabilization allows neurologic improvement of most Pekingese dogs with thoracolumbar vertebral instability.

To describe the diagnostic findings, surgical techniques, and outcomes of thoracolumbar vertebral instability associated with or without articular process (AP) anomalies in Pekingese dogs. 11 client-owned Pekingese dogs. Medical records (2007 to 2022) were reviewed. Inclusion criteria were Pekingese dogs with thoracolumbar vertebral instability that underwent decompressive laminectomy and vertebral stabilization. Dynamic myelographic study and/or intraoperative spinal manipulation were used to diagnose vertebral instability. Data on preoperative and postoperative neurologic status, diagnostic findings, surgical techniques, and outcomes were retrieved. The dogs presented with paraparesis (n = 9) or paraplegia (2). Five dogs had caudal AP anomalies. Dynamic myelographic study demonstrated single (n = 7) or multiple (4) dynamic compressions with poststress spinal cord height reduction (median, 12.5%; IQR, 6.8% to 21.2%). Of the 17 dynamic compression lesions, 5 lesions were at the disc spaces with caudal AP abnormalities. All dogs had vertebral instability confirmed by intraoperative spinal manipulation and underwent hemilaminectomy and unilateral vertebral stabilization. One dog had adjacent segment vertebral instability and underwent vertebral stabilization 3 months after the initial operation. All but 1 dog showed successful outcomes at the last follow-up (median, 16 months; IQR, 3 to 32 months). Vertebral instability associated with or without AP abnormalities is a potential cause of thoracolumbar spinal cord injury in Pekingese dogs. Dynamic myelographic studies and/or intraoperative spinal manipulation demonstrated vertebral instability. Spinal cord decompression and vertebral stabilization are effective, resulting in neurologic improvements in most dogs.

Creating and testing a questionnaire to predict immediate and strong positive responders to spinal manipulative therapy for non-specific low back pain. A pilot study

BackgroundMany chiropractors use spinal manipulative techniques (SMT) to treat spinal pain. A recent Delphi study posited 18 items across five domains as predictors of patients experiencing non-specific low back pain most likely to experience a strong and immediate positive response to SMT. We sought to create a ‘pen and paper’ questionnaire that would measure these items and then pilot its use in a clinical setting to determine its ‘usability’ for a larger study. Knowing this information would inform a more efficacious use of SMT.MethodOf the 18 items identified in the Delphi study, 13 were deemed historical in nature and readily provided by the chiropractor and patient. A literature search revealed reliable and valid measures for two more items. The remaining three items were generated by creating descriptive questions matched to an appropriate Likert scale. A panel of six chiropractors who had used SMT for at least 7 years when treating non-specific low back pain was formed to evaluate the items for clarity and relevance. Ten Western Australian chiropractors were then recruited to pilot the questionnaire on ten consecutive patients with non-specific low back pain where SMT was used from March to June 2020. Ethics approval was obtained from Murdoch University.ResultsCOVID-19 restrictions impacted on practitioner recruitment and delayed the data collection. Of the intended 100 participants, only 63 could be recruited over a 3-month period from seven chiropractors. Time constraints forced the closure of the data collection. The measures of all predictor items demonstrated ceiling effects. Feedback from open-ended practitioner questions was minimal, suggesting an ease of use.ConclusionThe length of time and level of participation required to collect the calculated sample size was inadequate and suggested that incentivization may be required for a larger investigation. Significant ceiling effects were found and suggested that participants did so because of a positive bias toward chiropractic care and the use of SMT. The questionnaires in this pilot study require alternative measures and further validation before use in a larger study.

Developing spinal manipulation psychomotor skills competency: A systematic review of teaching methods.

To update the state of the art regarding the acquisition of spinal high-velocity low-amplitude psychomotor skills competency among chiropractors and chiropractic students. Available electronic articles from 5 databases, published between June 2015 and August 2020, were obtained. Eligible studies underwent methodological quality assessments using the Joanna Briggs Institute Critical Appraisal Checklists and Cochrane Collaboration's Risk of Bias Tools. Fourteen critically appraised studies were identified, including 10 cohort studies and 4 randomized controlled trials. There was no literature excluded due to high risk of bias. The type of augmented devices included a mannequin on a force platform, a computer-connected device, a human analogue mannequin, and a 3-dimensional electrogoniometer with an instrumented spatial linkage. The use of augmented feedback devices such as human analogue mannequins with force-sensing table technology and computer-connected devices is potentially beneficial in the chiropractic curricula and may facilitate student learning and improvement of spinal manipulation. More studies are required to determine whether psychomotor skill aids translate directly into raised competency levels in novice clinicians.

Spinal manipulation characteristics: a scoping literature review of force-time characteristics

BackgroundSpinal manipulation (SM) is a recommended and effective treatment for musculoskeletal disorders. Biomechanical (kinetic) parameters (e.g. preload/peak force, rate of force application and thrust duration) can be measured during SM, quantifying the intervention. Understanding these force-time characteristics is the first step towards identifying possible active ingredient/s responsible for the clinical effectiveness of SM. Few studies have quantified SM force-time characteristics and with considerable heterogeneity evident, interpretation of findings is difficult. The aim of this study was to synthesise the literature describing force-time characteristics of manual SM.MethodsThis scoping literature review is reported following the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) statement. Databases were searched from inception to October 2022: MEDLINE (Ovid), Embase, CINAHL, ICL, PEDro and Cochrane Library. The following search terms and their derivatives were adapted for each platform: spine, spinal, manipulation, mobilization or mobilisation, musculoskeletal, chiropractic, osteopathy, physiotherapy, naprapathy, force, motor skill, biomechanics, dosage, dose-response, education, performance, psychomotor, back, neck, spine, thoracic, lumbar, pelvic, cervical and sacral. Data were extracted and reported descriptively for the following domains: general study characteristics, number of and characteristics of individuals who delivered/received SM, region treated, equipment used and force-time characteristics of SM.ResultsOf 7,607 records identified, 66 (0.9%) fulfilled the eligibility criteria and were included in the analysis. Of these, SM was delivered to the cervical spine in 12 (18.2%), the thoracic spine in 40 (60.6%) and the lumbopelvic spine in 19 (28.8%) studies. In 6 (9.1%) studies, the spinal region was not specified. For SM applied to all spinal regions, force-time characteristics were: preload force (range: 0-671N); peak force (17-1213N); rate of force application (202-8700N/s); time to peak thrust force (12-938ms); and thrust duration (36-2876ms).ConclusionsConsiderable variability in the reported kinetic force-time characteristics of SM exists. Some of this variability is likely due to differences in SM delivery (e.g. different clinicians) and the measurement equipment used to quantify force-time characteristics. However, improved reporting in certain key areas could facilitate more sophisticated syntheses of force-time characteristics data in the future. Such syntheses could provide the foundation upon which dose-response estimates regarding the clinical effectiveness of SM are made.

Can self-assessment and augmented feedback improve performance and learning retention in manual therapy: results from an experimental study

BackgroundThe purpose of this study was to investigate how feedback and self-assessment strategies affect performance and retention of manual skills in a group of chiropractic students.MethodsSeventy-five students participated in two spinal manipulation (SM) learning sessions using a force-sensing table. They were recruited between May and November 2022 during HVLA technical courses. Students were randomly assigned into three different groups: participants in group 1 received visual feedback, those in group 2 received visual feedback after self-assessment, and participants in group 3 (C) received no feedback. During the first session, participants started with one block of 3 familiarization trials, followed by two blocks of 6 SM HVLA (high velocity low amplitude) posterior-to-anterior thoracic SM trials, with 3 trials performed with a target force of 450 N and 3 others at 800 N. They received feedback according to their group during the first block, but no feedback was provided during the second block. All participants were invited to participate in a second session for the retention test and to perform a new set SM without any form of feedback.ResultsResults showed that visual feedback and visual feedback in addition to self-assessment did not improve short-term SM performance, nor did it improve performance at the one-week retention test. The group that received visual feedback and submitted to self-assessment increased the difference between the target force and the peak force applied, which can be considered a decrease in performance.ConclusionNo learning effects between the three groups of students exposed to different feedback and self-assessment learning strategies were highlighted in the present study. However, future research on innovative motor learning strategies could explore the role of external focus of attention, self-motivation and autonomy in SM performance training.

Efficacy of Combining Traditional Chinese Manual Therapy (Tuina) and Specific Therapeutic Neck Exercise in Young Adults with Non-Specific Chronic Neck Pain: Study Protocol for a Randomized Controlled Trial.

Non-specific chronic neck pain (NSCNP) is an increasingly common musculoskeletal disease and an important issue in the global healthcare system. Some studies have shown that the combination of manual therapy and exercise is effective in treating NSCNP but still with several limitations. Traditional Chinese manual therapy (tuina) is a Chinese manual therapy that consists of soft tissue manipulation and spinal manipulation. This study aims to design a randomized controlled trial to assess the effect of a tuina combined with specific therapeutic neck exercise modified protocol for NSCNP patients. This is a study protocol for a randomized, participant-, assessor- and analyst-blinded controlled trial. Eighty-eight eligible NSCNP patients will be randomly allocated into tuina combined with specific therapeutic neck exercise group (TSTE group) and tuina combined with sham therapeutic neck exercise group (TS group) in a ratio of 1:1. All participants will receive 8 treatment sessions applied in 4 weeks and then be followed up for another 12 weeks. Clinical data will be collected at baseline, during treatment phase (at the 2- and 4-week) and at the 8-, 12-, 16-week follow-ups. The primary outcome is the changes in neck pain intensity (visual analogue scale). The secondary outcomes include neck disability (Neck Disability Index), cervical range of motion (ROM), neck muscle endurance, cervical muscle cross-sectional area, cervical curvature and analgesic consumption. Adverse events will be collected and recorded throughout the study. We will discuss whether our tuina combined with specific therapeutic neck exercise modified protocol is more effective at improving pericervical muscle endurance, ROM, cervical muscle cross-sectional area and cervical curvature than tuina alone, thereby decreases neck pain and disability in individuals with NSCNP more effectively. Chinese Clinical Trials Registry, ChiCTR2300067903. Registered on 31 January 2023.

Additional effect of pain neuroscience education to spinal manipulative therapy on pain and disability for patients with chronic low back pain: a randomized controlled trial

BackgroundSpinal manipulative therapy (SMT) demonstrates small effects on pain intensity in low back pain. Combining SMT with a psychosocial intervention like pain neuroscience education (PNE) could promote additional effect. ObjectivesTo evaluate the additional effect of PNE when combined to SMT on pain intensity and low back pain-related disability in patients with chronic low back pain (CLBP). MethodOne hundred and four patients with CLBP of both sexes aged between 18 and 55 years were treated with PNE + SMT compared to SMT alone. The primary outcome measures were pain intensity and disability post-treatment (4 weeks). Secondary outcomes were fear-avoidance beliefs, global perceived effect of improvement, and pain self-efficacy. Results were obtained immediately post-treatment and at three follow-ups (30-days, 90-days, and 180-days). ResultsNo significant between-group difference was observed for pain intensity and disability post-treatment. In contrast, our results showed a significantly longer additional effect for the group treated with SMT + PNE for the following outcomes: pain intensity (change baseline to 90 day follow-up = −0.90 [95% CI= −1.76, −0.4] and change baseline to 180 day follow-up = −1.19 [95% CI= −2.06, −0.32]) and low back pain-related disability, global perceived effect of improvement and pain self-efficacy (180th day follow-up). ConclusionThe results of this trial suggest the addition of PNE to SMT did not bring any additional effect on pain intensity and disability in the short term, but SMT + PNE can result in longer-lasting effects in patients with CLBP and that such an effect could be related to a possible mediator effect of pain self-efficacy.

Comparison of the effectiveness of spinal stabilization exercises and chiropractic spinal manipulation in healthy individuals: Randomized controlled trial

Aim: The aim was to investigate the effects of exercise, manipulation and its combined application on endurance, muscle strength, joint position sense and balance. Materials and Methods: Eighty healthy people aged 18-45 years were included in the study. Individuals were divided into chiropractic manipulation, stabilization exercises, combined application and control group. Participants were evaluated with endurance, muscle strength, joint position sense and balance tests before, after and 1 month after the application. Results: After the application, significant improvement was observed in the endurance parameters in Group 3 compared to the other groups. There was a significant increase in quadriceps muscle strength in all groups compared to Group 4. Conclusion: The combined program may be more effective than other programs in improving muscular endurance and balance. All training programs are effective in improving quadriceps muscle strength, but do not have the same effect on knee joint position sense.

Benefits and Harms of Spinal Manipulative Therapy for Treating Recent and Persistent Nonspecific Neck Pain: A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to estimate the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain. DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials (RCTs). LITERATURE SEARCH: We searched the MEDLINE, Cochrane CENTRAL, Embase, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022. STUDY SELECTION CRITERIA: RCTs evaluating SMT compared to guideline-recommended and nonrecommended interventions, sham SMT, and no intervention for adults with neck pain were eligible for our systematic review. Prespecified outcomes included pain, range of motion, disability, health-related quality of life. DATA SYNTHESIS: Random-effects meta-analysis for clinically homogenous RCTs at short-term and long-term outcomes. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 Tool. We used the Grading of Recommendations, Assessment, Development, and Evaluations approach to judge the certainty of evidence. RESULTS: We included 28 RCTs. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short term (standardized mean difference [SMD], 0.66; 95% confidence interval [CI]: 0.35, 0.97) and long term (SMD, 0.73; 95% CI: 0.31, 1.16), and for reducing disability at short-term (SMD, 0.95; 95% CI: 0.48, 1.42) and long term (SMD, 0.65; 95% CI: 0.23, 1.06). Transient side effects only were found (eg, muscle soreness). CONCLUSION: There was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain. J Orthop Sports Phys Ther 2023;53(9):510-528. Epub: 10 August 2023. doi:10.2519/jospt.2023.11708.

Are YouTube videos claiming to describe lumbar spinal manipulation techniques adequate?

ABSTRACT Background and objective YouTube has become a digital visual library in almost all fields of life, including medicine. Healthcare professionals and students frequently use YouTube to gain new skills and knowledge; however, the content of these videos has not been scientifically evaluated. Therefore, this study aimed to determine the descriptive adequacy and quality of YouTube videos on lumbar spine manipulation techniques (LSMTs) prepared by different healthcare professionals. Methods The first 50 most relevant videos retrieved on searching YouTube for the keyword ‘lumbar spinal manipulation techniques’ were included in the study. The video metrics (total duration, number of views, time since upload, number of comments, number of likes, and number of dislikes) that could be accessed from video descriptions were recorded. However the videos were scored according to manipulation definition criteria proposed by the American Academy of Orthopedic Manual Physical Therapists (AAOMPT manipulation description score – AAOMPT-MDS) and benchmark criteria for quality of digital content by the Journal of American Medical Association’s (JAMA). The video metrics, AAOMPT-MDS and JAMA scores of the videos prepared by medical doctors, chiropractors, osteopaths, and physiotherapists were compared. Results Video metrics of groups were similar. The mean AAOMPT-MDS of the videos was 2.40 ± 1.57 out of 6.00 (higher score was better), and the mean JAMA score was 2.14 ± 1.05 out of 4.00 (higher score was better). Videos created by all professional groups had statistically comparable AAOMPT-MDS and JAMA scores (p > 0.05). Conclusion Although YouTube videos on LSMTs offer valuable information for professionals and students, creators should follow the proposed recommendations when producing these videos to ensure quality content and systematic presentation.

Immediate systemic neuroimmune responses following spinal mobilisation and manipulation in people with non-specific neck pain: a randomised placebo-controlled trial

Spinal mobilisation/manipulation is a common intervention for spinal pain, yet the working mechanisms are largely unknown. A randomised placebo-controlled trial was conducted to (1) compare the immediate neuroimmune responses following spinal mobilisation/manipulation and placebo spinal mobilisation/manipulation; (2) compare the immediate neuroimmune responses of those with a good outcome with those of a poor outcome following spinal mobilisation/manipulation; and (3) explore the association between neuroimmune responses and pain reduction. One hundred patients were randomly allocated to spinal mobilisation/manipulation or a placebo mobilisation/manipulation. Primary outcomes were whole blood in-vitro evoked released concentrations of IL-1β and TNF-α measured 10 min and 2 h after the intervention. Immediate effects were studied because successful mobilisation/manipulation is often associated with immediate pain reduction, and immediate neuroimmune responses are less affected by potential confounders than long-term responses. Secondary outcomes included multiple systemic inflammatory marker concentrations, phenotypic analysis of white blood cells and clinical outcomes. Outcomes were compared between the experimental and placebo group, and between people with a good and poor outcome in the experimental group. Estimates of intervention effects were based on intention-to-treat analyses, by using linear mixed-effect models. Although there was a substantial difference in pain reduction between groups (mean (SD) difference visual analogue scale: 30 (21) mm at 10 min and 32 (21) mm at 2 h (p < 0.001) in favour of mobilisation/manipulation, there were no differences in primary outcomes between groups or between people with a good and poor outcome (p ≥ 0.10). In conclusion, possible neuroimmune responses following spinal mobilisations/manipulation cannot be identified at a systemic level. Future research may focus on longer treatment duration and more localised neuroimmune responses.

Investigation of the factors influencing spinal manipulative therapy force transmission through the thorax: a cadaveric study

BackgroundSpinal manipulative therapy (SMT) clinical effects are believed to be linked to its force–time profile characteristics. Previous studies have revealed that the force measured at the patient-table interface is most commonly greater than the one applied at the clinician-patient interface. The factors explaining this force amplification remains unclear.ObjectiveTo determine the difference between the force applied to a cadaveric specimen’s thoracic spine and the resulting force measured by a force-sensing table, as well as to evaluate the relationship between this difference and both the SMT force–time characteristics and the specimens’ characteristics.MethodsTwenty-five SMTs with different force–time profiles were delivered by an apparatus at the T7 vertebra of nine human cadaveric specimens lying prone on a treatment table equipped with a force plate. The difference between the force applied by the apparatus and the resulting force measured by the force plate was calculated in absolute force (Fdiff) and as the percentage of the applied force (Fdiff%). Kinematics markers were inserted into T6 to T8 spinous and transverse processes to evaluate vertebral displacements during the SMT thrusts. Mixed-effects linear models were run to evaluate the variance in Fdiff and Fdiff% explained by SMT characteristics (peak force, thrust duration and force application rate), T6 to T8 relative and total displacements, and specimens’ characteristics (BMI, height, weight, kyphosis angle, thoracic thickness).ResultsSixty percent of the trials showed lower force measured at the force plate than the one applied at T7. Fdiff¸ was significantly predicted (R2marginal = 0.54) by peak force, thrust duration, thoracic thickness and T6–T7 relative displacement in the z-axis (postero-anterior). Fdiff% was significantly predicted (R2marginal = 0.56) by force application rate, thoracic thickness and total T6 displacements. For both dependant variables, thoracic thickness showed the highest R2marginal out of all predictors.ConclusionDifference in force between the clinician-patient and the patient-table interfaces is influenced by SMT force–time characteristics and by thoracic thickness. How these differences in force are associated with vertebral displacements remains unclear. Although further studies are needed, clinicians should consider thorax thickness as a possible modulator of forces being transmitted through it during prone SMT procedures.

Spinal Manipulative Therapy for Nonspecific Low Back Pain: Does Targeting a Specific Vertebral Level Make a Difference?: A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to examine whether targeting spinal manipulative therapy (SMT), by applying the intervention to a specific vertebral level, produces superior clinical outcomes than a nontargeted approach in patients with nonspecific low back pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, Scopus, PEDro, and Index to Chiropractic Literature were searched up to May 31, 2023. STUDY SELECTION CRITERIA: Randomized controlled trials comparing targeted SMT (mobilization or manipulation) to a nontargeted approach in patients with nonspecific low back pain, and measuring the effects on pain intensity and patient-reported disability. DATA SYNTHESIS: Data extraction, risk of bias, and evaluation of the overall certainty of evidence using the GRADE approach were performed by 2 authors independently. Meta-analyses were performed using the restricted maximum likelihood method. RESULTS: Ten randomized controlled trials (n = 931 patients) were included. There was moderate-certainty evidence of no difference between targeted SMT and a nontargeted approach for pain intensity at postintervention (weighted mean difference = -0.20 [95% CI: -0.51, 0.10]) and at follow-up (weighted mean difference = 0.05 [95% CI: -0.26, 0.36]). For patient-reported disability, there was moderate-certainty evidence of no difference at postintervention (standardized mean difference = -0.04 [95% CI: -0.36, 0.29]) and at follow-up (standardized mean difference = -0.05 [95% CI: -0.24, 0.13]). Adverse events were reported in 4 trials, and were minor and evenly distributed between groups. CONCLUSION: Targeting a specific vertebral level when administering SMT for patients with nonspecific low back pain did not result in improved outcomes on pain intensity and patient-reported disability compared to a nontargeted approach. J Orthop Sports Phys Ther 2023;53(9):1-11. Epub: 28 July 2023. doi:10.2519/jospt.2023.11962.

The association between cervical artery dissection and spinal manipulation among US adults.

Cervical artery dissection (CeAD), which includes both vertebral artery dissection (VAD) and carotid artery dissection (CAD), is the most serious safety concern associated with cervical spinal manipulation (CSM). We evaluated the association between CSM and CeAD among US adults. Through analysis of health claims data, we employed a case-control study with matched controls, a case-control design in which controls were diagnosed with ischemic stroke, and a case-crossover design in which recent exposures were compared to exposures in the same case that occurred 6-7months earlier. We evaluated the association between CeAD and the 3-level exposure, CSM versus office visit for medical evaluation and management (E&M) versus neither, with E&M set as the referent group. We identified 2337 VAD cases and 2916 CAD cases. Compared to population controls, VAD cases were 0.17 (95% CI 0.09 to 0.32) times as likely to have received CSM in the previous week as compared to E&M. In other words, E&M was about 5 times more likely than CSM in the previous week in cases, relative to controls. CSM was 2.53 (95% CI 1.71 to 3.68) times as likely as E&M in the previous week among individuals with VAD than among individuals experiencing a stroke without CeAD. In the case-crossover study, CSM was 0.38 (95% CI 0.15 to 0.91) times as likely as E&M in the week before a VAD, relative to 6months earlier. In other words, E&M was approximately 3 times more likely than CSM in the previous week in cases, relative to controls. Results for the 14-day and 30-day timeframes were similar to those at one week. Among privately insured US adults, the overall risk of CeAD is very low. Prior receipt of CSM was more likely than E&M among VAD patients as compared to stroke patients. However, for CAD patients as compared to stroke patients, as well as for both VAD and CAD patients in comparison with population controls and in case-crossover analysis, prior receipt of E&M was more likely than CSM.

Association between chiropractic spinal manipulation and gabapentin prescription in adults with radicular low back pain: retrospective cohort study using US data

ObjectivesRadicular low back pain (rLBP) is often treated off-label with gabapentin or by chiropractors using chiropractic spinal manipulative therapy (CSMT). To date, no studies have examined the association between these...