PAIN+ CPN

OBJECTIVE: To assess whether spinal manipulative therapy (SMT) application procedures (ie, target, thrust, and region) impacted changes in pain and disability for adults with spine pain. DESIGN: Systematic review with network meta-analysis. LITERATURE SEARCH: We searched PubMed and Epistemonikos for systematic reviews indexed up to February 2022 and conducted a systematic search of 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. We included randomized controlled trials (RCTs) from recent systematic reviews and newly identified RCTs published during the review process and employed artificial intelligence to identify potentially relevant articles not retrieved through our electronic database searches. STUDY SELECTION CRITERIA: We included RCTs of the effects of high-velocity, low-amplitude SMT, compared to other SMT approaches, interventions, or controls, in adults with spine pain. DATA SYNTHESIS: The outcomes were spinal pain intensity and disability measured at short-term (end of treatment) and long-term (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. Results were presented as network plots, evidence rankings, and league tables. RESULTS: We included 161 RCTs (11 849 participants). Most SMT procedures were equal to clinical guideline interventions and were slightly more effective than other treatments. When comparing inter-SMT procedures, effects were small and not clinically relevant. A general and nonspecific rather than a specific and targeted SMT approach had the highest probability of achieving the largest effects. Results were based on very low- to low-certainty evidence, mainly downgraded owing to large within-study heterogeneity, high RoB, and an absence of direct comparisons. CONCLUSION: There was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients' preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant. J Orthop Sports Phys Ther 2025;55(2):1-14. Epub 7 January 2025.https://doi.org/10.2519/jospt.2025.12707.

Rehab Clinician (OT/PT) rater

The findings are of low certainty. Perhaps this is the most interesting finding considering the large amount of research that has been conducted in this area. Importantly, the findings do little to indicate if, for a particular individual it makes a difference where or how a manipulation is performed. The findings may also indicate more about how we are at determining a better technique or target location rather than whether different techniques or locations make a difference to the patient.

Rehab Clinician (OT/PT) rater

These results are expected. The average treatment effect of spinal manipulative therapy (SMT) for reducing pain and disability in patients with spinal pain appears independent of where SMT was targeted, how the thrust was performed, and in what region it was delivered. Clinicians should not worry about the specific application procedures of SMT. Instead, they should choose the SMT procedure that they are most comfortable with and focus on patient and clinician preferences and safety.

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