The effect of a spinal thrust manipulation's audible pop on brain wave activity: a quasi-experimental repeated measure design.

Introduction: High velocity thrust manipulation is commonly used when managing joint dysfunctions. Often, these thrust maneuvers will elicit an audible pop. It has been unclear what conclusively causes this audible sound and its clinical meaningfulness. This study sought to identify the effect of the audible pop on brainwave activity directly following a prone T7 thrust manipulation in asymptomatic/healthy subjects. Methods: This was a quasi-experimental repeated measure study design in which 57 subjects completed the study protocol. Brain wave activity was measured with the Emotiv EPOC+, which collects data with a frequency of 128 HZ and has 14 electrodes. Testing was performed in a controlled environment with minimal electrical interference (as measured with a Gauss meter), temperature variance, lighting variance, sound pollution, and other variable changes that could have influenced or interfered with pure EEG data acquisition. After accommodation each subject underwent a prone T7 posterior-anterior thrust manipulation. Immediately after the thrust manipulation the brainwave activity was measured for 10 seconds. Results: The non-audible group (N = 20) consisted of 55% males, and the audible group (N = 37) consisted of 43% males. The non-audible group EEG data revealed a significant change in brain wave activity under some of the electrodes in the frontal, parietal, and the occipital lobes. In the audible group, there was a significant change in brain wave activity under all electrodes in the frontal lobes, the parietal lobe, and the occipital lobes but not the temporal lobes. Conclusion: The audible sounds caused by a thoracic high velocity thrust manipulation did not affect the activity in the audible centers in the temporal brain region. The results support the hypothesis that thrust manipulation with or without audible sound results in a generalized relaxation immediately following the manipulation. The absence of a significant difference in brainwave activity in the frontal lobe in this study might indicate that the audible pop does not produce a "placebo" mechanism.

One spinal manipulation session reduces local pain sensitivity but does not affect postural stability in individuals with chronic low back pain: a randomised, placebo-controlled trial.

BACKGROUND: Clinical practice guidelines recommend spinal manipulation for patients with low back pain. However, the effects of spinal manipulation have contradictory findings compared to placebo intervention. Therefore, this study investigated the immediate effects of lumbar spinal manipulation on pressure pain threshold (PPT) and postural stability in people with chronic low back pain (cLBP). Second, we investigated the immediate effect of lumbar spinal manipulation on pain intensity and the interference of the participant beliefs about which treatment was received in the PPT, postural stability, and pain intensity. METHODS: A two-arm, randomised, placebo-controlled, double-blind trial was performed. Eighty participants with nonspecific cLPB and a minimum score of 3 on the Numeric Pain Rating Scale received one session of lumbar spinal manipulation (n = 40) or simulated lumbar spinal manipulation (n = 40). Primary outcomes were local and remote PPTs and postural stability. Secondary outcomes were pain intensity and participant's perceived treatment allocation. Between-group mean differences and their 95% confidence intervals (CIs) estimated the treatment effect. One-way analysis of covariance (ANCOVA) was performed to assess whether beliefs about which treatment was received influenced the outcomes. RESULTS: Participants had a mean (SD) age of 34.9 (10.5) years, and 50 (62.5%) were women. Right L5 [between-group mean difference = 0.55 (95%CI 0.19 to 0.90)], left L5 [between-group mean difference = 0.45 (95%CI 0.13 to 0.76)], right L1 [between-group mean difference = 0.41 (95%CI 0.05 to 0.78)], left L1 [between-group mean difference = 0.57 (95%CI 0.15 to 0.99)], left DT [between-group mean difference = 0.35 (95%CI 0.04 to 0.65)], and right LE [between-group mean difference = 0.34 (95%CI 0.08 to 0.60)] showed superior treatment effect in the spinal manipulation group than sham. Neither intervention altered postural stability. Self-reported pain intensity showed clinically significant decreases in both groups after the intervention. A higher proportion of participants in the spinal manipulation group achieved more than two points of pain relief (spinal manipulation = 90%; sham = 60%). The participants' perceived treatment allocation did not affect the outcomes. CONCLUSION: One spinal manipulation session reduces lumbar pain sensitivity but does not affect postural stability compared to a sham session in individuals with cLPB. Self-reported pain intensity lowered in both groups and a higher proportion of participants in the spinal manipulation group reached clinically significant pain relief. The participant's belief in receiving the manipulation did not appear to have influenced the outcomes since the adjusted model revealed similar findings.

Spinal manipulation and mobilisation in paediatrics - an international evidence-based position statement for physiotherapists.

INTRODUCTION: An international taskforce of clinician-scientists was formed by specialty groups of World Physiotherapy - International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) - to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions. METHOD: A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes). RESULTS: Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.1. It is not recommended to perform:• Spinal manipulation and mobilisation on infants.• Cervical and lumbar spine manipulation on children.•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:• Spinal mobilisation and manipulation on adolescents;• Spinal mobilisation on children; or• Thoracic manipulation on children for neck-back pain only.3. No high certainty evidence to recommend these interventions was available.Reports of mild to severe harms exist; however, risk rates could not be determined. CONCLUSION: Specific directives to guide physiotherapists' clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Recent clinical practice guidelines for the management of low back pain: a global comparison.

BACKGROUND: Low back pain (LBP) is a significant health problem worldwide, with a lifetime prevalence of 84% in the general adult population. To rationalise the management of LBP, clinical practice guidelines (CPGs) have been issued in various countries around the world. This study aims to identify and compare the recommendations of recent CPGs for the management of LBP across the world. METHODS: MEDLINE, EMBASE, CINAHL, PEDro, and major guideline databases were searched from 2017 to 2022 to identify CPGs. CPGs focusing on information regarding the management and/or treatment of non-specific LBP were considered eligible. The quality of included guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. RESULTS: Our analysis identified a total of 22 CPGs that met the inclusion criteria, and were of middle and high methodological quality as assessed by the AGREE II tool. The guidelines exhibited heterogeneity in their recommendations, particularly in the approach to different stages of LBP. For acute LBP, the guidelines recommended the use of non-steroidal anti-inflammatory drugs (NSAIDs), therapeutic exercise, staying active, and spinal manipulation. For subacute LBP, the guidelines recommended the use of NSAIDs, therapeutic exercise, staying active, and spinal manipulation. For chronic LBP, the guidelines recommended therapeutic exercise, the use of NSAIDs, spinal manipulation, and acupuncture. CONCLUSIONS: Current CPGs provide recommendations for almost all major aspects of the management of LBP, but there is marked heterogeneity between them. Some recommendations lack clarity and overlap with other treatments within the guidelines.

Rehabilitation of back pain in the pediatric population: a mixed studies systematic review.

BACKGROUND: A significant proportion of children and adolescents experience back pain. However, a comprehensive systematic review on the effectiveness of rehabilitation interventions is lacking. OBJECTIVES: To evaluate benefits and harms of rehabilitation interventions for non-specific low back pain (LBP) or thoracic spine pain in the pediatric population. METHODS: Seven bibliographic electronic databases were searched from inception to June 16, 2023. Moreover, reference lists of relevant studies and systematic reviews, three targeted websites, and the WHO International Clinical Trials Registry Platform were searched. Paired reviewers independently conducted screening, assessed risk of bias, and extracted data related to study characteristics, methodology, subjects, and results. Certainty of evidence was evaluated based on the GRADE approach. RESULTS: We screened 8461 citations and 307 full-text articles. Ten quantitative studies (i.e., 8 RCTs, 2 non-randomized clinical trials) and one qualitative study were included. With very low to moderate certainty evidence, in adolescents with LBP, spinal manipulation (1-2 sessions/week over 12 weeks, 1 RCT) plus exercise may be associated with a greater likelihood of experiencing clinically important pain reduction versus exercise alone; and group-based exercise over 8 weeks (2 RCTs and 1 non-randomized trial) may reduce pain intensity. The qualitative study found information provided via education/advice and compliance of treatment were related to effective treatment. No economic studies or studies examining thoracic spine pain were identified. CONCLUSIONS: Spinal manipulation and group-based exercise may be beneficial in reducing LBP intensity in adolescents. Education should be provided as part of a care program. The overall evidence is sparse. Methodologically rigorous studies are needed. TRIAL REGISTRATION: CRD42019135009 (PROSPERO).

Exploring the immediate and short-term effect of lumbar spinal manipulation on pressure pain threshold: a randomized controlled trial of healthy participants.

BACKGROUND: Lumbar spinal manipulative therapy (SMT) is a common intervention used to treat low back pain (LBP); however, the exact neurophysiological mechanisms of SMT reducing pain measured through pain pressure threshold (PPT) have not been fully explored beyond an immediate timeframe (e.g., immediately or five-minutes following) referencing a control group. Therefore, the purpose of this study was to investigate the neurophysiological effects of lumbar SMT compared to deactivated ultrasound using PPT immediately following and 30-minutes following SMT. METHODS: A longitudinal, randomized controlled trial design was conducted between September to October 2023. Fifty-five participants were randomized into a control group of deactivated ultrasound (n = 29) or treatment group of right sidelying lumbar SMT (n = 26). PPT, recorded at the right posterior superior iliac spine (PSIS), was documented for each participant in each group prior to intervention, immediately, and 30-minutes after. A repeated measures ANOVA, with a post-hoc Bonferroni adjustment, was used to assess within-group and between-group differences in PPT. The significance level was set at a < 0.05 a priori. RESULTS: Statistically significant differences were found between the deactivated ultrasound and lumbar SMT groups immediately (p = .05) and 30-minutes (p = .02) following intervention. A significant difference in the lumbar SMT group was identified from baseline to immediately following (p < .001) and 30-minutes following (p < .001), but no differences between immediately following and 30-minutes following intervention (p = .10). The deactivated ultrasound group demonstrated a difference between baseline and immediately after intervention with a reduced PPT (p = .003), but no significant difference was found from baseline to 30-minutes (p = .11) or immediately after intervention to 30-minutes (p = 1.0). CONCLUSION: A right sidelying lumbar manipulation increased PPT at the right PSIS immediately after that lasted to 30-minutes when compared to a deactivated ultrasound control group. Future studies should further explore beyond the immediate and short-term neurophysiological effects of lumbar SMT to validate these findings. TRIAL REGISTRATION: This study was retrospectively registered on 4 December 2023 in ClinicalTrials (database registration number NCT06156605).

Waste not, want not: call to action for spinal manipulative therapy researchers.

BACKGROUND: Research waste is defined as research outcomes with no or minimal societal benefits. It is a widespread problem in the healthcare field. Four primary sources of research waste have been defined: (1) irrelevant or low priority research questions, (2) poor design or methodology, (3) lack of publication, and (4) biased or inadequate reporting. This commentary, which was developed by a multidisciplinary group of researchers with spinal manipulative therapy (SMT) research expertise, discusses waste in SMT research and provides suggestions to improve future research. MAIN TEXT: This commentary examines common sources of waste in SMT research, focusing on design and methodological issues, by drawing on prior research and examples from clinical and mechanistic SMT studies. Clinical research is dominated by small studies and studies with a high risk of bias. This problem is compounded by systematic reviews that pool heterogenous data from varying populations, settings, and application of SMT. Research focusing on the mechanisms of SMT often fails to address the clinical relevance of mechanisms, relies on very short follow-up periods, and has inadequate control for contextual factors. CONCLUSIONS: This call to action is directed to researchers in the field of SMT. It is critical that the SMT research community act to improve the way research is designed, conducted, and disseminated. We present specific key action points and resources, which should enhance the quality and usefulness of future SMT research.

Effectiveness and safety of thoracic manipulation in the treatment of neck pain: An updated systematic review and meta-analysis.

BACKGROUND: The purpose of this meta-analysis was to evaluate the effectiveness and safety of thoracic manipulation (TM) in patients with neck pain (NP). OBJECTIVE: The purpose of this meta-analysis was to evaluate the effectiveness and safety of thoracic manipulation (TM) in patients with neck pain (NP). METHODS: Seven electronic databases were searched from their inception through October 2023 by two authors. The methodological quality assessments were performed with the Physiotherapy Evidence Database (PEDro) scale. Pain, cervical range of motion (ROM), disability, and quality of life (QOL) were estimated for TM treatment in patients with NP. RESULTS: Eighteen randomized controlled trials (RCTs) with 914 patients were included with a PEDro score of 6.923 ± 3.120. Pooled effect sizes of pain (SMD =-0.481, 95% CI -0.653 to -0.309, P= 0.000), disability (SMD =-1.435, 95% CI -2.480 to -0.390, P= 0.007), QOL-physical component score (PCS) (SMD = 0.658, 95% CI 0.290 to 1.025, P= 0.000), ROM of flexion (SMD = 0.921, 95% CI 0.287 to 1.555, P= 0.000), ROM of extension (SMD = 0.572, 95% CI 0.321 to 0.822, P= 0.000), ROM of left lateral flexion (SMD = 0.593, 95% CI 0.075 to 1.112, P= 0.025) and ROM of left rotation (SMD = 0.230, 95% CI 0.010 to 0.450, P= 0.04) were favored by the TM group. CONCLUSIONS: TM provides short-term effect on relieving neck pain, increasing cervical ROM, and disability in patients with NP without serious side effects. Continuous therapy and distraction therapy are recommended as optimal choice on reducing pain and improving cervical ROM, especially in patients with chronic NP (> 3 months). The TM-induced improvements in the QOL of patients with NP should be verified by more further high-quality RCTs.

Cervical manipulation versus thoracic or cervicothoracic manipulations for the management of neck pain. A systematic review and meta-analysis.

BACKGROUND: Cervical and thoracic thrust or non-thrust manipulations have shown to be effective in patients with neck pain, but there is a lack of studies comparing both interventions in patients with neck pain. OBJECTIVE: To investigate the effects of cervical thrust or non-thrust manipulations compared to thoracic or cervicothoracic manipulations for improving pain, disability, and range of motion in patients with neck pain. DESIGN: Systematic review and meta-analysis. METHOD: Searches were performed in PubMed, PEDro, Cochrane Library, CINHAL, and Web of Science databases from inception to May 22, 2023. Randomized clinical trials comparing cervical thrust or non-thrust manipulations to thoracic or cervicothoracic manipulations were included. Methodological quality was assessed with PEDro scale, and the certainty of evidence was evaluated using GRADE guidelines. RESULTS: Six studies were included. Meta-analyses revealed no differences between cervical thrust or non-thrust manipulations and thoracic or cervicothoracic manipulations in pain intensity, disability, or cervical range of motion in any plane. The certainty of evidence was downgraded to very low for pain intensity, to moderate or very low for disability and to low or very low for cervical range of motion. CONCLUSION: There is moderate to very low certainty evidence that there is no difference in effectiveness between cervical thrust or non-thrust manipulations and thoracic or cervicothoracic manipulations for improving pain, disability, and range of motion in patients with neck pain. PROSPERO REGISTRATION: CRD42023429933.

Comparative effectiveness of cervical vs thoracic spinal-thrust manipulation for care of cervicogenic headache: A randomized controlled trial.

BACKGROUND: There is ample evidence supporting the use of different manipulative therapy techniques for Cervicogenic Headache (CgH). However, no technique can be singled as the best available treatment for patients with CgH. Therefore, the objective of the study is to find and compare the clinical effects of cervical spine over thoracic spine manipulation and conventional physiotherapy in patients with CgH. DESIGN, SETTING, AND PARTICIPANTS: It is a prospective, randomized controlled study conducted between July 2020 and January 2023 at the University hospital. N = 96 eligible patients with CgH were selected based on selection criteria and they were divided into cervical spine manipulation (CSM; n = 32), thoracic spine manipulation (TSM; n = 32) and conventional physiotherapy (CPT; n = 32) groups, and received the respective treatment for four weeks. Primary (CgH frequency) and secondary CgH pain intensity, CgH disability, neck pain frequency, neck pain intensity, neck pain threshold, cervical flexion rotation test (CFRT), neck disability index (NDI) and quality of life (QoL) scores were measured. The effects of treatment at various intervals were analyzed using a 3 × 4 linear mixed model analysis (LMM), with treatment group (cervical spine manipulation, thoracic spine manipulation, and conventional physiotherapy) and time intervals (baseline, 4 weeks, 8 weeks, and 6 months), and the statistical significance level was set at P < 0.05. RESULTS: The reports of the CSM, TSM and CPT groups were compared between the groups. Four weeks following treatment CSM group showed more significant changes in primary (CgH frequency) and secondary (CgH pain intensity, CgH disability, neck pain frequency, pain intensity, pain threshold, CFRT, NDI and QoL) than the TSM and CPT groups (p = 0.001). The same gradual improvement was seen in the CSM group when compared to TSM and CPT groups (p = 0.001) in the above variables at 8 weeks and 6 months follow-up. CONCLUSION: The reports of the current randomized clinical study found that CSM resulted in significantly better improvements in pain parameters (intensity, frequency and threshold) functional disability and quality of life in patients with CgH than thoracic spine manipulation and conventional physiotherapy. TRIAL REGISTRATION: Clinical trial registration: CTRI/2020/06/026092 trial was registered prospectively on 24/06/2020.

Spinal manipulation and mobilisation among infants, children, and adolescents: an international Delphi survey of expert physiotherapists.

OBJECTIVE: The aim of this study was to establish international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists. METHODS: Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale. RESULTS: Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included:Manipulation is not recommended: (1) for infants across all conditions, impairments, and spinal levels; and (2) for children and adolescents across most conditions and spinal levels.Manipulation may be recommended for adolescents to treat spinal region-specific joint hypomobility (thoracic, lumbar), and pain (thoracic).Mobilisation may be recommended for children and adolescents with hypomobility, joint pain, muscle/myofascial pain, or stiffness at all spinal levels. CONCLUSION: Consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents.

Effects of sustained natural apophyseal glides versus rocabado 6 × 6 program in subjects with cervicogenic headache.

BACKGROUND: Cervicogenic headache is designated as the most common type of secondary headache that results from conditions affecting the neck's bony components, muscles, and intervertebral discs rather than the head itself. OBJECTIVE: The purpose was to determine the effects of Sustained Natural Apophyseal Glides (SNAGs) versus the Rocabado 6 × 6 program in subjects with cervicogenic headaches. METHODS: This study was a randomized clinical trial. The sample size was 38, and participants aged 20-60 years (mean age 40.22 ± 9.66) suffering from cervicogenic headaches were randomly allocated using the lottery method into two groups with 19 participants in each group. Assessment of subjects was done before starting treatment and by the end of the 8th week for all the variables. Outcome measures were the Neck Disability Index (NDI), 6-item Headache Impact Test (HIT-6), Flexion-Rotation test (FRT) to assess the rotation range of motion at the level of C1-C2 (goniometer) and the Numeric Pain Rating Scale (NPRS) for the intensity of pain. Data analysis was done by SPSS (IBM) 25. To check the normality of the data the Shapiro-Wilk test was used. RESULTS: In the Shapiro-Wilk test p-value of all the testing variables i.e. NDI, HIT-6 score, FRT and NPRS was > 0.05, data was normally distributed and parametric tests were used. Group A showed a considerable improvement (p < 0.05) in all variables compared to Group B, while within-group analysis of both groups shows that all outcome measures show significant results (p < 0.05). CONCLUSION: It was concluded that both SNAGs and Rocabado's 6 × 6 exercises were effective for the treatment of cervicogenic headache but the effects of headache SNAG were superior and produced more improvement in intensity of headache, disability, frequency of headache, duration of headache as compared to Rocabado 6 × 6 exercises. TRIAL REGISTRATION NUMBER: This study was registered at ClinicalTrials.gov ID: NCT05865808 on date 19/05/2023.

The immediate effect of cervical rotation-traction manipulation on cervical paravertebral soft tissue: a study using soft tissue tension cloud chart technology.

BACKGROUND: To evaluate the reliability of the Soft Tissue Tension Cloud Chart (STTCC) technology, an original method combining multi-point Cervical Paravertebral Soft Tissue Test (CPSTT) with MATLAB software, we conducted a preliminary analysis on the immediate effects of Orthopaedic Manual Therapy (OMT) on cervical paravertebral soft tissue. METHODS: 30 patients with Cervical Spondylotic Radiculopathy (CSR) were included in this study. We analyzed the differences in CPSTT before and after treatment with Cervical Rotation-Traction Manipulation (CRTM), a representative OMT technique in Traditional Chinese Medicine, using the STTCC technology. RESULTS: The STTCC results demonstrated that post-treatment CPSTT levels in CSR patients were significantly lower than pre-treatment levels after application of CRTM, with a statistically significant difference (P < 0.001). Additionally, pre-treatment CPSTT levels on the symptomatic side (with radicular pain or numbness) were higher across the C5 to C7 vertebrae compared to the asymptomatic side (without symptoms) (P < 0.001). However, this difference disappeared after CRTM treatment (P = 0.231). CONCLUSIONS: The STTCC technology represents a reliable method for analyzing the immediate effects of OMT. CSR patients display uneven distribution of CPSTT characterized by higher tension on the symptomatic side. CRTM not only reduces overall cervical soft tissue tension in CSR patients, but can also balance the asymmetrical tension between the symptomatic and asymptomatic sides. TRIAL REGISTRATION: This study was approved by the Chinese Clinical Trials Registry (Website: . https://www.chictr.org.cn .) on 20/04/2021 and the Registration Number is ChiCTR2100045648.

Spinal displacement during thoracic manipulative therapy in mechanical neck pain patients: an observational study.

INTRODUCTION: Thoracic manipulative therapy (TMT) is recommended for treating patients with mechanical neck pain (MNP). However, there are multiple proposed recommendations for the mechanism for neck pain reduction. OBJECTIVE: To investigate displacement of the cervicothoracic spine during the application of TMT in patients with MNP. METHODS: Thirty-five male patients with MNP were recruited. Displacements of C3, C5, C7, T2, T4 and T6 were measured using a motion capture system while a therapist applied a grade III central posteroanterior TMT (cpa-TMT) to T6. RESULTS: Mean (SD) displacement ranged from 2.2 (0.62) to 5.5 (1.1) mm. A significant decrease in neck pain intensity at rest was found after the application of the cpa-TMT (mean difference 17 mm, p < 0.001). A downward trend in spinal displacement was noted, with the largest and smallest displacement occurring at T6 and C3, respectively. Correlations between the displacement of T6 and adjacent spinal levels were moderate to high (Pearson's r range 0.70-0.90, p < 0.001). It was showed that cpa-TMT applied to T6 produced the PA displacement toward the upper cervical spine. CONCLUSION: TMT produces spinal segmental displacements toward the upper cervical spine in MNP patients. These segmental displacements would activate the alleviation effect at both the spinal and supraspinal levels resulting in neck pain reduction. These findings would provide supporting evidence for the use of TMT in neck pain reduction.

Comparison of the Effects of Cervical Thrust Manipulation and Exercise in Mechanical Neck Pain: A Randomized Controlled Trial.

OBJECTIVE: This study aimed to compare the effectiveness of cervical thrust manipulation and exercise in patients with mechanical neck pain (MNP). METHOD: Sixty (mean age 31.45 ± 7.31 years) patients were randomized into three groups: manipulation (Group 1); exercise (Group 2); and manipulation plus exercise (Group 3). All interventions were performed 2 days a week for 6 weeks. The visual analog scale (VAS) and Neck Disability Index (NDI) were primary outcome measures; pressure pain threshold (PPT), range of motion (ROM), Short form-36 (SF-36), and Global Rating of Change (GROC) were secondary outcome measures. RESULTS: All parameters improved in all groups (p < .05). Only the minimal clinically important difference (MCID) for NDI was achieved in Group 3. Group 3 had greater improvement in: VAS-rest (p = .004); NDI (p < .001); PPT-left (p = .012); and vitality (p = .002), as well as higher GROC compared to the other groups (p = .043). Group 3 was superior to Group 2 in terms of: ROM (Lateral flexion [LF]-right, p = .003/left, p = .003, rotation-right, p = .012/left, p = .010), PPT-right (p = .022); and emotional well-being (p = .003). Group 1 was superior to Group 2 in terms of ROM (LF-left, p = .043/rotation-left, p = .049). The between-group effect sizes were large (0.12-0.36). CONCLUSION: The combined application of cervical thrust manipulation and exercise in MNP resulted in greater improvement in clinical parameters, especially function, and higher patient satisfaction in the short term compared to their application alone. Because of its positive effects, cervical thrust manipulation can be added to the exercise program according to the patient's needs and suitability for manipulation.

Effectiveness of mid thoracic spine mobilization on postural balance and gait ability in subacute stroke patients: A randomized clinical trial.

BACKGROUND: Although mulligan sustained natural apophyseal glides (SNAG) and maitland mobilization (MM) are common interventions for musculoskeletal disease, no study has directly compared the effectiveness of mid-thoracic spine mobilization in subacute stroke patients. OBJECTIVE: To investigate the effects of mid-thoracic spine mobilization (SNAG vs. MM) on postural balance and gait ability in subacute stroke patients. METHODS: Fifty subacute stroke patients were randomly allocated to the SNAG (n= 17), MM (n= 16), and control (n= 17) groups, each receiving a neuro-developmental therapy program for four successive weeks. The SNAG and MM groups additionally received mid-thoracic spine mobilization (T4∼8). The primary outcome measure was postural sway, and secondary outcome measures included the five times sit-to-stand test (FTSST), functional reach test (FRT), 10-m walk test (10MWT), 6-minute walk test (6MWT) and global rating of change (GRC). RESULTS: Participants reported no adverse events, and there was no loss to follow-up. The SNAG and MM group patients demonstrated significant improvements (p< 0.05) in postural sway, FTSST, FRT, 10MWT, and 6MWT compared with those in the control group, with no between-group differences. CONCLUSIONS: Mid-thoracic spine mobilization allows significant improvements in postural balance and gait ability in subacute stroke patients, with no differences between the SNAG and MM techniques.

Effectiveness of spinal manipulation in influencing the autonomic nervous system - a systematic review and meta-analysis.

BACKGROUND: Spinal manipulation (SM) has been hypothesized to influence the autonomic nervous system (ANS). Further, it has been proposed that the effects may vary depending on the segment manipulated. The aim of this systematic review was to synthesize the current level of evidence for SM in influencing the ANS in healthy and/or symptomatic population. METHODS: Various databases (n = 8) were searched (inception till May 2023) and 14 trials (n = 618 participants) were included in the review. Two authors independently screened, extracted and assessed the risk of bias in included studies. The data were synthesized using standard mean differences and meta-analysis for the primary outcome measures. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of the body of evidence for each outcome of interest. RESULTS: Overall, there was low quality evidence that SM did not influence any measure of ANS including heart rate variability (HRV), oxy-hemoglobin, blood pressure, epinephrine and nor-epinephrine. However, there was low quality evidence that cervical spine manipulation may influence high frequency parameter of HRV, indicating its influence on the parasympathetic nervous system. CONCLUSION: When compared with control or sham interventions, SM did not alter the ANS. Due to invalid methodologies and the low quality of included studies, findings must be interpreted with great caution. Future studies are needed which employ rigorous data collection processes to verify the true physiological implications of SM on ANS.

Psychometric measurement properties of patient-reported and observer-reported outcome measures for spinal mobilisations and manipulation on paediatric subjects with diverse medical conditions: A systematic review.

INTRODUCTION: Reliable, valid, and responsive outcomes is foundational to address concerns about the risks and benefits of performing spinal manipulation and mobilization in pediatric populations. The aim of this systematic review was to synthesize evidence on measurement properties from cohort/case-control/cross-sectional/randomized studies on patient-reported (SQLI - Scoliosis Quality of Life Index; VAS-Visual Analog Scale; PAQLQ - Pediatric Asthma Quality of Life Questionnaire), observer-reported (Crying Diaries; ATEC - Autism Treatment Evaluation Checklist) and mixed (PedsQL - Pediatric Quality of Life Inventory) outcome measurements identified through a scoping review on manipulation and mobilization for pediatric populations with diverse medical conditions. METHOD AND ANALYSIS: Electronic databases, clinicaltrial.gov and Ebsco Open Dissertations were searched up to 21 October 202221 October 2022. Two independent reviewers selected studies, extracted data, and assessed risk of bias. Qualitative synthesis was performed using COSMIN and Cochrane GRADE methodology to establish the certainty of evidence and overall rating: sufficient (+), insufficient (-), inconsistent (±), indeterminate (?). RESULTS: Eighteen studies (2 SQLI for scoliosis; 1 VAS - perceived influence of exertion or movement/position on low back problems; 1 PAQLQ for asthma; 1 Crying Diaries for infantile colic; 8 ATEC for autism; 5 PedsQL for cerebral palsy/scoliosis/healthy) with 9653 participants were selected. ATEC and PedsQL had overall sufficient (+) measurement properties with moderate certainty evidence. PAQLQ had indeterminate measurement properties with moderate certainty evidence. Very low certainty of evidence identified measurement properties to be indeterminate (?) for SQLI, Crying Diaries, and VAS- perceived influence of exertion or movement/position on low back problems. CONCLUSION: ATEC for autism and PedsQL for asthma may be a suitable clinical outcome assessment (COA); additional validation studies on responsiveness and the minimal important difference are needed. Other COA require further validation.

Effects of fasciatherapy versus fascial manipulation on pain, range of motion and function in patients with chronic neck pain.

BACKGROUND: Neck pain is among the common musculoskeletal problem that hinders a person's daily activities. Fascial tightness is a familiar cause of chronic neck pain that is often neglected and can further cause neck disability and a limited range of motion. OBJECTIVE: The purpose was to compare the effects of fascia therapy and fascial manipulation on pain, range of motion and function in patients with chronic neck pain. METHODS: A randomized clinical trial was conducted from February to August 2022 in the Riphah Rehabilitation Centre, Lahore, Pakistan. Fifty-two participants of both genders, aged 18-40 years with chronic neck pain of at least 3-6 months were included. Group A (n = 26) received fascia therapy along with a conventional physical therapy protocol of hot pack, strengthening and stretching, while group B (n = 26) received the fascial manipulation treatment with conventional physical therapy. All the participants were assessed at baseline and after 3 weeks (3 sessions per week). Numeric Pain Rating Scale (NPRS), Neck Disability Index (NDI) and Goniometer (range of motions) were the outcome measures. SPSS 25 was used for the data analysis and normality of the data through the Shaphiro-Wilk test (p > 0.05), and parametric tests were applied. RESULTS: The mean age of group A was 24.82 ± 2.64 years, and group B was 24.17 ± 2.20 years. The independent t-test result showed no significant difference (p ≥ 0.05) in all parameters except in cervical extension and right-side bending (p < 0.05). At the same time, the pair-wise comparison showed significant results (p < 0.05) for all outcome measures in both groups. CONCLUSION: DBM fascia therapy improved cervical extension and side bending (right) more than the fascial manipulation group.It is concluded that DBM fascia therapy shows more improvement as compared to other group. TRIAL REGISTRATION NUMBER: This study was registered at ClinicalTrials.gov ID: NCT05272111 on 09/03/2022.