Article Full Title
Biomechanical characteristics of lumbar manipulation performed by expert, resident, and student physical therapists
Author Names
Derian, J.; Smith, J.; Wang, Y.; Lam, W.; Kulig, K.
Reviewer Name
Sarah Adamo, MS, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background: Lumbar manipulation is a commonly used treatment for low back pain, but little research evidence exists regarding practitioner biomechanics during manipulation. Most existing evidence describes rate of force production through the hands into instrumented manikins and it is unclear how the practitioner moves their body and legs to generate this force. Objectives: To identify and characterize important kinetic and kinematic factors in practitioners of varying experience performing lumbar manipulation in order to identify which factors distinguish experts from less experienced practitioners. Study design: This was a cohort observational laboratory study. Methods: 43 male physical therapists (PT) and PT students (4 experts, 11 residents, 13 third year, and 15 first year students) performed 4 manipulations each on asymptomatic patient models. Angular and linear kinematics of the pelvis were measured using motion capture, and ground reaction forces were measured with force plates under the practitioner’s feet. Results: Peak pelvic angular velocity was greater and in the opposite direction in experts compared to other groups in the frontal plane (p 1⁄4 0.020) and transverse plane (p 1⁄4 0.000). Experts had greater downward pelvic linear velocity than third year students and first year students (p 1⁄4 0.000). Experts also demonstrated faster rate of vertical ground reaction force unloading during the manipulation (p 1⁄4 0.002). Conclusions: Expert performance of manipulation was characterized by increased speed of linear and angular pelvic motion, and increased modulation of vertical ground reaction force. These results help to inform educators and practitioners that teach and use this complex manual skill.
NIH Risk of Bias Tool
Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies
- Was the research question or objective in this paper clearly stated?
Yes
- Was the study population clearly specified and defined?
Yes
- Was the participation rate of eligible persons at least 50%?
Cannot Determine, Not Reported, Not Applicable
- Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?
Cannot Determine, Not Reported, Not Applicable
- Was a sample size justification, power description, or variance and effect estimates provided?
Yes
- For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?
Yes
- Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?
Yes
- For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?
Yes
- Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
Yes
- Was the exposure(s) assessed more than once over time?
No
- Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
Yes
- Were the outcome assessors blinded to the exposure status of participants?
Yes
- Was loss to follow-up after baseline 20% or less?
Cannot Determine, Not Reported, Not Applicable
- Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?
Yes
Key Finding #1
Expert and novice biomechanical performance of lumbar manipulation is statistically different in speed and direction of pelvic rotation and amount of vertical ground reaction unloading.
Key Finding #2
Biomechanical findings formed a graduated spectrum of improvement, ranging from novice to expert, by experience level.
Key Finding #3
Downward center of mass motion and loading on the cephalad (closer to the head) foot may be useful cues in teaching lumbar manipulation skills.
Please provide your summary of the paper
This study used an observational cohort design to explore the biomechanics of physical therapists at different experience levels during the performance of a lumbar manipulation. The results of this study are based on 43 males in the following categories: experts (minimum of 10 years of physical therapy practice and often performing lumbar manipulation and/or teaching the technique), Orthopedic and Sports Physical Therapy residents, third-year Doctor of Physical Therapy (DPT) students, and first-year DPT students. There has not been much research into the physical performance of lumbar manipulations despite their effectiveness in treating low back pain. The vertical ground reaction force unloading, peak pelvic angular velocity, pelvic linear velocity, and center of mass acceleration were measured during lumbar manipulations performed by the participants on male patient models meeting inclusion criteria (age 18-35, ≥1 hypomobile lumbar spine segment). The biomechanical characteristics of manipulation performance were significantly different between groups, with greater vertical ground reaction force unloading, peak pelvic angular velocity in the frontal plane, and pelvic linear velocity in experts than in first-year DPT students. In exploring these differences, an objective foundation for the biomechanics of this lumbar manipulation technique is created and can inform the education of this manual skill in the physical therapy profession.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study provides unique insight into potential learning objectives and cues that can be used to teach lumbar manipulation techniques. There is currently a lack of standardization in the performance of manipulation techniques, which can be challenging from a student perspective. This study’s participants were limited to all student groups attending the same institution, which warrants further exploration into potential differences in manipulation technique curriculum between DPT programs. As the study discussed, we are unable to extrapolate whether the differences found between participant groups led to varying levels of treatment effectiveness. Additionally, significant differences were often described between experts or residents and first and third-year DPT students, with less discussion comparing experts and residents. The factors affecting performance were not explored in depth or included outside of the categorization by experience level and the biomechanical factors. Further exploration, potentially into the confidence and self-efficacy of the therapist and the biomechanical characteristics could be an enlightening pathway to better understanding the reason behind the physical differences observed in this study.
Article Full Title : Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial
Author Names: Young I, Dunning J, Butts R, et al.
Reviewer Name: Karla Alvarado
Reviewer Affiliation(s): Duke University Doctor of Physical Therapy Student
Paper Abstract:
Background context: Nonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS.
Purpose: This study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS.
Study design/setting: Randomized, single-blinded, multi-center, parallel-group clinical trial.
Patient sample: One hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period.
Outcome measures: The primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months.
Methods: Patients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63).
Results: At 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group.
Conclusion: Patients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up.
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
- Were study participants and providers blinded to treatment group assignment?
No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
- Was there high adherence to the intervention protocols for each treatment group?
Yes
- 10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
- 11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- 12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
- 13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
One of the key findings from the study was measured using the NPRS to determine the pain intensity of participants with low back, buttock, and leg pain. Comparing the baseline pain with the 3-month follow-up, it was shown that the group who received Spinal Manipulation, Electrical Dry Needling, and Conventional Physical Therapy had a greater reduction in pain than those who received only conventional physical therapy.
Key Finding #2
Another key finding from the study is the improvement in disability scores, as measured by the Oswestry Disability Index (ODI). In this case, the improvement matched the MCID value for patients with lumbar stenosis. Patients themselves were able to feel an improvement in their daily function.
Key Finding #3
Another key finding from the study is the improvement in disability scores, as measured by the Oswestry Disability Index (ODI). In this case, the improvement matched the MCID value for patients with lumbar stenosis. Patients themselves were able to feel an improvement in their daily function.
Please provide your summary of the paper
This article focused on examining the influence of combining spinal manipulation, electrical dry needling, and conventional physical therapy(MEDNCPT) on patients with spinal stenosis, in comparison to those only receiving conventional physical therapy. The primary outcomes of the study were measured using the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI) at different time points as follow-ups during 2 weeks, 6 weeks, and 3 months, to assess the effects of both treatments groups on low back, buttock, and leg pain. Additionally, the physical therapists treating the patients were experienced clinicians each with approximately 10 years of practice. They had additional training in managing lumbar spinal stenosis, which further supports the reliability of the outcomes regarding patient symptom improvement.The results of the study suggest that combining treatment methods (MEDNCPT) was the most effective at decreasing pain in patients with spinal stenosis at 3 months. However, there was no follow-up assessment beyond 3 months, so the long-term benefits of incorporating this combination of treatments should be further studied.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The strengths of the study include randomization of the assigned groups and drop out percentage remaining low throughout the entire study. Additionally the assessments for determining outcome measures were standardized and even the eligibility for study remained consistent. One more strength was the clinician has specific training for the diagnoses of the patient population which can help in determining the efficiency of treatments implemented. However, a limitation of the study was that the only follow up was at 3 months which only takes into consideration short term benefits in implementing spinal manipulation, electrical dry needling, and conventional therapy (MEDNCPT). Another limitation was that the sample size of the study was small which can misrepresent the findings. Lastly both patient and the therapist should be blinded and in this case the patient already knew which group they were in but which already have caused an unintentional placebo effect.
Article Full Title
Lumbar osteopathic manipulative treatment can improve KOA symptoms: short-term efficacy observation and mechanism analysis
Author Names
Du, P; Li, X; Yin, S; Li, W; Sun, X; Zhang, Z; Zhao, J; Shijun, G; Du, S; Zhang, D
Reviewer Name
Hana Alvey, SPT, CPT
Reviewer Affiliation(s)
Duke University Doctor of Physical Therapy Program
Paper Abstract
Background: Manipulative treatment can effectively improve knee pain and function, but no previous studies have shown that lumbar osteopathic manipulative treatment can improve knee symptoms. To explore the influence of lumbar manipulation on KOA and analyze its principle relationship between coronal position of lumbar spine and KOA. Methods: Patients were divided into OMT group and DT group according to treatment. WOMAC scores were compared between the two groups, and X-ray examinations before and after treatment were performed in OMT group to analyze the imaging changes. Results: Both OMT group and DT group showed signi cant improvement in WOMAC score after treatment, and the improvement in OMT group was better than that in DT group. After OMT treatment, cTMI(P = 0.034), mL-SOD (P <0.001), mΔL-KOD (P = 0.001), LL (P = 0.036), and FTA(P = 0.026) were significantly changed. Conclusion: Compared with drug therapy, lumbar manipulation can better improve WOMAC scores in KOA patients. It relives symptoms by loosening muscles and correcting small joint disorders to improve local knee alignment.
Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies
- Was the research question or objective in this paper clearly stated?
Yes
- Was the study population clearly specified and defined?
Yes
- Was the participation rate of eligible persons at least 50%?
Yes
- Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?
Yes
- Was a sample size justification, power description, or variance and effect estimates provided?
Yes
- For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?
Yes
- Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?
Yes
- For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?
Yes
- Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
Yes
- Was the exposure(s) assessed more than once over time?
No
- Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
Yes
- Were the outcome assessors blinded to the exposure status of participants?
No
- Was loss to follow-up after baseline 20% or less?
No
- Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?
Yes
Key Finding #1
Both the Osteopathic Manipulative Treatment (OMT) group and the Drug Therapy (DT) group had improved WOMAC scores.
Key Finding #2
WOMAC scores improved more with the OMT group than the DT group.
Key Finding #3
OMT can correct malalignments of lumbar spine, thereby reducing knee mechanical stress, relieving knee pain and improving knee function.
Please provide your summary of the paper
Knee osteoarthritis is the most common type of OA, and manual therapy is a common and widely used treatment for OA in physical therapy. This research study, however, does not conduct manual therapy on the knee, but on the spine. The effectiveness of manual therapy on the lumbopelvic complex to improve knee symptoms has not been substantially reported, and this article looks at how WOMAC score are impacted by OMT of the spine compared to Drug Therapy (DT). Using the change in WOMAC scores from before treatment to after two weeks of treatment, this study finds that OMT and DT are both effective in reducing pain, stiffness, and improving function, but OMT is more effective than DT. Based on radiographs before and after treatment, OMT can relieve lumbar muscles, improve small joint disorders, and improve other lumbar malalignments. There are also effects on the rotation of the femur and straightening of the knee, which can improve the mechanical stress on the knee, reducing pain symptoms. In summary, OMT of the lumbopelvic complex can lead to decreased pain symptoms in the knee OA population.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This paper shows that OMT is effective in reducing pain, stiffness, and function in the knee OA population. This leads me to conclude that manual therapy would be great to consider in clinic for various patient populations and is worth implementing so we as clinicians can do everything we can to help reduce our patients’ pain and improve their physical function. This also encourages one to look at the whole patient, not just the area of complaint. The kinetic chain can provide insight into possible causes of symptoms that are not deemed typical, and this study does a great job of showing how malalignment in the spine can affect the knee. Also, if this alternative form of treatment does not prove beneficial for a particular patient, other conservative methods of treatment can be implemented without any drastic consequences.
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Article Full Title
Perceived factors and barriers affecting physiotherapists’ decision to use spinal manipulation and mobilisation among infants, children, and adolescents: an international survey
Author Names
Dice, J; Brismee, JM; Froment, F; Henricksen, J; Sherwin, R; Pool, J; Milne, N; Clewley, D; Basson, A; Olson, K; Gross, A
Reviewer Name
Devon Anthony
Reviewer Affiliation(s)
Duke University Doctor of Physical Therapy
Paper Abstract
Objective: To identify factors and barriers, which affect the utilisation of spinal manipulation and mobilisation among infants, children, and adolescents. Methods: Twenty-six international expert physiotherapists in manual therapy and paediatrics were invited to participate in a Delphi investigation using QualtricsⓇ. In Round-1 physiotherapists selected from a list of factors and barriers affecting their decision to use spinal manipulation and mobilisation in the paediatric population and had opportunity to add to the list. Round-2 asked respondents to select as many factors and barriers that they agreed with, resulting in a frequency count. The subset of responses to questions around barriers and facilitators are the focus of this study. Results: Twelve physiotherapists completed both rounds of the survey. Medical diagnosis, mechanism of injury, patient presentation, tolerance to handling, and therapist’s knowledge of techniques were the dominant deciding factors to use spinal manipulation and mobilisation among infants, children, and adolescents across spinal levels. More than 90% of the respondents selected manipulation as inappropriate among infants as their top barrier. Additional dominant barriers to using spinal manipulation among infants and children identified by ≥ 75% of the respondents included fear of injuring the patient, fear of litigation, lack of communication, lack of evidence, lack of guardian consent, and precision of the examination to inform clinical reasoning. Conclusion: This international survey provides much needed insight regarding the factors and barriers physiotherapists should consider when contemplating the utilisation of spinal mobilisation and manipulation in the paediatric population.
NIH Risk of Bias Tool
Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies
1. Was the research question or objective in this paper clearly stated? Yes
2. Was the study population clearly specified and defined? Yes
3. Was the participation rate of eligible persons at least 50%? No
4. Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants? Yes
5. Was a sample size justification, power description, or variance and effect estimates provided? No
6. For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured? Cannot Determine, Not Reported, Not Applicable
7. Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed? Cannot Determine, Not Reported, Not Applicable
8. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)? Cannot Determine, Not Reported, Not Applicable
9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? Yes
10. Was the exposure(s) assessed more than once over time? Cannot Determine, Not Reported, Not Applicable
11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? Yes
12. Were the outcome assessors blinded to the exposure status of participants? Yes
13. Was loss to follow-up after baseline 20% or less? Cannot Determine, Not Reported, Not Applicable
14. Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)? Cannot Determine, Not Reported, Not Applicable
Key Finding #1
The study found that among participants, patient presentation, tolerance to handling, MOI, and therapist knowledge were dominant factors in decision making around the use of manual therapy.
Key Finding #2
More than 80% of participants in this study identified concerns regarding guardian consent, soft tissue and skeletal integrity in infants and adolescents when considering the use of spinal mobilization and manipulation.
Key Finding #3
Participants identified unclear medical diagnoses and a lack of knowledge and training in techniques as prevalent barriers preventing the use of spinal manual therapy with infants and children.
Please provide your summary of the paper
This study looked at why therapists choose to use spinal manipulation and mobilization for children and adolescents, and what keeps them from doing so. The study found that, when it comes to the patient, common factors that influenced decision making are things like the child’s medical diagnosis, injury, and how well they could handle the treatment. From the standpoint of the practitioners, however, knowledge, comfortability, and scope of practice limitations played a significant role as well. Many agreed that while spinal manipulation may have its benefits, it is not safe for infants, with over 90% saying it was inappropriate. Barriers included fears of hurting the child, lawsuits, and a lack of evidence, training, or guardian consent. With that being said, the study also noted limitations due to the categorization of age groups, respondent attrition due to survey volume, and demographic factors. The study results are still valuable to suggest that, on an individual level, education and mentorship could help increase ability to recognize appropriate opportunities to utilize these techniques as well as increase confidence in using these techniques without fear of consequence.
Please provide your clinical interpretation of this paper.
Include how this study may impact clinical practice and how the results can be implemented. This paper, while it may not seem to have direct impacts on clinical practice, has the potential for reaching implications in education, training, and patient outcomes. This paper illustrates common barriers that are not simply a lack of knowledge, but a lack of training; this highlights the importance of mentorship, professional networking, continuing education, and to an extent, professional organizations like the APTA. These organizations can collect information from leading practitioners and researchers in the field to be distributed en masse, multiplying the impact of these individuals’ knowledge and technique. Furthermore, this paper identifies an area in which the field of Physical Therapy can progress the quality of patient care, encouraging further research on hazards and benefits of spinal manipulation and mobilization in infants.
Article Full Title
Does Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain Result in Better Long-Term Outcome?
Author Names
Senna M, Machaly S
Reviewer Name
Andrew Aronesty, SPT, CSCS
Reviewer Affiliation(s)
Duke University School of Medicine – Doctor of Physical Therapy Division
Paper Abstract
A prospective single blinded placebo controlled study was conducted. To assess the effectiveness of spinal manipulation therapy (SMT) for the management of chronic nonspecific low back pain (LBP) and to determine the effectiveness of maintenance SMT in long-term reduction of pain and disability levels associated with chronic low back conditions after an initial phase of treatments. SMT is a common treatment option for LBP. Numerous clinical trials have attempted to evaluate its effectiveness for different subgroups of acute and chronic LBP but the efficacy of maintenance SMT in chronic nonspecific LBP has not been studied. Sixty patients, with chronic, nonspecific LBP lasting at least 6 months, were randomized to receive either (1) 12 treatments of sham SMT over a 1-month period, (2) 12 treatments, consisting of SMT over a 1-month period, but no treatments for the subsequent 9 months, or (3) 12 treatments over a 1-month period, along with “maintenance spinal manipulation” every 2 weeks for the following 9 months. To determine any difference among therapies, we measured pain and disability scores, generic health status, and back-specific patient satisfaction at baseline and at 1-, 4-, 7-, and 10-month intervals. Patients in second and third groups experienced significantly lower pain and disability scores than first group at the end of 1-month period (P= 0.0027 and 0.0029, respectively). However, only the third group that was given spinal manipulations (SM) during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation. In the nonmaintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level. SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
- Were study participants and providers blinded to treatment group assignment?
No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
No
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
- Was there high adherence to the intervention protocols for each treatment group?
Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
C/D
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
Spinal manipulation therapy (SMT) may be an effective modality in chronic nonspecified low back pain, especially for short-term effects
Key Finding #2
Maintained, long-term, SMT after initial treatment may provide long-term benefits
Key Finding #3
SMT was more effective than sham SMT at reducing pain and disability in the short-term, which may indicate the efficacy of SMT to be specific as opposed to nonspecific (placebo).
Key Finding #4
N/A
Please provide your summary of the paper
This study primarily investigated the efficacy of long-term, or “maintained” spinal manipulation therapy SMT on chronic nonspecific low back pain (CNLBP). To evaluate the efficacy of maintained SMT, the researchers employed a randomized controlled trial, consisting of 60 participants by end-point. Initially, the study consisted of 93 eligible subjects, where eligibility was defined as being between 20 and 60 years old and having CNLBP that lasted for at least six months. Subjects with signs of serious pathologies like compression fractures or nerve root compression were ruled out. Notably, obesity, pregnancy, and previous experience with SMT were also used as exclusion criteria. Once the initial sample was gathered, the researchers matched the subjects by age and sex, and then randomly divided the participants into three groups: a control group where subjects would be receiving sham SMT for one month, a group receiving SMT for one month, and a group receiving SMT for one month plus maintenance SMT for nine subsequent months. All groups were instructed to do the same pelvic tilt exercise after the interventions were delivered and were instructed to continue this exercise on non-treatment days. Notably, several participants dropped out of the study by its culmination, and the authors note this as a major limitation. The primary outcome measure used in this study was the Oswestry disability questionnaire. Other outcomes measures used were the visual analogue scale (VAS), SF-36, modified Schober test, right lateral bending test, and left lateral bending test. The outcome measures were given after the first, fourth, seventh, and tenth months of the study. The results of the study indicated the groups receiving SMT had significantly lower pain and disability than the control at one month. At the four and seven-month evaluations, gains made by the non-maintained SMT group were lost, whereas the maintained group continued to see improvements in pain and disability. By the tenth month, only the maintained SMT group had favorable outcomes from baseline. The authors concluded that SMT may be an effective treatment for CNLBP, but to obtain long-term benefits, maintenance sessions may be indicated.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study lends support to the idea that SMT may be used in both short-term and long-term treatment plans with good effect. It supports the idea of spinal manipulation as a “maintenance therapy,” which is to say that patients with low back pain may benefit from continued use of this treatment technique after initial gains are made. As a counterpoint to this, the researchers only used one exercise, the pelvic tilt, as a co-treatment. The study does not explore whether progressive exercise therapy plus SPT would have resulted in the same significant differences seen in the results. In other words, due to the paucity of other treatment strategies, this study only shows that maintenance SPT with a relative absence of therapeutic exercise may have positive long-term effects. In light of these limitations, this study alone does not give license to promote maintenance SPT for low back pain. However, clinicians may use the conclusions of this study to support the idea of using SPT to help treat CNLBP in both the short and long term.
Article Full Title
Effects of a Patient-Centered Graded Exposure Intervention Added to Manual Therapy for Women With Chronic Pelvic Pain: A Randomized Controlled Trial
Author Names
Ariza-Mateos, Jose M; Cabrera-Martos, Irene; Ortiz-Rubio, Araceli; Torres-Sanchez, Irene; Rodriguez-Torres, Janet; Valenza, Marie Carmen
Reviewer Name
Ilene Avalos
Reviewer Affiliation(s)
Duke University Doctorate of Physical Therapy Student
Paper Abstract
Objective: To explore the effects of a 6-week patient-centered graded exposure intervention added to manual therapy in women with chronic pelvic pain (CPP) and fear of movement/(re)injury. Design: Prospective 3-armed randomized controlled trial. Setting: Faculty of Health Sciences. Participants: A total of 49 women with CPP and substantial fear of movement were randomly allocated to 1 of 3 groups: (1) patient-centered graded exposure intervention added to manual therapy; (2) manual therapy; (3) control group. Interventions: The 6-week intervention consisted of 12 sessions in the group receiving manual therapy and 6 additional sessions of graded exposure therapy in the group receiving both interventions. Main Outcome Measures: Primary outcomes were fear-avoidance behavior assessed using the Fear-Avoidance Beliefs Questionnaire and pain interference and severity evaluated with the Brief Pain Inventory. The secondary outcome was disability evaluated with the Oswestry Disability Index. All the variables were assessed in a blinded manner at baseline, after the treatment, and at 3-month follow-up. Results: Our results show interaction effects (P<.05) for all the outcomes. Graded exposure added to manual therapy is distinctly superior to manual therapy alone in maintaining improvements for long-term fear-avoidance behavior and physical functioning. Conclusions: Graded exposure added to manual therapy is a promising approach with long-term effects for women with CPP and fear of movement/(re)injury.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
- Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
- Was there high adherence to the intervention protocols for each treatment group?
Cannot Determine, Not Reported, or Not Applicable
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
- Graded exposure therapy coupled with manual therapy can have a higher impact on patient outcomes by providing an individualized approach to treating chronic pelvic pain.
Key Finding #2
- Graded exposure added to manual therapy can provided improvements in fear-avoidance behaviors and physical functioning in patients with chronic pelvic pain.
Please provide your summary of the paper
This study aimed to evaluate the effects of adding GET to manual therapy (MT) in women with CPP and fear of movement, using a randomized controlled trial. The results demonstrated significant improvements in fear-avoidance beliefs, pain intensity, disability, and occupational performance in the GET+MT group compared to MT alone and the control group, with lasting benefits observed at a 3-month follow-up.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The results of this study demonstrate the effectiveness of graded exposure therapy with manual therapy to further elicit a successful outcome in patients with chronic pelvic pain. By being able to gradually build the patient’s confidence in their abilities, the clinician is also providing the opportunity to evolve the patient’s pain experience when undergoing manual therapy treatments. Additionally, this study highlights the impact on being able to address the complexities of chronic pain through a biopsychosocial model.
Article Full Title
How Reproducible Are Manual Therapy Interventions in Trials for Low Back Pain? A Scoping Review
Author Names
Ruzich, J; Klopper, M; Dohrmann, C; Rhon, D; Young, J
Reviewer Name
Julie Bottarini, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
OBJECTIVES: To assess the reproducibility of manual therapy interventions used in clinical trials for low back pain (LBP), and summarize knowledge gaps in assessing the reproducibility of manual therapy interventions for LBP. DESIGN: Scoping review. LITERATURE SEARCH: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), and Embase were searched for trials from inception through April 2023. STUDY SELECTION CRITERIA: Randomized controlled trials were included if they described the use of manual therapy to treat LBP in adults 18 to 65 years old and were accessible in English. DATA SYNTHESIS: The Consensus on Exercise Reporting Template (CERT) checklist, used for exercise reporting, was previously modified for manual therapy reporting. This 11-item modified CERT was used to extract details of manual therapy reporting in the included trials. Frequency counts were calculated to identify items most and least commonly reported. RESULTS: Of 128 trials, none reported all 11 items of the modified CERT. The most commonly reported items were the description of how the application of manual therapy was decided (n = 113, 88.3%) and a description of adjunct interventions provided (n = 82, 64.1%). The least reported items were the description of an associated home program (n = 27, 21.1%) and a detailed description of the application of manual therapy (n = 22, 17.2%). CONCLUSION: Reporting of manual therapy interventions in trials investigating LBP was poor overall, limiting the reproducibility of these treatments. Using a checklist designed explicitly for manual therapy intervention reporting may improve reproducibility of these interventions and help align clinical outcomes with experimental findings.
NIH Risk of Bias Tool
1. Is the review based on a focused question that is adequately formulated and described? Yes
2. Were eligibility criteria for included and excluded studies predefined and specified? Yes
3. Did the literature search strategy use a comprehensive, systematic approach? Yes
4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias? Yes
5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity? Cannot Determine, Not Reported, Not Applicable
6. Were the included studies listed along with important characteristics and results of each study? Yes
7. Was publication bias assessed? Yes
8. Was heterogeneity assessed? (This question applies only to meta-analyses.) Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Reporting of manual therapy interventions in trials for treating LBP was poor, with fewer than 1 in every 5 trials providing a full description of the manual therapy techniques used.
Key Finding #2
The least reported item was an explanation of how to tailor manual therapy when the intervention was pragmatic, including a description of the decision making process for the starting point, type, grade and target of the techniques (8.2% of the 49 pragmatic trials in this review). Key
Finding #3
The most commonly reported items were the description of how the application of manual therapy was decided (n = 113, 88.3%) and a description of adjunct interventions provided (n = 82, 64.1%).
Please provide your summary of the paper
Extensive research has shown that manual therapy for low back pain (LBP) is effective in reducing pain and improving overall function. This Scoping Review analyzes the existing literature to determine the reproducibility of manual therapy treatment for patients with LBP. There are currently no standardized reporting tools to guide manual therapy interventions. This paper assesses the thoroughness and inconsistencies in intervention reporting. Selection criteria for this review includes randomized control trials that investigate adults ages 18-65 with LBP and use manual therapy techniques as a treatment. Manual therapy is defined as thrust joint manipulation, non thrust joint mobilization, or muscle energy techniques. A total of 128 trials are included in this review. The review uses a modified 11-item version of the Consensus on Exercise Reporting Template (CERT) to assess the thoroughness of intervention reporting. The results of this paper show that manual therapy intervention for LBP is poorly reported which limits the ability to reproduce the techniques and results of these studies. Less than a quarter of the trials include a description of how manual therapy was applied or how to tailor manual therapy when the intervention approach is pragmatic. While this paper acknowledges the benefit of a pragmatic approach to manual therapy that promotes clinician autonomy and more generalizability to real-life clinical practice, it encourages more specificity.
Please provide your clinical interpretation of this paper.
Include how this study may impact clinical practice and how the results can be implemented. This Scoping Review aims to improve the translation of research findings into clinical practice by revealing the need for more thorough reporting of manual therapy intervention in research trials. Clinical research is important for establishing best physical therapy practices, developing clinical practice guidelines, and improving patient outcomes. Clinicians can not use evidence-based practice if current research can not be effectively reproduced in the clinic. This review reveals the need for a standardized reporting measure for manual therapy intervention, so that clinicians can use evidence-based practice to influence their decision making when it comes to best treatment practices.
Article Full Title:
The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review
Author Names:
Reep NC, Leverett, SN, Heywood RM, Baker RT, Barnes DL, Cheatham SW
Reviewer Name:
Megan Broomfield, SPT
Reviewer Affiliation(s):
Duke University Doctor of Physical Therapy Program
Paper Abstract:
Background
Meniscal pathologies are common knee injuries and arthroscopic surgery is the current accepted gold standard for treatment. However, there is evidence to support the use of the Mulligan Concept (MC) Mobilization with Movement (MWM) for meniscal pathologies including the ‘Squeeze’ technique, tibial internal rotation (IR), and tibial external rotation (ER).
Hypothesis/Purpose
The purpose of this systematic review was to critically appraise the literature to investigate the effectiveness of MC MWMs for meniscal lesions on patient reported pain, function, and multi-dimensional health status in patients with clinically diagnosed meniscal pathologies.
Study Design
Systematic Review
Methods
A literature search was completed across multiple databases using combinations of the words “knee, function, mobilization with movement, MWM, mulligan concept, MC, meniscal pathology, meniscal derangement, and meniscal tear.” Studies written within the prior 10 years that examined MC MWM techniques to treat knee meniscal injury were included. Articles that met the inclusion criteria (used MC MWM ‘Squeeze’ technique, tibial IR, or tibial ER for treatment of clinically diagnosed meniscal pathologies; Patient reported outcome [PRO] measures had to be used in the assessment of knee pain or function) were analyzed for quality. Randomized control trials were analyzed using the PEDro scale and the Downs & Black (D&B) checklist, case series were analyzed using the Joanna Briggs Institute (JBI) checklist, and case reports were analyzed using the CARES checklist.
Results
Six articles met the inclusion criteria and were included in this review, two randomized controlled studies, two case series, and two case reports consisting of 72 subjects. All six papers included reports of improvements in pain and function that were either statistically significant or met the minimal clinically important difference (MCID). Five studies reported the Disablement in the Physically Active (DPA) scale that also demonstrated statistically significant differences or met the MCID. The MC MWM ‘Squeeze’ technique, tibial IR, or tibial ER demonstrated the ability to reduce pain, improve function, and improve patient perceived disability following treatment of a clinically diagnosed meniscal pathology. These studies demonstrated short term results lasting from one week to 21 weeks.
Conclusion
Treatment interventions incorporating MC MWM techniques demonstrated reduction of pain and improvement in function in the short term in patients with clinically diagnosed meniscal pathologies.
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?:
Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
Yes
- Did the literature search strategy use a comprehensive, systematic approach?
Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes
- Were the included studies listed along with important characteristics and results of each study?
Yes
- Was publication bias assessed?
Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
No
Key Finding #1:
There were substantial improvements in patient-reported pain severity using Mulligan Concept (MC) Mobilizations With Movement (MWM), particularly using the MC ‘Squeeze’ technique.
Key Finding #2:
Statically significant changes were found in the PSFS (Patient Specific Functional Scale) in all studies, indicating that the technique restored patient-defined function and provided a reduction in patient-defined pain.
Key Finding #3:
As measured by the DPA (Disablement in the Physically Active) scale, MC ‘Squeeze’ technique improved multi-dimensional health status, including feelings of disability and quality of life.
Key Finding #4: Joint ROM was a secondary outcome measured by 3 of the articles, and all found that the treatment increased joint ROM, providing further evidence for the effectiveness of MC MWM treatment.
Please provide your summary of the paper
This systematic review evaluated the literature available on the effectiveness of Mulligan Concept Mobilizations With Movement (MC MWM) in the short-term on patient-reported pain, function, and quality of life in patients with clinically diagnosed meniscus pathologies. Eligible articles were extracted across multiple databases, and those included in the study were written in the last 10 years, used patients with a set standard clinical diagnosis of a meniscal pathology, utilized patient reported outcome measures for assessment of knee pain or function, and utilized the MC MWM ‘Squeeze’ technique, tibial IR, or tibial ER for treatment. Six articles were found to meet this inclusion criteria. These articles found that there is initial support for the use of conservative MWM techniques to treat patients with clinically diagnosed meniscal pathology. The articles noted that these treatments were found to reduce pain, increase function, decrease patient reported symptoms of multidimensional health status impairment related to the meniscal pathology diagnosis, and some articles also measured an increase in knee range of motion. Limitations to this study include a lack of high-quality RCTs, a lack of long-term follow-ups, and the use of a younger, physically active population.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
From this article, we can interpret that although there is more research to be done with higher quality RCTs and a wider population, there is evidence to suggest that Mulligan Concept Mobilizations With Movement can improve patient-reported pain, function, and quality of life in patients with clinically diagnosed meniscus pathologies in the short term. The results of this systematic review can be implemented by utilizing MC MWM techniques, particularly the ‘Squeeze’ technique, tibial IR, or tibial ER, for treatment in the clinic for meniscus pathologies. Ultimately, utilizing these techniques would help decrease patients’ pain in the short term, thus providing a higher quality of life, and increase ROM and function, which increases the patients’ ability to carry out their activities.
Article Full Title
Assessment of a manual therapy and acupressure method as a treatment of nonspecific low back pain: A prospective, observational and non-interventional cohort study
Author Names
Ducret, Gilles; Guillaume, Marc; Fardini, Yann; Vejux, Sandrine; Chaabi, Hassène.
Reviewer Name
Holly Brown, SPT
Reviewer Affiliation(s)
Duke DPT
Paper Abstract
The first-line treatment for nonspecific low back pain (LBP) relief is physical exercise; however, there is no uniformity in recommendations regarding the type of exercise, and physicians predominantly prescribe pharmacological treatments. This creates a treatment gap in non-pharmacological management of LBP. Preliminary data suggest that manual therapy and acupressure could be relevant therapeutic options. The primary objective of this study was to describe the evolution of pain in patients with nonspecific LBP persisting for at least 4 weeks who received 2 treatment sessions combining manual therapy with acupressure (Biokinergie® method) as part of their routine management. In this prospective, observational, and non-interventional study, participants were monitored on the days of manual therapy session delivery (initial visit on Day 0 and follow-up visit on Day 21). Follow-up assessments occurred 3 days and 3 weeks post-therapy sessions. A total of 114 participants suffering from LBP for a median duration of 11.9 weeks were enrolled from May 2021 to May 2023. The intensity of average pain experienced over a 24-hour period was significantly reduced on Day 24 (−36.0 ± 27.2 mm on a visual analog scale of 100 mm, P < .001), with 82 (75.2%) participants reporting a decrease of at least 20 mm. Participants reported significant reductions in pain (−25.9 ± 23.9 mm on Day 3, −29.7 ± 26.7 mm on Day 21, and −40.9 ± 28.3 mm on Day 42, P < .001) and functional disability (Roland-Morris Disability Questionnaire score: −5.4 ± 0.4 points on Day 21 and −7.4 ± 0.4 points on Day 42, P < .001). This was associated with an improved Dallas Pain Questionnaire score, indicating a reduced impact of LBP on daily activities (−27.2 ± 2.0% on Day 21 and −35.8 ± 2.0% on Day 42, P < .001). Posttreatment, most participants (86.3%) reported reduced analgesic intake compared to baseline, and 83.3% were very satisfied with the therapy. A significant and clinically relevant reduction in lumbar pain was observed after 2 sessions of manual therapy combined with acupressure, paving the way for future clinical research.
NIH Risk of Bias Tool
Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies
- Was the research question or objective in this paper clearly stated?
Yes
- Was the study population clearly specified and defined?
Yes
- Was the participation rate of eligible persons at least 50%?
Yes
- Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?
Yes
- Was a sample size justification, power description, or variance and effect estimates provided?
Yes
- For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?
Yes
- For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?
Yes
- Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
Yes
- 10. Was the exposure(s) assessed more than once over time?
Yes
- 11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?
Yes
- 13. Was loss to follow-up after baseline 20% or less?
Yes
- 14. Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?
Yes
Key Finding #1
By Day 42 (3 weeks after the second treatment session delivery), 78.5% of participants reported a statistically significant and clinically meaningful reduction in pain intensity (≥ 20 mm on the VAS), with 86.3% of participants reporting a decrease in analgesic consumption for pain relief.
Key Finding #2
Dallas Pain Questionnaire scores revealed an overall significant decrease (average of -35.8%) in the impact low back pain had on participant quality of life by Day 42 (3 weeks after the second treatment session delivery), with improvement in all categories of daily activities (-35.8%), work-leisure activities (-31.8%), anxiety-depression (-22.9%), and social life (-14.0%).
Key Finding #3
Participant Roland Morris Disability Questionnaire (RMQ) scores decreased by an average of 7.4 points by Day 42 (3 weeks after the second treatment session delivery), which exceeds the clinically relevant threshold of a 2 point change.
Key Finding #4
90 participants (83.3%) expressed they were very satisfied with outcomes following the treatment regimen on a 5-point Likert scale.
Please provide your summary of the paper
This observational study examined the efficacy of the Biokinergie® method in reducing pain, decreasing functional disability, improving quality of life, and reducing analgesic use in patients with nonspecific low back pain. This method, which combines manual therapy with acupressure, was administered twice as part of routine management to 114 identified participants whose pain had persisted for at least four weeks, had not improved with physical exercise, and had not yet progressed to the chronic stage. Outcomes were measured using validated self-report tools, including the Visual Analog Scale (VAS), Roland-Morris Disability Questionnaire (RMDQ), and Dallas Pain Questionnaire (DPQ), with follow-ups conducted 3 days and 3 weeks post-treatment session. The study reported significant clinical changes, including reduction in pain intensity as measured by the VAS, improvement in quality of life as measured by the DPQ, decrease in disability as measured by the RMDQ, with reduced analgesic use. Strengths of this study include its relatively large sample size and unique inclusion criteria that focus on a specific population with limited prior investigation. However, the observational nature, lack of a control group, and variability in treatment delivery limit the generalizability of the findings. Further blinded interventional studies and RCTs are recommended to validate the clinical utility of the Biokinergie® method as a non-pharmacologic intervention in clinical practice.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study offers promising preliminary evidence supporting the Biokinergie® method as a potential non-pharmacological, non-exercise option for therapeutic management of nonspecific, non chronic low back pain. Based on the target population, it underscores the importance of early intervention to prevent the progression into chronic pain. The study also selects an intervention that integrates both manual therapy and acupressure, which aligns with the emphasis on multidisciplinary treatments for low back pain management. However, given low back pain’s nature to be highly variable dependent on stress and to resolve and relapse over time, it is difficult to be confident that the changes found are correlated with this method due to the limited control in the study design and generalizability of the findings. In conclusion, these results should most directly inspire additional research to address the current gap in literature and rather than impacting clinical care. Until RCTs or other blinded interventional studies are conducted, physical therapists adopting the Biokinergie® method should still do so with caution, closely monitoring outcomes and ensuring patients are aware of the lack of research backing these treatments in conjunction.
Article Full Title:
Effects of High-Velocity Spinal Manipulation on Quality of Life, Pain and Spinal Curvature in Children with Idiopathic Scoliosis: A Systematic Review
Author Names:
Mario Piqueras-Toharias, Alfonso Javier Ibáñez-Vera, Daniel Rodríguez-Almagro, Rafael Lomas-Vega, Ana Belén Peinado-Rubia, and Ana Sedeño-Vidal
Reviewer Name:
Abbie Bushinski, SPT
Reviewer Affiliation(s):
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract:
Background/Objectives: Scoliosis is a condition that involves deformation of the spine in the coronal plane and commonly appears in childhood or adolescence, significantly limiting a person’s life. The cause is multifactorial, and treatment aims to improve the spinal curvature, prevent major pathologies, and enhance aesthetics. The objective of this review was to determine whether high-velocity low-amplitude (HVLA) spinal manipulation is more effective than other treatments for children with idiopathic scoliosis (IS).
Methods: The PubMed, Web of Science, Scopus and PEDro databases were searched for both clinical trials and cohort studies. Methodological quality was assessed via the PEDro scale (for clinical trials) and the Newcastle–Ottawa scale (for observational studies). The protocol of this systematic review was registered in PROSPERO (CRD42024532442).
Results: Five studies were selected for review. The results indicated moderate improvements in pain and the Cobb angle and limited improvements in quality of life.
Conclusions: HVLA spinal manipulation does not seem to have significant effects on reducing spinal deformity in IS patients, nor does it significantly impact quality of life. However, this therapy may have significant effects on reducing pain in these patients. Keywords: scoliosis, adolescent health, spinal manipulation, chiropractic, osteopathic manipulation
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described? Yes
- Were eligibility criteria for included and excluded studies predefined and specified? Yes
- Did the literature search strategy use a comprehensive, systematic approach? Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias? Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity? Yes
- Were the included studies listed along with important characteristics and results of each study? Yes
- Was publication bias assessed? Cannot determine
- Was heterogeneity assessed? (This question applies only to meta-analyses.) Cannot determine
Key Finding #1
The methodological quality of the studies in the systematic review was analyzed to have a mean score of 5.5 on the PEDro scale indicating fair quality. This decreases the confidence in the study’s results and increases the possibility of potential research design limitations and bias.
Key Finding #2
The results of the reviewed studies indicated no statistically significant changes in structural deformity and no improvement in quality of life. However, a significant reduction in pain levels was noted following manipulative treatment in one study.
Key Finding #3
The systematic review indicated that manual therapy was rarely the exclusive form of treatment in the reviewed studies indicating that no definitive conclusions can be made about the isolated effect of HVLA manipulation on spinal curvature, quality of life, and pain.
Please provide your summary of the paper
This systematic review highlights the effects of HVLA spinal manipulation on idiopathic scoliosis and based on the overall findings from this systematic review it is indicated that more high-quality research needs to be conducted to conclude the effectiveness of the treatment. The systematic review analyzed five studies and looked at the impact of manual therapy on quality of life, pain, structural deformity, and spine flexibility. Many studies did not meet the criteria to be included in the review and therefore the quality and amount of data are very limited. It appears from the analyzed studies that HVLA spinal manipulation had a slight impact on spinal curvature. However, this decrease in the Cobb angle was not considered statistically significant. Additionally, there was no significant improvement in quality of life associated with the reviewed studies. However, the studies did conclude that reductions in pain as measured by the VAS may be associated with HVLA spinal manipulation. Although the reviewed studies indicated a possible association between manual therapy and improvements in pain, the systematic review determined that in these studies manual therapy was rarely the exclusive form of treatment. Therefore, indicating that no definitive conclusions can be made about the effect of HVLA manipulation in idiopathic scoliosis patients.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
My clinical interpretation of this paper is that there is not enough high-quality data to make a formal decision on whether HVLA is beneficial for quality of life, pain, and spinal curvature in children with scoliosis. Overall, this article does note a possible association between manual therapy and improvement based on the results of some of the studies that were reviewed. However, it also highlights a large amount of bias and low-quality evidence associated with the studies. Additionally, due to a combination of therapeutic approaches that were utilized in the reviewed studies, it is difficult to determine if the effects are based solely on the HVLA spinal manipulations or if improvements were due to the combination of treatments. Therefore, HVLA manipulations may be beneficial for patients with idiopathic scoliosis when combined with other approaches. However, at this time a causal relationship cannot be indicated between HVLA spinal manipulation and improvements in quality of life, pain, and spinal curvature. Additionally, this review indicated a need for further higher-quality RCTs to assess the effectiveness of HVLA manipulation as a treatment for idiopathic scoliosis before the implementation of this treatment can be fully supported in clinical practice.
Article Full Title
Comparison of the effects of dry needling and spinal manipulative therapy versus spinal manipulative therapy alone on functional disability and endurance in patients with nonspecific chronic low back pain: An experimental study
Author Names
Khan K, Ahmad A, Mohseni Bandpei MA, Kashif M.
Reviewer Name
Natanael Casiano-Agosto, SPT
Reviewer Affiliation(s)
Duke University School of Medicine Doctor of Physical Therapy Division Class of 2026
Paper Abstract
Low back pain (LBP) is a global musculoskeletal ailment. Over the past few years, dry needling (DN) has garnered interest from both physical therapists and patients. Physical therapy commonly employs spinal manipulation to alleviate persistent LBP and other musculoskeletal disorders. The aim of this study was to investigate the effects of spinal manipulation alone and in combination with DN on functional disability and endurance in individuals suffering from chronic nonspecific LBP. Patients of both genders who had chronic nonspecific LBP and who had not received physical therapy within the last 3 months were included in this single-blind, randomized controlled trial using purposive sampling. All participants were randomly assigned to either the experimental (SMT + DN) or control (SMT alone) group using computer-generated random numbers. The data were analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0. For between-group comparisons, the Mann-Whitney U test was used. A P-value < .05 was considered to indicate statistical significance. The analysis of the difference between the 2 groups revealed that the mean ± standard deviation (SD) for the SMT alone group was 16.09 ± 3.963 at baseline and 12.66 ± 3.801 at 8 weeks, whereas for the DN + ST group, it was 13.67 ± 3.904 at baseline and 10.92 ± 3.534 at 8 weeks, with a P-value of .003. Thus, the RMDQ score improved gradually in both groups, and the mean endurance score reported for the ST group was 2.5 to 4.5, while that reported for the DN + ST group was 3.1 to 5.1. The results of this study showed that both therapies effectively reduced LBP. When comparing the effects of spinal manipulation alone to those of spinal manipulation combined with DN, the latter showed significantly greater benefits.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
- Were study participants and providers blinded to treatment group assignment?
No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
No
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Cannot Determine, Not Reported, or Not Applicable
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Cannot Determine, Not Reported, or Not Applicable
- Was there high adherence to the intervention protocols for each treatment group?
Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
This RCT found that both SMT alone and SMT combined with DN significantly reduced functional disability in patients with chronic nonspecific low back pain.
Key Finding #2
The combination of SMT and DN showed greater improvements compared to SMT alone.
Key Finding #3
The study found that lumbar muscle endurance, measured by the Sorensen test, improved in both groups
Key Finding #4
The DN with SMT group showed higher endurance scores at follow up points compared to the SMT alone group.
Please provide your summary of the paper
This study was conducted as a single-blind, randomized controlled trial involving 114 participants. It demonstrated that both treatments significantly reduced functional disability and improved lumbar muscle endurance. However, the combination of spinal manipulative therapy (SMT) and dry needling (DN) led to greater improvements than SMT alone. The study concluded that integrating DN with SMT provides enhanced benefits for patients with chronic nonspecific low back pain (CNSLBP), resulting in better functional outcomes and increased lumbar muscle endurance. However, the study fell short in determining the long-term effectiveness of the treatments due to a lack of follow-up visits, which highlighted a significant limitation. The researchers suggested that future studies should involve larger sample sizes to address the impact of missed follow-ups more effectively. Furthermore, the research pointed out an absence of studies and the limited amount of data available comparing SMT alone to SMT with DN, indicating a need for further investigation to understand the effectiveness of these treatment options fully. Additionally, the study suggests that DN combined with SMT may offer a potentially cost-effective approach to managing CNSLBP, warranting further exploration.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The research highlights the significant benefits of combining DN with SMT for patients suffering from CNSLBP. However, the study’s patient population had a wide age range, with a relatively low average age of 37 years. Given this younger average, further research is needed to evaluate the effectiveness of combining DN with SMT in older populations. Additionally, neither the participants or the principal investigator were blinded in this study, which could have introduced bias. The researchers also could not draw conclusions about the long-term effectiveness of the treatment, marking a significant limitation. Although more data is needed to understand the long-term effects of the treatment and its effectiveness in specific patient populations, this approach may hold important implications for younger patient populations in clinical practice. It could lead to a cost-effective method for managing CNSLBP compared to other treatments. By enhancing functional outcomes and muscular endurance, integrating DN with SMT could serve as a valuable tool in optimizing treatment plans.
Article Full Title
The Effectiveness of Spinal Manipulative Therapy in Treating Spinal Pain Does Not Depend on the Application Procedures: A Systematic Review and Network Meta-Analysis
Author Names
Casper Nim, Sasha L. Aspinall, Chad E. Cook, Leticia A. Corrêa, Megan Donaldson, Aron S. Downie, Steen Harsted, Simone Hansen, Hazel J. Jenkins, David McNaughton, Luana Nyirö, Stephen M. Perle, Eric J. Roseen, James J. Young, Anika Young, Gong-He Zhao, Jan Hartvigsen, Carsten B. Juhl
Reviewer Name
Li Chen, PMP, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objectives: To assess whether spinal manipulative therapy (SMT) application procedures (i.e., 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 five databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Physiotherapy Evidence Database (PEDro), and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. We included randomized clinical 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 by 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 control, 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 follow-up (closest to 12 months). Risk of bias was assessed using the Cochrane Risk of Bias tool v.2. 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 non-specific, 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 risk of bias, and an absence of direct comparisons.
Conclusion: There was low-certainty evidence that clinicians could apply SMT according to their preferences and patients’ preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant.
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described? Yes
- Were eligibility criteria for included and excluded studies predefined and specified? Yes
- Did the literature search strategy use a comprehensive, systematic approach? Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias? Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity? Yes
- Were the included studies listed along with important characteristics and results of each study? Yes
- Was publication bias assessed? Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.) Yes
Key Findings
- No meaningful clinical differences in pain or disability outcomes based on how spinal manipulative therapy (SMT) was applied. Specifically, variations in target specificity, thrust type (e.g., generalized or targeted), or the spinal region treated did not significantly affect the outcomes. Challenges the emphasis on precision in SMT delivery often taught in clinical education.
- SMT applications involving generic vertebral targets, generalized thrusts across multiple vertebral levels, or treatments targeting non-symptomatic spinal regions showed slightly better outcomes in reducing pain and disability. However, the magnitude of these differences was small and not clinically meaningful, suggesting that specific targeting is not essential for achieving therapeutic effects.
- Contextual factors, such as the hands-on nature of SMT, patient-clinician interactions, and placebo effects, may be more influential in clinical outcomes than the procedural specifics of SMT. While biomechanical variables (e.g., thrust force and duration) may still contribute to the overall effect, the findings underscore the importance of considering the broader psychosocial context of care delivery.
Summary of the Paper
A comparison of SMT procedures and their effects on pain and disability. Debunks the myth that specific targeting, thrust type, or treatment region significantly affects clinical outcomes. While SMT does show modest benefits over other treatments for spinal pain, it doesn’t matter whether you’re adjusting C6 or C5, using a precise angle, or working on a symptomatic versus non-symptomatic region. Results were consistent across various techniques, making this study a game-changer for those who believe in “the perfect thrust.” Outcomes are more influenced by factors like clinician confidence, patient comfort, and psychosocial elements rather than the specifics of SMT delivery.
Clinical Interpretation
Published just 15 days ago, this paper brings a refreshing dose of pragmatism to the clinical application of SMT. It highlights that success isn’t about finding the “perfect” vertebra or angle but about creating a comfortable and confident environment for the patient. Novice clinicians can take comfort in knowing that precision isn’t the key to improving pain and disability—safety, smoothness, and patient preference are what truly matter. While refining technique is still important, this study encourages shifting focus toward a holistic, biopsychosocial approach where communication, trust, and tailoring care to the patient’s needs take center stage. Ultimately, patients value feeling heard and supported far more than the exactness of your technique. So, trust your training, keep your hands steady, and remember: the therapeutic relationship is just as important as the thrust.
Article Full Title
Treatment of Women With Primary Dysmenorrhea With Manual Therapy and Electrotherapy Techniques: A Systematic Review and Meta-Analysis
Author Names
González-Mena A, Leirós-Rodríguez R, Hernandez-Lucas P
Reviewer Name
Nayeli Chowdhury, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Abstract: Objective The objective of this study was to evaluate the efficacy of electrotherapy and manual therapy for the treatment of women with primary dysmenorrhea.
Methods: Systematic searches were conducted in Scopus, Web of Science, PubMed, CINAHL, and MEDLINE. The articles must have been published in the last 10 years, had a sample exclusively of women with primary dysmenorrhea, had a randomized controlled trial design, and used interventions that included some form of manual therapy and/or electrotherapy techniques. Two reviewers independently screened articles for eligibility and extracted data. Difference in mean differences and their 95% CIs were calculated as the between-group difference in means divided by the pooled standard deviation. The I2 statistic was used to determine the degree of heterogeneity.
Results: Twelve selected studies evaluated interventions, with 5 evaluating electrotherapy techniques and 7 evaluating manual therapy techniques. All studies analyzed identified improvements in pain intensity and meta-analysis confirmed their strong effect.
Conclusions: Manual therapy and electrotherapy are effective for the treatment of women with primary dysmenorrhea. Transcutaneous electrical nerve stimulation combined with thermotherapy and effleurage massage stands out for its effects on the intensity and duration of pain with the application of a few sessions and their long-term effects.
Impact: Manual therapy techniques and electrotherapy methods reduce the pain intensity of women with primary dysmenorrhea. Quality of life and degree of anxiety improved significantly with manual therapy interventions. Transcutaneous electrical nerve stimulation combined with thermotherapy and effleurage massage are the interventions with which positive effects were achieved with fewer sessions.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
Yes
- Did the literature search strategy use a comprehensive, systematic approach?
Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes
- Were the included studies listed along with important characteristics and results of each study?
Yes
- Was publication bias assessed?
Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
Yes
Key Finding #1
Both manual therapy and electrotherapy are effective treatment methods as compared to placebo interventions or drug treatments to decrease pain for women who experience primary dysmenorrhea.
Key Finding #2
Effleurage massage, manipulations, neuromuscular therapy, and connective tissue manipulation can significantly decrease medicine consumption and the duration, frequency, and intensity of pain levels.
Key Finding #3
Effleurage massage results in greater reduction of pain intensity levels as compared to an exercise program.
Key Finding #4
Manual therapy interventions including effleurage massage and connective tissue manipulation significantly reduce pain catastrophizing and anxiety levels for individuals with primary dysmenorrhea.
Please provide your summary of the paper
This paper examines the effectiveness of manual therapy and electrotherapy for individuals with primary dysmenorrhea through a systematic review and meta-analysis. Dysmenorrhea is a common condition for adolescents and adults who present with menstrual cramps with pelvic pain, as well as nausea, vomiting, and fatigue. There are two categories for dysmenorrhea, including primary dysmenorrhea, which has no underlying pathology, and secondary dysmenorrhea, which often has connections to endometriosis or IUD use. The cramping sensation that women with primary dysmenorrhea feel is associated with uterine hypercontractility and reduced blood supply. Various therapy methods were assessed including transcutaneous electrical nerve stimulation (TENS), diathermy, thermotherapy, effleurage massage, neuromuscular therapy, and connective tissue manipulation. The results of the paper discuss how manual therapy and TENS are effective methods that reduce pain parameters and reliance on medication use.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This paper highlighted the effectiveness of utilizing manual therapy and TENS to offer short-term pain relief. In clinical practice, this supports the idea of using these treatment methods to offer non-pharmacological pain relief as compared to relying on NSAIDs or other oral medication. Physical therapists can incorporate these treatment methods when working with patients with dysmenorrhea, in combination with pharmacological interventions or an alternative depending on if the patient presents with adverse side effects from medication.
Article Full Title
Effects of Manual Therapy on Parkinson’s Gait: A Systematic Review
Author Names
Delafontaine, A. et.al
Reviewer Name
Dylan Chruma
Reviewer Affiliation(s)
Duke DPT Class ’26
Paper Abstract
Manual therapy (MT) is commonly used in rehabilitation to deal with motor impairments in Parkinson’s disease (PD). However, is MT an efficient method to improve gait in PD? To answer the question, a systematic review of clinical controlled trials was conducted. Estimates of effect sizes (reported as standard mean difference (SMD)) with their respective 95% confidence interval (95% CI) were reported for each outcome when sufficient data were available. If data were lacking, p values were reported. The PEDro scale was used for the quality assessment. Three studies were included in the review. MT improved Dynamic Gait Index (SMD = 1.47; 95% CI: 0.62, 2.32; PEDro score: 5/10, moderate level of evidence). MT also improved gait performances in terms of stride length, velocity of arm movements, linear velocities of the shoulder and the hip (p < 0.05; PEDro score: 2/10, limited level of evidence). There was no significant difference between groups after MT for any joint’s range of motion during gait (p > 0.05; PEDro score: 6/10, moderate level of evidence). There is no strong evidence supporting the beneficial effect of MT on improving gait in PD. Further randomized controlled trials are needed to understand the impact of MT on gait in PD
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
Yes
- Did the literature search strategy use a comprehensive, systematic approach?
Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes
- Were the included studies listed along with important characteristics and results of each study?
Yes
- Was publication bias assessed?
Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Manual therapy, specifically lumbosacral mobilization and osteopathic manipulative treatment, showed improvements in specific gait aspects for Parkinson’s disease, such as stride length, propulsion, and velocity, and an overall measurement of the dynamic gait index.
Key Finding #2
Manual therapy of the lumbosacral region did not significantly improve joint ROM during gait, even though it did improve isolated hip mobility when comparing before and after treatment. Since there was a lack of improvement with gait ROM this suggests that manual therapy alone does not address these deficits in Parkinson’s patients during gait.
Key Finding #3
Manual therapy of the lumbosacral region as well as osteopathic manipulative shows improvements in patients stride length and gait speed. When comparing to the control groups the MT group showed the improvements, but there is lack of evidence due to insufficient data regarding effect size and quality of the trials.
Please provide your summary of the paper
This is a systematic review that looked at the effects of manual therapy on gait performance in individuals with PD. The studies involved assessing interventions such as lumbosacral mobilization and OMT and determining if gait was improved. Some improvements were observed regarding stride length, limb velocity, and DGI. The evidence put forth is not enough to support that MT is as its treatment improved gait parameters for PD patients. In conclusion, MT could be more effective when it is integrated into multidisciplinary rehab programs for PD patients rather than used by itself for treatment.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study provides us with an understanding of MT on gait improvements for PD patients. The evidence provides us with supportive information that MT used alongside other treatments can improve gait parameters such as limb velocity, stride length, and DGI. MT can be implemented as a multidisciplinary approach in treatment plans. Overall, can be used to help with fall prevention, improve gait parameters, and basic functional mobility for patients with PD. Lastly, MT shows improvement in addressing certain gait deficits in PD patients and should be used as part of a broader rehab strategy instead of its intervention.
Article Full Title
Kinesio Taping Does Not Provide Additional Benefits in Patients With Chronic Low Back Pain Who Receive Exercise and Manual Therapy: A Randomized Controlled Trial
Author Names
Nemitalla, M, Pena Costa, L, De Freitas, D, Fukunda, T, Monterio, R, Salomano, E, De Medeiron, F, Menezes Coast, L
Reviewer Name
Lauren Ciuba
Reviewer Affiliation(s)
Duke DPT Class of ’26
Paper Abstract Abstract
Study Design Randomized controlled trial. Background Many clinical practice guidelines endorse both manual therapy and exercise as effective treatment options for patients with low back pain. To optimize the effects of the treatments recommended by the guidelines, a new intervention known as Kinesio Taping is being widely used in these patients. Objectives To determine the effectiveness of Kinesio Taping in patients with chronic nonspecific low back pain when added to a physical therapy program consisting of exercise and manual therapy. Methods One hundred forty-eight patients with chronic nonspecific low back pain were randomly allocated to receive 10 (twice weekly) sessions of physical therapy, consisting of exercise and manual therapy, or the same treatment with the addition of Kinesio Taping applied to the lower back. The primary outcomes were pain intensity and disability (5 weeks after randomization) and the secondary outcomes were pain intensity, disability (3 months and 6 months after randomization), global perceived effect, and satisfaction with care (5 weeks after treatment). Data were collected by a blinded assessor. Results No between-group differences were observed in the primary outcomes of pain intensity (mean difference, −0.01 points; 95% confidence interval [CI]: −0.88, 0.85) or disability (mean difference, 1.14 points; 95% CI: −0.85, 3.13) at 5 weeks’ follow-up. In addition, no between-group differences were observed for any of the other outcomes evaluated, except for disability 6 months after randomization (mean difference, 2.01 points; 95% CI: 0.03, 4.00) in favor of the control group. Conclusion Patients who received a physical therapy program consisting of exercise and manual therapy did not get additional benefit from the use of Kinesio Taping. Level of Evidence Therapy, level 1b. Prospectively registered May 28, 2013 at www.ClinicalTrials.gov (NCT01866332). J Orthop Sports Phys Ther 2016;46(7):506–513. Epub 6 Jun 2016. doi:10.2519/jospt.2016.6590
NIH Risk of Bias Tool
Randomized Controlled Trial
1. Is the review based on a focused question that is adequately formulated and described? Yes
2. Were eligibility criteria for included and excluded studies predefined and specified? Cannot Determine, Not Reported, Not Applicable
3. Did the literature search strategy use a comprehensive, systematic approach? Cannot Determine, Not Reported, Not Applicable
4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias? No
5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity? Cannot Determine, Not Reported, Not Applicable
6. Were the included studies listed along with important characteristics and results of each study? Yes
Key Finding #1
In patients with back pain who received physical therapy consisting of exercises and manual therapy, this study did not identify an additional benefit from the use of Kinesio Taping
Key Finding #2
Both the intervention group (exercise, manual therapy, and Kinesio Taping) and the control group (exercise and manual therapy only) showed similar outcomes in terms of pain reduction and disability at 5 weeks, 3 months, and 6 months post-randomization
Key Finding #3
At the 6-month follow-up, the control group exhibited a slight but statistically significant improvement in disability scores compared to the intervention group, suggesting no long-term benefit from adding Kinesio Taping
Key Finding #4
Participants in both groups reported high levels of satisfaction with their care, indicating that the physical therapy programs were well-received, regardless of the inclusion of Kinesio Taping
Please provide your summary of the paper
The study discussed whether adding Kinesio Taping to a physical therapy program of exercise and manual therapy improved outcomes in patients with chronic low back pain. Results showed no significant differences in pain intensity or disability between the intervention group and the control group at various times. (5 weeks, 3 months, or 6 months) The control group demonstrated slightly better disability outcomes at the 6-month follow-up. The findings suggest that Kinesio Taping does not provide additional benefits beyond exercise and manual therapy for this patient population.
Please provide your clinical interpretation of this paper.
Include how this study may impact clinical practice and how the results can be implemented. This study can impact clinical practice by guiding healthcare professionals to focus on evidence-based treatments for chronic nonspecific low back pain, such as exercise and manual therapy, rather than incorporating Kinesio Taping, which does not provide additional benefits. Clinicians can optimize treatment plans by understanding the findings of this article.
Article Full Title
Effects of Manual Therapy on Fatigue, Pain, and Psychological Aspects in Women with Fibromyalgia
Author Names
Yolanda Nadal-Nicolás, Jacobo Ángel Rubio-Arias, María Martínez-Olcina, Cristina Reche-García, María Hernández-García, Alejandro Martínez-Rodríguez
Reviewer Name
Kaila Claiborne, SPT
Reviewer Affiliation(s)
Doctor of Physical Therapy Program, Duke University
Paper Abstract
Fibromyalgia is a condition characterised by chronic widespread muscle pain and fatigue, sleep disturbances, cognitive disorders, and mood disturbance. The purpose of this study was to determine the effectiveness of a manual therapy technique performed with moderate digital pressure in women with fibromyalgia (n = 24). In this randomised, controlled trial, the participants were randomly assigned to the experimental group or placebo group. The experimental group was assisted with manual therapy sessions based on connective tissue massage, whereas the placebo group was “treated” with ultrasound sessions performed without conductive gel and with the machine turned off as the placebo. Fatigue severity scale (FSS), visual analogical scale (VAS), Pittsburgh sleep quality index (PSQI), and profile of mood states (POMS-29) were completed before and after the intervention. In the experimental group (manual therapy), significant results were obtained on a VAS scale, referring to the neck pain in patients with fibromyalgia (p < 0.001). Correlations showed a relationship between fatigue and sleep variables (R = 0.411; p = 0.046) and pain variables with the POMS anger-hostility subscale (R = 0.436; p = 0.033). Although the size of the sample could be a limitation, the study concluded that the application of manual therapy in fibromyalgia patients performed with moderate pressure for 15 min on the posterior cervical musculature decreased the perception of pain, muscle fatigue, and the state of tension-anxiety.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
3. Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
4. Were study participants and providers blinded to treatment group assignment?
Cannot Determine, Not Reported, or Not Applicable
5. Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Cannot Determine, Not Reported, or Not Applicable
9. Was there high adherence to the intervention protocols for each treatment group?
Yes
10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Cannot Determine, Not Reported, or Not Applicable
13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
Manual therapy as an intervention for women with fibromyalgia promotes restful sleep, decreases anxiety and depression, and reduces the perception of pain which are all highly reported symptoms of patients with fibromyalgia. There was a positive relationship however they were not significant.
Key Finding #2
It was found that the pressure applied during application of manual therapy was important. The study emphasized that a moderate pressure gradually applied was the best for this population as any pressure higher than this may increase pain therefore outweighing the benefits of the intervention.
Key Finding #3
There was a positive relationship observed between the intervention of manual therapy and the decreased score on the fatigue severity score. However, it was not a significant finding. In this study the application of manual therapy was only applied on the cervical region of the body. The study states that most patient report an increase difficulty with household task, and this can be attributed to the decreased muscle strength in this population. Manual therapy on the posterior cervical neck despite being helpful in improving sleep, decreasing anxiety and depression, and improving the perception of pain, does not target the large muscle groups needed to increase strength to improve fatigue noted with household task.
Key Finding #4
More evidence is needed for patient with fibromyalgia to choose non-pharmacological treatment such as manual therapy. However. there is a correlation between decreased neck pain and improved sleep. Symptoms with this patient population work in a cycle, improving neck pain allowing for better quality of sleep also improves other commonly associated symptoms such as anxiety, depression and perception of pain.
Please provide your summary of the paper
This Randomized controlled trial studied the effects of manual therapy on patients with fibromyalgia. This study was performed on 24 women half receiving manual therapy as the control group and the other receiving ultrasound sessions performed without conductive gel and with the machine turned off as the placebo. Patients in this population suffer from symptoms such as fatigue, chronic musculoskeletal pain, anxiety, depression, sleep disturbances, mood disturbances, and cognitive disturbances. These psychological and physical symptoms decrease quality of life and function in these individuals. The study concluded that although not significant, there was a positive relationship between the moderate pressure manual therapy on the posterior neck for 15 minutes and decrease in the symptoms listed above. The study supports the use of manual therapy; however, it states that there is more evidence and research needed.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The study impacts clinical practice by providing information on the effects of manual therapy in patients with fibromyalgia. According to the study there is still further research needed to provide information on the significance of the use of the modality. However, the study reported a positive relationship in moderate pressure manual therapy on the posterior cervical spine for 15 minutes on sleep quality, pain perception, anxiety, depression, and fatigue. There was an emphasis on the pressure of the soft tissue therapy to be gradual and of moderate pressure to ensure it is not provoking more pain thus outweighing the benefits of the intervention. Overall this study supported the use of manual therapy as a non pharmacological choice for relief of symptoms such as sleep disturbance, anxiety, depression, pain perception, and fatigue in patients with fibromyalgia. This may impact clinical practice by encouraging practicing clinicians to implement manual therapy in their treatment plan for this patient population.
Article Full Title
Immediate Effects of Region-Specific and Non–Region-Specific Spinal Manipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Controlled Trial
Author Names
Fernando de Oliveira, R; Liebano, R; da Cunha Menezes Costa, L; Rissato, L; Oliveira Pena Costa, L.
Reviewer Name
Juliette Clavier, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background: Manual therapists typically advocate the need for a detailed clinical examination to decide which vertebral level should be manipulated in patients with low back pain. However, it is unclear whether spinal manipulation needs to be specific to a vertebral level.
Objective: The purpose of this study was to analyze the immediate effects of a single, region-specific spinal manipulation defined during the clinical examination versus a single non–region-specific spinal manipulation (applied on an upper thoracic vertebra) in patients with chronic nonspecific low back pain for the outcome measures of pain intensity and pressure pain threshold at the time of the assessment.
Design: This was a 2-arm, prospectively registered, randomized controlled trial with a blinded assessor. Setting: The study was conducted in an outpatient physical therapy clinic in Brazil. Patients. The study participants were 148 patients with chronic nonspecific low back pain (with pain duration of at least 12 weeks).
Randomization: The randomization schedule was generated by an independent statistician and was concealed by using consecutively numbered, sealed, opaque envelopes. Interventions. A single high-velocity manipulation was administered to the upper thoracic region of the participants allocated to the non–region-specific manip- ulation group and to the painful lumbar levels of the participants allocated to the region-specific manipulation group.
Measurements: Pain intensity was measured by a 0 to 10 numeric pain rating scale. Pressure pain threshold was measured using a pressure algometer. Limitations: It was not possible to blind the therapist and participants.
Results: A total of 148 patients participated in the study (74 in each group). There was no loss to follow-up. Both groups improved in terms of immediate decrease of pain intensity; however, no between-group differences were observed. The between- group difference for pain intensity and pressure pain threshold were 0.50 points (95% confidence interval=-0.10 to 1.10) and -1.78 points (95% confidence interval=-6.40 to 2.82), respectively. No adverse reactions were observed.
Conclusion: The immediate changes in pain intensity and pressure pain threshold after a single high-velocity manipulation do not differ by region-specific versus non–region-specific manipulation techniques in patients with chronic low back pain.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
- Were study participants and providers blinded to treatment group assignment?
No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was there high adherence to the intervention protocols for each treatment group?
Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
Despite the region-specific vs. non-region-specific manual therapy interventions used in this study, both groups had a 30% decrease in low back pain.
Key Finding #2
There might be various factors that explain pain reduction following both interventions such as neurophysiological, psychosocial, and expectation effects.
Please provide your summary of the paper
This study evaluated whether a non-region-specific vs. region-specific spinal manipulation would influence immediate outcomes for those suffering from chronic low back pain (CLBP). Through a randomized clinical trial, the investigators were able to recruit 148 participants with chronic nonspecific low back pain. Participants were examined by a physical therapist to determine the spinal level for the origin of the CLBP. Examination components included but were not limited to palpation, active trunk movements, and the Mitchell test. Randomization envelopes were used to assign each participant to either a a single non-region-specific or region-specific manipulative treatment. The non-region-specific intervention consisted of a single high-velocity manipulation between T1-T5, while the region-specific intervention was a single manipulation somewhere between L2-L5 depending on the level determined in the examination. Outcome measures included the numeric pain rating scale and pressure pain threshold. Results of the study note a similar 30% reduction in pain intensity after the interventions were performed in both groups. Therefore, it was shown that there are no differences seen between non-region-specific and region-specific manual therapy techniques when providing immediate relief in the low back pain population.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study looked at a small subset of the chronic musculoskeletal pain population. While it showed that there are no significant differences in results depending on location of applied manual therapy for treatment of this pain, it did further show that manual therapy can be an effective treatment to reduce pain in this sample. As the investigators mention in the paper, more research needs to be done to evaluate the mechanisms that cause non-region-specific and region-specific manual therapy to be similarly effective in reducing CLBP. However, in the meantime, this paper could encourage clinicians to consider utilizing manual therapy techniques for immediate relief of CLBP in the clinic.
Article Full Title
The Effect of Lumbopelvic Manipulation for Pain Reduction in Patellofemoral Pain Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Author Names
Long-Huei Lin, Ting-Yu Lin, Ke-Vin Chang, Wei-Ting Wu, Levent Özçakar
Reviewer Name
Ashleigh Conn, SPT
Reviewer Affiliation(s)
Duke School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Patellofemoral pain syndrome (PFPS) is one of the most common etiologies of knee pain and might be relieved with lumbopelvic manipulation (LPM). This meta-analysis aimed to investigate the effects of LPM on pain reduction in patients with PFPS. Electronic databases were searched from inception to December 2023 for randomized controlled trials (RCTs) investigating the effects of LPM on PFPS. The primary outcome was the change in visual analog or numeric rating scale scores assessing pain. Ten studies comprising 346 participants were included. Significant pain reduction was noted in the LPM group (Hedges’ g = −0.706, 95% confidence interval [CI] = −1.197 to −0.214, p = 0.005, 𝐼2 = 79.624%) compared with the control group. Moreover, pain relief was more pronounced when LPM was combined with other physical therapies (Hedges’ g = −0.701, 95% CI = −1.386 to −0.017, p = 0.045, 𝐼2 = 73.537%). No adverse events were reported during the LPM. The LPM appears to be a safe and effective adjuvant therapy for pain reduction in patients with PFPS. Clinicians should consider adding LPM to other physical therapies (e.g., quadriceps muscle strengthening) during the management of these patients.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
1. Is the review based on a focused question that is adequately formulated and described?
Yes
2. Were eligibility criteria for included and excluded studies predefined and specified?
Yes
3. Did the literature search strategy use a comprehensive, systematic approach?
No
4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Cannot Determine, Not Reported, Not Applicable
6. Were the included studies listed along with important characteristics and results of each study?
Yes
7. Was publication bias assessed?
Yes
8. Was heterogeneity assessed? (This question applies only to meta-analyses.)
Yes
Key Finding #1
Patients with patellofemoral pain syndrome demonstrated a remarkable reduction in pain, as indicated from the effect size of 10 trials, although moderate-to-high heterogeneity was noted. No adverse effects were reported in patients undergoing lumbopelvic manipulation.
Key Finding #2
The meta-analysis proved lumbopelvic manipulation resulted in notable pain alleviation in patients with patellofemoral pain syndrome. However, the benefits of lumbopelvic manipulation as a standalone treatment were considered borderline in terms of pain relief. When combined with other physical therapies, though, effects of lumbopelvic manipulation on pain relief were deemed significant.
Key Finding #3
Patellofemoral pain syndrome is sometimes attributed to delayed contraction of the quadriceps muscle, specifically the vastus medialis. Lumbopelvic manipulation was found to strengthen the quadriceps, possibly by enhancing muscle activation and thereby reducing knee pain.
Key Finding #4
Because the lumbopelvic manipulation-only group had a shorter treatment duration, the findings illustrate a possible positive link between treatment duration and the analgesic effect of lumbopelvic manipulation.
Please provide your summary of the paper
This meta-analysis aimed to examine multiple randomized-control trials (RCTs) to determine the effects of lumbopelvic manipulation (LPM) in patients with knee pain related to patellofemoral pain syndrome (PFPS). Electronic databases such as PubMed, Cochrane Library, Clinicaltrial.gov, and PEDro were utilized to develop a comprehensive dataset of 11 RCTs published up until December 2023. Collectively, this meta-analysis included 346 participants, with intervention durations of 1 day to 6 weeks. The meta-analysis included control groups and LPM groups, which were further broken down into subgroups of LPM-only and LPM with physical therapies.
The primary outcomes were changes in pain scores after LPM, measured using the Visual Analog Scale (VAS) and Numerical Pain Rating Scale (NPRS). Results of the meta-analysis proved substantial effects of LPM on knee pain reduction in patients with PFPS. The LPM-only experimental group showed borderline pain relief, whereas LPM combined with physical therapies demonstrated significant pain relief. Moreover, the subgroup of LPM combined with active interventions exhibited statistically significant pain reduction.
The study identified few limitations and only evaluated the pain domain. Future research should direct attention to the long-term effects of LPM, as well as its impact on the functional outcomes of patients with PFPS.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Traditional treatment of patellofemoral pain syndrome (PFPS) prioritizes strengthening of the lower quarter, particularly the gluteal and quadriceps muscles. The study reflects that incorporating lumbopelvic manipulation (LPM) as a supplement to traditional active intervention, which hip and knee strengthening, can result in significant analgesic effects for patients with PFPS.
Given the robust study design (meta-analysis) and the positive findings, the data from this study support and can justify the use of LPM by physical therapists when treating patients with PFPS in a clinical setting. It is important to recognize the considerable advantages of combining LPM with active interventions, rather than relying on LPM alone, as its effectiveness is rated borderline when used in isolation. PFPS is a common diagnosis in populations across the lifespan, so it is essential to consider LPM when developing a treatment plan for patients with knee pain related to PFPS.
Article Full Title
The Effect of Manual Therapy on Lower Extremity Joint Kinematics during Running: A single-subject case study
Author Names
Drapeaux, A., Carlson, K.
Reviewer Name
Julia Dawson, SPT
Reviewer Affiliation(s)
Duke University School of Medicine
Doctorate of Physical Therapy
Paper Abstract
Background: While there is scarcity of current literature to support the effectiveness of muscle energy techniques (MET) with musculoskeletal injuries, the overall impact on gait kinematics necessitates investigation. This case study involved a 48-year-old male runner and aimed to determine the effect of manual therapy, including joint mobilization and MET, on lower extremity (LE) kinematics. The subject had a medical history that included: Achilles tendonitis, low back pain, and iliotibial band syndrome.
Methods: A clinical exam and Xsens motion capture were performed on the subject prior to treatment and at the conclusion of the 6 weeks of treatment. Motion capture was used to examine bilateral foot contact time, hip transverse plane motion and ankle sagittal plane motion. Pre-treatment and post-treatment ipsilateral and bilateral differences between groups were analyzed.
Results: Changes were noted between ipsilateral and bilateral pre- and post-treatment contact times; right foot sagittal plane joint angle at foot off; left hip transverse plane joint angle at foot contact and foot off, all bilateral pre- and post-treatment hip angles at foot contact and foot off, all bilateral pre- and post-treatment ankle angles at foot contact and foot off.
Conclusions: Clinical exams paralleled the change in hip external rotation bringing the hips to a more neutral position. In addition, the final clinical exam noted a decrease in subtalar eversion bilaterally, which may relate to the improved pelvic symmetry and biomechanical compensation pattern. Clinically, these findings may coincide with improving proximal lumbopelvic symmetry assisting with normalizing distal mobility by using manual therapy.
Quality Assessment of Case-Control Studies
- Was the research question or objective in this paper clearly stated and appropriate?
yes
- Was the study population clearly specified and defined?
yes
- Did the authors include a sample size justification?
no
- Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same timeframe)?
no
- Were the definitions, inclusion and exclusion criteria, algorithms or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants?
yes
- Were the cases clearly defined and differentiated from controls?
yes
- If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible?
Not applicable/available
- Was there use of concurrent controls?
no
- Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case?
yes
- Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants?
yes
- Were the assessors of exposure/risk blinded to the case or control status of participants?
Not applicable/available
- Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis?
Not applicable/available
Key Finding #1
After 6 weeks of manual therapy treatment, there were differences from pre and post treatment with LE kinematics including: foot contact time, hip transverse angles, and ankle sagittal ankles.
Key Finding #2
There was a decrease in hip ER bilaterally after 6 weeks of manual therapy treatment. This finding could be related to improving pelvic alignment with muscle energy techniques.
Key Finding #3
Clinical changes found a decrease in mobility of the subtalar joint after improving hip rotation. Furthermore, it was hypothesized through the study that by improving transverse plane mobility in the hip joint, this was transmitted to decrease in transverse plane mobility at the ankle.
Please provide your summary of the paper
As running is one of the most highly prevalent activities that is utilized as a type of exercise, there is often a high correlation of injuries that come with this activity. The most common of these injuries are from overuse. To help manage these different MSK injuries, the authors Alisa Drapeaux and Kevin Carlson looked at how manual therapy, including muscle energy and joint mobilization, affected 3D running kinematic variables in a subject with low back and hip pain. Results found that isolated treatment of joint mobilization to the lumbar spine and LE, in addition to muscle energy techniques to the lumbopelvic area, was statistically significant in changing kinematic variables with a 3D running analysis.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
From the results that were found in this study, it is important to note the possibility of how implementation of manual therapy and muscle energy techniques to the lumbopelvic and LE areas can have an impact on biomechanical compensatory patterns with running. After a long duration of treatment (6 weeks) of manual therapy techniques, there were statistically significant changes in running mechanics from the patient. SLS time was increased, which shows that the subject’s pain level changed from pre to post treatment and they were able to withstand the initial landing with each stride. An inherent limitation of this study was the small sample size (N=1) and therefore the results can’t generalize to other populations.
Article Full Title
Effects of Manual Therapy on Fatigue, Pain, and Psychological Aspects in Women with Fibromyalgia
Author Names
Nadal-Nicolás, Y, Ángel Rubio-Arias, J, Martínez-Olcina, M, Reche-García, C, HernándezGarcía, M, Martínez-Rodríguez, A
Reviewer Name
Karleigh Derleth, ATC, LAT, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy
Paper Abstract
Fibromyalgia is a condition characterised by chronic widespread muscle pain and fatigue, sleep disturbances, cognitive disorders, and mood disturbance. The purpose of this study was to determine the eSectiveness of a manual therapy technique performed with moderate digital pressure in women with fibromyalgia (n = 24). In this randomised, controlled trial, the participants were randomly assigned to the experimental group or placebo group. The experimental group was assisted with manual therapy sessions based on connective tissue massage, whereas the placebo group was “treated” with ultrasound sessions performed without conductive gel and with the machine turned oS as the placebo. Fatigue severity scale (FSS), visual analogical scale (VAS), Pittsburgh sleep quality index (PSQI), and profile of mood states (POMS-29) were completed before and after the intervention. In the experimental group (manual therapy), significant results were obtained on a VAS scale, referring to the neck pain in patients with fibromyalgia (p < 0.001). Correlations showed a relationship between fatigue and sleep variables (R = 0.411; p = 0.046) and pain variables with the POMS anger-hostility subscale (R = 0.436; p = 0.033). Although the size of the sample could be a limitation, the study concluded that the application of manual therapy in fibromyalgia patients performed with moderate pressure for 15 min on the posterior cervical musculature decreased the perception of pain, muscle fatigue, and the state of tension-anxiety.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT Yes
2. Was the method of randomization adequate (i.e., use of randomly generated assignment)? Yes
3. Was the treatment allocation concealed (so that assignments could not be predicted)? Yes
4. Were study participants and providers blinded to treatment group assignment? Yes
5. Were the groups similar at baseline on important characteristics that could a5ect outcomes (e.g., demographics, risk factors, co-morbid conditions)? Yes
6. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? No
7. Was the di5erential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? No
8. Was there high adherence to the intervention protocols for each treatment group? Yes
9. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? Yes
10.Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? Yes
11.Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? Yes
Key Finding #1
Manual therapy showed to have a significant reduction in pain values as identified by the VAS.
Key Finding #2
The study shows solid findings for short term pain relief in individuals with fibromyalgia.
Please provide your summary of the paper
This paper discussed the aspects of fatigue, psychological characteristics, and pain in individuals with fibromyalgia. This specifically targeted women and assessed their outcomes using the fatigue severity scale(FSS), visual analog scale (VAS), Pittsburgh sleep quality index (PSQI), and the profile of mood states (POMS-29). The study divided the women into two groups. One received manual therapy involving connective tissue massage and the other group was a control group “treated” with ultrasound that was not turned on.This study occurred twice a week for four weeks. Connections were found with the sleep quality and fatigue scales, as well as the VAS with the anger hostility subscale of the POMS29. There seemed to be a connection with manual therapy on these variables, however the study acknowledges limitations such as a small sample size, a short study period, and a high dropout rate.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This paper seems to have brought up many potential variables that manual therapy could have an eSect on. While the study indicates a connection with manual therapy and decreasing pain, the limitations seem to potentially cloud the results. The smaple size was incredibly small, being only 24 women, and this was only onducted for four weeks. That being said, they acknowledged there is a need for a longer term study to fully look at variable likes sleep quality. This study helped to indicate that manual therapy should be a beneficial treatment in the cinic, but needs more research to see the long term eSects and possibilities on other populations.
Article Full Title
The Effects of Manual Therapy in Pain and Safety of Patients with Knee Osteoarthritis: A Systematic Review and Meta Analysis
Author Names
Brown, Zhu et. al
Reviewer Name
Isha Dixit
Reviewer Affiliation(s)
Duke DPT (Student – Class of 2026)
Paper Abstract
Background: Manual therapy (MT) is frequently used in combination with management of osteoarthritis of the knee, but there is no consensus on the exact efficacy of this treatment strategy. The purpose of this systematic review and meta-analysis was to evaluate the pain relief and safety of MT for treatment of knee osteoarthritis (KOA). Methods: Randomized controlled trials evaluating MT in patients with KOA in major English and Chinese journals were searched in the following databases: Wanfang, China Science and Technology Journal Database (VIP database), China National Knowledge Infrastructure (CNKI), PubMed, Embase, Web of Science, and the Cochrane Library databases through June 2023. The methodological quality and quality of evidence of the included studies were assessed using Cochrane’s risk-of-bias 2 (ROB 2) tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. Data analysis was performed using Stata version 15.0 software. After use of Galbraith plots to exclude studies that could lead to heterogeneity, random effects models were used to analyze the remaining data and test the consistency of the findings. We used meta-regression to assess the effect of treatment period, patient age, and sex ratio on outcomes. Funnel plots and Egger’s test were used to evaluate publication bias. Sensitivity analyses were used to determine the reliability of the results. Results: A total of 25 studies, with 2376 participants, were included in this review. The overall methodological quality of the included studies was limited. Our findings suggest that MT has a positive impact on pain relief outcomes in KOA patients. The meta-analysis showed that MT was superior to usual care (SMD = 2.04, 95% CI 0.94, 3.14, I 2 = 96.3%; low evidence quality) and exercise (SMD = 1.56, 95% CI 0.41, 2.71, I 2 = 96.3%; low evidence quality) for reducing pain. In terms of improvement in visual analogue scale (VAS) scores, MT treatment beyond 4 weeks (SMD = 1.56, 95% CI 0.41, 2.71, I 2 = 96.3%) may be superior to treatments less than or equal to 4 weeks (SMD = 1.24, 95% CI 0.56, 1.95, I 2 = 94.7%). No serious adverse events associated with MT were reported. Conclusions: MT may be effective at reducing pain in patients with KOA and may be more effective after a 4-week treatment period. Compared with usual care and exercise therapy, MT may be superior at reducing KOA pain in the short term (9 weeks), but its longterm efficacy requires careful consideration of evidence-based outcomes. MT appears to be safe for KOA patients, though clinicians should inform patients of the potential risk of MT-related adverse events. Keywords: Knee osteoarthritis; Manual therapy; Meta-analysis; Pain; Safety.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
1. Is the review based on a focused question that is adequately formulated and described? Yes
2. Were eligibility criteria for included and excluded studies predefined and specified? Yes
3. Did the literature search strategy use a comprehensive, systematic approach? Yes
4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias? Yes
5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity? Yes
6. Were the included studies listed along with important characteristics and results of each study? Yes
7. Was publication bias assessed? Yes
8. Was heterogeneity assessed? (This question applies only to meta-analyses.) Yes
Key Finding #1
Manual therapy was found to be no less effective than other exercise interventions for pain relief in patients with knee osteoarthritis and was superior to usual care (medication, acupuncture treatment) in the short term (9 weeks).
Key Finding #2
Manual therapy is safe for patients with knee osteoarthritis but physical therapists are strongly recommended to establish better monitoring and reporting skills when incorporating this intervention to treatment sessions.
Key Finding #3
Although this study suggests that manual therapy is an effective intervention for patients with knee osteoarthritis in the short term, there may need to be more studies done to establish the effectiveness of the intervention in the long term.
Please provide your summary of the paper
This systematic review and meta-analysis evaluated both safety and pain ratings when applying manual therapy as an intervention for patients with knee osteoarthritis. Those in the control group received any type of therapy besides manual therapy (acupuncture, exercise, medication) while those in the experimental group only received manual therapy (massage and manipulative). When looking at pain ratings they assessed Visual Analog Scale (VAS) reportings as well as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Safety was assessed through adverse events following treatment.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study suggests that manual therapy, although probably not an effective stand-alone treatment, can lead to improvements in patient reporting of pain when incorporated into treatment sessions in patients presenting with knee osteoarthritis (OA). This allows for a new intervention to be explored during sessions in order to further assist patients experiencing knee (and possibly other joint) OA especially if other treatment options such as exercise interventions, or medication don’t seem to be working as well. Incorporating manual therapy into treatment sessions for patients with knee OA may allow for better outcome measures and patient reportings.
Article Full Title
Effects of Manual Therapy on Parkinson’s Gait: A Systematic Review
Author Names
Arnaud Delafontaine, Thomas Vialleron, Gaëtan Barbier, María García-Escudero, Arnaud Lardon, Mélodie Barrière, Laurent Fabeck, Martin Descarreaux
Reviewer Name
Kiley Doerzbacher, SPT
Reviewer Affiliation(s)
Duke University School of Medicine Doctor of Physical Therapy Division
Paper Abstract
Manual therapy (MT) is commonly used in rehabilitation to deal with motor impairments in Parkinson’s disease (PD). However, is MT an efficient method to improve gait in PD? To answer the question, a systematic review of clinical controlled trials was conducted. Estimates of effect sizes (reported as standard mean difference (SMD)) with their respective 95% confidence interval (95% CI) were reported for each outcome when sufficient data were available. If data were lacking, p values were reported. The PEDro scale was used for the quality assessment. Three studies were included in the review. MT improved Dynamic Gait Index (SMD = 1.47; 95% CI: 0.62, 2.32; PEDro score: 5/10, moderate level of evidence). MT also improved gait performances in terms of stride length, velocity of arm movements, linear velocities of the shoulder and the hip (p < 0.05; PEDro score: 2/10, limited level of evidence). There was no significant difference between groups after MT for any joint’s range of motion during gait (p > 0.05; PEDro score: 6/10, moderate level of evidence). There is no strong level of evidence supporting the beneficial effect of MT to improve gait in PD. Further randomized controlled trials are needed to understand the impact of MT on gait in PD.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
Yes
- Did the literature search strategy use a comprehensive, systematic approach?
Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes
- Were the included studies listed along with important characteristics and results of each study?
Yes
- Was publication bias assessed?
Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
Yes
Key Finding #1
No strong level of evidence supporting the use of MT alone on the effects of gain in PD.
Key Finding #2
Multidisciplinary intensive rehabilitation, including MT, could potentially slow motor decline, delay drug interventions, and develop a neuroprotective impact.
Key Finding #3
More data and statistical heterogeneity is needed to further research in this area and explore the potential evidence based impacts of MT on gait in PD.
Please provide your summary of the paper
The study aims to analyze the effect of Manual Therapy (MT) on gain in Parkinson’s Disease (PD) by comparing gait outcomes in intervention and control groups. Selected criteria include patients with idiopathic PD and all MT techniques. A systematic review was conducted on three studies out of 425 titles screened from the initial identification stage. In the three studies, 89 patients with idiopathic PD participated, and two studies included 51 control participants. The average participant age ranged from 45-68 years old with a mean age of 66.94 ± 8.43 years. MT interventions included Cyriax mobilization techniques on the lumbosacral region and osteopathic manipulative treatment (OMT) targeting flexibility, muscle length, and spine mobility. One study used the Dynamic Gait Index, identified as an RCT, and found a PEDro score of 5/10 resulting in a moderate level of evidence. Two studies focused on the effects of OMT on joint ROM during gait which resulted in no significant difference between groups. Overall, the results found no strong evidence supporting MT effects on gain outcome improvements. The major limitations include a lack of statistical heterogeneity and only randomized or clinical control trials used in the systematic review. The lack of data continues to hinder study advancement and additional randomized control trials are needed to further understand the impacts of MT on gain in PD.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study has potential to encourage more studies relating to the effects of MT on patients with PD. When more data is found and heterogeneity implemented, patients suffering with gait deviations from PD will have better options for combined physical therapy interventions. Results from a more comprehensive study can change the treatment approach for patients with PD at all stages of diagnosis.
Article Full Title
Immediate effect of a spinal mobilisation intervention on muscle stiffness, tone and elasticity in subjects with lower back pain – A randomized cross-over trial
Author Names
Hamilton R, Garden C, Brown S
Reviewer Name
Nathalie Donado De Janon, SPT ’26
Reviewer Affiliation(s)
Duke University School of Medicine, Department of Physical Therapy Division
Paper Abstract
Background: Despite the lack of objective evidence, spinal manual therapies have been common practice for many years, particularly for treatment of lower back pain (LBP). This exploratory study measured and analysed the effect of a spinal mobilisation intervention on muscle tissue quality in LBP sufferers. Methods: 40 people with LBP participated in a within-subject repeated measures cross-over study with intervention and control conditions. A myometer was used to assess the change in para-spinal muscle tissue quality before and after the intervention. Analysis considered the magnitude of muscle response together with individual covariates as potential contributors. Results: A significant post-intervention reduction was observed in muscle stiffness (p = 0.012, η 2 partial = 0.15), tone (p = 0.001, η 2 partial = 0.25) and elasticity (p = 0.001, η 2 partial = 0.24). Significant increases were seen in 2 variables post-control: stiffness (p = 0.004, η 2 partial = 0.19), tone (p = 0.006, η 2 partial = 0.18) and a significant decrease in elasticity (p ˂ 0.000, η 2 partial = 0.3). Significant contributing covariates include baseline stiffness, BMI, waist circumference and sex. Baseline stiffness and tone were significantly correlated to their response levels. Conclusions: The significant reduction in all muscle tissue qualities following the intervention provide preliminary data for an evidence-based LBP therapeutic. Baseline stiffness, BMI, waist circumference and sex could act as significant contributors to magnitude of response. The results warrant further investigation into spinal mobilisation therapies to further build the objective evidence base.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
- Were study participants and providers blinded to treatment group assignment?
No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
No
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
- Was there high adherence to the intervention protocols for each treatment group?
Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
There was an immediate measurable effect on lower back para-spinal stiffness after a 30-minute manual therapy treatment session, that demonstrated a reduction in stiffness as compared to pre-treatment measurements.
Key Finding #2
The control group demonstrated the impact of sedentary behavior and its implications of low back pain and chronic stiffness.
Key Finding #3
There were similar findings for both muscle tone and stiffness, indicating that manual therapy intervention would have a similar, positive effect on muscle tone, leading to a reduction in stiffness.
Key Finding #4
Both conditions of the study, the control and intervention, resulted in decreased muscle elasticity, which suggests that both stationary relaxing and manual therapy intervention affected elasticity of lower para-spinal muscles similarly.
Please provide your summary of the paper
A single 30-minute session of manual therapy intervention showed immediate significant improvements on muscle stiffness and tone, as opposed to the control, which demonstrated its effect on muscle quality and suggests it could be implemented on populations with low back pain and chronic stiffness. Although this study’s intervention focused on a single treatment session, further investigation exploring repeated treatment sessions may provide more evidence of effectiveness in those populations.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
I expected results of improvement in muscle tone and stiffness, given that the control group involved no treatment, but did not expect that muscle elasticity would be equally affected in both groups. Since the study showed that manual therapy improves both stiffness and tone, it would be useful to implement in patients with chronic low back pain and stiffness that do not have contraindications.
Article Full Title
The Effect of Combining Spinal Manipulation and Dry Needling in Individuals With Nonspecific Low Back Pain
Author Names
Jedidiah Farley, ⁎ Lisa Taylor-Swanson, † Shane Koppenhaver, ‡ Anne Thackeray, ⁎ Jake Magel, ⁎ and Julie M. Fritz
Reviewer Name
Hannah Dougherty, SPT
Reviewer Affiliation(s)
Duke University Doctor of Physical Therapy Program
Paper Abstract
Low back pain (LBP) is one of the most common and costly musculoskeletal conditions impacting health care in the United States. The development of multimodal strategies of treatment is imperative in order to curb the growing incidence and prevalence of LBP. Spinal manipulative therapy (SMT), dry needling (DN), and exercise are common nonpharmacological treatments for LBP. This study is a 3-armed parallel-group design randomized clinical trial. We enrolled and randomized 96 participants with LBP into a multimodal strategy of treatment consisting of a combination of DN and SMT, DN only, and SMT only, followed by an at-home exercise program. All participants received 4 treatment sessions in the first 2 weeks followed by a 2-week home exercise program. Outcomes included clinical (Oswestry Disability Index, numeric pain intensity rating) and mechanistic (lumbar multifidus, erector spinae, and gluteus medius muscle activation) measures at baseline, 2, and 4 weeks. Participants in the DN and SMT groups showed larger effects and statistically significant improvement in pain and disability scores, and muscle percent thickness change at 2 weeks and 4 weeks of treatment when compared to the other groups. This study was registered prior to participant enrollment.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
- Were study participants and providers blinded to treatment group assignment?
No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
- Was there high adherence to the intervention protocols for each treatment group?
Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
No
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Cannot Determine, Not Reported, or Not Applicable
Key Finding #1
Patient-centered outcomes for pain intensity reveled the following: The combination group had significantly different outcomes in reported pain intensity compared to the dry needling group alone. The combination group had greater improvement in scores on the NPRS compared to dry needling group. The combination group had significantly different outcomes in reported pain intensity compared to the spinal manipulative therapy group alone. The combination group had greater improvement in scores on the NPRS compared to spinal manipulative therapy. ** Overall, the combination group had greater improvements in reported pain intensity compared to the dry needling and spinal manipulative therapy techniques independently.***
Key Finding #2
Patient-centered outcomes for ODI revealed the following: The combination treatment group DN + SMT had improved ODI scores compared to DN and SMT groups independently.
Key Finding #3
The combination treatment group of DN + SMT also showed significant difference in mechanistic outcomes compared to the DN and SMT groups independently.
Please provide your summary of the paper
In the study by Farley and colleagues, multimodal treatment strategies such as dry needling (DN) and spinal manipulative therapy (SMT) were used in combination and independently to evaluate the physiologic and clinical outcomes in patients with nonspecific low back pain. The researchers focused their efforts on reducing patient symptoms while increasing patient adherence to exercise programs. The study included 96 participants and three randomized intervention groups including dry needling, spinal manipulative therapy, and both dry needling and spinal manipulative therapy. The subjects participated in two weeks of their assigned treatment and two weeks of an at-home exercise program consecutively. Patients were screened for inclusion criteria and assessed using the numerical pain rating scale and the Oswestry Disability Index (ODI) to evaluate symptoms at baseline, one week, two weeks, and four weeks. Mechanistic outcome measures using ultrasound images were employed to track changes in lumbar multifidus muscle, erector spinae, and gluteus medius muscle activation and thickness. The spinal manipulative therapy technique was performed on patients in the side-lying position with two attempts per side noting any cavitations that occurred if any. The dry needling technique was performed in the lumbar multifidus, erector spinae, and gluteus medius muscles and at the appropriate spinal level based on prior examination for a total of 10 minutes. In the combined treatment group, patients received SMT, immediately followed by DN with the same procedures as the independent groups. At the conclusion of the four-week study, patient-centered outcomes for pain (NPRS) and disability (ODI) as well as the mechanistic outcomes improved and showed a significant difference when the combination group (SMT+DN) was compared to the DN and SMT group individually. Overall, “the highest level of treatment effects in both subjective and objective measures were found in the group combining DN and SMT” (Farley et al, 2024). Due to the decrease in subjective reports of pain and disability, individuals had improved abilities to participate in the at-home program and perform strengthening exercises targeting spinal musculature. The study outlines the importance and efficacy of cointerventions rather than solo interventions for the treatment of low back pain and the benefits of controlling the psychological fear factor associated with pain prior to beginning exercise.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
I believe this study was effective to increase the evidence base regarding the use of multiple intervention techniques and their role in reducing pain, disability, and improving function. I believe it was a well rounded study with limited bias. This study will impact clinical practice by informing clinicians to include additional manual therapy techniques into their practice with patients to maximize the effects instead of solo interventions.
Article Full Title
Effectiveness of Cognitive Functional Therapy Versus Core Exercises and Manual Therapy in Patients With Chronic Low Back Pain After Spinal Surgery: Randomized Controlled Trial
Author Names
Leonardo Avila, PhD, Morgana Duarte da Silva, PhD, Marcos Lisboa Neves, Msc, Andre Rogerio Abreu, PT, Cibelle Ramos Fiuza, PhD, Leandro Fukusawa, Arthur de Sá Ferreira, PhD, Ney Meziat-Filho, PhD
Reviewer Name
Julia Douglas
Reviewer Affiliation(s)
Duke University
Paper Abstract
Objective Our aim was to investigate whether cognitive functional therapy (CFT) was more effective than core exercises and manual therapy (CORE-MT) in improving pain and function for patients with chronic low back pain after spinal surgery. Methods This study was a randomized controlled superiority trial in a university hospital and a private physical therapist clinic in Santa Catarina, Brazil. Eighty participants who were 18 to 75 years old and had chronic low back pain after spinal surgery received 4 to 12 treatment sessions of CFT or CORE-MT once per week for a maximum period of 12 weeks. Primary outcomes were pain intensity (numeric pain rating scale, scored from 0 to 10) and function (Patient-Specific Functional Scale, scored from 0 to 10) after intervention. Results We obtained primary outcome data for 75 participants (93.7%). CFT was more effective, with a large effect size, than CORE-MT in reducing pain intensity (mean difference [MD] = 2.42; 95% CI = 1.69–3.14; effect size [d] = 0.85) and improving function (MD = −2.47; 95% CI = −3.08 to −1.87; effect size = 0.95) after intervention (mean = 10.4 weeks [standard deviation = 2.17] after the beginning of treatment). The differences were maintained at 22 weeks for pain intensity (MD = 1.64; 95% CI = 0.98–2.3; effect size = 0.68) and function (MD = −2.01; 95% CI = −2.6 to −1.41; effect size = 0.81). Conclusion CFT was more effective than CORE-MT, with large effect sizes, and may be an option for patients with chronic low back pain after spinal surgery. Impact CFT reduces pain and improves function, with large effect sizes, compared with CORE-MT. The difference between CFT and CORE-MT was sustained at the midterm follow-up. Treatment with CFT may be an option for patients with chronic low back pain after spinal surgery.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
Yes
- Were study participants and providers blinded to treatment group assignment?
No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Yes
- Was there high adherence to the intervention protocols for each treatment group?
Cannot Determine, Not Reported, or Not Applicable
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
Yes
Key Finding #1
Primary and secondary outcomes showed that CFT is more effective than CORE-MT at reducing pain and improving function in patients with chronic low back pain after spinal surgery.
Key Finding #2
The difference in outcomes between CFT and CORE-MT treatment was sustained at the mid-term follow up, thus further supporting that CORE-MT may not be the most effective treatment for chronic low back pain after spinal surgery.
Please provide your summary of the paper
This study compared Cognitive Functional Therapy (CFT) with Core Exercises and Manual Therapy (CORE-MT) for patients with chronic low back pain following spinal surgery. In this randomized control trial, participants were randomized to receive either CFT treatment, or CORE-MT treatment for 4-12 weeks. Results showed a significant difference in outcomes between CFT and CORE-MT, with CFT showing greater improvement of symptoms than CORE-MT. Improvements were seen in pain reduction, functional outcomes, and psychosocial factors, such as fear and catastrophization. In conclusion, CFT is a superior treatment approach for patients with chronic low back pain following a spinal surgery, when compared to a CORE-MT treatment approach.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study can be applied in clinical practice for patients with chronic low back pain following spinal surgery to address both their physical symptoms and cognitive factors, such as fear of movement and catastrophization. As observed in this study, CFT can tailor to a patient’s needs through a holistic approach to achieve pain relief and improved functional outcomes. Although the CORE-MT approach is often used, the CFT approach may be a more beneficial biopsychosocial approach to use for patients dominated by cognitive factors. Applying the principles of CFT, rather than focusing on CORE-MT treatment may provide an enhanced quality of life and improved patient satisfaction.
