Lumbopelvic

Article Full Title 

Effect of Exercise and Manual Therapy or Kinesiotaping on sEMG and Pain Perception in Chronic Low Back Pain: A Randomized Trial 

Author Names 

Blanco-Gimenez, P., Vicente-Mampel, J., Gargallo, P., Maroto-Izquierdo, S., Martin-Ruiz, J., Jaenada-Carrilero, E., Barrios, C. 

Reviewer Name 

Leara Stanley, SPT 

Reviewer Affiliation(s) 

Duke University School of Medicine, Doctor of Physical Therapy Division 

Paper Abstract 

The importance of incorporating lumbo-pelvic stability core and controlling motor exercises in patients with chronic low back pain (CLBP) reinforces the use of strategies to improve biopsychosocial beliefs by reducing biomedical postulations. However, clinical practice guidelines recommend multimodal approaches incorporating exercise and manual therapy (MT) and instead reject the application of kinesiotape (KT) in isolation. Therefore, the objectives of this study were to analyze the effects of 12 weeks of exercises combined with MT or KT on perceived low back pain using the visual analog scale (VAS) and muscle electric activity measured with electromyography (EMG) of the rectus abdominis and multifidus in CLBP (mild disability) and to explore the relationship between the rectus abdominis and multifidus ratios and pain perception after intervention. A blinded, 12-week randomized controlled trial (RCT) was carried out, involving three parallel groups of patients with CLBP. The study was registered at Clinicaltrial.gov and assigned the identification number NCT05544890 (19/09/22). The trial underwent an intention-to-treat analysis. The primary outcome revealed a multimodal treatment program supplemented by additional therapies such as MT and KT, resulting in significant reductions in perceived low back pain. The subjective assessment of individuals with CLBP indicated no discernible distinction between exclusive core stability exercises and control-motor training when combined with MT or KT. Notably, our findings demonstrated positive alterations in both the mean and peak EMG values of the right rectus abdominis in the exercise group, suggesting a beneficial impact on muscle activation. This study focused on assessing the activation levels of the trunk musculature, specifically the rectus abdominis (RA) and multifidus (MF), in individuals with CLBP exhibiting mild disability according to the Oswestry Disability Index. Importantly, improvements in the VAS values were observed independently of changes in muscle electrical activity. 

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 

1. Was the method of randomization adequate (i.e., use of randomly generated assignment)? 

Yes 

1. Was the treatment allocation concealed (so that assignments could not be predicted)? 

Yes 

1. Were study participants and providers blinded to treatment group assignment? 

No 

1. Were the people assessing the outcomes blinded to the participants’ group assignments? 

Yes 

1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 

Yes 

1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? 

Yes 

1. Was there high adherence to the intervention protocols for each treatment group? 

Yes 

1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 

Yes 

1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? 

Yes 

1. 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 

1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? 

Yes 

1. 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 

Engaging in a multimodal treatment program, with or without any additional complementary therapies such as manual therapy or kinesiotaping, results in significant reductions in perceived low back pain. 

Key Finding #2 

There is no discernible difference in perceived low back pain between groups undergoing core stability exercises exclusively, and treatment groups receiving exercise protocol in conjunction with manual therapy or kinesiotaping. 

Key Finding #3 

Individual therapies such as exercise, manual therapy, or kinesiotaping present with their own individual strengths and can be beneficial as one form of treatment in patients with chronic low back pain. 

Key Finding #4 

Neither manual therapy nor kinesiotaping combined with exercise were superior to exercise alone. Although all three intervention groups demonstrated moderately improved perception of low back pain, it is unclear which treatment demonstrated greatest significance for extrapolation to larger populations. 

Please provide your summary of the paper. 

The purpose of the randomized control trial was to determine if an exercise protocol targeting core stabilization and motor control, in conjunction with other treatment therapies such as manual therapy (MT) or kinesiotaping (KT) would be more advantageous than an exercise protocol exclusively, in reducing pain perception in patients with mild disability as a result of chronic low back pain (CLBP). The outcome measures used to determine effectiveness of treatments were a 10-point visual analog scale (0-10) and surface electromyography (sEMG) amplitudes measuring signal intensity of two major muscle groups—the rectus abdominis and multifidus, bilaterally. All participants, regardless of treatment group placement, were provided a lumbo-pelvic core stabilization exercise protocol consisting of exercises such as dead bugs, shoulder bridges, regular and lateral planks, cat camel, pointers, and lumbar flexion. Divided into three treatment groups (receiving exercise protocol alone, exercise protocol + MT, or exercise protocol + KT), participants underwent a 12-week study consisting of two therapy sessions per week (24 total sessions/patient). Results from the study revealed that combining exercise with either manual therapy or kinesiotaping was not superior to exercise alone when attempting to minimize pain perception in patients with CLBP, although all three treatment group participants reported improvements in pain overall. In fact, patients who received only the exercise protocol without additional therapies were more effective in reducing perception of pain within the first six weeks of the study compared to patients receiving manual therapy or kinesiotaping in combination with exercise. Limitations within this study include a lack of clinical change among intervention groups based on EMG activity, and recruiting participants with only mild disability, scoring less than 20% on the Oswestry Disability Index (ODI). Future studies would benefit from assessing treatment interventions for longer training periods, i.e., greater than 12 weeks, to more confidently understand the impacts of the therapies tested. Additionally, other factors such as individual preference, previous experiences in healthcare, cultural beliefs, and other psychosocial factors should be considered when determining effectiveness of treatments and establishing treatment guidelines for CLBP patients.   

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented. 

Chronic low back pain (CLBP) is one of the most common syndromes, with up to 85-95% of patients failing to present with a pathoanatomical cause for diagnosis. CLBP also contributes to disability and perceived pain, which are influenced by several other factors including social, psychological, and biological factors. Although this study was unable to definitively determine which, if any, additional therapies combined with exercise might have the greatest reduction in pain perception, it still highlights the importance of implementing core stabilization exercises during therapy sessions to reduce pain in patients with chronic low back pain diagnoses. Each of the treatment groups demonstrated value and a positive effect on patients when comparing baseline to post-treatment outcomes. Although results from the study were only preliminary, the study still emphasizes the importance of implementing a multimodal approach when treating patients with chronic conditions such as low back pain, whether it is through exercise alone, or exercise in combination with other therapeutic interventions. It also highlights the importance of considering factors outside of those that are biological when determining the best course of action for treatment of chronic conditions. This includes, but is not limited to, cultural, psychological, and social factors. As with any patient or diagnosis, treatments should be individualized and tailored to the specific needs of the patient and their goals/values.  However, considering chronic low back pain is one of the most common conditions likely seen by physical therapists, this study continues to support research highlighting the necessity for PT services and specialized providers as an integral part of treatment for patients with chronic low back pain.  

Article Full Title

Effectiveness of Manual Treatment on Pregnancy Symptoms: Usefulness of Manual Treatment in Treating Pregnancy Symptoms

Author Names

Boris, S Reviewer Name Torri Tippett, SPT

Reviewer Affiliation(s)

University of South Alabama Duke University School of Medicine

Paper Abstract

Objectives: To determine the usefulness of manual treatment in reducing or eliminating pregnancy symptoms during first and second trimester. Methods: Manual treatment of the cervical and thoracic spine was performed in a group of 115 pregnant women who developed pregnancy symptoms during normal pregnancy. A rotational traction of the cervical spine was applied. Patients in whom the treatment was unsuccessful underwent second round of treatment after a pause of a minimum 3 days. Patients for whom the treatment was initially successful but later relapsed also repeated whole procedure. Pregnancy symptoms analyzed in this study were heartburn, nausea, vomiting, dizziness, headache, insomnia, neck pain, hyperosmia and hypersalivating. Results: Manual treatment successfully treated pregnancy symptoms in 91 (79.1%) patients, it was partially successful for 22 (19.1%), and unsuccessful for 2 patients (1.7%) after the first treatment. After the second treatment, out of a total 56 patients, the treatment was completely successful in 40 (71.4%), partially successful in 14 (25%), and unsuccessful in 2 (3.6%) patients. The highest success rate was in eliminating headache (97.3%), vomiting (95.9%), dizziness (94.5%), nausea (92.9%), neck pain (92.9%), insomnia (91.9%), heartburn (88.8%), hyperosmia (78.5%) and hyper salivating (78%). Conclusion: Manual therapy in pregnancy is a drugless, etiological, usually highly e”ective therapy. It is a low cost, rapid, safe, and well tolerated treatment for pregnancy symptoms which frequently has an immediate e”ect, thus making it an optimal treatment for pregnancy symptoms. Keywords: manual treatment, pregnancy symptoms, e”ectiveness.

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 Cannot Determine, Not Reported, or Not Applicable

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)? No

4. Were study participants and providers blinded to treatment group assignment? No

5. Were the people assessing the outcomes blinded to the participants’ group assignments? No

6. Were the groups similar at baseline on important characteristics that could a5ect 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? Cannot Determine, Not Reported, or Not Applicable

8. Was the di5erential 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 of the cervical and thoracic spine is a treatment option to reduce pregnancy symptoms in women throughout their pregnancy.

Key Finding #2

This study suggests that the treatment techniques completed in the study could help treat GERD in pregnant women.

Key Finding #3

There was no comparison group of women who did not receive treatment or who received a di”erent treatment; therefore, the therapist should use their clinical discretion in practice.

Please provide your summary of the paper

The study examined the effects of cervical and thoracic spine manipulation on symptoms such as nausea, vomiting, headache, dizziness, back pain, etc, on pregnant women at different stages of their pregnancy. The study participants made no lifestyle changes, such as diet, and did not use any other treatment other than manual therapy to reduce symptoms. Most patients had immediate relief of symptoms, a few required 2 to 3 sessions to alleviate their symptoms. Some patients noticed new symptoms after the 1st or 2nd treatment, which could be related to being farther along in their pregnancy, but none noticed new symptoms after the 3rd treatment. There was one manual therapy technique for the cervical spine and one for the thoracic spine done by a therapist who followed the same process every time.

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 impacts clinical practice by providing insight into how manual therapy can impact pregnancy symptoms. Some clinicians and physicians may not be sure if manual therapy is safe to do on pregnantwomen. This study shows that it is safe and may even relieve symptoms for women if done correctly.

Article Full Title 

A Combined Treatment Approach Emphasizing Impairment-Based Manual Physical Therapy for Plantar Heel Pain: A Case Series 

Author Names 

Young, B., Walker, M., Strunce, J., Boyles, R.  

Reviewer Name 

Katelyn Wang, CPT, SPT 

Reviewer Affiliation(s) 

PT Student at Duke University 

Paper Abstract 

Objective: To describe an impairment-based physical therapy treatment approach for 4 patients with plantar heel pain. 

Background: There is limited evidence from clinical trials on which to base treatment decision making for plantar heel pain. 

Methods and measures: Four patients completed a course of physical therapy based on an impairment-based model. All patients received manual physical therapy and stretching. Two patients were also treated with custom orthoses, and 1 patient received an additional strengthening program. Outcome measures included a numeric pain rating scale (NPRS) and self-reported functional status. 

Results: Symptom duration ranged from 6 to 52 weeks (mean duration+/-SD, 33+/-19 weeks). Treatment duration ranged from 8 to 49 days (mean duration+/-SD, 23+/-18 days), with number of treatment sessions ranging from 2 to 7 (mode, 3). All 4 patients reported a decrease in NPRS scores from an average (+/-SD) of 5.8+/-2.2 to 0 (out of 10) during previously painful activities. Additionally, all patients returned to prior activity levels. 

Conclusion: In this case series, patients with plantar heel pain treated with an impairment-based physical therapy approach emphasizing manual therapy demonstrated complete pain relief and full return to activities. Further research is necessary to determine the effectiveness of impairment-based physical therapy interventions for patients with plantar heel pain/plantar fasciitis. 

NIH Risk of Bias Tool 

Quality Assessment Tool for Case Series Studies 

1. Was the study question or objective clearly stated? 

Yes 

1. Was the study population clearly and fully described, including a case definition? 

Yes 

1. Were the cases consecutive? 

Cannot Determine, Not Recorded, Not Applicable 

1. Were the subjects comparable? 

Yes 

1. Was the intervention clearly described? 

Yes 

1. Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants? 

Yes 

1. Was the length of follow-up adequate? 

Yes 

1. Were the statistical methods well-described? 

No 

1. Were the results well-described? 

Yes 

Key Finding #1 

A key finding is that within all cases trialed, patients resulted with 0/10 pain at the end of their treatment. The immediate reduction in pain was attributed to ankle and foot manipulations selected by patient specific intervention. Follow-up reports of 0/10 pain were largely resulted by provider education on home exercise program of self-manipulation as well as calf stretches. 

Key Finding #2 

Another key finding would be that although all patients reported heel pain, their pain generators were not all alike (joint hypomobility, plantar fascia tightness, limited ROM, etc.), therefore the individualized treatments per patient were successful to each case. Each treatment plan involved a form of ankle/foot manual therapy in conjunction with calf stretching. This demonstrates the significance of determining the contributions to the patient’s pain in order to select the appropriate manipulation. 

Key Finding #3 

A third key finding is the sustainability of the manual therapy techniques for long term decreased pain within all of the trials. The follow up reports per patient were between 3 weeks – 2 months after their last session, and with all 4 cases, they all reported sustaining 0/10 heel pain with their activities of daily living. 

Please provide your summary of the paper 

This case series followed 4 patients with chief complaints of heel pain. The use of a combined treatment approach was provided to each patient. Although each treatment plan was unique to the individual and their evaluation findings, each consisted of manual therapy techniques in combination with stretching. The participants collectively had plantar heel pain, however, they ranged in impairments from reduced joint mobility, lack of ROM, plantar fascia tightness, weakness, and compensated gait patterns. The use of a posterior talocrural joint mobilization was commonly used for compromised ankle dorsiflexion, which in multiple scenarios had an immediate effect leaving the patient with 0/10 or decreased pain. Additional effects were equal bilateral ROM in dorsiflexion. Subtalar joint distraction manipulations addressed inversion and eversion limitations when necessary, prescribed orthoses, calf stretches, and strengthening programs were also implemented per individual case. The findings of combined individualized treatment were 0/10 pain on the VAS in all 4 cases, as well as 0/10 pain in a follow up between 2 weeks and 4 months after their last session. 

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 impacts clinical practice due to its reproducible outcomes of decreased pain with the use of a combined treatment approach. It was valuable to the therapist to first identify the specific impairments per patient prior to implementing the manual therapy technique. In clinical practice this should be the case rather than implementing the same technique to all participants with similar chief complaints. In taking the time to identify specific weaknesses, range of motion limitations, and assessment of mobility, the therapists were able to provide efficient care to the patient. Even in cases where findings might not have determined the specific pain generator, looking at their joint limitations/weaknesses and providing treatment to address those details had a significant impact on functionality and resulted in decreased pain as well. 

Article Full Title 

Holistic Approaches in Endometriosis – as an Effective Method of Supporting Traditional Treatment: A Systematic Search and Narrative Review 

Author Names 

Agnieszka Mazur-Bialy, Sabina Tim, Anna Pępek, Kamila Skotniczna, Gabriela Naprawa 

Reviewer Name 

Maggie Wentz SPT 

Reviewer Affiliation(s) 

Duke School of Medicine  Department of Physical Therapy  

Paper Abstract 

Endometriosis is one of the gynecological diseases where women suffer from pain, quality of life decreased. The aim ofthis review was to describe the most common non-medical methods used in the treatment of symptoms associated with endometriosis and to determine their effectiveness. The review was performed in PubMed, Embase and Web of Science databases. Randomized controlled trials, case studies, observational studies, retrospective studies, prospective studies, pilot studies, trails, publications in English or Polish were searched based on the Participant-Intervention-ComparatorOutcomes-Study design (PICOS) format. The criteria used to select studies were: women with endometriosis, no cancer, included any physiotherapeutic or non-medical intervention. 3706 articles were found, however only 26 met the inclusion criteria and were included in the review. Quality of the studies was assessed by Risk of Bias 2 tool and ROBINS-1 tool. The most holistic approach used in the treatment of symptoms of endometriosis include physical therapy, manual therapy, electrophysical agents acupuncture, diet and psychological interventions. Most research has focused on relieving pain and increasing quality of life. Non-medical methods showed reduction of symptoms of endometriosis. Physical activity, manual therapy, electrophysical agents, acupuncture, diet and cognitive behavioral therapy showed no negative side effects and reduced pain, what improved the quality of life and reduced the perceived stress. 

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 

1. Were eligibility criteria for included and excluded studies predefined and specified? 

Yes 

1. Did the literature search strategy use a comprehensive, systematic approach? 

Yes 

1. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias? 

Yes 

1. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity? 

Yes 

1. Were the included studies listed along with important characteristics and results of each study? 

Yes 

1. Was publication bias assessed? 

Yes 

1. Was heterogeneity assessed? (This question applies only to meta-analyses.) 

Cannot Determine, Not Reported, Not Applicable 

Key Finding #1 

Manual therapy has been found to be effective at relieving endometriosis symptoms by breaking up adhesions, decreasing tone, and restoring proper muscle function with myofascial release, soft tissue massage, and visceral therapy. 

Key Finding #2 

The physical activity that was most effective for improving quality of life with or without medication was yoga that included breathing techniques, stretching exercises, and mindfulness. 

Key Finding #3 

Diet and cognitive behavior therapy have proven to increase quality of life by managing symptoms preventatively, but not impacting the overall condition. 

Please provide your summary of the paper 

Endometriosis is a condition that about 15% of females in the age of menstruation experience. This is a proinflammatory condition in which endometrial tissue develops on the outside of the uterus, instead of within the reproductive organs. This tissue production leads to adhesions, which impact quality of life due to muscle tone changes, severe pain, along with many other symptoms. While medication and surgery are widely used for this condition, this review investigates the effectiveness of physiotherapy and “non medical” interventions for women with endometriosis. Across the studies, VAS was the pain scale used and for researchers searched and reviewed studies that were applicable to their guidelines. While many forms of physical activity were investigated, yoga appears to be the most beneficial and most appropriate for women experiencing severe pain. Manual therapy by a physical therapist was also found to be beneficial as they are able to work on muscle dysfunction, adhesions, and myofascial tensions. TENs and acupuncture have often been found to decrease pain severity, but not many other symptoms. Finally, while diet and cognitive behavioral therapy were used to manage symptoms, they aid in a more preventative manner. Most of the studies reviewed were very small and focused on severe endometriosis which introduces numerous limitations. Moving forward, this area of study will continue to grow with improved diagnostic measures and more publicity around the condition of endometriosis. 

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented. 

This research will influence clinical practice by providing education on how to approach conversations with women who are suffering from endometriosis, especially when it comes to setting expectations. This review made clear that there is unlikely to be a single easy solution in the near future and therefore, the best outcomes are going to occur for patients who take a holistic approach to the treatment of endometriosis. This research serves as encouragement for patients that prefer to stay away from medication and surgical intervention, but have been unsuccessful in finding methods that work to relieve their symptoms.  

Article Full Title 

Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic Review  

Author Names 

Vohra, S. ; Johnston, B. ; Cramer, K. ; Humphreys, K. 

Reviewer Name 

Julie Wilkerson 

Reviewer Affiliation(s) 

Duke University Doctor of Physical Therapy 

Paper Abstract 

BACKGROUND. Spinal manipulation is a noninvasive manual procedure applied to specific body tissues with therapeutic intent. Although spinal manipulation is commonly used in children, there is limited understanding of the pediatric risk estimates. OBJECTIVE. Our goal was to systematically identify and synthesize available data on adverse events associated with pediatric spinal manipulation. METHODS. A comprehensive search was performed of 8 major electronic databases (eg, Medline, AMED, MANTIS) from inception to June 2004 irrespective of language. Reports were included if they (1) were a primary investigation of spinal manipulation (eg, observation studies, controlled trials, surveys), (2) included a study population of children who were aged 18 years or younger, and (3) reported data on adverse events. Data were summarized to demonstrate the nature and severity of adverse events that may result rather than their incidence. RESULTS. Thirteen studies (2 randomized trials, 11 observational reports) were identified for inclusion. We identified 14 cases of direct adverse events involving neurologic or musculoskeletal events. Nine cases involved serious adverse events (eg, subarachnoidal hemorrhage, paraplegia), 2 involved moderately adverse events that required medical attention (eg, severe headache), and 3 involved minor adverse events (eg, midback soreness). Another 20 cases of indirect adverse events involved delayed diagnosis (eg, diabetes, neuroblastoma) and/or inappropriate provision of spinal manipulation for serious medical conditions (ie, meningitis, rhabdomyosarcoma). CONCLUSIONS. Serious adverse events may be associated with pediatric spinal manipulation; neither causation nor incidence rates can be inferred from observational data. Conduct of a prospective population-based active surveillance study is required to properly assess the possibility of rare, yet serious, adverse events as a result of spinal manipulation on pediatric 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?

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.)

Cannot Determine, Not Reported, Not Applicable 

Key Finding #1 

Adverse events after spinal manipulation in children are categorized into serious, moderate, and minor, however there are also adverse events that might occur due to delayed diagnosis or “indirect” adverse events. 

Key Finding #2 

There could be risk factors that predispose a child to adverse events during spinal manipulation, such as the immature spine or high velocity, rotational manipulations. 

Key Finding #3 

Serious adverse events (such as paraplegia, subarachnoid hemorrhage) might be correlated to pediatric spinal manipulation, but cannot be confirmed from this systematic review. The risk and incidence is still unknown. In order to efficiently address the relation, a prospective population-based surveillance study is required. 

Please provide your summary of the paper 

The purpose of this study was to obtain a better understanding of the risk of spinal manipulation and adverse events in pediatrics via a systematic review, however there cannot be any conclusions made without more research such as randomized control trials and a better process for reporting adverse events. Researchers performed a systematic review and found 13 studies that qualified under their requirements (directly investigated spinal manipulation, included population of 18 and under, and data on adverse events). While a conclusion about the incidence of adverse events in pediatrics after spinal manipulation cannot be determined from the systematic review, the reviewed research provided valuable insight about possible correlations. Despite having an unknown risk level in pediatrics, spinal manipulation, a manual therapy technique, is commonly used. Children could be at a predisposition to severe, moderate, or minor adverse events after manipulation or indirect adverse events due to a delayed diagnosis. There is also a lack of research done on the topic and an unknown amount of cases that could be going unreported that might contribute to evidence in the impact of spinal manipulation in pediatrics.  

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented. 

An important takeaway from this article is that the impact of spinal manipulation in pediatrics is still widely unknown and under researched, but has the possibility of correlating with adverse events. As a clinician it is important to consider that when treating the pediatric population and using resources to make the best decision for the patient. This research also suggests that taking a proper patient history is critical to ensure red flags are ruled out or possibility of delayed diagnosis. From here, hopefully more research will be done on spinal manipulation in pediatrics to conclude more definite risk and under what conditions is the risk increased or decreased when treating the immature spine. It also suggests there is some discrepancy in what is being reported and those that go unreported, so as clinicians we should be reporting any adverse events so that future research has evidence to utilize.  

Article Full Title  

The efficacy and safety of non-resistance manual therapy in inpatients with acute neck pain caused by traffic accidents 

Author Names 

kim et al 

Reviewer Name 

Albert yang, spt 

Reviewer Affiliation(s) 

Duke DPT co 2026 

Paper Abstract 

Background: Neck pain and functional impairment are common complications of traffic accidents (TAs); however, the effects of manual therapy on these symptoms have rarely been studied in the literature. Thus, this randomized controlled trial aims to assess the effectiveness and safety of non-resistance manual therapy (NRT)-a treatment combining mobilization and pressure release techniques-on acute neck pain caused by TA.  Method: This study will use a two-armed, parallel, assessor-blinded randomized controlled trial design and will be conducted in the Daejeon Jaseng Hospital of Korean Medicine in South Korea. One hundred twenty patients will be recruited and randomized into an integrative Korean medicine treatment (IMKT) + NRT group and IMKT group in a 1:1 ratio. The primary outcome is a change in the numeric rating scale for neck pain immediately after treatment on hospital day 5 compared to those at baseline. The secondary outcomes are numeric rating scale for radiating arm pain, visual analogue scale for neck pain and radiating arm pain, cervical active range of motion, neck disability index, Patient Global Impression of Change, Short Form-12 Health Survey, and Posttraumatic Stress Disorder Checklist for DSM-5.  Discussion: The findings of this study on the effectiveness and safety of NRT will be helpful for patients with TA-induced neck pain in clinical practice and will provide evidence for developing relevant healthcare-related policies. 

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 

Y 

1. Was the method of randomization adequate (i.e., use of randomly generated assignment)? 

Y 

1. Was the treatment allocation concealed (so that assignments could not be predicted)? 

Y 

1. Were study participants and providers blinded to treatment group assignment? 

n 

1. Were the people assessing the outcomes blinded to the participants’ group assignments? 

y 

1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 

y 

1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? 

n/a 

1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? 

n/a 

1. Was there high adherence to the intervention protocols for each treatment group? 

y 

1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 

y 

1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? 

y 

1. 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? 

Y 

1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? 

y 

1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? 

y 

Key Finding #1 

The study highlights the safety of non-resistance manual therapy (NRT), with adverse events (AEs) categorized using the World Health Organization-Uppsala Monitoring Center’s causality assessment and Spilker classification. The paper emphasizes monitoring for unintended effects but does not report significant safety concerns during the trial. 

Key Finding #2 

The additional use of NRT was hypothesized to show superior outcomes in secondary measures such as the vas and ndi compared to IKMT (integrative korean medicine treatment) alone. 

Key Finding #3 

NRT combined with IKMT could help prevent the chronic progression of pain by effectively reducing acute neck pain and addressing fear of movement, which can potentially lead to a quicker return to normal life and reduce long-term disability risks. 

Please provide your summary of the paper 

This study was a RCT designed to evaluate the effectiveness and safety of non-resistance manual therapy (NRT) combined with integrative korean medicine treatment (IKMT) for patients with acute neck pain caused by traffic accidents (TAs). Neck pain and functional impairment are common outcomes of TAs, often leading to chronic pain and disability. While manual therapy is widely used, high-quality evidence on its effectiveness and safety remains limited. NRT—a combination of joint mobilization and pressure release techniques—is a form of Chuna manual therapy commonly used in Korean medicine.  In terms of the method, 120 patients hospitalized with TA-induced acute neck pain were randomized equally into two groups, one being the experimental group receiving IKMT + NRT, and one being the control group, only receiving IKMT. The primary outcome measured was the change in numberic rating scale (NRS) for neck pain by hospital day 5 compared to baseline.   The key findings of the paper included that NRT combined with IKMT may enhance pain relief, improve neck function, and prevent chronic progression of TA-related neck pain. Additionally, NRT is reported as a safe intervention with adverse events monitored systematically. Lastly, the findings reported that NRT is an effective addition to conventional treatment, offering benefits for patients.  

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented. 

To me, this paper highlights the potential benefits of NRT as a supplementary treatment for acute neck pain. Although it was based on Korean traditional medicine, the concepts and interventions described in the study may provide valuable insights for my practice here in the U.S. when translated into evidence-based care. NRT’s techniques are similar to widely used interventions such as myofascial release and graded mobilizations, making them easily adaptable to existing clinical practice here as well. This study not only demonstrates some key points like tracking progress with tools like pain and disability scales, but it also encourages us to advocate for timely care and work closely with other health professionals, even from around the world.  

Article Full Title 

The effect of sacroiliac joint manual therapy on heart rate variability in women with primary dysmenorrhea 

Author Names 

Park, S., Song, S., Jung, J., Joo, Y., Yang, Y., Lee, S. 

Reviewer Name 

Madison Zaun, SPT 

Reviewer Affiliation(s) 

Duke University School of Medicine – Doctor of Physical Therapy 

Paper Abstract 

Objective: Disorder of the autonomic nervous system is considered to be the cause of primary dysmenorrhea. The spine has a close relationship with the autonomic nervous system, and the sacrum is mechanically and neurologically connected to the uterus through ligaments. Therefore, this study was conducted to check the effect on the autonomic nervous system through measurement of heart rate variability by applying manual therapy to the sacroiliac joints of subjects with primary dysmenorrhea and to suggest an effective treatment method for dysmenorrhea.  Design: Randomized controlled trial.  Methods: Thirty females with dysmenorrhea were assigned to either the manual therapy group and sham treatment group according to the random treatment method. The manual therapy was applied to the sacroiliac joints, and the sham treatment was only treated with the hands placed in the same position of the intervention. Heart rate variability and the Visual Analogue Scale (VAS) were measured on the day when menstruation began ±2. Interventions were performed between the groups, followed by a 5-minute break and then re-measurements were made.  Results: There were significant differences in autonomic balance and VAS scores in the manual therapy group before and after the intervention between groups (p<0.05). In the sham treatment group, there were significant differences in low frequency, autonomic balance, and VAS scores (p<0.05). There were significant differences in autonomic balance between groups (p<0.05).  Conclusions: In females with primary dysmenorrhea, manual therapy applied to the sacroiliac joint was found to be effective for a short time on autonomic activity 

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 

1. Was the method of randomization adequate (i.e., use of randomly generated assignment)? 

Yes 

1. Was the treatment allocation concealed (so that assignments could not be predicted)? 

Cannot Determine, Not Reported, or Not Applicable 

1. Were study participants and providers blinded to treatment group assignment? 

Yes 

1. Were the people assessing the outcomes blinded to the participants’ group assignments? 

No 

1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 

Yes 

1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? 

Yes 

1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? 

No 

1. Was there high adherence to the intervention protocols for each treatment group? 

Yes 

1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 

Cannot Determine, Not Reported, or Not Applicable 

1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? 

Yes 

1. 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 

1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? 

Cannot Determine, Not Reported, or Not Applicable 

1. 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 

The article sought to determine whether applying manual therapy to the sacroiliac joint in women with primary dysmenorrhea could be an effective treatment method through changes in the autonomic nervous system assessed with heart rate variability analysis. The researchers found that the manual therapy group is more effective in achieving autonomic balance than the sham therapy group.  

Key Finding #2 

The manual therapy treatment group showed a larger decrease in VAS scores than in the Sham treatment group. The difference between the two groups, however, was not significant.  

Please provide your summary of the paper 

The paper sought to determine whether applying manual therapy to the sacroiliac joint in women with primary dysmenorrhea could be an effective treatment method through confirming changes in the autonomic nervous system. The researchers recruited 37 women to participate in study. Selection criteria for the study included BMI between 20 and 30kg/m^2, a menstrual cycle length between 24 and 32 days, and related back pain symptoms above 50mm on the visual analog scale (VAS). Exclusion criteria for the study included, women with secondary dysmenorrhea, women taking contraceptives or NSAIDs, women who received manipulation within the last month, and women whom manual therapy would be contraindicated for. The participants were randomly assigned to one of two treatment groups, the manual therapy treatment group and the sham treatment group. They were not aware of which treatment group they were assigned to. The manual therapy treatment group was to receive a sacroiliac joint HVLA manipulation and the sham treatment group would be in a treatment room with a therapist and would be in the same position as the HVLA, but would not receive a manipulation. All participants underwent heart rate variability measurement before and after the intervention and reported their subjective pain level in their lower back using the VAS. The results showed that there was a significant difference in autonomic balance between the two groups, where the manual therapy group had a post treatment ratio of sympathetic nervous system to the parasympathetic nervous system that was closer to normal. The sham treatment group had a ratio that was further from normal autonomic balance. The researchers also posit from the study that manual therapy is more effective in relieving back pain than sham therapy, however there was so significant difference between the two groups. The manual therapy treatment group, did show a significant decrease in VAS scores. While the paper found statistical significance regarding using manual therapy as a treatment for women with primary dysmenorrhea, the study has several limitations. The age range may have been to large (18-50 years of age) to account for the autonomic nervous system being highly related to age. There were also only 30 participants by the end of the study, which is not enough to generalize. The researchers stand that additional studies should be conducted with more narrow and specific age requirements and with a larger number of subjects.  

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 around the mechanism behind manual therapy is growing every day. This paper seeks to determine whether manual therapy can impact the autonomic nervous system mechanistically, as a treatment method for women with primary dysmenorrhea. Additionally, Physical therapy is increasingly becoming a direct access option and even primary care for patients. With that, it is important to find new ways that physical therapy can help patients, such as women with primary dysmenorrhea. The study is preliminary and will need additional studies to refine and further investigate the effectiveness of manual therapy for women with primary dysmenorrhea. However, it is a step in the right direction towards increasing scope and value of physical therapy. It also is helpful in supporting manual therapy’s effectiveness as a treatment method in physical therapy.  

Author Names

Botelho, M., Alvarenga, B., Molina, N., Ribas, M., Baptista, A.

Reviewer Name

Julia Dawson, SPT

Reviewer Affiliation(s)

Duke University School of Medicine Doctor of Physical Therapy

Paper Abstract

Objective: The purpose of this study was to review the literature regarding the relationship between spinal manipulative therapy (SMT) and sports performance.

Methods: PubMed and Embase databases were searched for original studies published up to July 2016. Inclusion criteria were if SMT has been applied to athletes and if any sports performance–related outcome was measured.

Results: Of the 581 potential studies, 7 clinical trials were selected. Most studies had adequate quality (≥6/11) when assessed by the PEDro scale. None of those studies assessed performance at an event or competition. Four studies revealed improvement in a sports performance test after SMT. Meta-analysis could not be performed because of the wide differences in methodologies, design, and outcomes measured. Spinal manipulative therapy influences a wide range of neurophysiological parameters that could be associated with sports performance. Of the 3 studies where SMT did not improve test performance, 2 used SMT not for therapeutic correction of a dysfunctional vertebral joint but to an arbitrary previously set joint.

Conclusions: Although 4 of 7 studies showed that SMT improved sports performance tests, the evidence is still weak to support its use. Spinal manipulative therapy may be a promising approach for performance enhancement that should be investigated with more consistent methodologic designs.

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?

Not applicable/available

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Not applicable/available

Key Finding #1

Of the 7 included studies in this systematic review, 4 of them found improvements in hip extension, increased full-swing in golfers, increased grip strength, and increased kicking speed in soccer players after spinal manipulative therapy (SMT).

Key Finding #2

All selected studies evaluated individual performance of specific tests (running velocity, jump height, strength, grip strength, etc.) but sports performance itself, at an event, was not assessed by any of the studies.

Key Finding #3

CNS modulation through sensorimotor integration, combined with cortical motor neuron and spinal reflex excitability changes after SMT, should be the central mechanism associated with the increased full-swing in golfers, increased kicking speed in soccer players, and the increased hip extension in runners.

Please provide your summary of the paper

Spinal manipulative therapy (SMT) has been increasingly utilized in sports and has been shown to have a beneficial effect for biomechanical joint dysfunction. There has been some disagreement and controversy on SMT’s effectiveness in past years regarding sports performance. Several neurophysiological effects have been described, but a clear physiological mechanism is still not clear. CNS modulation seems to have a big effect on muscle strength, muscle inhibition, and muscle fatigue, which can all contribute to aspects of sports performance. As sports performance can be influenced by physiological, psychological, and sociocultural factors, finding a way to objectively measure performance (e.g. time in swimming or track and field events) can accurately demonstrate if an athlete’s performance is better or worse at that moment. This study measured specific components of sports performance (speed, strength, kicking speed, etc.) but not the performance of an athlete as a whole. Furthermore, there is still limited evidence to support SMT’s ability to enhance sports performance.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

As most of the included studies (4 of 7) showed that SMT led to improved sports performance test results, the evidence from this systematic review is relatively weak to support its use with this claim. Through this systematic review, the studies could have improved on measuring outcomes before and after each intervention. This would not only address the duration of the SMT effects but also show whether there is any cumulative effect from repeated SMT interventions. When measuring sports performance, the best way to assess this is during a real sports event. Isolating physical aspects such as strength does not fully account for enhancement of sports performance. Furthermore, one of the main limitations of this study was the difficulty to obtain an appropriate sample size, especially when dealing with high performance athletes. The small sample size makes it hard to generalize results to other populations.

Author Names

Lotan. S and Kalichman. L

Reviewer Name

Kaila Claiborne

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Abstract

Background

Adolescent idiopathic scoliosis (AIS) is a common orthopedic condition with a prevalence of 2%–3% in children aged 10–16 years. Conservative interventions remain controversial and are usually based on physical therapy exercises and treatments. Manual therapy techniques may also serve as adequate treatments for AIS due to their ability to improve range of motion and decrease muscle tone and pain.

Objective

To critically assess the current literature on the effectiveness of manual therapy methods used to treat AIS.

Methods

PubMed, PEDro, BioMed Central, and Google Scholar databases were searched from inception until December 2016 using keywords associated with scoliosis and manual therapy. Criteria for inclusion were studies investigating the effect of manual therapy methods on AIS treatment. We analyzed all published material with an emphasis on randomized controlled trials (RCT). Trials of any methodological quality written in English were included in the review. Major findings Fourteen papers were reviewed, all presenting manual therapy treatments such as manipulation, mobilization, and soft tissue techniques used to treat AIS. All case studies showed a significant improvement, post-treatment, in most measured parameters. Observational studies showed mixed results. Only one RCT concluded manual therapy techniques were ineffective in improving trunk morphology and spine flexibility in AIS patients.

Conclusion

Case reports and small-scale clinical trials of poor methodological quality presented in this review did not allow us to draw a clear conclusion about the effectiveness of manual therapy in the treatment of AIS. On the other hand, they provide us a basis to assume that manual therapy techniques such as myofascial release and spinal manipulative techniques may potentially be effective in treating AIS in conjunction with other conservative treatments. Further high-quality studies are essential to determine the effectiveness of the different manual therapy techniques.

Quality Assessment of Systematic Reviews and Meta-Analyses

1. Is the review based on a focused question that is adequately formulated and described?

no

2. Were eligibility criteria for included and excluded studies predefined and specified?

no

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?

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?

no

6. Were the included studies listed along with important characteristics and results of each study?

no

7. Was publication bias assessed?

no

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

No

Key Finding #1

The first key finding in the article is while manual therapy techniques such as spinal manipulation and myofascial release showed positive results in case studies and small clinical trials, the evidence remains inconclusive due to the low quality of these studies. Improvements were noted in outcomes like Cobb angle

reduction, range of motion (ROM) enhancement, and pain relief, but these studies lacked the rigorous design required for firm conclusions.

Key Finding #2

Second, the review concluded that manual therapy should not be seen as a standalone treatment for AIS. While it may provide symptomatic relief, such as decreasing back pain and increasing spinal flexibility, it appears to work best when combined with other conservative treatments like bracing or exercise

Key Finding #3

The article emphasized the critical need for high-quality, randomized controlled trials (RCTs) to better assess the efficacy of manual therapy techniques. Existing studies, including the only RCT reviewed, did not provide enough evidence to confirm that manual therapy significantly improves spinal morphology or curvature in the long term, pointing to a gap in the research that must be addressed to determine its true effectiveness in AIS management.

Please provide your summary of the paper

This review evaluates the current literature on the effectiveness of manual therapy techniques, such as spinal manipulation, myofascial release, and soft tissue mobilization, for treating adolescent idiopathic scoliosis (AIS). The findings from case reports and small-scale clinical trials suggested that manual therapy may offer benefits, including improvements in pain relief, range of motion, and potential reductions in the Cobb angle of spinal curvature. However, these studies were generally of low methodological quality, with small sample sizes and limited control groups, making it difficult to draw definitive conclusions. The only randomized controlled trial (RCT) reviewed found that osteopathic manual intervention did not significantly improve trunk morphology or spine flexibility, further emphasizing the need for more rigorous research. The review concluded that while manual therapy might be effective for symptom management in AIS, it should not be relied upon as a standalone treatment. It is most likely to be beneficial when combined with other conservative interventions like physical therapy and bracing. The article stressed the importance of conducting high-quality, well-designed studies, particularly RCTs, to evaluate the long-term effects and overall effectiveness of manual therapy in AIS treatment. The current body of evidence remains insufficient to make strong recommendations, and further research is necessary to establish whether manual therapy can play a significant role in the management of this common orthopedic condition.

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 may have important implications for clinical practice in physical therapy in the management of adolescent idiopathic scoliosis (AIS). Although the evidence supporting manual therapy for AIS is not conclusive, the study suggests that techniques such as spinal manipulation, myofascial release, and soft tissue mobilization can provide symptom relief, such as reducing back pain, increasing range of motion (ROM), and potentially aiding in the management of spinal curvature. This could encourage physical therapists to consider manual therapy as a supplementary intervention when treating AIS patients, particularly when other conservative treatments like exercise and bracing are not sufficient to fully address symptoms. Clinicians may begin integrating manual therapy into a broader, multimodal treatment plan, combining it with therapeutic exercises, postural correction, and bracing to optimize outcomes. To implement the findings of this review in clinical practice, physical therapists should proceed with caution, given the lack of high-quality evidence supporting manual therapy as a primary intervention for AIS. However, clinicians can experiment with manual therapy techniques as part of a comprehensive treatment program tailored to each patient’s specific needs, with the understanding that it may provide temporary symptom relief (e.g., pain reduction, improved spinal flexibility) rather than long-term correction of spinal curvature. In practice, therapists should ensure that manual therapy is complementary to other well-established treatments, such as exercise-based physical therapy and bracing. Additionally, physical therapists should stay updated with emerging research and be open to adopting more evidence-based approaches as future studies provide more rigorous data on the efficacy of manual therapy in AIS management.

Author Names 

Erhard. R, Delltto, A., Clbulka M.  

Reviewer Name 

Albert Yang, SPT 

Reviewer Affiliation(s) 

Duke DPT CO 2026 

Paper Abstract  

Background and purpose: The relative effectiveness of an extension program and a manipulation program with flexion and extension exercises was examined in patients with low back syndrome.  Subjects: Forty-nine patients with less than a 3-month history of low back pain were seen at physical therapy clinics in western Pennsylvania, southern Mississippi, and eastern Missouri during a 6-month period. Twenty-seven of the 49 patients were classified a priori into a treatment-oriented category of extension/mobilization and were then randomly assigned to participate in an extension program or a program of manipulation followed by hand-heel rocks (flexion and extension). Two patients dropped out of the study (1 patient returned to work, and the other patient was unable to comply with the treatment schedule), and 1 patient was eliminated from the study because of magnified illness behavior. The remaining 24 patients (15 male, 9 female; mean age = 44 years, SD = 15, range = 14-73) were assigned randomly and equally to the two groups. Eight physical therapists participated in the study.  Methods: A randomized clinical trial comparing the two regimens was conducted for a 1-week period. Outcome was assessed using an Oswestry Low Back Pain Questionnaire initially (before treatment) and at 3 and 5 days posttreatment, and data were analyzed using a 2 x 3 (group x time) analysis of variance.  Results: A significant interaction of the group and time variables was demonstrated, indicating that the rate of positive response was greater in the manipulation/hand-heel rock group than in the extension group.  Conclusion and discussion: In this category of patients with low back pain, the use of manipulation as an adjunct to an ongoing exercise program appears to be warranted. 

Quality Assessment of Controlled Intervention Studies  

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT 

Y 

1. Was the method of randomization adequate (i.e., use of randomly generated assignment)? 

Y 

1. Was the treatment allocation concealed (so that assignments could not be predicted)? 

N/A 

1. Were study participants and providers blinded to treatment group assignment? 

N 

1. Were the people assessing the outcomes blinded to the participants’ group assignments? 

N/A 

1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)? 

Y 

1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment? 

Y 

1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower? 

Y 

1. Was there high adherence to the intervention protocols for each treatment group? 

Y 

1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)? 

Y 

1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants? 

Y 

1. 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? 

N/A 

1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)? 

N/A 

1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis? 

N/A 

Key Finding #1 

The paper’s findings revealed that the group receiving spinal manipulation combined with a flexion/extension exercise program demonstrated a faster improvement in symptmos compared to the group receiving an extension-oriented program alone  

Key Finding #2 

The paper suggests that following spinal manual therapy procedures, movement itself, irrespective of flexion/extension, may be important in progressing the patient through the acute phase as fast as possible.  

Key Finding #3 

The paper also proposed that a subgroup of patients with referred pain may benefit from an extension – based program.   

Please provide your summary of the paper 

This study investigated the effectiveness of two treatment approaches for patients with acute low back syndrome (LBS). First, an extension-oriented exercise program and second, a combination of manipulation with flexion and extension exercises (referred to as the manipulation/hand-heel rock group). A total of 49 participants with LBS lasting less than three months were screened, and 27 were classified me the study’s predefined criteria. These participants were then randomly assigned to one of the two treatment groups, with outcomes assessed over approximately one week. The primary outcome measure was the Oswestry Low Back Pain Questionnaire (ODI), used to evaluate functional disability related to low back pain.  The study found that participants in the manipulation/hand-heel rock group demonstrated much greater improvements in symptoms compared to those in the extension-only group. By the end of the treatment period, 75% of participants in the manipulation group met the discharge criteria, (Oswestry score below 11), compared to only 17% in the extension group. These findings suggest that manipulation combined with exercises may speed up recovery in selected patients with acute LBS. The authors concluded that manipulation could be a valuable supplement to exercise in the early phases of treatment, promoting faster pain relief and and functional improvement. However, limitations such as the small sample size and lack of blinding were stated, so results should be interpreted with more data.  

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented. 

To me, this study highlighted the potential benefit of combining spinal manipulation with a structured exercise program for patients with acute low back syndrome (LBS). The findings suggest that manipulation may provide faster short-term symptom relief compared to extension-oriented exercises alone, allowing patients to engage more effectively in rehabilitation and self-management.  Even though this study provides promising evidence, it did have limitations such as the small sample size, lack of blinding, and short follow-up. Therefore, in my own practice, I will utilize this paper in conjunction with future research that hopefully includes larger, more diverse samples and longer-term outcomes, to assist my patients. That being said, this study supports a multi-faceted approach to managing acute LBS, blending passive and active interventions for optimal patient outcomes. 

Author Names

Wenxia, Z., et al.

Reviewer Name

Rachel Scott

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Program

Paper Abstract

Background

Adolescent idiopathic scoliosis (AIS) is a pathological condition characterized by vertebral curvature and associated trunk deformities in adolescents. The clinical efficacy of conservative treatment in alleviating spinal curvature of AIS remains a topic of ongoing debate. The objective of this study was to investigate the impact of combined physiotherapeutic scoliosis-specific exercises (PSSE) and manual therapy (MT) on trunk deformity, spinal function, mobility, and mental health in patients with AIS.

Methods

Thirty-one participants who were diagnosed with AIS whose Cobb angle was between 10–45°were enrolled in the study. Participants in the intervention group received 50 min of PSSE combined with 10 min of MT, while the control group performed 50 min of PSSE as their home exercise program. Both treatments were implemented three times a week for four weeks. Cobb angle, spinal mobility, trunk morphology (vertebral rotation angle, apical deviation, pelvic obliquity distance and angle), movement capability, and quality of life (QOL) were assessed at baseline and post intervention. The treatment effects between the intervention and control groups were analyzed using a two-way repeated measures ANOVA.

Results

Following a 4-week treatment period, Cobb angle was significantly reduced from 21.58° to 18.58° in intervention group and increased from 18.00° at baseline and 19.14° post intervention in the control group. Significant improvements were also observed in spinal mobility, movement capability, quality of life, and some of the trunk morphology indices in the intervention group compared to baseline (p < 0.05). Improvements were significantly higher in the intervention group than the control group.

Conclusion

Combining PSSE and MT shows potential benefits in alleviating AIS symptoms and improving QOL. Further studies to substantiate these findings are warranted. Trial registration The trial was retrospectively registered in the Chinese Clinical Trial Registry (https://www.chictr.org.cn) with the registration number: ChiCTR2300071357, (Date: 12/05/2023).

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

no

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Not Reported or Cannot Determine

Was the treatment allocation concealed (so that assignments could not be predicted)?

No

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?

Not reported or Cannot determine

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Not reported or cannot determine

Was there high adherence to the intervention protocols for each treatment group?

Not reported or cannot determine

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

No

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

Cobb angle was significantly decreased in the intervention group. Although statistically significant, the results did not reach MCID threshold.

Key Finding #2

Spinal mobility was improved in the intervention group but not the control group.

Key Finding #3

Quality of life was improved in the intervention group.

Please provide your summary of the paper

This is a non-randomized controlled trial which aims to compare high-velocity, low amplitude spinal thrust manipulation (MT) to health education and home-based physiotherapeutic scoliosis-specific exercises (PSSE). Participants included 31 people with Adolescent Idiopathic Scoliosis age 10-18 years old and a Cobb angle of 10-45 degrees in thoracic or lumbar spine. Outcome measured included Cobb angle, spinal mobility/ROM using handheld inclinometer, trunk shape assessed with surface topography, and quality of life using Scoliosis Research Society-22 (SRS-22) questionnaire. Results of the study showed improved Cobb angle, improved spinal ROM, and improved QOL for the MT group compared to the control group. The authors recognize the limitations of the small sample size, non-randomized nature of group selection, and shorter-term intervention period (4 weeks). Larger clinical trials are recommended to further study the findings and improve generalizability of results.

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 is of a small sample size and participants were not randomized into intervention vs. treatment groups. Because of this, the results should be interpreted with caution. There were promising results for improving Cobb angle, spinal range of motion, and quality of life with the manual therapy group compared to the home exercise group. Since the participants and their parents were allowed to choose if they wanted the intervention or home exercise alone, their preconceived notions about MT may have influenced response to treatment. Nevertheless, HVLA spinal manipulations may be effective for improving QOL, ROM, and Cobb angle in patients with Adolescent Idiopathic Scoliosis. Further research is needed to improve support for this treatment.

Author Names

Aljarallah, S., Alrobian, S., Alsaleem, R., and Attaminimi, M.

Reviewer Name

Megan Ringo, Student Physical Therapist

Reviewer Affiliation(s)

Duke DPT, Class of 2026

Paper Abstract

Background: Chronic lower back pain (CLBP) is a prevalent condition often managed with manual therapy techniques. This study aimed to compare the effectiveness of spinal manipulation, mobilization, and massage therapy on pain relief and functional improvement in CLBP patients. Methods: A randomized controlled trial was conducted with 135 participants allocated into three groups: spinal manipulation (n=45), mobilization (n=45), and massage therapy (n=45). Pain and function were assessed using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI), respectively, at baseline, immediately post-treatment, and at 3-month follow-up. Quality of life and patient satisfaction were also evaluated. Results: All interventions significantly reduced pain and improved function (p < 0.001). Spinal manipulation provided greater pain relief immediately post-treatment and at 3-month follow-up compared to mobilization and massage therapy (p = 0.03 and p = 0.02, respectively). Mobilization resulted in the greatest functional improvement (p = 0.04 and p = 0.03, respectively). Quality of life improvements and patient satisfaction were similar across groups. Conclusion: Spinal manipulation, mobilization, and massage therapy are all effective in managing CLBP, with spinal manipulation offering superior pain relief and mobilization yielding the most significant functional gains. These findings support the tailored use of manual therapy techniques based on individual patient needs and clinical goals.

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)?

Cannot Determine, Not Reported, or Not Applicable

4. Were study participants and providers blinded to treatment group assignment?

No

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?

Yes

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)?

Cannot Determine, Not Reported, or Not Applicable

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

All manual therapy techniques examined in this paper (spinal manipulation, mobilization, and massage therapy) were effective in managing chronic low back pain.

Key Finding #2

Spinal manipulation offered the most significant pain relief out of the three possible interventions provided.

Key Finding #3

Mobilization yielded the most significant functional gains out of the three possible interventions provided.

Please provide your summary of the paper

This study’s main aim centered around comparing different manual therapy techniques on the overall management of chronic low back pain, through a randomized control trial, to optimize future treatment approaches and help establish guidelines for care. While overall this study established that all three of the interventions examined (spinal manipulation, mobilization, and massage therapy) were effective in pain relief and overall functional improvement, different techniques had higher effectiveness in certain categories over others. This study utilized a total of 135 participants aged 18-65 years old, who were diagnosed with chronic low back pain that persisted for more than 12 weeks. These participants were then divided into three groups, with each group receiving one intervention: spinal manipulation, mobilization, or massage therapy, all of which were provided by physical therapists with at least 5 years of experience. Interventions were provided for 30-minute sessions, two times a week for 6 weeks. Primary outcomes included pain relief using the VAS to measure outcomes, and functional improvement using the ODI. Secondary outcomes included quality of life measures using the Short Form-36 Health Survey and overall patient satisfaction using a Likert scale ranging from 1(very dissatisfied)  – to 5 (very satisfied). Findings demonstrate that the spinal manipulation group exhibited significantly larger pain relief compared to the other two interventions both immediately post-treatment and at a 3-month follow-up, whereas mobilization exhibited significantly larger improvements in functional improvement compared to the other two interventions both immediately post-treatment and at a 3-month follow-up. All groups demonstrated improvement in quality of life and patient satisfaction, with no significant difference between all three intervention groups.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

As a whole, all three manual therapy interventions are great options when it comes to the management of adult chronic low back pain. However, certain techniques provide better outcomes in their respective domains, so carefully selecting a technique to elicit specific improvements will be the most effective and efficient way to achieve patient goals. Paying attention to what will be most impactful for each patient you treat will optimize patient outcomes. 

Author Names

Nim, C., Aspinall, S., Cook, C., Correa, L., Donaldson, M., Downie, A., Harsted, S., Hansen, S., Jenkins, H., McNaughton, D., Nyiro, L., Perle, S., Roseen, E., Young, J., Young, A., Zhao, G., Hartvigsen, J., Juhl, C.

Reviewer Name

Chloee Richey

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 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 Finding #1

The average treatment effect of SMT for reducing pain and disability in patients with spinal pain appears independent of where SMT was targeted, how the thrust was performed, and in what region it was delivered.

Key Finding #2

This comparison of SMT across target, thrust, and region procedures suggests that different SMT approaches led to similar average effects on pain and disability.

Key Finding #3

The authors advise caution when interpreting the results due to the low confidence resulting from within-study heterogeneity, risk of bias, and a lack of studies comparing different SMT application procedures, as all outcomes were assessed based on average treatment effects.

Please provide your summary of the paper

This study was performed to assess if different spinal manipulative therapies (SMT), such as target, thrust, and region, could change pain and disability in adults with spinal pain. This systematic review with network meta-analysis encompassed 11,849 participants, who on average had either cervical or low back pain exceeding 12 weeks. A generic target had the highest probability of providing the largest effects and was also statistically better than a clinician-selected target based on palpation or exam. None of the SMT thrust procedure estimates differed statistically, except for a generalized thrust compared to an unclear thrust, as a generalized thrust was found to provide the largest effect. Applying SMT at the symptomatic region had the highest probability of providing the largest effects with less than 0.07 difference in probability to the non-symptomatic region. The discussion talks about how the overall best effects were found the more generalized the 3 SMT techniques were performed. The confidence rating was evaluated as low (30%) or very low (70%) for all networks, due to high within-study heterogeneity, high RoB, and lack of direct comparisons. The paper recommends that institutions refrain from teaching manual techniques to be “perfect” or “correct” and rather based on patient comfort and results. The authors encouraged more research to be done on the topic, as the confidence level was very low. Overall, the findings suggest that SMT techniques should be based on patient preferences and comfort, and not a specific target, thrust, or region, as these showed similar average effects on pain and disability in adults with spinal pain.

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 discussed that since many patient’s LBP cannot be targeted to a specific region, it makes sense that the more generalized thrusts could be more clinically effective. This paper believes that it is unnecessary to find the “perfect” place to provide a thrust, but rather focus on the patient’s pain and symptoms. I think this is extremely relevant to clinical practice, as it is nice to know that now every manual technique needs to be perfectly executed for a patient to get results or find relief. This can help provide more patient-centered care, as the SMT techniques can be altered to make the patient more comfortable or alternate techniques can be used to help get the same outcome.

Author Names: Akhtar Rasul

Reviewer Name: Ranffy Perez

Reviewer Affiliation(s): Duke Doctor of Physical Therapy Division

Paper Abstract

Low back pain, being the highly prevalent and cost consuming condition, though occasionally proving to be a serious pathology, is a main cause of pain and disability along with high socioeconomic cost. Therefore, we aimed to conduct a comparative study on the efficacy of Manual Therapy and Electrotherapy in patients presenting with chronic low back pain. The background of the study was that persistence or having multiple acute onsets or recurrences are the hallmark feature of chronic pain. Effective management of low back pain still remains point of conflict even though it is quite common disorder. Superiority of one form of the therapeutic modalities over the other is yet to be established. Forty patients who presented with chronic low back pain made voluntary participation for this research (21 males and 19 females) with an average age of 40±5.3 years and average weight of 72.6±14.5 kg. Manual therapy and Electrotherapy grouping was randomly assigned to the patients and data which included determination of functional performance by using Oswestry low back pain disability questionnaire? It was done at baseline, after 2nd week and after 4th week. Statistical analysis was done by using SPSS; repeated measure analysis of variance was used to detect significant differences. (α=0.01). The results showed that Manual therapy was found more effective than electrotherapy (p< 0.01). So the Manual Therapy proved to be superior in efficacy over electrotherapy in patients presenting with chronic low back pain.

Key Finding #1

The main finding was that manual therapy is the better treatment approach in management of chronic low back pain when compared to Electrotherapy

Key Finding #2

The second main finding was that manual therapy is more efficient than Electrotherapy in helping improve pain intensity, activities of daily living (ADL’S) such as sitting, lifting, standing walking, personal care, sleeping, sexual life, social life, and traveling.

Please provide your summary of the paper

The main objective of this paper was to compare and contrast the effect of Manual Therapy and Electrotherapy on the functional ability of patients with chronic lumbar pain. The study recruited 40 patients, 21 males, and 19 females, of similar age 40±5.3 years and weight 72.6±14.5 Kgs who fit the inclusion and exclusion criteria. The 40 participants were then randomly assigned into two groups: group A (Manual therapy) and group B (Electrotherapy). The data of the groups was collected through the outcome measure Oswestry Low Back Disability Index (ODI) questionnaire. The questionnaire was completed at baseline, the 2nd-week post-intervention, and the 4th-week post-intervention. The statistical significance of the results was obtained by using the Analysis of variance (ANOVA) test with repeated measures. The baseline scores of the questionnaire for group A was 39.55 and for group B 37.7 helping to confirm that both treatment groups had similar ratings (p>0.01) in symptoms and disability at the start of the experiment. After the 2nd week of interventions, the score for group A dropped to 20.1 and for group B to 31.45. This difference was explained to be significant (p<0.01) by the authors, highlighting that Manual therapy was more efficient. Lastly, on the 4th week of treatment, the scores of the ODI questionnaire for group A was 10.2 and for group B 17.2. Here the authors again explained that the rating for manual therapy was significantly (p<0.01) lower than the patients receiving manual therapy. This accumulation of data led the authors to conclude that manual therapy was the superior approach when compared to Electrotherapy, as it was more efficient in decreasing the level of disability in patients.

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 is beneficial in showing a possible relationship between hip manipulation and muscle activity with the gluteus medius during hip abduction. Results were varied based on individual participants and showed inconsistencies with TFL activation and both GM and TFL strength. The study was helpful in determining possible benefits of hip joint manipulation in terms of hip abduction strength and activation. Further studies should be done to minimize variations in participants or to identify how those variations affect hip manipulation outcomes.

Author Names

Studnicki, R., Szymczyk, P., Adamczewski, T., Studzińska, K., Hansdorfer-Korzon, R., Silva, A. F., & Kawczyński, A.

Reviewer Name

Evonne Iau, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Division

Paper Abstract

Background Manual traction, a therapeutic technique frequently employed in healthcare, involves applying controlled pulling force by hand, usually to the spine, to stretch muscles and decompress joints, thereby alleviating pain. This method can be particularly beneficial for addressing lumbosacral spine pain exacerbated by radicular symptoms, characterized by pain radiating from the lower back due to compression or irritation of spinal nerves. Purpose This study aimed to compare the effects of manual traction against control group in alleviating the lumbosacral spine pain caused by radicular symptoms. Methods A randomized controlled study design was utilized with a sample of 60 patients experiencing lumbosacral spine pain, evenly distributed between an experimental group (n = 30; receiving manual traction) and a control group (n = 30). Patients underwent assessments before and after six treatment sessions, which included the Straight Leg Raise test, modified Bragard’s test, Kernig’s test, and the visual analogue scale for pain perception. Results Between-group significant differences were found at post-intervention, favoring the experimental group on SLR – Left (°) (p = 0.004; medium effect size), SLR – Right (°) (p = 0.004; medium effect size), Modified Bragard test – Left (°) (p = 0.024; small effect size), Modified Bragard test – Right (°) (p = 0.003; medium effect size), Kernig’s Test – Left (°) (p = 0.013; medium effect size) and Kernig’s Test – Right (°) (p = 0.010; medium effect size). Additionally, between-group significant differences were found at post-intervention, favoring the experimental group on VAS scores at SLR left (p < 0.001; medium effect size), and right (p < 0.001); medium effect size, Modified Bragard test left (p < 0.001; medium effect size) and right (p < 0.001; medium effect size) and at Kernig’s Test left (p < 0.001; medium effect size) and right (p < 0.001; medium effect size). Conclusions In conclusion, manual traction is recommended as an effective approach for alleviating lumbosacral spine pain in patients experiencing symptoms resulting from irritation or compression of a spinal nerve root.

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? 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? 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)? Not reported

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 traction is significantly effective and superior in alleviating lumbosacral spine pain in patients with radicular symptoms.

Key Finding #2

The manual traction group and control group both experienced a significant reduction in pain intensity, but the magnitude of the reduction was significantly smaller in the control group.

Key Finding #3

Manual traction improved goniometry angles in SLR, modified Bragard test, and Kernig’s test.

Key Finding #4

The control group did not exhibit significant improvements in goniometry angles.

Please provide your summary of the paper

This study looked at the effectiveness of manual traction against a control group on alleviating lumbosacral spine pain caused by radicular symptoms. A total of n=60 participants were randomly assigned into either group and underwent 6 treatment sessions over a 2-week therapy program. Each group received diadynamic currents, light therapy, and magnetotherapy. The experimental group received 6 additional manual traction sessions. Assessments were measured with VAS and via goniometry for SLR, Modified Bragard’s Test, and Kernig’s Test. The findings suggest that manual therapy is significantly effective in reducing pain intensity and improving angles in SLR, Modified Bragard’s Test, and Kernig’s Test for patients experiencing lumbosacral pain due to radicular symptoms.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The direct clinical impacts of this paper include the potential benefits of implementing manual traction as an intervention in clinical practice. Clinicians who have a patient with lumbosacral pain as a result of radiculopathy could consider trying manual traction as a way to reduce pain intensity. The long-term effects of manual traction or comparing manual traction with mechanical therapy was not measured in this study, but the short-term pain alleviation and functional improvements are worth noting that this intervention can be a safe and effective option for this patient population.

Author Names: José, M; Inmaculada, C; José Antonia, G

Reviewer Name: Mason Kosik

Reviewer Affiliation(s): Duke DPT CO 2026

Paper Abstract:

Objective: To compare the different physiotherapy treatments and determine the most effective treatment to reduce the nonspecific low back pain (NSLBP) intensity in children and adolescents.

Data Sources: Eight databases (Cochrane Library, MEDLINE, PEDro, Web of Science, LILACS, IBECS, PsycINFO, and SCOPUS), and 2 health-specialized journals (BMJ and Spine) were searched from inception to May 2023, with no language restriction.

Study Selection: Individuals aged 6-18 years with NSLBP were selected, and physical therapy treatments were considered. Studies were required to be controlled clinical trials with pretest and posttest evaluations, and to report pain intensity.

Data Extraction: Data extraction and risk of bias assessment were performed independently by 2 reviewers.

Data Synthesis: A meta-analysis of 11 controlled trials with 827 participants found that physiotherapy treatments effectively reduced NSLBP intensity on posttest measurement (d+=0.75; 95% confidence interval [CI], 0.30-1.20) and 6-month follow-up (d+=0.35; 95% CI, −0.72 to 1.40). Network meta-analysis showed both therapeutic exercise (d+=1.11; 95% CI, 0.48-1.74) and a combination of therapeutic exercise and manual therapy (d+=1.45; 95% CI, 0.40-2.49) were effective compared to no treatment. There were no significant differences between therapeutic exercise and the combination of therapeutic exercise and manual therapy.

Conclusions: Physical exercise has proven to be the most effective treatment for addressing the intensity of NSLBP in children and adolescents. While combining it with manual therapy may yield even better results, it is crucial to emphasize that physical exercise should serve as the cornerstone in the physiotherapeutic approach to managing NSLBP intensity in this age group.

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 therapeutic exercise (d+=1.11 [95% CI, 0.48 to 1.74]) and therapeutic exercise + manual therapy treatment groups (d+=1.45 [95% CI, 0.40 to 2.49]) had statistically significant improvements in pain intensity when compared to no treatment.

Key Finding #2

Therapeutic exercise + manual therapy was found to have a slightly favorable effect size compared to therapeutic exercise. However, this difference was not statistically significant (d+=0.33 [95% CI, -1.78 to 1.11]).

Please provide your summary of the paper

The results of this study show that therapeutic exercise is likely an effective treatment for reducing pain intensity in children with non-specific low back pain (NSLBP). The results also suggest that manual therapy performed in addition to therapeutic exercise could have an added benefit, however the difference was minimal. The stated goal of this study was to determine the most effective treatment to reduce NSLBP pain intensity in children and adolescents, and it gave good evidence in support of therapeutic exercise, however the study is limited in its ability to be generalized to all children and adolescents with NSLBP. Of the 11 studies included in the meta-analysis, only two of them addressed participants with high physical activity (which the study defined as >3 hours per week), and both studies consisted of female rowers. Further studies are needed to investigate treatment for highly active children and adolescents with NSLBP, as therapeutic exercise may not be as effective if they are already routinely exercising. Another limitation of this study is that there was high variety in the treatment duration across the 11 studies, meaning it is unclear how long treatment must be performed to be effective. Overall, this study provides a good start towards determining how to properly treat children and adolescents with NSLBP, and it shows that manual therapy could potentially be beneficial for this 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 shows clinicians that as of now, therapeutic exercise is the most supported treatment for children and adolescents with NSLBP. Therefore, children and adolescents who present to physical therapy with NSLBP should be primarily treated with therapeutic exercise, which should be prescribed and dosed according to the patients’ needs and goals. If the clinician believes that manual therapy techniques may be effective, this paper suggests that it may have some added benefit, however it likely is not an essential aspect of treatment for children and adolescents with NSLBP.