Manual Therapy Hall of Fame Papers

Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 2000 Feb 1;132(3):173-81.

The study was an RCT that involved 83 patients with osteoarthritis of the knee who were randomly assigned to receive treatment or placebo. Clinically and statistically significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks were seen in the manual therapy group but not the placebo group. The authors report that a combination of manual physical therapy and supervised exercise yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.

Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976). 2002 Dec 15;27(24):2835-43.

This paper was the first to usher in the concept of clinical predication rules in manual therapy. Its goal was to create a clinical prediction rule for classifying patients with low back pain who are likely to respond to a manipulation. They derived a clinical prediction rule with five variables (symptom duration, fear-avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee); four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%. Although the design is too simple to stand alone, it was the basis of the Childs et al. (2004) paper, which validated the tool against exercise.

UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ. 2004 Dec 11;329(7479):1381.

In this very large study involving 1287 (96%) of 1334 trial participants, the authors find that spinal manipulation is a cost effective addition to “best care” for back pain in general practice. They also indicate that manipulation alone probably gives better value for money than manipulation followed by exercise. There were several studies that were spun from this data and this study showed that a large scale project could be performed with good quality.

Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004 Dec 21;141(12):920-8.

This study involved 131 consecutive patients with low back pain, 18 to 60 years of age, who were referred to physical therapy. The study was an RCT that was used to validate the Flynn CPR. The authors reported that a patient who was positive on the rule and received manipulation has a 92% chance of a successful outcome, with an associated number needed to treat for benefit at 4 weeks of 1.9 (CI, 1.4 to 3.5). The paper was published in Annals, which has an impact factor of 51.6 (2021).

Pettman E. A history of manipulative therapy. J Man Manip Ther. 2007;15(3):165-74. 

In this eloquently written paper, Erl Pettman provides a detailed history of manipulative therapy. He reports that the first documented events of manipulation use were from 400 BCE and that practitioners are present worldwide across multiple professions. It is likely the most detailed history of manipulative therapy present outside of book format.

Puentedura EJ, March J, Anders J, Perez A, Landers MR, Wallmann HW, Cleland JA. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther. 2012 May;20(2):66-74.

In this very clever study, which won the 2013 John Medeiros award, the authors analyzed all available documented case reports in the literature describing patients who had experienced severe adverse events (AEs) after receiving cervical manipulation. They endeavored to determine if the cervical manipulation was used appropriately, and if these types of AEs could have been prevented using sound clinical reasoning on the part of the clinician. Their review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44.8% of AEs associated with cervical manipulation. Additionally, 10.4% of the events were unpreventable, suggesting some inherent risk associated with cervical manipulation even after a thorough exam and proper clinical reasoning.

Abbott JH, Robertson MC, Chapple C, Pinto D, Wright AA, Leon de la Barra S, Baxter GD, Theis JC, Campbell AJ; MOA Trial team. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness. Osteoarthritis Cartilage. 2013 Apr;21(4):525-34. 

The study included 206 adults (mean age 66 years) who met the American College of Rheumatology criteria for hip or knee OA.  In this extremely well done, high fidelity, large, well-funded study, the authors found that manual physiotherapy provided benefits over usual care that were sustained to 1 year. Exercise physiotherapy also provided physical performance benefits over usual care. There was no added benefit from a combination of the two therapies. Subsequent work found that manual therapy was cost-effective as well.

Cook C, Learman K, Showalter C, Kabbaz V, O’Halloran B. Early use of thrust manipulation versus non-thrust manipulation: a randomized clinical trial. Man Ther. 2013 Jun;18(3):191-8.

In this pragmatic, randomized controlled trial the authors found no difference between early use of mobilization versus manipulation. This refuted a prevailing theory at the time that manipulation was more effective than mobilization. Perhaps most importantly, the authors found a strong relationship between the personal equipoise of the clinicians applying the treatment to the outcomes of the patient. This suggest that the clinicians’ beliefs can be imparted on the patient.

Bishop MD, Mintken P, Bialosky JE, Cleland JA. Patient Expectations of Benefit from Interventions for Neck Pain and Resulting Influence on Outcomes. JOSPT. 2013;43(7):457-65. doi:10.2519/jospt.2013.4492.

In this forward thinking secondary analysis of data from a clinical trial of interventions for neck pain, the authors showed that believing that manipulation would help and not receiving manipulation lowered the odds of success (OR = 0.16; 95% CI: 0.04, 0.72) compared to believing manipulation would help and receiving manipulation. The authors conclude their findings with the report that general expectations of benefit have a strong influence on clinical outcomes for patients with neck pain.

Tsertsvadze A, Clar C, Court R, Clarke A, Mistry H, Sutcliffe P. Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: a systematic review and narrative synthesis of evidence from randomized controlled trials. J Manipulative Physiol Ther. 2014 Jul-Aug;37(6):343-62.

In this systematic review, 11 trial-based economic evaluations compared cost-effectiveness and/or cost-utility of manual therapy interventions to other treatment alternatives in reducing pain (spinal, shoulder, ankle). Findings found that manual therapy techniques (e.g., osteopathic spinal manipulation, physiotherapy manipulation and mobilization techniques, and chiropractic manipulation with or without other treatments) were more cost-effective than usual general practitioner (GP) care alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability.

Gross A, Langevin P, Burnie SJ, Bedard-Brochu MS, Empey B, Dugas E, Faber-Dobrescu M, Andres C, Graham N, Goldsmith CH, Bronfort G, Hoving JL, LeBlanc F. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. The Cochrane database of systematic reviews. 2015(9):CD004249. doi:10.1002/14651858.CD004249.pub4.

In this highly rigorous, carefully designed systematic review that included 51 trials (2920 participants, 18 trials of manipulation/mobilization versus control; 34 trials of manipulation/mobilization versus another treatment, 1 trial had two comparisons) the authors report that manipulation and mobilization present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilization and comparing mobilization or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.

Bialosky JE, Bishop MD, Penza CW. Placebo Mechanisms of Manual Therapy: A Sheep in Wolf’s Clothing? J Orthop Sports Phys Ther. 2017;47(5):301-4. doi:10.2519/jospt.2017.0604.

In this smart Viewpoint, the authors conceptualize placebo as an active and important mechanism of MT and argue that placebo mechanisms deserve consideration as an important component of the treatment effect. The authors argue that the context in which the patient, therapist, and environment interact, may contribute to the clinical outcomes seen and should be enhanced and/or further studied.

Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2018 Jan;48(1):8-18.

This well referenced paper was a follow up to a previously designed mechanism model that was published in 2009 and one that crosses professions and philosophies. The model has been used in countless grants as a reference toward mechanistic findings in manual therapy. It is one of the first papers to consolidate the findings in mechanistic research and create a theory of how these findings influence humans when applied. They concluded that the implementation of effective manual therapy depends on many factors, including a thorough understanding of the underlying multifactorial mechanisms through which these interventions exert their effectiveness.

Hutting N, Kerry R, Coppieters MW, Scholten-Peeters GGM. Considerations to improve the safety of cervical spine manual therapy. Musculoskelet Sci Pract. 2018;33:41-5. doi:10.1016/j.msksp.2017.11.003.

In this smart and clinically meaningful paper, the authors highlight key areas including: Prevention of potential serious adverse events is important in manual therapy; Identifying a possible vasculogenic origin or other serious pathology is important; Indications, contraindications and risk factors for manual therapy must be assessed; and Patient interviewing, clinical assessment, interpretation and analysis are important skills.

Cook CE, Cleland JA, Mintken PE. Manual Therapy Cures Death: I Think I Read That Somewhere. J Orthop Sports Phys Ther. 2018 Nov;48(11):830-832.

In this editorial, the authors outline their experience with predatory publishing, in which they wrote a paper about how they cured a dead human using spinal manipulation. Sadly, the paper was published by a predatory journal. The authors discuss the potential risks of predatory publishing such as “source amnesia-hence the title” and make recommendations on how to review current misinformation within the literature.

Côté P, Bussières A, Cassidy JD, Hartvigsen J, Kawchuk GN, Leboeuf-Yde C, Mior S, Schneider M; 140 signatories# call for an end to pseudoscientific claims on the effect of chiropractic care on immune function. A united statement of the global chiropractic research community against the pseudoscientific claim that chiropractic care boosts immunity. Chiropr Man Therap. 2020 May 4;28(1):21.

In this bold unified statement, top chiropractic researchers and 140 signatories condemn the International Chiropractic Associations claim that that chiropractic care can impact the immune system. They report that the ICA provided no valid clinical scientific evidence that chiropractic care can impact the immune system. The authors call on regulatory authorities and professional leaders to take robust political and regulatory action against those claiming that chiropractic adjustments have a clinical impact on the immune system. This is a great example of how profession leaders can assist in dictating a proper message associated with the effects of force-based manipulations.

Deyle GD, Allen CS, Allison SC, Gill NW, Hando BR, Petersen EJ, Dusenberry DI, Rhon DI. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. N Engl J Med. 2020 Apr 9;382(15):1420-1429. doi: 10.1056/NEJMoa1905877. PMID: 32268027.

In this exceptionally well designed study involving 156 subjects, the authors found that patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection. Physical therapy interventions consisted of The physical therapy intervention included instructions and images for exercises, joint mobilizations, and the clinical reasoning underlying the priorities, dosing, and progression of treatment. Fidelity was a strong point of this study. The paper was published in the New England Journal of Medicine, which has an impact factor of 176.1 (2021).

Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, Beneciuk JM, Leech RL, Selfe J. International Framework for Red Flags for Potential Serious Spinal Pathologies. Journal of Orthopaedic & Sports Physical Therapy. 2020;50(7):350-72. doi:10.2519/jospt.2020.9971.

In this important framing of red flag findings, which was sanctioned by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT), a framework was developed to help clinicians assess and manage people who may have serious spinal pathology. The authors report that Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. Perhaps the most important aspect of this study is the use of figures and infographics to improve understanding of how to reason red flag findings.

Fernández-de-Las-Peñas C, Arias-Buría JL, Cleland JA, Pareja JA, Plaza-Manzano G, Ortega-Santiago R. Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up From a Randomized Controlled Trial. Phys Ther. 2020 Oct 30;100(11):1987-1996. 

This study looked at 4 year outcomes of a manual therapy approach versus surgery, in women with carpal tunnel syndrome.  In the long term, manual therapy, including desensitization maneuvers of the central nervous system, resulted in similar outcomes and similar surgery rates compared with surgery in women with CTS. Both interventions were combined with a tendon/nerve gliding exercise program at home.

Nim CG, Downie A, O’Neill S, Kawchuk GN, Perle SM, Leboeuf-Yde C. The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: Myth or reality? A systematic review. Sci Rep. 2021 Dec 3;11(1):23415.

The study was a systematic review, which evaluated whether a specific spinal manipulation was more effective than a non-specifically applied manipulation. The study found that none of the nine studies with low or moderate risk of bias reported statistically significant between-group differences for any outcome. The tenth study reported a small effect on pain but had a high risk of bias. Similar findings have been reported elsewhere in mobilization research. Perhaps the strongest part of this paper is the liberating comments by the authors in the discussion, suggesting this might be a good finding and one that might open MT up to more users.

Rhon DI, Deyle GD. Manual Therapy: Always a Passive Treatment? J Orthop Sports Phys Ther. 2021 Oct;51(10):474-477. 

In this well written viewpoint, two stellar researchers who have a strong track record of providing care with high fidelity, argue that manual therapy involves a wide variety of treatments, some with passive components and some that are primarily passive in certain scenarios. They outline that manual therapy can be an integral part of highly active treatment strategies. The authors conclude the viewpoint by imploring investigators to describe manual therapy interventions in sufficient detail so that they can be reproduced and thereby help the end users of research (including clinicians) to better assess the value of such interventions.

Rushton A, Carlesso LC, Flynn T, Hing WA, Rubinstein SM, Vogel S, Kerry R. International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework. Journal of Orthopaedic & Sports Physical Therapy. 2023;53(1):7-22. doi:10.2519/jospt.2022.11147.

This position statement, stemming from the International IFOMPT (International Federation of Orthopaedic Manipulative Physical Therapists) Cervical Framework, was developed based upon the best contemporary evidence and expert opinion to assist clinicians during their clinical reasoning process when considering presentations involving the head and neck. The paper provides beautiful figures to aid in its delivery. The authors conclude that the IFOMPT cervical  framework  provides a starting point to guide clinical reasoning when clinicians are assessing and managing patients who are presenting with potential vascular pathologies.