The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: Myth or reality? A systematic review

Abstract

The concept that spinal manipulation therapy (SMT) outcomes are optimized when the treatment is aimed at a clinically relevant joint is commonly assumed and central to teaching and clinical use (candidate sites). This systematic review investigated whether clinical effects are superior when this is the case compared to SMT applied elsewhere (non-candidate sites). Eligible study designs were randomized controlled trials that investigated the effect of spinal manipulation applied to candidate versus non-candidate sites for spinal pain. We obtained data from four different databases. Risk of bias was assessed using an adjusted Cochrane risk of bias tool, adding four items for study quality. We extracted between-group differences for any reported outcome or, when not reported, calculated effect sizes from the within-group changes. We compared outcomes for SMT applied at a ‘relevant’ site to SMT applied elsewhere. We prioritized methodologically robust studies when interpreting results. Ten studies, all of acceptable quality, were included that reported 33 between-group differences—five compared treatments within the same spinal region and five at different spinal regions. 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 (1.2/10, 95%CI − 1.9 to − 0.5) but had a high risk of bias. None of the nine articles of low or moderate risk of bias and acceptable quality reported that “clinically-relevant” SMT has a superior outcome on any outcome compared to “not clinically-relevant” SMT. This finding contrasts with ideas held in educational programs and clinical practice that emphasize the importance of joint-specific application of SMT.

Mitigating Gait Decline in a Woman With Parkinson’s Disease: A Case Report

“…Spinal manipulation therapy, broadly speaking, is primarily used to treat musculoskeletal issues, with emphasis on a range of strategies to mobilize restricted structures and relieve neural compromise, and maximize the functions of contracted joints and affected muscles [ 4 ]. The positive changes observed after spinal manipulation and exercise-based training may be unrelated to treatment specificity but a systemic effect of functional changes in a biomechanical interdependence [ 14 ]. It is speculated that pain relief following manipulative remedies may improve disc diffusion, neural proprioception of muscles, motor functions, and postural balance [ 4 , 14 ].…”

“…The positive changes observed after spinal manipulation and exercise-based training may be unrelated to treatment specificity but a systemic effect of functional changes in a biomechanical interdependence [ 14 ]. It is speculated that pain relief following manipulative remedies may improve disc diffusion, neural proprioception of muscles, motor functions, and postural balance [ 4 , 14 ].…”

Conservative Management of Low Back Pain Related to an Unresectable Aggressive Sacral Hemangioma: A Case Report

“…Spinal manipulation can provide relief by providing a mechanoreceptive stimulus that inhibits pain, relaxes hypertonic muscle, and influences posture [ 13 ]. In addition, recent evidence suggests spinal manipulation can produce clinical benefits at regions of the spine away from the area of application [ 14 ]. These mechanisms could explain the low back and lower extremity pain relief afforded by thoracic spinal manipulation in the present case.…”

Impact of audible pops associated with spinal manipulation on perceived pain: a systematic review

“…In addition, Sillevis and Cleland [ 21 ] and Cleland et al [ 22 ] reported similar results for patients with neck pain in the short-term. As support of these conclusions, Nim et al [ 31 ] published a systematic review that questioned the concept of segmental specificity on pain outcomes suggesting non-local effects at play, with none of the included studies detecting significant differences in outcome measurements including pain between clinician-determined “correct” vertebral level and surrounding vertebral levels. Such non-local effects support the absence of association between pain reduction and localized ‘pops’, as historically envisaged by early chiropractic theories where the audible sound was originally seen as a result of specific vertebra returning to ‘position’.…”

“…The common occurrence of multilevel cavitation is in accordance with reports of other studies [ 36 , 37 ]. Nim et al [ 31 ] suggest positive changes observed after SMT may be unrelated to targeting vertebral sites and might be better explained by mechanisms ranging from neuromuscular or biomechanical interactions, such as functional changes in biomechanical chain and spinal region interdependence [ 38 ], to contextual factors modulating pain through cognitively higher interpretations of treatment effects by patients.…”