The effectiveness of spinal manipulative therapy in treating spinal pain does not depend on the application procedures: a systematic review and network meta-analysis

Casper Nim; Sasha L. Aspinall; Chad E. Cook; Leticia A. Corrêa; Megan Donaldson; Aron S. Downie; Steen Harsted; Simone Hansen; Hazel J. Jenkins; David McNaughton; Luana Nyirö; Stephen M. Perle; Eric J. Roseen; James J. Young; Anika Young; Gong He Zhao; Jan Hartvigsen; Carsten B. Juhl

doi:10.2519/jospt.2025.12707

The effectiveness of spinal manipulative therapy in treating spinal pain does not depend on the application procedures: a systematic review and network meta-analysis

Casper Nim, Sasha L. Aspinall, Chad E. Cook, Leticia A. Corrêa, Megan Donaldson, Aron S. Downie, Steen Harsted, Simone Hansen, Hazel J. Jenkins, David McNaughton, Luana Nyirö, Stephen M. Perle, Eric J. Roseen, James J. Young, Anika Young, Gong He Zhao, Jan Hartvigsen^*, Carsten B. Juhl^*

^*Corresponding author for this work

Department of Chiropractic

Research output: Contribution to journal › Review article › peer-review

1 Citation (Scopus)

8 Downloads (Pure)

Abstract

OBJECTIVE: To assess whether spinal manipulative therapy (SMT) application procedures (ie, 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 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. We included randomized controlled 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 through 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 controls, 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 (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. 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 nonspecific 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 RoB, and an absence of direct comparisons.

CONCLUSION: There was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients' preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant. J Orthop Sports Phys Ther 2025;55(2):1-14. Epub 7 January 2025.https://doi.org/10.2519/jospt.2025.12707.

Original language	English
Pages (from-to)	109-122
Number of pages	14
Journal	The Journal of orthopaedic and sports physical therapy
Volume	55
Issue number	2
Early online date	27 Jan 2025
DOIs	https://doi.org/10.2519/jospt.2025.12707
Publication status	Published - Feb 2025

Bibliographical note

Copyright the Author(s) 2025. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.

Keywords

interventions
manual therapy
physical therapists
spinal pain

Access to Document

10.2519/jospt.2025.12707

Publisher version (open access)Final published version, 34.6 MBLicence: CC BY

Cite this

Nim, C., Aspinall, S. L., Cook, C. E., Corrêa, L. A., Donaldson, M., Downie, A. S., Harsted, S., Hansen, S., Jenkins, H. J., McNaughton, D., Nyirö, L., Perle, S. M., Roseen, E. J., Young, J. J., Young, A., Zhao, G. H., Hartvigsen, J., & Juhl, C. B. (2025). The effectiveness of spinal manipulative therapy in treating spinal pain does not depend on the application procedures: a systematic review and network meta-analysis . The Journal of orthopaedic and sports physical therapy, 55(2), 109-122. https://doi.org/10.2519/jospt.2025.12707

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title = "The effectiveness of spinal manipulative therapy in treating spinal pain does not depend on the application procedures: a systematic review and network meta-analysis ",

abstract = "OBJECTIVE: To assess whether spinal manipulative therapy (SMT) application procedures (ie, 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 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. We included randomized controlled 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 through 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 controls, 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 (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. 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 nonspecific 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 RoB, and an absence of direct comparisons. CONCLUSION: There was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients' preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant. J Orthop Sports Phys Ther 2025;55(2):1-14. Epub 7 January 2025.https://doi.org/10.2519/jospt.2025.12707.",

keywords = "interventions, manual therapy, physical therapists, spinal pain",

author = "Casper Nim and Aspinall, {Sasha L.} and Cook, {Chad E.} and Corr{\^e}a, {Leticia A.} and Megan Donaldson and Downie, {Aron S.} and Steen Harsted and Simone Hansen and Jenkins, {Hazel J.} and David McNaughton and Luana Nyir{\"o} and Perle, {Stephen M.} and Roseen, {Eric J.} and Young, {James J.} and Anika Young and Zhao, {Gong He} and Jan Hartvigsen and Juhl, {Carsten B.}",

note = "Copyright the Author(s) 2025. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher. ",

year = "2025",

month = feb,

doi = "10.2519/jospt.2025.12707",

language = "English",

volume = "55",

pages = "109--122",

journal = "The Journal of orthopaedic and sports physical therapy",

issn = "0190-6011",

publisher = "American Physical Therapy Association",

number = "2",

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Nim, C, Aspinall, SL, Cook, CE, Corrêa, LA, Donaldson, M, Downie, AS, Harsted, S, Hansen, S, Jenkins, HJ, McNaughton, D, Nyirö, L, Perle, SM, Roseen, EJ, Young, JJ, Young, A, Zhao, GH, Hartvigsen, J & Juhl, CB 2025, 'The effectiveness of spinal manipulative therapy in treating spinal pain does not depend on the application procedures: a systematic review and network meta-analysis ', The Journal of orthopaedic and sports physical therapy, vol. 55, no. 2, pp. 109-122. https://doi.org/10.2519/jospt.2025.12707

The effectiveness of spinal manipulative therapy in treating spinal pain does not depend on the application procedures: a systematic review and network meta-analysis . / Nim, Casper; Aspinall, Sasha L.; Cook, Chad E. et al.
In: The Journal of orthopaedic and sports physical therapy, Vol. 55, No. 2, 02.2025, p. 109-122.

Research output: Contribution to journal › Review article › peer-review

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T1 - The effectiveness of spinal manipulative therapy in treating spinal pain does not depend on the application procedures

T2 - a systematic review and network meta-analysis

AU - Nim, Casper

AU - Aspinall, Sasha L.

AU - Cook, Chad E.

AU - Corrêa, Leticia A.

AU - Donaldson, Megan

AU - Downie, Aron S.

AU - Harsted, Steen

AU - Hansen, Simone

AU - Jenkins, Hazel J.

AU - McNaughton, David

AU - Nyirö, Luana

AU - Perle, Stephen M.

AU - Roseen, Eric J.

AU - Young, James J.

AU - Young, Anika

AU - Zhao, Gong He

AU - Hartvigsen, Jan

AU - Juhl, Carsten B.

N1 - Copyright the Author(s) 2025. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.

PY - 2025/2

Y1 - 2025/2

N2 - OBJECTIVE: To assess whether spinal manipulative therapy (SMT) application procedures (ie, 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 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. We included randomized controlled 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 through 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 controls, 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 (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. 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 nonspecific 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 RoB, and an absence of direct comparisons. CONCLUSION: There was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients' preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant. J Orthop Sports Phys Ther 2025;55(2):1-14. Epub 7 January 2025.https://doi.org/10.2519/jospt.2025.12707.

AB - OBJECTIVE: To assess whether spinal manipulative therapy (SMT) application procedures (ie, 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 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. We included randomized controlled 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 through 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 controls, 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 (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. 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 nonspecific 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 RoB, and an absence of direct comparisons. CONCLUSION: There was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients' preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant. J Orthop Sports Phys Ther 2025;55(2):1-14. Epub 7 January 2025.https://doi.org/10.2519/jospt.2025.12707.

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The effectiveness of spinal manipulative therapy in treating spinal pain does not depend on the application procedures: a systematic review and network meta-analysis

Abstract

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Keywords

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