07/01/2025
Just published in JOSPT 🔥
The Effectiveness of Spinal Manipulative Therapy in Treating Spinal Pain Does Not Depend on the Application Procedures: A Systematic Review and Network Meta-Analysis 💡
👉 A brand-new systematically reviewed by Nim and colleagues analyzed the effectiveness of various spinal manipulative therapy (SMT) procedures for reducing spinal pain and disability in adults. (https://www.jospt.org/doi/10.2519/jospt.2025.12707)
👉 Objectives
The study aimed to determine whether specific SMT application procedures—such as
▶︎ target selection (clinician-selected or generic approach and the rationale for the selection approach),
▶︎thrust technique (thrust procedure according to vertebral level specificity (i.e., single-level vs. multi-level thrust, thrust delivered by hand vs thrust delivered via an instrument such as Activator, or
▶︎ regional application (such as patients with low back pain receiving SMT in the lower back; a region without pain, such as patients with neck pain receiving thoracic SMT; or multiple regions, such as patients with neck pain receiving cervical and thoracic SMT
— impact the outcomes of pain relief and disability reduction.
👉 Methods
✅ Study Design: Systematic review and network meta-analysis of randomized clinical trials (RCTs).
✅ Literature Search: Sourced data from five major databases and recent systematic reviews up to September 2023. Artificial intelligence tools were employed to identify additional relevant studies.
✅ Inclusion Criteria: Focused on adults with spinal pain (cervical, thoracic, or lumbar) comparing SMT to other SMT procedures, non-recommended treatments, sham, or no-treatment controls.
✅ Outcomes Measured: Pain intensity and disability at short-term (end of treatment) and long-term (up to 12 months).
✅ Data Synthesis: Utilized network plots and evidence rankings, with heterogeneity and bias assessments.
📊 Results
👉 Studies analyzed: Included 161 RCTs with 11,849 participants. SMT procedures were primarily delivered by physiotherapists and chiropractors.
👉 Efficacy of SMT: SMT was more effective than sham or no treatment, achieving comparable results to guideline-recommended interventions (e.g., exercise, education).
👉 Comparisons Among SMT Approaches:
✅ Differences between targeted, generalized, and region-specific SMT were small and not clinically significant.
✅ Non-specific SMT applications (e.g., generalized thrusts or targeting non-symptomatic regions) had the highest probability of achieving the greatest effects on pain and disability.
✅ These findings were based on low-certainty evidence due to high within-study variability, risk of bias, and limited direct comparisons.
Clinical Importance
📌 Paradigm Shift in SMT Application: The findings challenge the long-held belief that specific SMT targeting is superior. Instead, a generalized approach appears equally effective.
📌 Focus on Patient Preferences: Clinicians are encouraged to prioritize patient comfort, preferences, and safety over adherence to specific SMT procedures.
📌 Contextual Factors: The hands-on, clinician-driven nature of SMT and associated contextual effects may significantly contribute to its therapeutic outcomes.
📌Educational Implications: Training programs should de-emphasize the importance of targeting specific spinal regions and specific biomechanical reasoning models during SMT and instead teach a more patient-centered approach.
⭕ Limitations
The evidence was rated as low or very low confidence due to methodological heterogeneity and high risk of bias in included studies.
🔑 Conclusion
This study underscores that the clinical effects of SMT on spinal pain and disability are largely independent of application procedures. These results advocate for a simplified, patient-centric approach to SMT, aligning it with modern evidence-based clinical guidelines.
