Jung A, Adamczyk WM, Ahmed A, et al. No Sufficient Evidence for an Immediate Hypoalgesic Effect of Spinal Manual Therapy on Pressure Pain Thresholds in Asymptomatic and Chronic Pain Populations: A Systematic Review and Meta-Analysis. Phys Ther. 2023 Mar 3;103(3):pzad003. doi: 10.1093/ptj/pzad003. (Systematic review)

OBJECTIVE: Spinal manual therapy (SMT) is often used to treat patients with spinal disorders; however, the underlying mechanisms of SMT are not fully understood. This systematic review and meta-analysis investigates the effect of SMT compared with sham treatment or no intervention on local or remote (segmental or non-segmental) pressure pain thresholds (PPTs) in patients with chronic musculoskeletal conditions and people who are pain free.

METHODS: A systematic search was conducted in the PubMed, Cochrane Library, Web of Science, and CINAHL databases. Randomized controlled trials investigating the effect of SMT on PPTs in patients with chronic musculoskeletal conditions and in people who were pain free were included. Quality assessment and evidence synthesis were performed according to Cochrane Handbook recommendations. A meta-analysis was performed using standardized mean difference and 95% CIs.

RESULTS: Twenty-two reports were included in the present review. There were no significant results for an immediate effect of SMT on local (low certainty of evidence), remote (segmental) (low certainty of evidence), and remote (non-segmental) (low certainty of evidence) PPTs in patients with chronic pain as well as on local (moderate certainty of evidence) and remote (segmental) (low certainty of evidence) PPTs in people who were pain free. A small but significant effect (standardized mean difference = 0.26; 95% CI = 0.01 to 0.51; low certainty of evidence) was observed on remote (non-segmental) PPTs in people who were pain free, which was not considered a meaningful effect size.

CONCLUSION: No immediate, consistent, or meaningful hypoalgetic effect of SMT was shown on PPTs on various body areas. Involvement of spinal or supraspinal underlying mechanisms were, therefore, not confirmed via PPTs but should still be investigated using methods designed to assess central nervous pain processing.

IMPACT: No consistent and meaningful hypoalgesic effects of spinal manual therapy were demonstrated on PPTs in participants who were pain free and in patients with chronic musculoskeletal disorders.

Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Physician 5 / 7
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Comments from MORE raters

Physician rater

This well-conducted systematic review shows that there are no immediate, significant hypoalgesic effects of spinal manual therapy on pressure pain thresholds of different body regions in asymptomatic participants and in patients with chronic musculoskeletal disorders. The hypoalgesic effects of mobilizations have been demonstrated previously, but the central nervous mechanisms of pain processing should still be investigated.

Physician rater

As is true for many alternative medicines, there is insufficient evidence for spinal manual therapy on pressure pain.

Physician rater

Chronic pain is a frequent complaint in primary care. There are many different strategies to cope with this problem that are not always efficient or useful. Mechanical and electrical stimulation have been proposed as effective, but the results are inconclusive. Individualizing patients and sharing decisions could be the best avenue.

Physician rater

It is commendable to try to demonstrate physiotherapy techniques that are of questionable effect as they are often not scientifically based. The proof of the pudding is in the eating, and there is still no evidence of SMT for chronic pain.

Rehab Clinician (OT/PT) rater

The findings of this article are very important to the patient in clinical practice. As a physiotherapist and scientist, my colleagues frequently ask me about spinal manual therapy benefits, and now that I have an answer, I will refer them to this article.

Rehab Clinician (OT/PT) rater

This is a useful overview of the strength of evidence to support manual therapy.
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