Introduction
Background
Previous research
Rationale and research questions
Methods
Eligibility criteria
Data sources and searches
“spinal manipulative therapy” OR “spinal manipulation” OR “spine manipulation” OR “thrust manipulation” OR “joint manipulation” OR “cervical manipulation” OR “thoracic manipulation” OR “lumbar manipulation” OR “cervicothoracic manipulation” OR “thoracolumbar manipulation” OR “lumbosacral manipulation” OR “sacroiliac manipulation” OR “osteopathic manipulation” OR “chiropractic manipulation” OR “chiropractic adjustment” OR “orthopedic manipulation” OR “musculoskeletal manipulations”
“pain perception” OR “pain sensitivity” OR “experimental pain” OR “experimental pain sensitivity” OR “experimentally induced pain” OR “experimentally-induced pain” OR “quantitative sensory testing” OR “pain measurement” OR “pain tolerance” OR “pain threshold” OR “pressure pain” OR “pressure pain threshold” OR “pressure sensitivity” OR “pressure pain sensitivity” OR “thermal pain” OR “mechanical pain” OR “exercise-induced pain” OR “electrical pain” OR “chemical pain” OR “pain modulation” OR “analgesia” OR “analgesic” OR “hypoalgesia” OR “hypoalgesic” OR “hyperalgesia” OR “allodynia” OR “algometry” OR “algometer” OR “temporal sensory summation” OR “temporal summation” OR “wind-up” OR “suprathreshold heat response”
Study selection
Data extraction and quality assessment
Area | Cervical spine SMT | Thoracic spine SMT | Lumbar spine SMT |
---|---|---|---|
Local | Cervical spine and paraspinal muscles in close vicinity to SMT location | Thoracic spine and paraspinal muscles in close vicinity to SMT location | Lumbar spine and paraspinal muscles in close vicinity to SMT location |
Regional | Upper limb, & head/face if upper/mid cervical SMT | Rest of thorax, e.g. mid/lower trapezius, ribs | Lower limb, pelvis |
Remote | Anywhere else | Anywhere else | Anywhere else |
Quality item | Details/explanation | Scoring key (total max. 13) |
---|---|---|
Was PPT measured correctly, and was reliability pre-tested? | Valid/reliable technique includes taking 3 measures and averaging all 3 or last 2. | Both = 1, Valid technique only = 0.5, Pre-tested reliability only = 0.5, Neither = 0 |
Was the assessor blinded? | – | Yes = 1, No = 0 |
Was there appropriate random number generation and concealment? | Random sequence generation, e.g. random number generator. Adequate concealment until randomisation occurs, e.g. sequential opaque envelopes. | Method appropriate = 1, Method for one component but not both reported and appropriate = 0.5, Method NR = 0 |
Were active and control interventions well described? | – | Yes = 1, No = 0 |
Were practitioners appropriate and sufficiently experienced? | Practitioner with training in spinal manipulative therapy, ≥3 years clinical experience. | Yes = 1, No/NR = 0 |
Were attempts made to keep participants naïve to study aims? If sham-controlled, were they blinded, and confirmed? | If sham group: Blinded? Confirmed? Naïve to study aims? If no sham group: Naïve to study aims? | If sham: Blinding confirmed = 1, Blinding attempted but not confirmed and/or naïve = 0.5, Not blind/naïve = 0 If no sham: Naïve = 1, Not naïve/NR = 0 |
Were study conditions controlled? | An effort to control temperature, room, interactions, expectations | Yes = 1, No/NR = 0 |
Was there control for psychosocial modifiers/confounders? | Statistical control | Yes = 1, No = 0 |
Was a sample size calculation performed and met? | Performed based on PPT estimates? | Yes = 1, Performed and met but NR based on what = 0.5, Not performed, not performed based on PPT, or not met = 0 |
Were losses and exclusions reported clearly? | – | Yes = 1, No = 0 |
Missing data reported? Imputation method reported and appropriate, if required? | – | Yes = 1, No/NR = 0 |
Were estimates and p-values/CIs reported for between-group differences? | – | Yes = 1, Estimates/CIs NR but p-values non-significant = 1, No = 0 |
Data synthesis and interpretation
Meta-analyses
Results
Study characteristics
1st author, year, country | Design | No. of participants | Age (range) | Male/ Female | Musculoskeletal pain type | Source of participants | SMT | Control or comparison/s | Outcome measure/s | PPT area | Time of follow-up |
---|---|---|---|---|---|---|---|---|---|---|---|
Bautista-Aguirre 2017, Spain [27] | 3 arm RCT | 88 (28/30/30) | 32 (NR) | 24/64 | Chronic non-specific NP | Primary care | 1. C7 HVLA SMT 2. T3 HVLA SMT (NR if 2nd allowed) | Control (manual contact to head for 3 min) | PPT @ median nerve at wrist & elbow, ulnar nerve at elbow, radial nerve at upper arm | 1. Regional 2. Remote | Immediate |
Bialosky 2009, USA [22] | 3 arm RCT | 36 (12/12/12) | 32 (NR) | 10/26 | Non-specific LBP | General population & primary care | Bilateral SIJ HVLA SMT (2 regardless of cavitation) | 1. Stationary bicycle (5 min) 2. Lumbar extension exercises | TS @ palmar hand & plantar foot Aδ “first” pain @ volar forearm & calf |
NA
| Immediate |
Bialosky 2014, USA [23] | 4 arm RCT | 110 (28/27/27/28) | 32 (NR) | 33/77 | Non-specific LBP | General population & primary care (not direct referral) | Bilateral SIJ HVLA SMT (2 regardless of cavitation) | 1. Sham SMT 2. Sham SMT + positive expectation 3. Control (5 min quiet sitting) | Mechanical pain sensitivity @ PSIS & 1st web-space of foot Suprathreshold heat response @ plantar foot Aftersensations @ plantar foot |
NA
| Immediate |
Casanova-Méndez 2014, Spain [28] | 2 arm RCT | 60 (30/30) | 38 (NR) | 17/43 | Chronic non-specific NP | Primary care | 1. T4 supine HVLA SMT 2. T4 toggle-recoil HVLA SMT (2nd if no cavitation) |
Nil
| PPT @ C4 SP, T4 SP, & upper trapezius | Local & remote | Immediate 20 min |
Coronado 2015, USA [33] | 3 arm RCT | 78 (26/27/25) | 39 (NR) | 42/36 | General shoulder pain | General population & primary care | Mid-cervical HVLA SMT (NR if pre-specified, 2nd if no cavitation) | 1. Shoulder manipulation 2. Shoulder exercise program | PPT @ acromion & tibialis anterior HPT @ volar forearm TS @ volar forearm | Regional & remote | Immediate 1–2 wks |
Côté 1994, Canada [25] | 2 arm RCT | 30 (16/14) | 31 (22–50) | 16/14 | Chronic non-specific LBP | Primary care | L5-S1 or SIJ HVLA SMT (therapist-chosen level, NR if 2nd allowed) | Lumbar mobilisation | PPT @ L5 paraspinals, SIJ, & upper gluteal muscles | Local & regional | Immediate 15 min 30 min |
De Oliveira 2013, Brazil [32] | 2 arm RCT | 148 (74/74) | 46 (NR) | 39/109 | Chronic non-specific LBP | General population & primary care | 1. “Global” T1-T5 HVLA SMT (pre-specified) 2. Lumbar HVLA SMT (therapist-chosen level) (NR if 2nd allowed) |
Nil
| PPT @ L3 & L5 paraspinals, & tibialis anterior | 1. Remote 2. Local & regional | Immediate |
Fernández-Carnero 2008, Spain [34] | 2 arm cross-over RCT | 10 | 42 (30–49) | 5/5 | Lateral epicondylalgia | General population | C5–6 HVLA SMT (2nd if no cavitation) | Sham SMT | PPT @ lateral epicondyle HPT @ lateral epicondyle CPT @ lateral epicondyle | Regional | 5 min |
Kardouni 2015, USA [35] | 2 arm RCT | 45 (24/21) | 31 (18–59) | 22/23 | Shoulder pain | General population & primary care | Thoracic HVLA SMT (NR if pre-specified, 2 thrusts in each of lower, mid, and upper) | Sham SMT | PPT @ deltoid & lower trapezius | Regional & remote | Immediate |
Lopez-Lopez 2015, Spain [29] | 3 arm RCT | 48 (15/16/17) | 35/36/37 by group (NR) | 6/42 | Chronic non-specific NP | Primary care | Cervical HVLA SMT (therapist-chosen level, 2nd if no cavitation) | 1. P-A grade III mobilisation 2. Sustained apophyseal natural glide mobilisation | PPT @ C2 SP | Local | 5 min |
Maduro de Camargo 2011, Brazil [30] | 2 arm RCT | 37 (17/20) | 31/28 by group (19–45) | 21/16 | Non-specific NP | General population | C5–6 HVLA SMT (2nd if no cavitation) | Control (2 min quiet sitting) | PPT @ upper trapezius, deltoid, & C5 SP | Local & regional | 5 min |
Mansilla-Ferragut 2009, Spain [26] | 2 arm RCT | 37 (18/19) | 35 (21–50) | 0/37 | Chronic non-specific NP | General population | Bilateral C0–1 HVLA SMT (2nd if no cavitation) | Sham SMT | PPT @ temple | Regional | 5 min |
Martínez-Segura 2012, Spain [21] | 3 arm RCT | 90 (29/28/33) | 37 (NR) | 44/46 | Chronic non-specific NP | Primary care | 1. Right mid-cervical HVLA SMT 2. Left mid-cervical HVLA SMT 3. Broad T1-T4 HVLA SMT (therapist-chosen level, 2nd if no cavitation) |
Nil
| PPT @ C5–6 facet, lateral epicondyle, & tibialis anterior | 1 & 2. Local, regional & remote 3. Remote | 10 min |
Packer 2014, Brazil [24] | 2 arm RCT | 32 (16/16) | 23/26 by group (21–29) | 0/32 | Chronic temporo-mandibular disorder & non-specific NP | NR | T1 HVLA SMT (2nd if no cavitation) | Sham SMT | PPT @ masseter, temporalis, & temporomandibular joint | Remote | Immediate 48–72 h |
Salom-Moreno 2014, Spain [31] | 2 arm RCT | 52 (27/25) | 33 (NR) | 22/30 | Chronic non-specific NP | Primary care | T3-T6 HVLA SMT (2nd if no cavitation) | T3-T6 grade III-IV mobilisation | PPT @ C5–6 facet, 2nd metacarpal, & tibialis anterior | Remote | 10 min |
Populations
Quantitative sensory testing outcomes
Interventions
Follow-up
Other factors
Quality of studies
1st author, year | Was PPT measured correctly, & was reliability pre-tested? | Was the assessor blinded? | Was there appropriate random number generation & concealment? | Were active & control interventions well described? | Were practitioners appropriate & sufficiently experienced? | Were attempts made to keep participants naïve to study aims? If sham-controlled, were they blinded, & confirmed? | Were study conditions controlled? | Was there control for psychosocial modifiers/ confounders? | Was a sample size calculation performed & met? | Were losses and exclusions reported clearly? | Missing data reported? Imputation method reported & appropriate, if required? | Were estimates & p-values/CIs reported for between-group differences? | Quality score |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Casanova-Méndez 2014 [28] | Technique ✔, not pre-tested (0.5) | Yes (1) | Yes (1) | Yes (1) | Yes (1) | Were naïve (1) | NR (0) | No (0) | Calculation done & met, NR based on what (0.5) | Yes (1) | NR (0) | Yes (1) | 8 |
Coronado 2015 [33] | Technique ✔, not pre-tested (0.5) | Yes (1) | Yes (1) | Yes (1) | Yes (1) | Not naïve (0) | NR (0) | No (0) | Calculation done & met, NR based on what (0.5) | Yes (1) | Yes, acceptably imputed (1) | Yes (1) | 8 |
Kardouni 2015 [35] | Technique ✔, pre-testing found reliable (1) | Yes (1) | Yes (1) | Yes (1) | Yes (1) | Blinding confirmed effective (1) | NR (0) | No (0) | Calculation done, NOT met (0) | Yes (1) | NR (0) | Yes (1) | 8 |
Bautista-Aguirre 2017 [27] | Technique ✔, not pre-tested (0.5) | Yes (1) | Yes (1) | Yes (1) | Yes (1) | Not naïve (0) | NR (0) | No (0) | Calculation done & met (1) | Yes (1) | NR (0) | Yes (1) | 7.5 |
Martínez-Segura 2012 [21] | Technique ✔, not pre-tested (0.5) | Yes (1) | Yes (1) | Yes (1) | Yes (1) | Not naïve (0) | NR (0) | No (0) | Calculation done & met (1) | Yes (1) | NR (0) | Yes (1) | 7.5 |
De Oliveira 2013 [32] | Technique ✔, pre-testing found reliable (1) | Yes (1) | Yes (1) | Yes (1) | Yes (1) | Not naïve (0) | NR (0) | No (0) | Calculation based on subjective pain intensity (0) | Yes (1) | NR (0) | Yes (1) | 7 |
Maduro de Camargo 2011 [30] | Technique ✔, not pre-tested (0.5) | Yes (1) | Method NR (0) | Yes (1) | Yes (1) | Were naïve (1) | NR (0) | No (0) | Calculation done & met (1) | No (0) | NR (0) | Yes (1) | 6.5 |
Packer 2014 [24] | NR if PPT tested × 3, not pre-tested (0) | Yes (1) | Yes (1) | Yes (1) | NR (0) | Blinded, not checked, NR if naïve (0.5) | NR (0) | No (0) | Calculation done & met (1) | Yes (1) | NR (0) | Yes (1) | 6.5 |
Salom-Moreno 2014 [31] | Technique ✔, not pre-tested (0.5) | Yes (1) | Yes (1) | Yes (1) | NR (0) | Not naïve (0) | NR (0) | No (0) | Calculation done & met (1) | Yes (1) | NR (0) | Yes (1) | 6.5 |
Côté 1994 [25] | NR if PPT tested × 3, not pre-tested (0) | Yes (1) | Concealment method NR (0.5) | Yes (1) | NR (0) | Not naïve (0) | NR (0) | No (0) | Calculation done & met (1) | Yes (1) | NR (0) | p-value non-significant, estimates & CIs NR (1) | 5.5 |
Lopez-Lopez 2015 [29] | Technique ✔, not pre-tested (0.5) | Yes (1) | Yes (1) | Yes (1) | NR (0) | Not naïve (0) | NR (0) | Yes (1) | Calculation based on subjective pain intensity (0) | Yes (1) | NR (0) | No (0) | 5.5 |
Mansilla-Ferragut 2009 [26] | Technique ✔, not pre-tested (0.5) | Yes (1) | Concealment method NR (0.5) | Yes (1) | Yes (1) | Not blinded, not naïve (0) | NR (0) | No (0) | No calculation (0) | No (0) | NR (0) | Yes (1) | 5 |
Fernández-Carnero 2008 [34] | Technique ✔, not pre-tested (0.5) | Yes (1) | Method NR (0) | Yes (1) | Yes (1) | Not blinded, not naïve (0) | NR (0) | No (0) | No calculation (0) | No (0) | NR (0) | Yes (1) | 4.5 |
Answers to research questions
Is there a difference in PPT comparing SMT to sham, or SMT to control?
1st author, year | Groups | PPT testing site/s & follow-up time/s | Within-group estimates; mean change from baseline in kg/cm2 (SD, % change) | Significant within-group change (SMT groups only)?^ | Difference in mean change in kg/cm2 [group 1 minus group 2] | Significant between-group difference?^ | Quality score |
---|---|---|---|---|---|---|---|
Casanova-Méndez, 2014 [28] | Supine TSMT (TSMT 1), Toggle-recoil TSMT (TSMT 2) | C4 SP, T4 SP, & upper trapezius,a immediately & 20 mins after intervention |
C4 SP
|
TSMT 1 vs TSMT 2
| 8 | ||
SMT 1 immed.: 0.21 (0.48, 10.4%) | Yes | C4 SP immed.: 0.00 | No | ||||
SMT 1 20 min: 0.25 (0.59, 12.4%) | Yes | C4 SP 20 min: − 0.05 | No | ||||
SMT 2 immed.: 0.21 (0.32, 10.7%) | Yes | T4 SP immed.: 0.03 | No | ||||
SMT 2 20 min: 0.30 (0.42, 15.3%) | Yes | T4 SP 20 min: − 0.23 | No | ||||
T4 SP
| Trapezius immed.: − 0.19 | No | |||||
TSMT 1 immed.: 0.40 (0.59, 10.8%) | Yes | Trapezius 20 min: − 0.11 | No | ||||
TSMT 1 20 min: 0.47 (0.76, 12.7%) | Yes | ||||||
TSMT 2 immed.: 0.37 (0.67, 11.0%) | Yes | ||||||
TSMT 2 20 min: 0.70 (0.79, 20.9%) | Yes | ||||||
Trapezius
| |||||||
TSMT 1 immed.: 0.22 (0.60, 6.7%) | Yesc | ||||||
TSMT 1 20 min: 0.32 (0.80, 9.7%) | Yesc | ||||||
TSMT 2 immed.: 0.41 (0.51, 13.6%) | Yesc | ||||||
TSMT 2 20 min: 0.43 (0.53, 14.2%) | Yesc | ||||||
Coronado, 2015 [33] | CSMT, Shoulder manipulation, Shoulder exercises | Acromion & tibialis anterior, immediately after intervention |
Acromion
|
CSMT vs Shoulder manipulation
| 8 | ||
CSMT: 0.37 (0.68, 14.2%) | Yesc | Acromion: 0.18 | No | ||||
Shoulder manipulation: 0.19 (0.70, 5.6%) | - | Tibialis anterior: 0.26 | No | ||||
Exercise: 0.10 (0.69, 3.1%) | - |
CSMT vs Exercise
| |||||
Tibialis anterior
| Acromion: 0.27 | No | |||||
CSMT: 0.35 (0.84, 7.4%) | Yesc | Tibialis anterior: 0.10 | No | ||||
Shoulder manipulation: 0.09 (0.83, 1.7%) | - | ||||||
Exercise: 0.25 (1.89, 4.5%) | - | ||||||
Kardouni, 2015 [35] | TSMT, Sham SMT | Deltoida & lower trapezius,a immediately after intervention |
Deltoid
|
TSMT vs Sham
| 8 | ||
TSMT: 0.10 (1.65, 2.8%) | No | Deltoid: 0.11 | No | ||||
Sham: − 0.01 (1.51, − 0.1%) | - | Trapezius: 0.11 | No | ||||
Trapezius
| |||||||
TSMT: 0.09 (1.70, 2.2%) | No | ||||||
Sham: − 0.02 (1.49, − 0.3%) | - | ||||||
Bautista-Aguirre, 2017 [27] | CSMT, TSMT, Control | Median nerve (wrist),a median nerve (elbow),a ulnar nerve,a & radial nerve,a immediately after intervention |
Median nerve (wrist)
|
CSMT vs control
| 7.5 | ||
CSMT: 0.24 (1.41, 3.4%) | Noc | Median nerve (wrist): 0.29 | No | ||||
TSMT: 0.27 (1.38, 3.9%) | Noc | Median nerve (elbow): 0.14 | No | ||||
Control: − 0.05 (3.52, − 0.8%) | - | Ulnar nerve: 0.26 | No | ||||
Median nerve (elbow)
| Radial nerve: 0.44 | No | |||||
CSMT: 0.2 (0.72, 6.8%) | Noc |
TSMT vs control
| |||||
TSMT: 0.2 (0.7, 6.8%) | Noc | Median nerve (wrist): 0.33 | No | ||||
Control: 0.07 (0.91, 2.6%) | - | Median nerve (elbow): 0.14 | No | ||||
Ulnar nerve
| Ulnar nerve: 0.25 | No | |||||
CSMT: 0.38 (1.01, 9.2%) | Noc | Radial nerve: 0.42 | No | ||||
TSMT: 0.37 (0.99, 9.1%) | Noc |
CSMT vs TSMT
| |||||
Control: 0.11 (0.7, 2.8%) | - | Median nerve (wrist): − 0.03 | No | ||||
Radial nerve
| Median nerve (elbow): 0.01 | No | |||||
CSMT: 0.83 (1.25, 24.1%) | Yesc | Ulnar nerve: 0.01 | No | ||||
TSMT: 0.81 (1.21, 23.6%) | Yesc | Radial nerve: 0.02 | No | ||||
Control: 0.39 (0.82, 11.3%) | - | ||||||
Martínez-Segura, 2012 [21] | CSMT,b TSMT | C5–6 facet,a lateral epicondyle,a & tibialis anterior,a 10 mins after intervention |
C5–6 facet
|
CSMT vs TSMT
| 7.5 | ||
CSMT: 0.40 (0.33, 29.1%) | Yes | C5–6 facet: 0.10 | No | ||||
TSMT: 0.30 (0.32, 23.1%) | Yes | Lateral epicondyle: 0.05 | No | ||||
Lateral epicondyle
| Tibialis anterior: 0.07 | No | |||||
CSMT: 0.45 (0.46, 31.6%) | Yes | ||||||
TSMT: 0.40 (0.36, 28.6%) | Yes | ||||||
Tibialis anterior
| |||||||
CSMT: 0.82 (0.67, 38.8%) | Yes | ||||||
TSMT: 0.75 (0.46, 36.6%) | Yes | ||||||
De Oliveira, 2013 [32] | “Non-region specific” TSMT, “Region-specific” LSMT | Lumbar paraspinals & tibialis anterior, immediately after intervention |
Paraspinals
|
TSMT vs LSMT
| 7 | ||
TSMT: 0.37 (1.36, 7.5%) | Yes | Paraspinals: 0.18 | No | ||||
LSMT: 0.19 (1.53, 3.8%) | No | Tibialis anterior: − 0.12 | No | ||||
Tibialis anterior
| |||||||
TSMT: 0.11 (1.26, 1.7%) | No | ||||||
LSMT: 0.23 (1.12, 3.6%) | No | ||||||
Maduro de Camargo, 2011 [30] | CSMT, Control | Upper trapezius,a deltoid,a & C5 SP, 5 mins after intervention |
Trapezius
|
CSMT vs Control
| 6.5 | ||
CSMT: 0.3 (0.41, 9.0%) | Yesc | Trapezius: 0.10 | No | ||||
Control: 0.2 (0.69, 5.7%) | - | Deltoid: 0.45 | Yes | ||||
Deltoid
| C5 SP: 0.20 | Yes | |||||
CSMT: 0.25 (0.49, 7.7%) | Yesc | ||||||
Control: − 0.2 (0.58, − 6.3%) | - | ||||||
C5 SP
| |||||||
CSMT: 0.1 (0.19, 4.3%) | Yesc | ||||||
Control: − 0.1 (0.53, − 4.3%) | - | ||||||
Packer, 2014 [24] | TSMT, Sham SMT | TMJ,a masseter,a & temporalis,a immediately after intervention |
TMJ
|
TSMT vs Sham
| 6.5 | ||
TSMT: − 0.05 (NR, − 7.7%) | No | TMJ: − 0.05 | No | ||||
Sham: 0.00 (NR, 0.0%) | - | Masseter: 0.05 | No | ||||
Masseter
| Temporalis: 0.00 | No | |||||
TSMT: 0.05 (NR, 10.0%) | No | ||||||
Sham: 0.00 (NR, 0.0%) | - | ||||||
Temporalis
| |||||||
TSMT: 0.00 (NR, 0.0%) | No | ||||||
Sham: 0.00 (NR, 0.0%) | - | ||||||
Salom-Moreno, 2014 [31] | TSMT, Thoracic mob. | C5–6 facet,a 2nd metacarpal,a & tibialis anterior,a 10 mins after intervention |
C5–6 facet
|
TSMT vs Mob.
| 6.5 | ||
TSMT: 0.37 (0.17, 27.2%) | Yes | C5–6 facet: 0.26 | No | ||||
Mob.: 0.11 (0.20, 7.4%) | - | 2nd metacarpal: 0.03 | No | ||||
2
nd
metacarpal
| Tibialis anterior: 0.00 | No | |||||
TSMT: 0.20 (0.12, 7.4%) | Yes | ||||||
Mob.: 0.16 (0.43, 6.4%) | - | ||||||
Tibialis anterior
| |||||||
TSMT: 0.09 (0.45, 2.1%) | Yes | ||||||
Mob.: 0.09 (0.10, 2.2%) | - | ||||||
Côté, 1994 [25] | LSMT, Lumbar mob. | L5 paraspinals, SIJs, & gluteal muscles, immediately, 15 mins & 30 mins after intervention |
L5 paraspinals
|
LSMT vs Mob.
| 5.5 | ||
LSMT immed.: 0.00 (NR, 0.0%) | No | L5 paraspinals immed.: 0.65 | No | ||||
LSMT 15 min: − 0.11 (NR, − 2.1%) | No | L5 paraspinals 15 min: 0.65 | No | ||||
LSMT 30 min: 0.20 (NR, 3.7%) | No | L5 paraspinals 30 min:1.07 | No | ||||
Mob. immed.: − 0.65 (NR, − 11.0%) | - | SIJs immed.: 0.95 | No | ||||
Mob. 15 min: − 0.77 (NR, − 12.9%) | - | SIJs 15 min: 0.45 | No | ||||
Mob. 30 min: − 0.87 (NR, − 14.7%) | - | SIJs 30 min: 1.10 | No | ||||
SIJs
| Gluteals immed.: 0.32 | No | |||||
LSMT immed.: 0.66 (NR, 12.9%) | No | Gluteals 15 min: 0.12 | No | ||||
LSMT 15 min: 0.09 (NR, 1.7%) | No | Gluteals 30 min: 0.44 | No | ||||
LSMT 30 min: 0.53 (NR, 10.4%) | No | ||||||
Mob. immed.: − 0.29 (NR, − 4.7%) | - | ||||||
Mob. 15 min: − 0.36 (NR, − 6.0%) | - | ||||||
Mob. 30 min: − 0.57 (NR, − 9.4%) | - | ||||||
Gluteals
| |||||||
LSMT immed.: 0.31 (NR, 6.1%) | No | ||||||
LSMT 15 min: 0.44 (NR, 8.9%) | No | ||||||
LSMT 30 min: 0.59 (NR, 11.9%) | No | ||||||
Mob. immed.: − 0.02 (NR, − 0.3%) | - | ||||||
Mob. 15 min: 0.32 (NR, 6.4%) | - | ||||||
Mob. 30 min: 0.16 (NR, 3.1%) | - | ||||||
Lopez-Lopez, 2015 [29] | CSMT, P-A cervical mob. (mob. 1), glide cervical mob. (mob. 2) | C2 SP, 5 mins after intervention |
C2 SP
|
CSMT vs Mob. 1
| 5.5 | ||
CSMT: 0.08 (0.43, 4.6%) | Yes | C2 SP: −0.13 | No | ||||
Mob. 1: 0.21 (0.40, 14.1%) | - |
CSMT vs Mob. 2
| |||||
Mob. 2: 0.30 (0.41, 18.0%) | - | C2 SP: − 0.22 | No | ||||
Mansilla Ferragut, 2009 [26] | CSMT, Sham SMT | Sphenoid bone, 5 mins after intervention |
Sphenoid bone
|
CSMT vs Sham
| 5 | ||
CSMT: 0.1 (0.20, 12.5%) | Yesc | Sphenoid bone: 0.20 | Yes | ||||
Sham: − 0.1 (0.30, − 12.5%) | - | ||||||
Fernández-Carnero, 2008 [34] | CSMT, Sham SMT | Lateral epicondyle,a 5 mins after intervention |
Lateral epicondyle
|
CSMT vs Sham
| 4.5 | ||
CSMT: 1.00 (0.68, 27.9%) | Yes | Lateral epicondyle: 0.90 | Yes | ||||
Sham: 0.10 (0.45, 2.5%) | - |
Meta-analysis | Correlation for variance calculationsa | Mean kg/cm2 | Hedge’s g | Standard error | 95% confidence interval | p-value | I2 | Sample size |
---|---|---|---|---|---|---|---|---|
Change over time after SMT (all areas) | 0.75 0.25 | 0.320 0.320 | 0.238 0.248 | 0.051 0.049 | 0.220–0.421 0.224–0.416 | .000 .000 | 82.5% 85.5% | 693 |
Local subgroup | 0.75 0.25 | 0.259 0.259 | 0.169 0.169 | 0.078 0.078 | 0.106–0.412 0.106–0.412 | .001 .001 | 81.7% 81.7% | 383 |
Regional subgroup | 0.75 0.25 | 0.349 0.348 | 0.178 0.184 | 0.085 0.082 | 0.181–0.516 0.187–0.509 | .000 .000 | 79.8% 80.1% | 533 |
Remote subgroup | 0.75 0.25 | 0.374 0.372 | 0.216 0.231 | 0.073 0.068 | 0.230–0.517 0.238–0.506 | .000 .000 | 84.1% 86.0% | 561 |
SMT vs. Sham difference | 0.75 0.25 | 0.412 0.398 | 0.166 0.169 | 0.256 0.243 | −0.090 - 0.913 −0.079 - 0.875 | .108 .102 | 70.1% 70.3% | 92 |
Is there a difference in PPT comparing SMT to mobilisation or other therapy?
Does PPT change over time after SMT?
Are any changes in PPT local, regional, or remote?
Additional observations
Other types of quantitative sensory testing
Discussion
Summary
Explanation and comparisons
Effect of spinal manipulative therapy on pressure pain threshold
Clinical relevance of change in pressure pain threshold
Effect of spinal manipulative therapy on other types of quantitative sensory testing
Methodological considerations for this review
Methodological considerations for included studies
Recommendations for future research
1. | Use CONSORT guidelines to improve study quality and reporting. |
2. | Consider measuring other types of QST apart from PPT, e.g. temporal summation. |
3. | Measure QST in a variety of locations, e.g. local, regional, remote. |
4. | To address the significant between-study heterogeneity, consider choosing commonly used QST locations, standard QST protocols, and commonly used intervention protocols. |
5. | |
6. | Consider including a sham group, and ensure sham interventions are appropriate and believable, and assess the effectiveness of blinding. |
7. | Consider comparing changes in QST against clinically relevant baseline features or treatment outcomes. |
8. | Consider assessing psychosocial variables at baseline for use as modifiers/confounding variables, if appropriate based on statistical analysis. |