Manual and manipulation techniques for rheumatic disease.

Table 1 summarizes many of the studies cited in this article. Can we specifically answer the question, "Does manipulation effectively treat musculoskeletal disorders and arthritis?" It is apparent that many individuals make decisions to see therapists who use manual techniques for pain relief and improved function even though few third-party payers cover such treatments. If this question could unequivocally be answered in the affirmative, these treatments would likely be reimbursed by the payers. The studies noted in Table 1 show mixed results for several conditions. Each study has its strengths and weaknesses, but the most powerful ones indicate that manual techniques are beneficial for back and neck pain when compared with no treatment or "placebo." Comparative studies against other techniques such as physical therapy, education, or exercise do not show a clear superiority for manual therapy, however. Thus, one would have to conclude that these techniques have usefulness, primarily as adjuncts to a comprehensive treatment program. Particularly, manual techniques are useful for painful conditions as a means to break the pain cycle and increase tolerance of exercise and other educational approaches. Although clinical trials do provide important information, they do not provide information on the mechanism by which the therapy assists in the healing process. Further work is needed to understand the mechanism by which manipulation affects pain and motion. Such research should clarify the discrepancies reported in the clinical trials and provide better designs for future studies.     

Are manual therapies effective in reducing pain from tension-type headache?: a systematic review

OBJECTIVES: A systematic review was performed to establish whether manual therapies have specific efficacy in reducing pain from tension-type headache (TTH). METHODS: Computerized literature searches were performed in MEDLINE, EMBASE, AMED, MANTIS, CINAHL, PEDro, and Cochrane databases. Papers were included if they described clinical (open noncontrolled studies) or randomized controlled trials in which any form of manual therapy was used for TTH, and if they were published after 1994 in the English language. The methodologic quality of the trials was assessed using the PEDro scale. Levels of scientific evidence, based on the quality and the outcomes of the studies, were established for each manual therapy: strong, moderate, limited, and inconclusive evidence. RESULTS: Only six studies met the inclusion criteria. These trials evaluated different manual therapy modalities: spinal manipulation (three trials), classic massage (one trial), connective tissue manipulation (two trials), soft tissue massage (one trial), Dr. Cyriax's vertebral mobilization (one trial), manual traction (one trial), and CV-4 craniosacral technique (one trial). Methodologic PEDro quality scores ranged from 2 to 8 points out of a theoretical maximum of 10 points (mean=5.8+/-2.1). Analysis of the quality and the outcomes of all trials did not provide rigorous evidence that manual therapies have a positive effect in reducing pain from TTH: spinal manipulative therapy showed inconclusive evidence of effectiveness (level 4), whereas soft tissue techniques showed limited evidence (level 3). CONCLUSIONS: The authors found no rigorous evidence that manual therapies have a positive effect in the evolution of TTH. The most urgent need for further research is to establish the efficacy beyond placebo of the different manual therapies currently applied in patients with TTH.     

Efficacy of spinal manipulative therapy for low back pain of less than three months' duration

OBJECTIVES: To review the efficacy of spinal manipulation for low back pain of less than 3 months duration.Data sources Randomized clinical trials on spinal manipulative therapy for low back pain were identified by searching EMBASE, CINAHL, MEDLINE, and the Physiotherapy Evidence Database (PEDro).Study selection Outcome measures of interest were pain, return to work, adverse events, disability, quality of life, and patient satisfaction with therapy.Data extraction Methodological assessment of the trials was performed using the PEDro scale. Trials were grouped according to the type of intervention, outcome measures, and follow-up time. Where there were multiple studies with sufficient homogeneity of interventions, subjects, and outcomes, the results were analyzed in a meta-analysis using a random effects model.Data synthesis Thirty-four papers (27 trials) met the inclusion criteria. Three small studies showed spinal manipulative therapy produces better outcomes than placebo therapy or no treatment for nonspecific low back pain of less than 3 months duration. The effects are, however, small. The findings of individual studies suggest that spinal manipulative therapy also seems to be more effective than massage and short wave therapy. It is not clear if spinal manipulative therapy is more effective than exercise, usual physiotherapy, or medical care in the first 4 weeks of treatment. CONCLUSIONS: Spinal manipulative therapy produces slightly better outcomes than placebo therapy, no treatment, massage, and short wave therapy for nonspecific low back pain of less than 3 months duration. Spinal manipulative therapy, exercise, usual physiotherapy, and medical care appear to produce similar outcomes in the first 4 weeks of treatment.     

Manual therapy and exercise for neck pain: A systematic review

Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI:?1.69,?0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI:?0.76,?0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made.     

Massage Therapy for Low Back Pain: A Systematic Review

Massage therapy is frequently employed for low back pain (LBP). The aim of this systematic review was to find the evidence for or against its efficacy in this indication. Four randomized clinical trials were located in which massage was tested as a monotherapy for LBP. All were burdened with major methodological flaws. One of these studies suggests that massage is superior to no treatment. Two trials imply that it is equally effective as spinal manipulation or transcutaneous electrical stimulation (TES). One study suggests that it is less effective than spinal manipulation. It is concluded that too few trials of massage therapy exist for a reliable evaluation of its efficacy. Massage seems to have some potential as a therapy for LBP. More investigations of this subject are urgently needed.     

Epidural steroid injections are useful for the treatment of low back pain and radicular symptoms: Pro

Epidural steroid injection has been used to treat low back pain for many decades. Numerous randomized trials have examined the efficacy of this approach. This review details the findings of older systematic reviews, newer randomized controlled trials, and two recent systematic reviews that examine the effectiveness of this treatment. Collectively, studies in acute radicular pain due to herniated nucleus pulposus have failed to show that epidural steroid injection reduces long-term pain or obviates the need for surgery. Similarly, there is scant evidence that epidural steroids have any beneficial effect in those with acute low back pain without leg pain or in those with chronic low back or leg pain. However, most studies have demonstrated more rapid resolution of leg pain in those who received epidural steroid injections versus those who did not. The role of epidural steroid injections in the management of acute radicular pain due to herniated nucleus pulposus is simply to provide earlier pain relief.     

Chronic Mechanical Neck Pain in Adults Treated by Manual Therapy: A Systematic Review of Change Scores in Randomized Controlled Trials of a Single Session

We report a systematic analysis of group change scores of subjects with chronic neck pain not due to whiplash and without headache or arm pain, in randomized clinical trials of a single session of manual therapy. A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2006 was conducted. Trials that scored above 60% on the PEDro Scale were included. Change scores were analyzed for absolute, percentage change and effect size (ES) whenever possible. Nine trials were identified: 6 for spinal manipulation, 4 for spinal mobilization or non-manipulative manual therapy (2 overlapping trials), and 1 trial using ischemic compression. No trials were identified for massage therapy or manual traction. Four manipulation trials (five groups) reported mean immediate changes in 100-mm VAS of −18.94 (9.28) mm. ES for these changes ranged from .33 to 2.3. Two mobilization trials reported immediate VAS changes of −11.5 and −4 mm (ES of .36 and .22, respectively); one trial reported no difference in immediate pain scores versus sham mobilization. The ischemic compression study showed statistically significant immediate decreases in 100-mm pain VAS (average = −14.6 mm). There is moderate-to-high quality evidence that immediate clinically important improvements are obtained from a single session of spinal manipulation. The evidence for mobilization is less substantial, with fewer studies reporting smaller immediate changes. There is insufficient evidence for ischemic compression to draw conclusions. There is no evidence for a single session of massage or manual traction for chronic neck pain.     

Cost-Effectiveness of Manual Therapy for the Management of Musculoskeletal Conditions: A Systematic Review and Narrative Synthesis of Evidence From Randomized Controlled Trials

Objectives

The purpose of this study was to systematically review trial-based economic evaluations of manual therapy relative to other alternative interventions used for the management of musculoskeletal conditions.

Methods

A comprehensive literature search was undertaken in major medical, health-related, science and health economic electronic databases.

Results

Twenty-five publications were included (11 trial-based economic evaluations). The studies compared cost-effectiveness and/or cost-utility of manual therapy interventions to other treatment alternatives in reducing pain (spinal, shoulder, ankle). Manual therapy techniques (eg, osteopathic spinal manipulation, physiotherapy manipulation and mobilization techniques, and chiropractic manipulation with or without other treatments) were more cost-effective than usual general practitioner (GP) care alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. Chiropractic manipulation was found to be less costly and more effective than alternative treatment compared with either physiotherapy or GP care in improving neck pain.

Conclusions

Preliminary evidence from this review shows some economic advantage of manual therapy relative to other interventions used for the management of musculoskeletal conditions, indicating that some manual therapy techniques may be more cost-effective than usual GP care, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. However, at present, there is a paucity of evidence on the cost-effectiveness and/or cost-utility evaluations for manual therapy interventions. Further improvements in the methodological conduct and reporting quality of economic evaluations of manual therapy are warranted in order to facilitate adequate evidence-based decisions among policy makers, health care practitioners, and patients.     

Thesis Review

Abstract

We report a systematic analysis of group change scores of subjects with chronic neck pain not due to whiplash and without headache or arm pain, in randomized clinical trials of a single session of manual therapy. A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2006 was conducted. Trials that scored above 60% on the PEDro Scale were included. Change scores that scored above 60% on the PEDro Scale were included. Change scores were analyzed for absolute, percentage change and e ect size (ES) whenever possible. Nine trials were identi ed: 6 for spinal manipulation, 4 for spinal mobilization or non-manipulative manual therapy (2 overlapping trials), and 1 trial using ischemic compression. No trials were identi ed for massage therapy or manual traction. Four manipulation trials (Five groups) reported mean immediate changes in 100-mm VAS of –18.94 (9.28) mm. ES for these changes ranged from .33 to 2.3. Two mobilization trials reported immediate VAS changes of –11.5 and –4 mm (ES of .36 and .22, respectively); one trial reported no difference in immediate pain scores versus sham mobilization. e ischemic compression study showed statistically signi cant immediate decreases in 100-mm pain VAS (average = –14.6 mm). There is moderate-to-high quality evidence that immediate clinically important improvements are obtained from a single session of spinal manipulation. e evidence for mobilization is less substantial, with fewer studies reporting smaller immediate changes. ere is insu cient evidence for ischemic compression to draw conclusions. There is no evidence for a single session of massage or manual traction for chronic neck pain.     

The effectiveness of sub-group specific manual therapy for low back pain: a systematic review

BackgroundManual therapy is frequently used to treat low back pain (LBP), but evidence of its effectiveness is limited. One explanation may be sample heterogeneity and inadequate sub-grouping of participants in randomized controlled trials (RCTs) where manual therapy has not been targeted toward those likely to respond.ObjectivesTo determine the effectiveness of specific manual therapy provided to sub-groups of participants identified as likely to respond to manual therapy.Data sourcesA systematic search of electronic databases of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled trials (CENTRAL).Trial eligibility criteriaRCTs on manual therapy for participants identified as belonging to a sub-group of LBP likely to respond to manual therapy were included.Trial appraisal and synthesis methodsIdentified trials were assessed for eligibility. Data from included trials were extracted by two authors independently. Risk of bias in each trial was assessed using the PEDro scale and the overall quality of evidence rated according to the GRADE domains. Treatment effect sizes and 95% confidence intervals were calculated for pain and activity.ResultsSeven RCTs were included in the review. Clinical and statistical heterogeneity precluded meta-analysis. Significant treatment effects were found favouring sub-group specific manual therapy over a number of comparison treatments for pain and activity at short and intermediate follow-up. However, the overall GRADE quality of evidence was very low.ConclusionsThis review found preliminary evidence supporting the effectiveness of sub-group specific manual therapy. Further high quality research on LBP sub-groups is required.     

The effect of muscle energy techniques on disability and pain scores in individuals with low back pain

CLINICAL SCENARIO: Low back pain is the most common type of pain reported by adults in the United States. A variety of manual therapy techniques are used in the management of low back pain to reduce pain, improve function, and reduce disability. In recent years, muscle energy techniques have been increasingly used in clinics to treat low back pain. By definition, a muscle energy technique involves the patient performing a voluntary muscle contraction "in a precisely controlled direction, against a distinctly executed counter force applied by the operator." Muscle energy techniques provide a conservative alternative for clinicians treating patients with precautions or contraindications to joint manipulation.     

A randomized, controlled trial of manual therapy and specific adjuvant exercise for chronic low back pain

OBJECTIVE: This article examines the effectiveness of manual therapy with specific adjuvant exercise for treating chronic low back pain and disability. METHODS: A single blind, randomized, controlled trial was employed. Patients were prescribed an exercise program that was tailored to treat their musculoskeletal dysfunctions or given a nonspecific program of general stretching and aerobic conditioning. In addition, patients received manual therapy or sham manual therapy. Participants were seen for 6 weekly sessions and were asked to perform their exercise program twice daily. RESULTS: Seventy-two out of 100 patients completed the study. Multivariate tests conducted for measures of pain and disability revealed a significant group by time interaction (P = 0.04 and P = 0.05, respectively), indicating differential change in these measures pretreatment to posttreatment as a function of the treatment received. When controlling for pretreatment scores, patients receiving manual therapy with specific adjuvant exercise reported significant reductions in pain. No change in perceived disability was observed, with the exception that patients receiving sham manual therapy with specific adjuvant exercise reported significantly greater disability at posttreatment. DISCUSSION: Manual therapy with specific adjuvant exercise appears to be beneficial in treating chronic low back pain. Despite changes in pain, perceived function did not improve. It is possible that impacting chronic low back pain alone does not address psychosocial or other factors that may contribute to disability. Further studies are needed to examine the long-term effects of these interventions and to address what adjuncts are beneficial in improving function in this population.     

Clinical assessment of manipulation and mobilization of the lumbar spine. A critical review of the literature

The widespread use of manual therapy techniques suggests some degree of success in their application. In this article, I review the applied clinical research on the effectiveness of using manipulation or mobilization of the lumbar spine. The literature reviewed indicates highly equivocal results when the goal of therapy was to decrease pain and increase motion. Because of a high incidence of spontaneous recovery from low back syndromes, performance measures may appear to improve significantly when proper controls are not used. Evaluation of the therapeutic effects of manual therapy is complicated by potentially confounding variables when used with other physical therapy procedures. I discuss the need for further, well-designed studies.     

关节突关节源性腰痛的中医外治研究现状

关节突关节的退变是影响腰椎稳定性的重要因素,也是引起腰痛的重要原因之一。随着诊疗技术的发展,关节突关节源性腰痛的研究越来越受重视。中医外治关节突关节源性腰痛包括:针灸、温针灸、针刀、手法、中药外敷、放血疗法、中药制剂注射、综合治疗等。临床虽然取得一定疗效,但该病命名混乱,尚未形成统一的诊断、治疗及疗效评估体系,影响了该病的进一步研究。规范该病命名,形成统一的诊断、分型及疗效评估标准,有助于推广安全有效的中医外治技术,从而更有效的诊治关节突关节源性腰痛。     

Does spinal manipulative therapy help people with chronic low back pain?

A systematic review of randomised clinical trials was conducted to assess the effect of spinal manipulative therapy on clinically relevant outcomes in patients with chronic low back pain. Databases searched included EMBASE, CINAHL, MEDLINE and PEDro. Methodological assessment of the trials was performed using the PEDro scale. Where there was sufficient homogeneity, a meta-analysis was conducted. Nine trials of mostly moderate quality were included in the review. Two trials were pooled comparing spinal manipulative therapy and placebo treatment, and two other trials were pooled comparing spinal manipulative therapy and non-steroidal anti-inflammatory drugs (NSAIDs). Spinal manipulative therapy reduced pain by 7mm on a 100mm visual analogue scale (95% CI 1 to 14) at one month follow-up when compared with placebo treatment, and by 14mm (95% CI -11 to 40) when compared with NSAIDs. Spinal manipulative therapy reduced disability by 6 points (95% CI 1 to 12) on a 100-point disability questionnaire when compared with NSAIDs. It is concluded that spinal manipulation does not produce clinically worthwhile decreases in pain compared with sham treatment, and does not produce clinically worthwhile reductions in disability compared with NSAIDs for patients with chronic low back pain. It is not clear whether spinal manipulation is more effective than NSAIDs in reducing pain of patients with chronic low back pain.     

Patient positioning and spinal locking for lumbar spine rotation manipulation

High velocity low amplitude (HVLA) thrust techniques are widely used by many manual therapists to treat low back pain. There is increasing evidence that spinal manipulation produces positive patient outcomes for acute low back pain. HVLA thrust techniques are associated with an audible release in the form of a pop or cracking sound that is widely accepted to represent cavitation of a spinal zygapophyseal joint. This audible release distinguishes these techniques from other manual therapy interventions. When using long lever HVLA thrust techniques spinal locking is necessary to localize forces and achieve cavitation at a specific vertebral segment. A critical factor in applying lumbar spine manipulation with minimal force is patient positioning and spinal locking. A knowledge of coupled movements of the lumbar spine aids an understanding of the patient positioning required to achieve spinal locking consistent with maximal patient comfort and cooperation. Excessive rotation can result in pain, patient resistance and failed technique. This masterclass presents a model of patient positioning for the lumbar spine that minimizes excessive use of rotation to achieve spinal locking prior to the application of the thrust.     

Manual therapy with or without physical medicine modalities for neck pain: a systematic review

Manual therapy interventions are often used with or without physical medicine modalities to treat neck pain. This review assessed the effect of 1) manipulation and mobilisation, 2) manipulation, mobilisation and soft tissue work, and 3) manual therapy with physical medicine modalities on pain, function, patient satisfaction, quality of life (QoL), and global perceived effect (GPE) in adults with neck pain. A computerised search for randomised trials was performed up to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (RR) and standardised mean differences (SMD) were calculated when possible. We included 19 trials, 37% of which had a low risk of bias. Moderate quality evidence (1 trial, 221 participants) suggested mobilisation, manipulation and soft tissue techniques decrease pain and improved satisfaction when compared to short wave diathermy, and that this treatment combination paired with advice and exercise produces greater improvements in GPE and satisfaction than advice and exercise alone for acute neck pain. Low quality evidence suggests a clinically important benefit favouring mobilisation and manipulation in pain relief [1 meta-analysis, 112 participants: SMD ?0.34(95% CI: ?0.71, 0.03), improved function and GPE (1 trial, 94 participants) for participants with chronic cervicogenic headache when compared to a control at intermediate and long term follow-up; but no difference when used with various physical medicine modalities.     

The efficacy of chiropractic manipulation for back pain: blinded review of relevant randomized clinical trials.

OBJECTIVE: To assess the efficacy of chiropractic for patients with back pain. DATA SOURCES: Randomized clinical trials (RCTs) on spinal manipulation were identified with a Medline search (1966-1990), by citration tracking, and by manual examination of the relevant chiropractic reference systems [Chiropractic Research Archives Collection and Index to Chiropractic Literature]. [Indexing terms, Medline; backache, musculoskeletal diseases, manipulation, osteopathy or chiropractic in combination with evaluation studies, outcome and process assessment, prospective studies, comparative studies, clinical trials or double blind method. Indexing terms, Chiropractic Research Archives Collection: backache therapy-chiropractic clinical trials, cost benefit analysis, evaluation studies--chiropractic, manipulation--spinal, prospective studies, sciatica-therapy. Indexing terms, Index to Chiropractic Literature, backache therapy, clinical trials, cost benefit analysis, intervertebral disc displacement-therapy.] STUDY SELECTION: All RCTs involving chiropractors as therapists. To find additional evidence from nonchiropractic RCTs, chiropractic standards similar to the type of treatment used in nonchiropractic trials were determined by a panel of blinded chiropractors. DATA EXTRACTION: Review by two blinded reviewers independently, using a list of methodological criteria, each of which was attached to a weight. The maximum was set at 100 points. DATA SYNTHESIS: We identified five chiropractic RCTs. No similarity to chiropractic standards could be detected in any of the nonchiropractic RCTs. No chiropractic RCT had a methodological score of more than 50 points. The authors of four of the trials report favorable results for chiropractic, while one refrains from drawing conclusions. The results of the chiropractic RCTs differed on the timing of maximal effect as well as on the subgroups showing the best treatment results. CONCLUSIONS: Although the small number of chiropractic RCTs and the poor general methodological quality precludes the drawing of strong conclusions, chiropractic seems to be an effective treatment of back pain. However, more studies with a better research methodology are clearly still needed.     

Effectiveness of manual therapy in the treatment of non-specific neck pain: a review

Abstract

The aim of the current review was to assess the evidence for the effectiveness of cervical spine manipulation and mobilisation in the treatment of non-specific neck pain. A review of the literature was performed in a systematic format, based upon a structured search of six computerised bibliographic databases, together with manual searching of selected journals and reference lists to identify randomised clinical trials (RCTs) researching the effectiveness of manual therapy in the treatment of non-specific neck pain. The methodological quality of the studies was assessed using a set of pre-defined criteria adapted from Koes et al. (Koes BW, Assendelft WJJ, van der Heijden GJMG, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ 1991; 303 :1298–303) and updated in the light of recent literature.

A total of 12 RCTs met the selection criteria. The scores achieved for methodological quality of the studies ranged from 25 points to 67 points out of a possible 100 points. Only four RCTs scored above 50 points: two of these reached a positive conclusion about the effectiveness of spinal manual therapy in the treatment of non-specific neck pain, and two a negative conclusion. Eight RCTs scored below 50 points; six of these reached a positive conclusion and two a negative conclusion.

RCTs researching the effectiveness of manual therapy for non-specific neck pain demonstrate methodological shortcomings in both design and reporting. The effectiveness of spinal manual therapy on non-specific neck pain remains inconclusive. The available evidence favoured spinal manual therapy when it was used in conjunction with exercise, particularly in the treatment of patients with chronic non-specific neck pain. Further, well-designed RCTs are needed to draw valid conclusions about the effectiveness of spinal manual therapy on nonspecific neck pain. In such future RCTs, placebo treatments should be designed to be indistinguishable (as far as possible) from manual therapy, and without the specific effects of active therapy. Furthermore, psychosocial factors should be considered prior to randomisation of patients by using appropriate measures.     

Spinal manipulation: a systematic review of sham-controlled, double-blind, randomized clinical trials

For many years, spinal manipulation has been a popular form of treatment. Yet the debate about its clinical efficacy continues. The research question remains: Does spinal manipulation convey more than a placebo effect? To summarize the evidence from sham-controlled clinical trials of spinal manipulation as a treatment of various conditions, and to assess the methodological quality of these studies, a comprehensive search strategy was designed to locate all sham-controlled, double-blind, randomized trials of spinal manipulation as a treatment of any medical condition. Data were extracted from these trials and validated by two independent reviewers in a standardized fashion. All trials were critically analyzed and their methodological quality evaluated. Eight studies fulfilled the pre-defined inclusion/exclusion criteria. Three trials (two on back pain and one on enuresis) were judged to be burdened with serious methodological flaws. The results of the three most rigorous studies (two on asthma and one on primary dysmenorrhea) do not suggest that spinal manipulation leads to therapeutic responses which differ from an inactive sham-treatment. This analysis demonstrates that sham-controlled trials of spinal manipulation are sparse but feasible. The most rigorous of these studies suggest that spinal manipulation is not associated with clinically-relevant specific therapeutic effects.