Assessing the effect of sample size, methodological quality and statistical rigour on outcomes of randomised controlled trials on mobilisation, manipulation and massage for low back pain of at least 6 weeks duration

Objectives

To assess the effect of sample size, methodological quality and statistical rigour on outcomes of randomised controlled trials (RCTs) on manual therapy (i.e. manipulation, mobilisation and/or massage) for non-specific low back pain (LBP) of at least 6 weeks duration, and to report results from RCTs with adequate sample size, methodological quality and statistical rigour.

Data sources

MedLine, EMBASE, CINAHL, AMED, Cochrane, PEDro and the library collection of the Chartered Society of Physiotherapy.

Review methods

RCTs were identified that compared manual therapy with a control or alternative intervention in adults with non-specific LBP of at least 6 weeks duration. The sample size, methodological quality (adapted 10-point van Tulder scale) and statistical rigour were then assessed. RCTs were regarded as higher quality if they fulfilled the following three criteria: (a) >40 subjects in the manual therapy group; (b) scoring >5/10 on the Van Tulder scale; and (c) reporting statistical tests that compared the change in the intervention group with the change in the control group.

Results

Ten RCTs were included in the review but only two qualified as higher quality RCTs. Results from smaller trials and lower quality RCTs showed more variation in differences between the intervention and control groups than larger or higher quality trials. Evidence from large, high-quality RCTs with adequate statistical analyses showed that, for improvement in pain and function, a mobilisation/manipulation package is an effective intervention [compared with general practitioner (GP) care], whilst manipulation used in isolation showed no real benefits over sham manipulation or an alternative intervention. No higher quality evidence considering massage was identified.

Conclusions

Many RCTs in the area of manual therapy for LBP have shortcomings in sample size, methodological quality and/or statistical rigour, but there remains evidence from higher quality RCTs to support the use of a manual therapy package, compared with GP care, for non-specific LBP of at least 6 weeks duration.     

Effectiveness of trigger point dry needling for multiple body regions: a systematic review

Background: Trigger point dry needling (TDN) is commonly used to treat musculoskeletal pain related to myofascial trigger points (MTrPs). To date, no systematic review of high-quality randomised controlled trials (RCTs) investigating TDN to multiple body regions exists.

Purpose: The aim of this review is to determine the effectiveness of TDN based on high-quality RCTs for all body regions.

Methods: To ensure thorough reporting, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed as the methodological basis for this systematic review. PubMed, Physiotherapy Evidence Database (PEDro), Cinahl, Cochrane and reference lists were searched for the years 2000–2014 and the terms ‘TDN’, ‘dry needling NOT trigger point’, ‘functional dry needling’ and ‘intramuscular manual therapy’. Inclusion criteria: RCTs with PEDro scores 6–10 investigating TDN. Exclusion criteria: duplicates, non-human participants, non-English language, exclusive focus on acupuncture or medicinal injections. Three investigators searched databases, applied criteria, read and assigned PEDro scores to every RCT. Nineteen studies met the criteria. As compared to either baseline or control groups, significant differences were found for pain (14 studies), range of motion (ROM) (five studies) and at least one item on function and quality of life measures (six studies).

Limitations: This review was limited by inclusion criteria, timeframe, language and databases searched.

Conclusion: The majority of high-quality studies included in this review show measured benefit from TDN for MTrPs in multiple body areas, suggesting broad applicability of TDN treatment for multiple muscle groups. Further high-quality research is warranted to standardise TDN methods to determine clinical applicability.     

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.     

Work Motivating Factors in Rehabilitation: A Brief Review

Abstract

Background: Back pain is a common condition for which chiropractic treatment is often recommended.

Aim: To evaluate critically the evidence for or against the effectiveness of chiropractic spinal manipulation for back pain.

Data sources: Five independent literature searches were carried out and bibliographies were searched.

Study selection: Only randomised clinical trials of chiropractic spinal manipulation with patients suffering from back pain were included.

Data extraction: The authors extracted data on trial design, methodological quality, sample size, patient characteristics, nature of intervention, outcome measures, follow-up and results.

Main results: Twelve studies could be included. They related to all forms of back pain. Many trials had significant methodological shortcomings. Some degree of superiority of chiropractic spinal manipulation over control interventions was noted in 5 studies. More recent trials and those with adequate follow-up periods tended to be negative.

Conclusions: The effectiveness of chiropractic spinal manipulation is not supported by compelling evidence from the majority of randomised clinical trials.     

Barriers to Compliance With Evidence-Based Clinical Practice Guidelines

Abstract

Study design: Systematic literature review and meta-analysis.

Objective: In symptomatic subjects to: (1) examine the effects of a single session of joint mobilization on pain at rest and with most painful movement, and (2) compare the effects when joint mobilization is provided to a specific or non-specific spinal level.

Background: Joint mobilization is routinely used for treating spinal pain in conjunction with other interventions, but its unique effect is not well understood. Further, there is controversy about the role of ‘specific level’ techniques in producing benefit.

Methods: Searches were performed for randomized controlled trials (RCTs) using electronic databases (MEDLINE, CINAHL, and PEDro) from 1966 through November 2010. Methodological quality was assessed using previously detailed criteria. Meta-analysis and meta-regression were conducted on eligible studies.

Results: Eight RCTs with a mean methodological score of 10/12 were included. Significant heterogeneity (P?=?0·075) was found in the overall meta-analysis estimate. When stratified by body location, no significant individual effect was found for pain at rest. However, there was a statistical mean difference [0·71 (95% confidence interval: 0·13–1·28)] between pain at rest for the cervical and lumbar individual means.

Conclusions: We found multiple studies which provided evidence that a single session of joint mobilization can lead to a reduction of pain at rest and with most painful movement. When using joint mobilization, the need for specific versus non-specific level mobilization may be influenced by anatomical region; the direction of effect in the cervical spine was toward specific mobilization and in the lumbar spine towards non-specific mobilization.     

The influence of home exercise programs for patients with non-specific or specific neck pain: a systematic review of the literature

Abstract

Study design: Systematic review of randomized controlled trials (RCT).

Objectives: To examine the effects of a therapeutic home exercise program (HEP) for patients with neck pain (associated with whiplash, non-specific, or specific neck pain, with or without radiculopathy, or cervicogenic headache) on pain, function, and disability. Our secondary aim was to describe the design, dosage, and adherence of the prescribed HEPs.

Background: Neck pain is a leading cause of disability that affects 22–70% of the population. Different techniques have been found effective for the treatment of neck pain. However, there is conflicting evidence to support the role of a therapeutic HEP to reduce pain, disability, and improve function and quality of life (QOL).

Methods: A systematic review in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement for reporting systematic reviews. The full-text review utilized the Maastricht–Amsterdam assessment tool to assess quality among RCTs.

Results: A total of 1927 subjects included within seven full-text articles met our specific search strategy. It was found that HEPs with a focus on strength and endurance-training exercises, as well as self- mobilization, have a positive effect when used in combination with other conservative treatments or alone.

Conclusions: Home exercise programs that utilize either self-mobilizations within an augmented HEP to address specific spinal levels, or strengthening, and/or endurance exercise are effective at reducing neck pain, function, and disability and improving QOL. The benefit of HEPs in combination with other conservative interventions yields some benefit with a range of effect sizes.     

The effect of vibration therapy on neck myofascial trigger points: A randomized controlled pilot study

BackgroundThe purpose of this study was to evaluate the effect of low-frequency self-administered vibration therapy into myofascial trigger points in the upper trapezius and levator scapulae on patients with chronic non-specific neck pain.MethodsTwenty-eight patients with chronic non-specific neck pain were randomly assigned into a vibration group, receiving 10 self-applied sessions of vibration therapy in the upper trapezius and levator scapulae trigger points; or a control group, receiving no intervention. Self-reported neck pain and disability (Neck Disability Index) and pressure pain threshold were assessed at baseline and after the first, fifth and 10th treatment sessions.FindingsSignificant differences were found in the vibration group when compared to the control group after the treatment period: the vibration group reached lower Neck Disability Index scores (F = 4.74, P = .033, η² = 0.07) and greater pressure pain threshold values (F = 7.56, P = .01, η² = 0.10) than the control group. The vibration group reported a significant reduction in Neck Disability Index scores (χ2 = 19,35, P = .00, Kendall's W = 0.28) and an increase in pressure pain threshold (χ2 = 87,10, P = .00, Kendall's W = 0.73) between the assessment times over the course of the treatment. The mean increase in pressure pain threshold in the vibration group after the 10 sessions was 8.54 N/cm2, while the mean reduction in Neck Disability Index scores was 4.53 points.InterpretationVibration therapy may be an effective intervention for reducing self-reported neck pain and disability and pressure pain sensitivity in patients with chronic non-specific neck pain. This tool could be recommended for people with non-specific neck pain.     

Thoracic manual therapy in the management of non-specific shoulder pain: a systematic review

ObjectivesNon-specific shoulder pain (NSSP) is often persistent and disabling leading to high socioeconomic costs. Cervical manipulation has demonstrated improvements in patients with NSSP, although risks associated with thrust techniques are documented. Thoracic manual therapy (TMT) may utilise similar neurophysiological effects with less risk. The current evidence for TMT in treating NSSP is limited to systematic reviews of manual therapy (MT) applied to the upper quadrant. These reviews included trials that used shoulder girdle manual therapy (SG-MT) in the TMT group. This limits the scope of their conclusions with regard to the exclusive effectiveness of TMT for NSSP.MethodsThis review used a steering group for subject and methodological expertise and was reported in line with Preferred Reporting items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Key databases were searched (1990–2014) using relevant search terms and medical subject headings (MeSH); eligibility was evaluated independently by two reviewers based on pre-defined criteria. Study participants had NSSP including impingement syndrome and excluding cervical pain. Interventions included cervicothoracic junction and TMT with or without supplementary exercises. Studies that included MT applied to the shoulder girdle including the glenohumeral joint, acromioclavicular joint or sternoclavicular joint in the TMT group, without a control, were excluded. Included studies utilised outcome measures that monitored pain and disability scores. Randomized controlled trials (RCTs) and clinical studies were eligible. Using a standardised form, each reviewer independently extracted data. Risk of bias was assessed using GRADE and PEDro scale. Results were tabulated for semi-quantitative comparison.ResultsOver 912 articles were retrieved: three RCTs, one single-arm trial and three pre–post test studies were eligible. Studies varied from poor to high quality. Three RCTs demonstrated that TMT reduced pain and disability at 6, 26 and 52 weeks compared with usual care. Two pre–post test studies found between 76% and 100% of patients experienced significant pain reduction immediately post-TMT. An additional pre–post test study and a single-arm trial showed reductions in pain and disability scores 48 hours post-TMT.DiscussionThoracic manual therapy accelerated recovery and reduced pain and disability immediately and for up to 52 weeks compared with usual care for NSSP. Further, high-quality RCTs investigating the effect of TMT in isolation for the treatment of patients with NSSP are now required.     

Low reproducibility of randomized clinical trials methodology related to sampling: a systematic methodological review

Objectives: The reporting of sampling methods in Randomized Clinical Trials (RCTs) allows for research quality assessment, determination of sampling bias, and assures the presence of details necessary for reproducibility in future trials. The purpose of this study was to: (1) determine if sampling methodology was reproducible in RCTs related to musculoskeletal physical therapy (MSKPT) interventions to treat non-specific low back pain (NSLBP) and (2) establish if there was a relationship between sample reproducibility and established measures of research quality.

Methods: Data were collected through a systematic review by a professional librarian. The identified RCTs were assessed for methodological quality by two blinded individual reviewers. Data analysis was performed by a third, blinded researcher; additional comparisons were made based on Journal Impact Factor and PEDro score.

Results: Ninety-nine published peer-reviewed RCTs were identified that met inclusion criteria. Only 29% of the articles were judged to be reproducible based on the reported sampling methodology. There were meaningful correlations between two out of ten of the sampling reporting criteria and the judgement made if the sample was reported in significant detail to allow for replication. There was no relationship between sampling reporting criteria, Journal Impact Factors (JIFs), and Physiotherapy Evidence Database (PEDro) scores.

Discussion: The reporting of sampling methodology needs to be considered to ensure reproducibility and avoid sampling bias. Despite the proliferation of measures of research quality, the overall reporting quality of RCTs continues to be inadequate to allow widespread reproducibility of trials.

Level of Evidence: 1a     

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.     

Chiropractic Care of Adults With Postpartum-Related Low Back,Pelvic Girdle,or Combination Pain: A Systematic Review

ObjectiveThe purpose of this study was to conduct a systematic review (SR) of the literature to assess the effectiveness of specific chiropractic care options commonly used for postpartum low back pain (LBP), pelvic girdle pain (PGP), or combination (LBP and PGP) pain.MethodsA search strategy was developed. Interventions were those manual or other nonpharmacologic therapies commonly used by chiropractors (not requiring additional certifications). The outcomes were self-reported changes in pain or disability self-reported outcomes. We used the Scottish Intercollegiate Guideline Network checklists. Strength of the evidence (excluding cohort studies) was determined using an adapted version of the US Preventive Services Task Force criteria as described in the UK report.ResultsOf the 1611 published articles, 16 were included. These were 5 SRs, 10 randomized controlled trials (RCTs), and 1 cohort study. Postpartum LBP (1 RCT): moderate, favorable strength for spinal manipulation therapy/mobilization. Postpartum PGP (4 RCTs): moderate, unclear strength for exercise; and inconclusive, unclear strength for patient education. Postpartum LBP or PGP (3 SRs and 4 RCTs): inconclusive, unclear strength for exercise, self-management, and physiotherapy; while osteopathic manipulative therapy was inconclusive, favorable.ConclusionNo treatment option was identified as having sufficient evidence to make a clear recommendation. This SR identified a scarcity of literature regarding chiropractic care and back pain for postpartum women, as well as inconsistency among the terms LBP, PGP, and combination pain.     

Exercise and manual therapy for the treatment of impingement syndrome of the shoulder: a systematic review

Abstract

'Impingement syndrome' is a generic term for rotator cuff lesions encompassing all stages of tendon disease. The fundamental aim of this review was to assess whether the quality of randomised controlled trials (RCTs) on this specific topic has improved during the last 3 years. A computer-aided search of databases was carried out from 2003 to 2005, using a combination of key words. Five RCTs were critically appraised using the PEDro scale and the American College of Sports and Medicine guidelines. The mean quality score of the included trials was 6.2, ranging from 4 to 8 points out of a possible 10. There is moderate evidence that supports the use of therapeutic exercises alone in reducing pain and function, whereas there is limited evidence to support the effectiveness of both manual and exercise therapy in combination. Future studies should better define impingement syndrome, based upon well-designed research methodology and the use of validated measurement tools.     

Physical therapy management of pediatric and adolescent neck pain: a call to action

Abstract

Background: Neck pain is reported to be as high as 40% in adolescents and can be a precursor to developing adult persistent neck pain.

Objectives: To identify and review literature on physical therapy management of pediatric and adolescent neck pain.

Methods: A sensitive search strategy adhered to PRISMA guidelines. Our systematic review used the databases PubMed, CINAHL, and Embase including articles published from inception to May 2019. For the article to be included, it had to meet the following criteria: (a) age under 18?years old; (b) musculoskeletal neck pain; (c) any intervention or treatment provided by physical therapists; (d) English language; (e) any outcome measure that reported disability, function, or pain; (f) any and all published literature: randomized controlled trials (RCTs), systematic reviews, cohort studies, case reports, editorials, and commentaries.

Results: Our comprehensive search yielded 5,115 articles and two studies met eligibility. Both articles were written by the same author group. The articles investigated the effect of pain neuroscience education (PNE) plus deep neck muscle strengthening in twenty-one students ages 15-18?years old with chronic idiopathic neck pain. The results concluded there may be some benefit to PNE plus deep neck flexor and extensor strength.

Conclusions: The main finding of this systematic review is the paucity of published research on physical therapy management of pediatric and adolescent neck pain. Our systematic review serves as a call to action for physical therapists to perform further research in order to provide the best evidence-based care for this population.     

Quality Assessment of Trials: A Comparison of Three Criteria Lists

Abstract

Objective. The conclusion of a systematic review depends on the quality of the individual studies included. This article presents the results of a qualitative comparison using three different methods of quality assessment.

Method. A data set of 21 randomised clinical trials (RCTs) from a systematic review concerning the efficacy of laser therapy in patients with musculoskeletal disorders is used. The criteria lists to assess the methodological quality were the 'Maastricht' list, the 'Jadad' list and the 'Delphi' list.

Results. The three criteria lists show moderate to good correlation. Major differences between the lists are the number of items, and differences in wording of the items seem to affect the ranking of the studies.

Conclusion. Based on our results, we conclude that the Delphi list seems the most practical and satisfactory instrument for quality assessment of RCTs.     

Manuelle Triggerpunktbehandlung gegen Kopfschmerzen

Background

Tension type headache (TTH) is a common health problem and elicits a considerable socio-economic burden. It has been shown that patients with TTH have more myofascial trigger points (mTrP) in the neck and shoulder region.

Aim

Primary studies were investigated with respect to the effectiveness of manual mTrP treatment of TTH.

Material and methods

A systematic literature review was undertaken in Medline, AMED, Cochrane, CINAHL, PEDro and Academic Journal Databases. A total of five studies fulfilled the inclusion criteria and were analyzed according to the methodological quality. Studies with homogeneous data were pooled for a meta-analysis.

Results

The meta-analysis revealed a small treatment effect of manual mTrP therapy in the neck and shoulder region in comparison to placebo or no therapy for pain intensity. There were either insufficient or methodologically reduced evidence for other pain outcomes.     

The effectiveness of manual therapy in the management of musculoskeletal disorders of the shoulder: A systematic review

A systematic review of randomised controlled trials (RCTs) was conducted to determine the effectiveness of manual therapy (MT) techniques for the management of musculoskeletal disorders of the shoulder. Seven electronic databases were searched up to January 2007, and reference lists of retrieved articles and relevant MT journals were screened. Fourteen RCTs met the inclusion criteria and their methodological qualities were assessed using the PEDro scale. Results were analyzed within diagnostic subgroups (adhesive capsulitis (AC), shoulder impingement syndrome [SIS], non-specific shoulder pain/dysfunction) and a qualitative analysis using levels of evidence to define treatment effectiveness was applied. For SIS, there was no clear evidence to suggest additional benefits of MT to other interventions. MT was not shown to be more effective than other conservative interventions for AC, however, massage and Mobilizations-with-Movement may be useful in comparison to no treatment for short-term outcomes for shoulder dysfunction.     

Differential Diagnosis and Treatment of Chronic Neck and Upper Trapezius Pain and Upper Extremity Paresthesia: A Case Study Involving the Management of an Elevated First Rib and Uncovertebral Joint Dysfunction

Abstract

Diagnosis and effective treatment of patients presenting with cervicobrachial symptoms are often challenging due to the large number of potential pain sources and the high degree of convergence of sensory afference in the cervical region. A 42-year-old female presented in the clinic with a six-month history of neck pain, upper trapezius pain, and upper extremity paresthesia. A careful history, specific functional examination, and selected special tests led to diagnosis-specific orthopedic manual therapy management of this patient. The patient fully recovered within 6 physical therapy treatment sessions, which included management of an elevated first rib, double-crush phenomenon, uncovertebral joint dysfunction, and careful ergonomic intervention with home instructions. Although controlled trials are needed to evaluate the effectiveness of these techniques and allow generalizability of such interventions, the recovery of this patient suggests the efficacy of manual techniques and ergonomic intervention in the management of uncovertebral joint dysfunction and thoracic outlet syndrome associated with a double-crush phenomenon.     

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.     

Chiropractic Care for Adults With Pregnancy-Related Low Back,Pelvic Girdle Pain,or Combination Pain: A Systematic Review

ObjectiveThe purpose of this study was to conduct a systematic review (SR) of the literature to assess the effectiveness of chiropractic care options commonly used for pregnancy-related low back pain (LBP), pelvic girdle pain (PGP), or combination pain for both experienced practitioners and students of chiropractic.MethodsWe included procedures that were commonly used by chiropractors and not requiring additional certifications. Outcomes were self-reported changes in pain or disability. We used the Scottish Intercollegiate Guideline Network checklists to assess outcomes. For strength of evidence, we used the adapted version of the US Preventive Services Task Force criteria as described in the UK report.ResultsFifty articles were included from 18 SRs, 30 randomized controlled trials (RCTs), and 2 cohort studies. Pregnancy LBP (7 SRs and 12 RCTs): moderate, favorable evidence for electrotherapy and osteopathic manipulative therapy; inconclusive, favorable strength for chiropractic care, exercise, and support devices; and inconclusive, unclear strength for spinal manipulative therapy. Pregnancy PGP (4 SRs and 4 RCTs): inconclusive, favorable strength for exercise; and inconclusive, unclear evidence for patient education, information, and support devices. Pregnancy LBP or PGP (13 SRs and 12 RCTs): moderate, unclear evidence for complementary and alternative medicine; moderate, unclear evidence for exercise; inconclusive, favorable evidence for multimodal care, patient education, and physiotherapy; and inconclusive, unclear strength for spinal manipulative therapy, osteopathic manipulative therapy, and support devices.ConclusionAlthough there is a lack of conclusive evidence, many of the interventions have moderate or unclear but favorable evidence.     

Manual therapy directed at the knee or lumbopelvic region does not influence quadriceps spinal reflex excitability

Manual therapies, directed to the knee and lumbopelvic region, have demonstrated the ability to improve neuromuscular quadriceps function in individuals with knee pathology. It remains unknown if manual therapies may alter impaired spinal reflex excitability, thus identifying a potential mechanism in which manual therapy may improve neuromuscular function following knee injury.AimTo determine the effect of local and distant mobilisation/manipulation interventions on quadriceps spinal reflex excitability.MethodsSeventy-five individuals with a history of knee joint injury and current quadriceps inhibition volunteered for this study. Participants were randomised to one of five intervention groups: lumbopelvic manipulation (grade V), lumbopelvic manipulation positioning (no thrust), grade IV patellar mobilisation, grade I patellar mobilisation, and control (no treatment). Changes in spinal reflex excitability were quantified by assessing the Hoffmann reflex (H-reflex), presynaptic, and postsynaptic excitability. A hierarchical linear-mixed model for repeated measures was performed to compare changes in outcome variables between groups over time (pre, post 0, 30, 60, 90 min).ResultsThere were no significant differences in H-reflex, presynaptic, or postsynaptic excitability between groups across time.ConclusionsManual therapies directed to the knee or lumbopelvic region did not acutely change quadriceps spinal reflex excitability. Although manual therapies may improve impairments and functional outcomes the underlying mechanism does not appear to be related to changes in spinal reflex excitability.