Evidence you
can follow.
Go from a question to a guide.
From a guide to the original research.
For curious patients and fellow practitioners: a selection of the publications behind what we write. We include the studies that call a treatment into question as well as the ones that support it.
Find a publication146 publications
Research, with context.
Selected published sources behind what we've written, each with what it found and what it can't tell us. We give you both halves because no paper can diagnose you or predict how your own care will go.
Risk factors for cervical artery dissection: a systematic review with meta-analysis
128 study reports of people with cervical artery dissection and control groups, 54 of them with healthy controls, searched to September 2024.
What it foundMigraine was among the identified risk factors for a neck artery tear, with moderate-certainty evidence, along with genetic, cardiovascular and infection-related factors and minor trauma.
What it can't tell usMost studies were case-control designs at high risk of bias, and certainty was low or very low for every factor except migraine and MTHFR TT homozygosity.
Publication details & citation
Jacobs et al. Risk factors for cervical artery dissection: a systematic review with meta-analysis. Stroke and Vascular Neurology. 2026. DOI: 10.1136/svn-2025-004186.
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Efficacy of extracorporeal shock wave therapy combined with conventional physical therapy for chronic low back pain: a systematic review and network meta-analysis of randomized controlled trials
Randomized trials of adults with chronic low-back pain, comparing shock wave therapy, conventional physical therapy, the two combined, and sham; 14 reported pain and 8 reported function.
What it foundThe combination of shock wave therapy and physical therapy ranked first for pain and function and did better than physical therapy alone. Shock wave therapy alone reduced pain more than sham but showed no significant effect on function.
What it can't tell usThe authors call for more high-quality trials before the finding is settled. Devices and doses varied across the trials; the result doesn't describe StemWave or any single device.
Publication details & citation
Qiao et al. Efficacy of extracorporeal shock wave therapy combined with conventional physical therapy for chronic low back pain: a systematic review and network meta-analysis of randomized controlled trials. Frontiers in Physiology. 2026. DOI: 10.3389/fphys.2026.1807929.
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Chiropractic Management of Adults with Cervicogenic or Tension-Type Headaches: Development of a Clinical Practice Guideline
31 systematic reviews and 1 clinical practice guideline (2017 to August 2023) on non-drug care for adults with cervicogenic or tension-type headache, with recommendations agreed by a 57-member Delphi panel (55 doctors of chiropractic, one medical physician, one pharmacist).
What it foundRecommends offering spinal manipulation for cervicogenic headache (high-certainty evidence, strong recommendation), with dry needling and therapeutic exercise as options. For tension-type headache it recommends manipulation only as part of combined care with joint mobilization, soft-tissue techniques or modalities.
What it can't tell usA consensus guideline whose panel was almost all chiropractors, for adults only. Certainty was low or moderate for several treatments, and it doesn't cover migraine.
Publication details & citation
Trager et al. Chiropractic Management of Adults with Cervicogenic or Tension-Type Headaches: Development of a Clinical Practice Guideline. Journal of Integrative and Complementary Medicine. 2026. DOI: 10.1177/27683605251397769.
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Comparison of the effectiveness of high-intensity laser therapy versus low-level laser therapy in musculoskeletal disorders: a systematic review and network meta-analysis
22 randomized trials with 1,353 people with muscle and joint disorders, comparing high-intensity laser with low-level laser, placebo laser or other treatments.
What it foundHigh-intensity laser reduced pain a little more than low-level laser in some comparisons, especially alongside exercise or other physical therapy.
What it can't tell usThe differences were generally modest and often smaller than the change considered clinically important, and the certainty of the evidence was mostly very low. The authors advise caution and placing laser within a broader rehabilitation plan.
Publication details & citation
de la Barra Ortiz et al. Comparison of the effectiveness of high-intensity laser therapy versus low-level laser therapy in musculoskeletal disorders: a systematic review and network meta-analysis. Lasers in Medical Science. 2026. DOI: 10.1007/s10103-026-04812-9.
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Is There Any Difference Between High-Intensity Laser and Low-Level Laser in the Treatment of Tennis Elbow? A Meta-analysis of Randomized Controlled Trials
12 randomized trials of high-intensity or low-level laser therapy for tennis elbow.
What it foundPain improved from baseline with both high-intensity and low-level laser, function and grip strength improved with both, high-intensity laser showed the greater gains in grip strength and low-level laser the more consistent results for pain.
What it can't tell usHigh-intensity laser's advantage over placebo for pain wasn't statistically significant. Improvement measured against baseline doesn't separate the laser's effect from recovery over time.
Publication details & citation
Zhang et al. Is There Any Difference Between High-Intensity Laser and Low-Level Laser in the Treatment of Tennis Elbow? A Meta-analysis of Randomized Controlled Trials. American Journal of Physical Medicine & Rehabilitation. 2026. DOI: 10.1097/PHM.0000000000002834.
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Effect of Local Laser Therapy on Plantar Fasciitis: A Meta-Analysis
13 randomized trials, 784 participants with plantar fasciitis, comparing laser therapy with placebo or other physical treatments.
What it foundLaser therapy may reduce heel tenderness. It showed no significant difference in overall pain, function or the thickness of the plantar fascia.
What it can't tell usThe trials mixed low-level and high-intensity lasers, and the pain and function results were highly inconsistent between trials. The authors say laser should be considered an add-on, not a primary treatment; the result doesn't describe any one device.
Publication details & citation
Ortiz-Romero et al. Effect of Local Laser Therapy on Plantar Fasciitis: A Meta-Analysis. Journal of Clinical Medicine. 2026. DOI: 10.3390/jcm15031307.
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Efficacy of High-Intensity Laser Therapy Combined With Plantar Fascia Stretching Exercises in the Treatment of Plantar Fasciitis: Randomized, Double-Blind, Sham-Controlled Trial
36 people with plantar fasciitis in one foot (34 completed), given nine sessions of high-intensity or sham laser over three weeks, all doing the same plantar fascia and Achilles stretching program.
What it foundBoth groups improved in pain, foot function and fascia thickness, with no significant difference between real and sham laser. No adverse events were reported with real laser.
What it can't tell usA small, single-center trial of one laser protocol, with outcomes measured right after the three weeks of treatment, so how long any effect lasts is unknown.
Publication details & citation
Jitpimolmard et al. Efficacy of High-Intensity Laser Therapy Combined With Plantar Fascia Stretching Exercises in the Treatment of Plantar Fasciitis: Randomized, Double-Blind, Sham-Controlled Trial. JMIR Rehabilitation and Assistive Technologies. 2026. DOI: 10.2196/77419.
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Chiropractic spinal manipulative therapy versus physical therapist-led exercise and the risk of cauda equina syndrome in adults with lumbar disc herniation, stenosis, or radiculopathy
34,376 matched pairs of US adults with lumbar disc herniation, spinal stenosis or radiculopathy in a health-records research network, 2005 to 2025, excluding people with existing cauda equina syndrome, incontinence, serious spinal pathology or recent spine surgery or injection, comparing spinal manipulation by a chiropractor with physical therapist-led exercise.
What it foundThe study did not identify an association between spinal manipulation and a higher risk of cauda equina syndrome (risk ratio 0.88, 95% CI 0.43 to 1.79). Bladder catheterization and fecal incontinence were less common in the manipulation group.
What it can't tell usA records study shows association, not cause, depends on how diagnoses were coded, and the confidence interval is wide. One author reports royalties from books on sciatica. A letter to the journal and the authors' reply were published in August 2026.
Publication details & citation
Trager et al. Chiropractic spinal manipulative therapy versus physical therapist-led exercise and the risk of cauda equina syndrome in adults with lumbar disc herniation, stenosis, or radiculopathy. PM&R. 2026. DOI: 10.1002/pmrj.70071.
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Association between spinal manipulative therapy and cervical artery dissection in patients with neck pain or headache: a retrospective cohort study
431,492 adults per group with a new episode of neck pain or headache in US health records (2010-2025), given chiropractic neck manipulation or an outpatient visit with an ibuprofen prescription.
What it foundNo evidence of a higher risk of cervical artery dissection within 30 days after chiropractic neck manipulation than after an ibuprofen-prescribed visit; overall risk was lower, and vertebral artery dissection risk was not significantly different.
What it can't tell usAn observational records study: negative control outcomes were only partially balanced, and the authors call for more research on subgroups such as migraine and on stroke.
Publication details & citation
Trager et al. Association between spinal manipulative therapy and cervical artery dissection in patients with neck pain or headache: a retrospective cohort study. Chiropractic & Manual Therapies. 2026. DOI: 10.1186/s12998-026-00678-4.
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Therapist delivered massage for Veterans with chronic neck pain: a randomized control trial
290 veterans with chronic neck pain, assigned twice-weekly 60-minute sessions with a massage therapist for 12 weeks or a waitlist.
What it foundMassage reduced neck disability at 1 and 3 months and pain severity at 1, 3 and 6 months more than the waitlist. At 3 months, 43% versus 15% had a clinically meaningful drop in pain.
What it can't tell usThe comparison was a waitlist, not a sham or another treatment, and only 15% of participants were women. The authors call the 6-month results less robust and suggest longer treatment or booster sessions.
Publication details & citation
Munk et al. Therapist delivered massage for Veterans with chronic neck pain: a randomized control trial. Pain Medicine. 2026. DOI: 10.1093/pm/pnaf118.
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Common Mechanisms in Migraine, Migraine-Related Neck Pain, and Low Back Pain: Implications for Treatment
Clinical and neurophysiological studies of migraine, migraine-related neck pain and low back pain.
What it foundThe three conditions share central pain-processing mechanisms; in migraine, the evidence for exercise-based rehabilitation and CGRP-targeted medicines appeared stronger than for manual therapy approaches.
What it can't tell usA narrative review without a formal grading of the evidence, and two authors report travel or consulting payments from drug companies.
Publication details & citation
Onan et al. Common Mechanisms in Migraine, Migraine-Related Neck Pain, and Low Back Pain: Implications for Treatment. Pain and Therapy. 2026. DOI: 10.1007/s40122-026-00871-6.
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Frequency and severity of adverse events associated with dry needling: a systematic review and meta-analysis
59 studies: case reports and series, surveys of 2,380 professionals, and trials and observational studies covering 1,947 patients.
What it foundMinor adverse events were common, reported in 0% to 48% of treatments depending on the study. Major adverse events were uncommon per treatment (0% to 0.43%) but were reported by a meaningful share of clinicians over a whole career.
What it can't tell usWhat counted as an event, and how it was reported, differed widely between studies. The rates describe the literature as a whole, not any one clinician, technique or body region.
Publication details & citation
Rabanal-Rodríguez et al. Frequency and severity of adverse events associated with dry needling: a systematic review and meta-analysis. Physical Therapy. 2026. DOI: 10.1093/ptj/pzag050.
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Effects of dry needling on functioning and pain relief in patients with chronic nonspecific neck pain: a systematic review and meta-analysis of randomized controlled trials
Five randomized trials of adults with chronic nonspecific neck pain, comparing dry needling, alone or added to physiotherapy, with sham, physical therapy or nothing.
What it foundDry needling reduced pain more than the comparison groups, but was not significantly better for function on the Neck Disability Index.
What it can't tell usFive trials only, and the authors call for further high-quality studies. It doesn't show dry needling is better than manual or physical therapy for function.
Publication details & citation
de Sire et al. Effects of dry needling on functioning and pain relief in patients with chronic nonspecific neck pain: a systematic review and meta-analysis of randomized controlled trials. Disability and Rehabilitation. 2026. DOI: 10.1080/09638288.2025.2529423.
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Spinal Manipulation and Clinician-Supported Biopsychosocial Self-Management for Acute Back Pain: The PACBACK Randomized Clinical Trial
1,000 adults with low back pain of 2 to 12 weeks, at medium or high risk of persistent disabling pain on the STarT Back tool, treated for up to 8 weeks and followed for a year.
What it foundSelf-management coached by a physical therapist or chiropractor, with or without spinal manipulation, lowered average disability over the year by about 1 point on a 24-point scale compared with medication-based medical care. Spinal manipulation alone did not differ significantly from medical care on disability, and pain did not differ significantly between groups. All three groups not given medication-based care used medication in fewer months.
What it can't tell usThe researchers call the disability difference small, and the secondary outcomes, medication use among them, were exploratory. Neither patients nor clinicians were blinded, the main outcomes were self-reported, and the self-management groups got much more clinician time.
Publication details & citation
Bronfort et al. Spinal Manipulation and Clinician-Supported Biopsychosocial Self-Management for Acute Back Pain: The PACBACK Randomized Clinical Trial. JAMA. 2026. DOI: 10.1001/jama.2025.21990.
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Spinal Manipulation and Clinician-Supported Self-Management for Preventing Chronic Low Back Pain Impact: The PACBACK Randomized Clinical Trial
The same 1,000 PACBACK participants: adults with low back pain of 2 to 12 weeks at moderate to high risk of chronic pain, followed for a year.
What it foundAt 10 to 12 months, back pain impact (8 to 50 scale) was 1.7 points lower with physical therapist- or chiropractor-supported self-management and 1.3 points lower with self-management plus spinal manipulation than with medical care. Spinal manipulation alone did not differ from medical care, and adding it to self-management gave no additional benefit.
What it can't tell usThe researchers call the impact difference small, and judge it clinically relevant from the responder analyses and secondary outcomes. Per the trial's first report, patients and clinicians were not blinded and the main outcomes were self-reported.
Publication details & citation
Bronfort et al. Spinal Manipulation and Clinician-Supported Self-Management for Preventing Chronic Low Back Pain Impact: The PACBACK Randomized Clinical Trial. JAMA Internal Medicine. 2026. DOI: 10.1001/jamainternmed.2026.1893.
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Manual therapy treatments in the management of pregnancy related pelvic girdle pain: a scoping review
16 studies (8 randomized trials plus case, observational and other designs) of manual therapy for pregnancy-related pelvic girdle pain.
What it foundManual therapy, alone or combined with exercise, education or standard care, was generally associated with reduced short-term pain intensity, and no serious adverse events were reported.
What it can't tell usA scoping review, not a meta-analysis: effects were often small or inconsistent, and many studies were small, pilot designs without blinding.
Publication details & citation
Juneja et al. Manual therapy treatments in the management of pregnancy related pelvic girdle pain: a scoping review. Journal of Manual & Manipulative Therapy. 2026. DOI: 10.1080/10669817.2026.2733479.
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Chronic life stressors and pain incidence in adults 50 and older: a longitudinal analysis with implications for pain prevention and public health promotion
2,622 US adults aged 50 and over in the Health and Retirement Study who were not often troubled by pain in 2018, asked again in 2020.
What it foundEach additional moderately or very upsetting long-running stressor raised the odds of new pain two years later by 13% after adjustment; ongoing problems with their own health had 1.62 times the odds. Financial strain and health problems in a spouse or child were linked before adjustment, and again in a check that left out self-rated health, but not in the fully adjusted model.
What it can't tell usPain was a single yes or no question with no location or chronic pain definition, the two-year gap between surveys rules out conclusions about cause, and activity, diet, sleep and resilience were not measured.
Publication details & citation
Spector et al. Chronic life stressors and pain incidence in adults 50 and older: a longitudinal analysis with implications for pain prevention and public health promotion. Frontiers in Public Health. 2026. DOI: 10.3389/fpubh.2026.1905906.
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The effects of different types of thoracic manual therapy for shoulder dysfunction: a systemic review with meta-analysis
12 randomized trials with 508 people with shoulder dysfunction, mainly subacromial impingement and adhesive capsulitis (frozen shoulder), searched to October 2025.
What it foundMaitland mobilization of the thoracic spine improved pain and disability more than control interventions in subacromial impingement. High-velocity thrust techniques showed no significant effect in impingement or adhesive capsulitis.
What it can't tell usTwelve trials is a small base, evidence for the Mulligan technique was insufficient, and the authors call for higher-quality trials to confirm the findings.
Publication details & citation
Yu et al. The effects of different types of thoracic manual therapy for shoulder dysfunction: a systemic review with meta-analysis. Musculoskeletal Science and Practice. 2026. DOI: 10.1016/j.msksp.2026.103565.
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Efficacy of manual therapy by different healthcare professionals on pain and function in temporomandibular disorders: a systematic review of randomized controlled trials
18 randomized trials of manual therapy for TMD, given by physical therapists, chiropractors, osteopaths, dental specialists and doctors.
What it foundCompared with other treatments, placebo, sham treatment or no treatment, manual therapy was associated with less pain and wider mouth opening across professions and techniques, mostly in the short term.
What it can't tell usThe certainty of the evidence was limited, techniques and settings varied too much for firm conclusions on long-term effect or on which approach is better, and most of the trials were of physical therapists.
Publication details & citation
Chiaramonte et al. Efficacy of manual therapy by different healthcare professionals on pain and function in temporomandibular disorders: a systematic review of randomized controlled trials. Journal of Manual & Manipulative Therapy. 2026. DOI: 10.1080/10669817.2026.2629282.
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The Effectiveness of Ergonomic Training and Chiropractic Treatment in Industrial Workers with Nonspecific Chronic Neck Pain: A Randomized Controlled Trial
45 male industrial workers with chronic nonspecific neck pain, 15 per group, given four weeks of ergonomic training alone, with sham manipulation, or with chiropractic treatment.
What it foundAdding chiropractic treatment to ergonomic training reduced pain and biopsychosocial impact (Bournemouth Neck Questionnaire) more than sham manipulation or training alone. Neck disability improved comparably in all three groups, and sleep quality was unchanged.
What it can't tell usA small trial in men only, measured before and after four weeks with no longer follow-up, published online ahead of print. The full text is paywalled, so the abstract does not say who gave the treatment or which techniques it used; the authors are in physiotherapy and rehabilitation departments.
Publication details & citation
Balikçi et al. The Effectiveness of Ergonomic Training and Chiropractic Treatment in Industrial Workers with Nonspecific Chronic Neck Pain: A Randomized Controlled Trial. Journal of Occupational and Environmental Medicine. 2026. DOI: 10.1097/JOM.0000000000003872.
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Effectiveness of manual therapy in dizziness intensity and cervical range of motion in patients with cervicogenic dizziness: A systematic review
8 randomized trials of manual therapy for cervicogenic dizziness, each with at least 20 people and a PEDro score of 7 or more.
What it foundMost trials showed less intense dizziness and more neck movement in the short term.
What it can't tell usA qualitative review with no pooled estimate, and the long-term effects remain uncertain.
Publication details & citation
Casado-Sánchez et al. Effectiveness of manual therapy in dizziness intensity and cervical range of motion in patients with cervicogenic dizziness: A systematic review. Journal of Bodywork and Movement Therapies. 2025. DOI: 10.1016/j.jbmt.2025.03.021.
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Extracorporeal shock wave therapy shows comparative results with other modalities for the management of plantar fasciitis: A systematic review and meta-analysis
15 randomized trials, 1,123 patients with plantar fasciitis, comparing shock wave therapy with placebo and six other conservative treatments.
What it foundShock wave therapy did better than placebo for pain and better than corticosteroid injection for function. Platelet-rich plasma injection did better than shock wave therapy for both, and custom orthotics improved function more than shock wave therapy; other comparisons showed no significant difference.
What it can't tell usTrials published after 2013 only, with varied protocols and devices. The pooled result doesn't describe StemWave or any single device, and can't tell us which device or dose produced it.
Publication details & citation
Tung et al. Extracorporeal shock wave therapy shows comparative results with other modalities for the management of plantar fasciitis: A systematic review and meta-analysis. Foot and Ankle Surgery. 2025. DOI: 10.1016/j.fas.2024.11.005.
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Efficacy of Spine High-Velocity Low-Amplitude Thrust Manipulations in Patients With Radiculopathy: A Systematic Review With Meta-Analysis
11 randomized trials, 991 people with nerve-root pain (radiculopathy); eligibility covered the neck, mid back and low back, and the pooled results are reported for neck and low back radiculopathy, comparing thrust manipulation with sham manipulation, physical therapy or other treatments.
What it foundThrust manipulation was associated with less pain than sham manipulation and than non-recommended treatments in both neck and low back radiculopathy, and with less pain than physical therapy alone in the short and medium term. There was no difference at long-term follow-up.
What it can't tell usThe overall risk of bias was high and the certainty of evidence very low to moderate. A corrigendum was published in June 2026; its text is behind the publisher's paywall, and the journal's online abstract, shown with the correction notice, reports these results unchanged (checked 2026-10-22). A letter re-examining the evidence and its clinical relevance was published with the authors' reply in May 2026.
Publication details & citation
Giovannico et al. Efficacy of Spine High-Velocity Low-Amplitude Thrust Manipulations in Patients With Radiculopathy: A Systematic Review With Meta-Analysis. Journal of Orthopaedic & Sports Physical Therapy. 2025. DOI: 10.2519/jospt.2025.13103.
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Neck pain in migraine: A narrative review and steps to correct evaluation and treatment
Preclinical, clinical, neurophysiological and imaging research on neck pain in people with migraine.
What it foundNeck pain in migraine can be a symptom, a trigger or a coexisting condition, occurs during attacks and between them, and is often misdiagnosed as a neck disorder; assessment needs a thorough history, a physical exam and exclusion of secondary causes. Some migraine medicines may help reduce neck pain, and physical therapy, acupuncture and behavioural strategies show some promise.
What it can't tell usA narrative review, not a systematic one, and it found the evidence on relieving neck pain in migraine limited.
Publication details & citation
Rees et al. Neck pain in migraine: A narrative review and steps to correct evaluation and treatment. Cephalalgia. 2025. DOI: 10.1177/03331024251387449.
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Recommendations for Mobilization and Manipulation Treatment and Screening for Vascular Complications in Clinical Practice Guidelines for Neck Pain: A Systematic Review
19 international clinical practice guidelines for neck pain published 2000 to 2022, appraised with AGREE II and AGREE-REX.
What it foundAll five guidelines rated high quality recommend manipulation or mobilization, with or without exercise.
What it can't tell usA review of guidelines, not of patients. Only 8 of the 19 guidelines described screening for the risk of vascular complications, and only 2 did so completely.
Publication details & citation
Peters et al. Recommendations for Mobilization and Manipulation Treatment and Screening for Vascular Complications in Clinical Practice Guidelines for Neck Pain: A Systematic Review. Physical Therapy. 2025. DOI: 10.1093/ptj/pzae179.
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Efficacy of manipulation and therapeutic exercise applied to the neck region of patients with temporomandibular disorders: A systematic review and meta-analysis
14 randomized trials with 825 patients whose TMD came from the chewing muscles.
What it foundManipulation and exercise aimed at the neck lowered jaw and face pain ratings. Manipulation alone made little difference to how wide people could open their mouths; manipulation combined with neck exercises improved it.
What it can't tell usThe authors note that many manipulation and exercise approaches exist, with varying effects, and called for larger, better-designed trials. It covers muscle-related TMD only, not problems inside the joint.
Publication details & citation
Qu et al. Efficacy of manipulation and therapeutic exercise applied to the neck region of patients with temporomandibular disorders: A systematic review and meta-analysis. Journal of Stomatology, Oral and Maxillofacial Surgery. 2025. DOI: 10.1016/j.jormas.2025.102530.
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Lumbar Tractions in Radicular Pain Caused by Herniated Disc: Randomised, Open-Label, Superiority, and Controlled Trial on 424 Participants
424 patients at a hospital rheumatology unit with leg pain from a herniated disc that had not settled with outpatient treatment; all received medical treatment including at least two epidural injections, and half also received lumbar traction.
What it foundAt one month, 62% of the traction group and 51% of the medical-treatment group had at least a 25% improvement in leg pain (388 of the 424 were analysed). At three months the leg-pain difference (63% against 54%) was not statistically significant, and back pain improved in the same share of both groups (51%) at one month.
What it can't tell usNobody was blinded, the main result was measured at one month, and the patients were hospital referrals already having injections, so it doesn't show what traction does on its own or for milder leg pain.
Publication details & citation
Bernhard et al. Lumbar Tractions in Radicular Pain Caused by Herniated Disc: Randomised, Open-Label, Superiority, and Controlled Trial on 424 Participants. Journal of Clinical Medicine. 2025. DOI: 10.3390/jcm14155192.
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The Effects of Cervical Manipulation Compared with a Conventional Physiotherapy Program for Patients with Acute Whiplash Injury: A Randomized Controlled Trial
119 drivers aged 18 to 60 seen in an emergency department after a car collision, with acute grade II whiplash and no radiculopathy.
What it foundThree sessions of cervical manipulation gave results comparable to 20 sessions of a conventional physiotherapy program for pain, function and neck mobility, measured up to 120 days after treatment began.
What it can't tell usOne single-blind trial whose authors say more research is needed on the acute phase: therapists and patients could not be fully blinded, three different therapists delivered the comparison program, and some participants were lost to follow-up.
Publication details & citation
Parera-Turull et al. The Effects of Cervical Manipulation Compared with a Conventional Physiotherapy Program for Patients with Acute Whiplash Injury: A Randomized Controlled Trial. Healthcare (Basel). 2025. DOI: 10.3390/healthcare13070710.
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Decision aids for people facing health treatment or screening decisions
209 studies of decision aids across a range of treatment and screening choices.
What it foundDecision aids improved knowledge and understanding of risks and helped people make choices that reflected their informed values.
What it can't tell usMost of the decisions studied had nothing to do with chiropractic care. It supports laying out the options and trade-offs plainly. It doesn't rank clinics, check credentials or show that any particular treatment works.
Publication details & citation
Stacey et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2024. DOI: 10.1002/14651858.CD001431.pub6.
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Exercise for osteoarthritis of the knee
139 randomized trials with 12,468 people with knee osteoarthritis, comparing land-based exercise with placebo or attention control, with no treatment or usual care, or added to another treatment.
What it foundExercise probably improves pain, physical function and quality of life in the short term. Added to another treatment, it likely improved pain more than that treatment alone, and no one type of exercise did better than the others.
What it can't tell usThe certainty of the evidence was low to moderate, most participants knew which treatment they got, and the authors judged the average benefits to be of uncertain clinical importance.
Publication details & citation
Lawford et al. Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews. 2024. DOI: 10.1002/14651858.CD004376.pub4.
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Effects of high-intensity laser therapy on subacromial impingement syndrome: a systematic review and meta-analysis
6 trials, five of them randomized, with 284 people with shoulder impingement, comparing high-intensity laser with conventional therapy.
What it foundHigh-intensity laser did better than conventional therapy for pain and for shoulder and arm function, right after treatment and three months later.
What it can't tell usIt made no difference to shoulder flexion or outward rotation, and six trials is a small base.
Publication details & citation
Hao et al. Effects of high-intensity laser therapy on subacromial impingement syndrome: a systematic review and meta-analysis. Lasers in Medical Science. 2024. DOI: 10.1007/s10103-024-04190-0.
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Quality appraisal of systematic reviews on high-intensity laser therapy for musculoskeletal pain management: an umbrella review
20 systematic reviews of high-intensity laser for muscle and joint pain, including the knee, shoulder, neck, low back and plantar fascia.
What it foundThe reviews reported pain relief across several conditions, with the largest effects in reviews of spinal disorders, frozen shoulder and neck pain.
What it can't tell usIt rated the reviews' own methods generally low to critically low in quality, with weak handling of publication bias and funding disclosure, so the pooled results are less certain than they look.
Publication details & citation
de la Barra Ortiz et al. Quality appraisal of systematic reviews on high-intensity laser therapy for musculoskeletal pain management: an umbrella review. Lasers in Medical Science. 2024. DOI: 10.1007/s10103-024-04241-6.
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The effects of photobiomodulation and transcutaneous electrical nerve stimulation on chronic neck pain: A double-blind, randomized, sham-controlled trial
144 people with chronic neck pain, assigned photobiomodulation, electrical stimulation, both, or sham treatment for ten sessions over two weeks.
What it foundThe groups did not differ in the primary outcome of pain at rest. Some secondary outcomes favored the combined treatment.
What it can't tell usThe secondary findings came from light and electrical stimulation combined, so they can't tell us what light therapy alone does. The treatment period was also short.
Publication details & citation
Rampazo et al. The effects of photobiomodulation and transcutaneous electrical nerve stimulation on chronic neck pain: A double-blind, randomized, sham-controlled trial. Brazilian Journal of Physical Therapy. 2024. DOI: 10.1016/j.bjpt.2024.101124.
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Spinal manipulations for migraine: an updated systematic review and meta-analysis of randomized clinical trials
6 randomized trials (645 people) of spinal manipulation for migraine, searched through September 2023; an update of the same authors' earlier review.
What it foundNo clear effect of spinal manipulation on migraine intensity (very low certainty) or duration (low certainty) compared with placebo, drug therapy or usual care.
What it can't tell usThe evidence was downgraded for bias, inconsistency and imprecision, and a 2025 commentary (PMID 41131621) questioned the review's search and analysis methods.
Publication details & citation
Posadzki et al. Spinal manipulations for migraine: an updated systematic review and meta-analysis of randomized clinical trials. Systematic Reviews. 2024. DOI: 10.1186/s13643-024-02719-6.
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Effects of High-Velocity Spinal Manipulation on Quality of Life, Pain and Spinal Curvature in Children with Idiopathic Scoliosis: A Systematic Review
Five studies (two randomized trials and three observational studies) with 123 children with idiopathic scoliosis, mean age about 13.
What it foundThe authors concluded that spinal manipulation may be useful for pain, but that there is not yet enough evidence to say if it improves pain or quality of life, and no evidence that it effectively reduces curve severity.
What it can't tell usPain was measured in only one of the five studies, which compared pain in 50 children before and after manipulation given alongside a brace. The two randomized trials were tiny (6 and 20 children), and manipulation was usually combined with other care.
Publication details & citation
Piqueras-Toharias et al. Effects of High-Velocity Spinal Manipulation on Quality of Life, Pain and Spinal Curvature in Children with Idiopathic Scoliosis: A Systematic Review. Children. 2024. DOI: 10.3390/children11101167.
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Massage for neck pain
33 randomized trials, 1,994 adults with acute to chronic neck pain, comparing massage with placebo, no treatment, or as an add-on to the same co-treatment.
What it foundAgainst a placebo, massage may make little or no difference to pain, function or quality of life at up to 12 weeks, and may slightly improve self-rated treatment success. A higher dose (at least 8 sessions of 30 minutes or more over four weeks) showed a clinically important difference.
What it can't tell usThe evidence is low certainty, most placebo trials tested a single session, serious adverse event data were not available, and adverse events were too poorly reported to analyse.
Publication details & citation
Gross et al. Massage for neck pain. Cochrane Database of Systematic Reviews. 2024. DOI: 10.1002/14651858.CD004871.pub5.
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The effectiveness of dry needling for plantar fasciitis: a systematic review and meta-analysis
12 randomized trials, 781 people with plantar fasciitis, pooled by comparison: dry needling added to routine care against routine care alone, and dry needling against other treatments.
What it foundIn the four trials that added dry needling to routine care such as stretching, exercise and massage, pain scores were lower than with that care alone. Against other treatments, dry needling improved foot function with no significant difference in pain, each result pooled from four trials. Side effects reported in six trials (pain, bleeding, hematomas, bruising) were all self-limiting.
What it can't tell usEach comparison between treatments pooled only two to four small trials. Allocation concealment was unclear in 5 of the 12 trials and only 3 blinded their patients, and the trials differed in comparison treatments, needling sites and schedules. The authors call for larger, multi-center trials.
Publication details & citation
Yang et al. The effectiveness of dry needling for plantar fasciitis: a systematic review and meta-analysis. Frontiers in Neurology. 2024. DOI: 10.3389/fneur.2024.1520585.
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Pneumothorax as a complication of dry needling technique
Four patients treated for pneumothorax after dry needling of the shoulder or neck region at one Belgian university hospital over 15 months.
What it foundThe authors conclude that pneumothorax after dry needling is not extremely rare, and that consent should name it as a considerable risk for needling in the neck, shoulder or chest region.
What it can't tell usA case series establishes that a harm can happen, not how often. Frequency estimates come from the systematic review of adverse events, not from this series.
Publication details & citation
Bontinck et al. Pneumothorax as a complication of dry needling technique. ERJ Open Research. 2024. DOI: 10.1183/23120541.00156-2024.
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Spinal manipulation and mobilisation in paediatrics – an international evidence-based position statement for physiotherapists
Evidence and recommendations concerning infants, children and adolescents, developed through evidence reviews and professional consensus.
What it foundThe statement recommends against manipulation or mobilization in infants, cervical or lumbar manipulation in children, and these interventions for non-musculoskeletal childhood conditions.
What it can't tell usIt's a position statement written for physiotherapists, not a treatment trial. High-certainty evidence was missing, and the harms reported ranged in severity, with no reliable figure for how often they happen. Research on adult back pain can't show that a treatment is safe or helpful for a child.
Publication details & citation
Gross et al. Spinal manipulation and mobilisation in paediatrics – an international evidence-based position statement for physiotherapists. Journal of Manual & Manipulative Therapy. 2024. DOI: 10.1080/10669817.2024.2332026.
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High-intensity laser therapy in low back pain management: a systematic review with meta-analysis
Randomized trials in adults with low back pain, published before January 2023, comparing high-intensity laser with control treatments.
What it foundPain after treatment was lower with high-intensity laser than in the control groups, and two disability scores were lower too.
What it can't tell usThe disability results rested on three trials, the pain results varied a fair amount between trials, and the abstract doesn't weigh the differences against the change patients consider meaningful.
Publication details & citation
Abdildin et al. High-intensity laser therapy in low back pain management: a systematic review with meta-analysis. Lasers in Medical Science. 2023. DOI: 10.1007/s10103-023-03827-w.
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Clinical Efficacy of High-Intensity Laser Therapy on Lateral Epicondylitis Patients: A Systematic Review and Meta-analysis
Six randomized trials with 344 patients with persistent lateral epicondylitis (tennis elbow).
What it foundLow-quality evidence that high-intensity laser produced a small reduction in pain, during activity and at rest, and a small improvement in the physical component of quality of life compared with control groups.
What it can't tell usGrip strength, hand function and overall quality of life didn't differ significantly from other therapies. The trials tested high-intensity laser in general, not a particular device or how any one person will respond.
Publication details & citation
ElMeligie et al. Clinical Efficacy of High-Intensity Laser Therapy on Lateral Epicondylitis Patients: A Systematic Review and Meta-analysis. American Journal of Physical Medicine & Rehabilitation. 2023. DOI: 10.1097/PHM.0000000000002039.
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High-intensity laser therapy on pain relief in symptomatic knee osteoarthritis: A systematic review and meta-analysis
9 studies of high-intensity laser for knee osteoarthritis pain, compared with sham laser, other lasers, conventional physiotherapy or exercise.
What it foundAll nine studies reported less knee pain with high-intensity laser. The authors called it promising, especially combined with exercise.
What it can't tell usThe comparison against a sham laser rested on two studies with 136 people over a short course of treatment.
Publication details & citation
Cai et al. High-intensity laser therapy on pain relief in symptomatic knee osteoarthritis: A systematic review and meta-analysis. Journal of Back and Musculoskeletal Rehabilitation. 2023. DOI: 10.3233/BMR-220228.
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The effectiveness of high-intensity laser therapy in individuals with neck pain: a systematic review and meta-analysis
8 randomized trials of high-intensity laser in people with neck pain.
What it foundCompared with placebo, high-intensity laser may improve pain and some neck movements, on moderate-quality evidence. The authors suggest it as an add-on treatment.
What it can't tell usLow-quality evidence found no clear benefit for everyday function, and there was little information on quality of life.
Publication details & citation
Xie et al. The effectiveness of high-intensity laser therapy in individuals with neck pain: a systematic review and meta-analysis. Physiotherapy. 2023. DOI: 10.1016/j.physio.2023.07.003.
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The combined effects of manual therapy and exercise on pain and related disability for individuals with nonspecific neck pain: A systematic review with meta-analysis
22 studies of individuals with nonspecific neck pain, comparing manual therapy plus exercise with exercise alone, manual therapy alone or control treatments.
What it foundManual therapy plus exercise reduced pain and disability more than exercise alone and more than control treatments, and gave results similar to manual therapy alone.
What it can't tell usThe comparison with exercise alone rests on low-certainty evidence, and quality of life did not differ between the combined approach and exercise alone.
Publication details & citation
Wilhelm et al. The combined effects of manual therapy and exercise on pain and related disability for individuals with nonspecific neck pain: A systematic review with meta-analysis. Journal of Manual & Manipulative Therapy. 2023. DOI: 10.1080/10669817.2023.2202895.
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Is Neck Pain Related to Sagittal Head and Neck Posture?: A Systematic Review and Meta-analysis
26 studies comparing sagittal head and neck posture between people with neck pain and pain-free people.
What it foundThe craniovertebral angle was about 3 degrees smaller in people with neck pain (pooled difference -2.93 degrees) and correlated negatively with pain and disability scores. Two other posture measures showed no significant difference.
What it can't tell usA 3-degree pooled difference is of the same order as the age and sex differences the same review found (about 2.4 and 2.6 degrees), and the studies were observational, so direction of cause is unknown.
Publication details & citation
Rani et al. Is Neck Pain Related to Sagittal Head and Neck Posture?: A Systematic Review and Meta-analysis. Indian Journal of Orthopaedics. 2023. DOI: 10.1007/s43465-023-00820-x.
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Spinal manipulation and adverse event reporting in the pregnant patient limits estimation of relative risk: a narrative review
18 peer-reviewed studies in which high-velocity, low-amplitude thrust manipulation was performed on currently pregnant participants.
What it foundOnly three studies described the manipulation technique, and 14 documented adverse events but only seven gave details, so the relative risk and safety of spinal manipulation in pregnancy could not be determined.
What it can't tell usA narrative review of reporting quality; it doesn't estimate harm or benefit, and proposes a reporting checklist instead.
Publication details & citation
Stickler & Kearns Spinal manipulation and adverse event reporting in the pregnant patient limits estimation of relative risk: a narrative review. Journal of Manual & Manipulative Therapy. 2023. DOI: 10.1080/10669817.2022.2118653.
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Management of chronic pain secondary to temporomandibular disorders: a systematic review and network meta-analysis of randomised trials
153 trials involving 8,713 participants contributed to the network analyses of chronic TMD pain.
What it foundAmong comparisons with more certain evidence, approaches supporting movement and coping improved pain. These included selected supervised exercises, mobilization and psychological approaches.
What it can't tell usCertainty varied by treatment and outcome, and evidence about adverse events was low or very low certainty. It isn't evidence for treating every headache or an acute jaw injury.
Publication details & citation
Yao et al. Management of chronic pain secondary to temporomandibular disorders: a systematic review and network meta-analysis of randomised trials. BMJ. 2023. DOI: 10.1136/bmj-2023-076226.
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The effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome: 24-month follow-up of a randomized trial
Follow-up of 234 adults randomized to injection or night splinting for mild-to-moderate carpal tunnel syndrome.
What it foundSymptom, function and pain scores did not significantly differ between the groups at 12 or 24 months.
What it can't tell usAbout 71% to 73% responded at 24 months. Severe carpal tunnel syndrome was outside this comparison, and the trial didn't test chiropractic care.
Publication details & citation
Burton et al. The effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome: 24-month follow-up of a randomized trial. Rheumatology. 2023. DOI: 10.1093/rheumatology/keac219.
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The Bárány Society position on Cervical Dizziness
The published literature on dizziness and vertigo attributed to the neck, reviewed by the Bárány Society Classification OverSight Committee.
What it foundEvidence for a mechanism linking vertigo to the neck is lacking, and migraine, including vestibular migraine, is by far the commonest cause of neck pain and vestibular symptoms together. The committee proposes no diagnostic criteria for cervical dizziness for clinical use outside research studies.
What it can't tell usA consensus position, not new data, and the committee says it may change as new research is published.
Publication details & citation
Seemungal et al. The Bárány Society position on Cervical Dizziness. Journal of Vestibular Research. 2022. DOI: 10.3233/VES-220202.
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Effects of non-surgical decompression therapy in addition to routine physical therapy on pain, range of motion, endurance, functional disability and quality of life versus routine physical therapy alone in patients with lumbar radiculopathy; a randomized controlled trial
60 people with lumbar radiculopathy, all given routine physical therapy, half also given non-surgical decompression on a computerized table, 12 sessions over four weeks.
What it foundThe decompression group improved more in pain, disability, back range of motion, back muscle endurance and two quality-of-life measures at four weeks.
What it can't tell usIt was one small trial with no sham treatment, and its outcomes were reported at the end of the four weeks of treatment, so it can't say how long any difference lasts.
Publication details & citation
Amjad et al. Effects of non-surgical decompression therapy in addition to routine physical therapy on pain, range of motion, endurance, functional disability and quality of life versus routine physical therapy alone in patients with lumbar radiculopathy; a randomized controlled trial. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05196-x.
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Short-term effects of the traction-manipulation protocol in dizziness intensity and disability in cervicogenic dizziness: a randomized controlled trial
40 people with cervicogenic dizziness, given a traction-manipulation protocol or kept lying on their back as a control.
What it foundDizziness intensity, Dizziness Handicap Inventory scores and pain improved more with the protocol at 48 hours and at one month.
What it can't tell usA small trial with one month of follow-up and a control group that received no hands-on treatment.
Publication details & citation
Carrasco-Uribarren et al. Short-term effects of the traction-manipulation protocol in dizziness intensity and disability in cervicogenic dizziness: a randomized controlled trial. Disability and Rehabilitation. 2022. DOI: 10.1080/09638288.2021.1872719.
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Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness
13 randomized trials with 898 people with cervicogenic dizziness, six of which tested manual therapy: sustained glides, sustained glides with mobilisation, or in one trial a traction-manipulation.
What it foundModerate-quality evidence that manual therapy reduces cervicogenic dizziness, neck symptoms and balance problems. Combined with exercise the effect looked stronger, on very low quality evidence.
What it can't tell us6 of the 13 trials were rated low methodological quality, 5 moderate and 2 high, they used several treatments at once and defined cervicogenic dizziness differently, and 12 of the 13 tested physiotherapy techniques.
Publication details & citation
De Vestel et al. Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness. Journal of Manual & Manipulative Therapy. 2022. DOI: 10.1080/10669817.2022.2033044.
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Prevalence of neck pain in migraine: A systematic review and meta-analysis
24 observational studies with eligible data on neck pain in people with migraine and in people without headache.
What it foundIn clinic-based studies, 77% of people with migraine reported neck pain, against 23% of people without headache; it was more common in chronic migraine (87%) than in episodic migraine (77%).
What it can't tell usThe studies varied a lot (moderate to high heterogeneity), and how often neck pain occurs says nothing about what causes it or which treatment helps it.
Publication details & citation
Al-Khazali et al. Prevalence of neck pain in migraine: A systematic review and meta-analysis. Cephalalgia. 2022. DOI: 10.1177/03331024211068073.
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Spinal manipulation and mobilisation in the treatment of infants, children, and adolescents: a systematic scoping review
87 articles on spinal manipulation and mobilisation from birth to under 18 years, across conditions including back and neck pain, scoliosis, torticollis, colic and headache.
What it foundSome individual high-quality studies showed positive results, but taken together the evidence did not support spinal manipulation or mobilisation in children for any condition: it was inconclusive or insufficient for most, back and neck pain included. Mild, short-lived symptoms were commonly described in trials, and moderate to severe adverse events were reported on occasion. It is the literature review behind the 2024 IOPTP position statement (Gross et al.).
What it can't tell usArticle quality varied, and a scoping review maps evidence rather than pooling it. Inconsistent harm reporting means it couldn't give a rate for adverse events.
Publication details & citation
Milne et al. Spinal manipulation and mobilisation in the treatment of infants, children, and adolescents: a systematic scoping review. BMC Pediatrics. 2022. DOI: 10.1186/s12887-022-03781-6.
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Appraisal of the New Posture Analyzing and Virtual Reconstruction Device (PAViR) for Assessing Sagittal Posture Parameters: A Prospective Observational Study
70 rehabilitation patients at one Korean hospital, each measured on the same day by full-body EOS radiography and by PAViR version 2.11 (Moti Physio, MG Solutions) with an Orbbec depth camera.
What it foundForward head, T1 tilt and pelvic tilt correlated moderately with the radiographs (r 0.62 to 0.80); knee flexion and lumbar lordosis correlated fairly (r about 0.5). Median values differed significantly on four of the seven measures. The authors call the validation acceptable and the accuracy in need of improvement.
What it can't tell usOne clinic, one examiner reading the radiographs, patients in tight clothing with markers attached, and a test position the authors note the device does not normally use. The tested version has since been superseded, and no later validation is cited.
Publication details & citation
Jang et al. Appraisal of the New Posture Analyzing and Virtual Reconstruction Device (PAViR) for Assessing Sagittal Posture Parameters: A Prospective Observational Study. International Journal of Environmental Research and Public Health. 2022. DOI: 10.3390/ijerph191711109.
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Differential diagnosis of temporomandibular disorders - a review of the literature
57 articles selected from 445 publications (PubMed, Scopus and other sources; English-language, 2005 to 2020, plus a supplementary 1996 to 2020 PubMed search on Lyme disease).
What it foundDental and jawbone conditions, ear and maxillary sinus disease, nerve and blood vessel conditions, tumors and, less often, viral, bacterial and parasitic infections can cause pain that resembles TMD. A correct diagnosis rests on the history, a thorough physical exam and the results of additional tests, and head and neck pain may need more than one kind of care.
What it can't tell usA narrative review; the abstract reports no pooled data or evidence grading, so it lists what to consider rather than how often each cause occurs.
Publication details & citation
Krasińska-Mazur et al. Differential diagnosis of temporomandibular disorders - a review of the literature. Folia Medica Cracoviensia. 2022. DOI: 10.24425/fmc.2022.141703.
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Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision
People with lateral ankle sprains or chronic ankle instability.
What it foundThe guideline supports rehabilitation that includes mobility, balance and neuromuscular exercise. Manual therapy can accompany exercise.
What it can't tell usThe plan depends on the injury and the stage of recovery. The recommendations don't apply to fractures, and they don't show that a brace alone resolves chronic instability.
Publication details & citation
Martin et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision. Journal of Orthopaedic & Sports Physical Therapy. 2021. DOI: 10.2519/jospt.2021.0302.
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2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis
People with rheumatoid arthritis, including recommendations for disease-modifying medication and management strategies.
What it foundTreatment recommendations center on disease-modifying medicines and monitoring disease activity, with decisions informed by the patient’s circumstances and preferences.
What it can't tell usMany recommendations are conditional. It isn't a study of manual therapy, and symptom relief from hands-on care can't show that an autoimmune disease is under control.
Publication details & citation
Fraenkel et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care & Research. 2021. DOI: 10.1002/acr.24596.
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Exercise therapy for chronic low back pain
249 trials of exercise therapy in adults with chronic nonspecific low-back pain.
What it foundExercise probably improves pain compared with no treatment, usual care or placebo. Average improvements in function were smaller.
What it can't tell usThe programs, and what they were compared with, varied. The review doesn't point to one best exercise for everyone, and it doesn't apply to a new fracture, an infection or a neurological problem that's getting worse.
Publication details & citation
Hayden et al. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. 2021. DOI: 10.1002/14651858.CD009790.pub2.
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Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials
30 randomized trials with 2,123 people with lateral elbow tendinopathy, comparing exercise with passive treatments, wait-and-see or injections.
What it foundExercise did better than passive interventions, with or without injections, and outperformed corticosteroid injections on all outcomes at all time points except short-term pain.
What it can't tell usThe evidence was low or very low in certainty and the effects were small. Against wait-and-see only some outcomes differed, and exercise programmes varied widely in equipment, load, duration and frequency.
Publication details & citation
Karanasios et al. Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials. British Journal of Sports Medicine. 2021. DOI: 10.1136/bjsports-2020-102525.
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Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline
Adults with chronic insomnia disorder, considering behavioral and psychological treatments.
What it foundThe guideline strongly recommends multicomponent cognitive behavioral therapy for insomnia. Sleep hygiene alone is not recommended as a single treatment.
What it can't tell usThe guideline covers insomnia care. It doesn't test chiropractic care, mattress brands or sleep apnea treatment, and ongoing sleep trouble may need its own medical assessment.
Publication details & citation
Edinger et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine. 2021. DOI: 10.5664/jcsm.8986.
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Photobiomodulation therapy is not better than placebo in patients with chronic nonspecific low back pain: a randomised placebo-controlled trial
148 adults with chronic nonspecific low-back pain, receiving 12 active or placebo sessions over four weeks; both groups received education.
What it foundThere was no clinically important difference in the primary pain and disability outcomes at four weeks.
What it can't tell usPatients, therapists and assessors were all blinded. It tested one protocol, so it doesn't show that every laser device performs the same, and it gives no support to claims that light regenerates a disc.
Publication details & citation
Guimarães et al. Photobiomodulation therapy is not better than placebo in patients with chronic nonspecific low back pain: a randomised placebo-controlled trial. Pain. 2021. DOI: 10.1097/j.pain.0000000000002189.
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Spinal Manipulative Therapy for Acute Neck Pain: A Systematic Review and Meta-Analysis of Randomised Controlled Trials
Six randomized trials of spinal manipulation for acute neck pain, alone or combined with other treatment.
What it foundSpinal manipulation, alone or with other treatment, was effective for acute neck pain. In one trial it eased pain more than an injected pain medicine (ketorolac) one day after treatment. Minor, temporary effects such as increased pain and headache were reported, and no serious ones.
What it can't tell usSix trials only, with pragmatic designs and results that varied a lot from trial to trial, which the authors say limit the findings.
Publication details & citation
Chaibi et al. Spinal Manipulative Therapy for Acute Neck Pain: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Journal of Clinical Medicine. 2021. DOI: 10.3390/jcm10215011.
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Effects of Trigger Point Dry Needling for Nontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis
6 randomized trials of trigger point dry needling, alone or added to other care, for shoulder pain of musculoskeletal origin that did not start with an injury.
What it foundModerate-quality evidence that dry needling reduced shoulder pain intensity by a small amount, and low-quality evidence of a large improvement in pain-related disability, compared with the comparison groups.
What it can't tell usThe effect on pain was found only in the short term, results varied between trials, and long-term effects have not been studied.
Publication details & citation
Navarro-Santana et al. Effects of Trigger Point Dry Needling for Nontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis. Physical Therapy. 2021. DOI: 10.1093/ptj/pzaa216.
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Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial
708 adults with a new episode of a rotator cuff disorder.
What it foundMore supervised exercise sessions did not improve the primary outcome over 12 months compared with a best-practice advice session. Injection offered no long-term benefit.
What it can't tell usThe advice session included home exercise and self-management. Major trauma and several other shoulder diagnoses were excluded, and it doesn't compare every shoulder treatment.
Publication details & citation
Hopewell et al. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial. The Lancet. 2021. DOI: 10.1016/S0140-6736(21)00846-1.
Read the publication recordEffectiveness of Mechanical Traction for Lumbar Radiculopathy: A Systematic Review and Meta-Analysis
Eight randomized trials in adults with lumbar radiculopathy (leg pain from an irritated nerve root), five of them pooled.
What it foundTraction given lying face up and added to physical therapy reduced pain and disability in the short term, up to three months. Traction given lying face down showed no significant effect in the higher-quality studies.
What it can't tell usThe face-up result came from low-quality studies, and it reaches only three months. It's evidence about traction added to physical therapy, not traction on its own.
Publication details & citation
Vanti et al. Effectiveness of Mechanical Traction for Lumbar Radiculopathy: A Systematic Review and Meta-Analysis. Physical Therapy. 2021. DOI: 10.1093/ptj/pzaa231.
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World Health Organization 2020 guidelines on physical activity and sedentary behaviour
Recommendations for children, adolescents, adults and older adults, including people living with selected chronic conditions or disability.
What it foundThe guideline recommends regular activity, strength work and less sedentary time. For adults, the general target is 150 to 300 minutes of moderate activity or 75 to 150 minutes of vigorous activity weekly.
What it can't tell usPopulation targets have to be adapted to a person's health, capacity and recovery, and some activity is better than none. The guideline doesn't test chiropractic care, and it isn't a rehabilitation plan for an injury.
Publication details & citation
Bull et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. British Journal of Sports Medicine. 2020. DOI: 10.1136/bjsports-2020-102955.
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Shock wave therapy for rotator cuff disease with or without calcification
32 trials, 2,281 participants with rotator cuff disease, most with calcific deposits; the main comparison was shock wave therapy against placebo at three months.
What it foundPain and function were slightly better with shock wave therapy than placebo, by less than the amount the authors considered clinically important. Adverse events were more frequent with treatment (41 of 156 versus 10 of 139 in five trials), with safety described as uncertain.
What it can't tell usEvery trial was susceptible to bias and none measured quality of life. The devices were extracorporeal or radial shock wave systems at varied doses; the result doesn't describe StemWave or any single device, dose or protocol.
Publication details & citation
Surace et al. Shock wave therapy for rotator cuff disease with or without calcification. Cochrane Database of Systematic Reviews. 2020. DOI: 10.1002/14651858.CD008962.pub2.
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Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee
156 patients with knee osteoarthritis in the US military health system.
What it foundPatients assigned physical therapy had less pain and disability at one year than those assigned glucocorticoid injection.
What it can't tell usIt was a physical therapy trial in one particular setting. It doesn't show cartilage regeneration, and it doesn't vouch for every treatment offered for knee pain.
Publication details & citation
Deyle et al. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. New England Journal of Medicine. 2020. DOI: 10.1056/NEJMoa1905877.
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The Nordic maintenance care program: maintenance care reduces the number of days with pain in acute episodes and increases the length of pain free periods for dysfunctional patients with recurrent and persistent low back pain - a secondary analysis of a pragmatic randomized controlled trial
319 patients from the Nordic maintenance care trial with recurrent or persistent low-back pain.
What it foundMaintenance care did not change the time to, or risk of, a new episode of low back pain in any subgroup. The whole effect was attributed to the dysfunctional subgroup, who had fewer days of activity-limiting pain within each episode and 9.8 more weeks pain-free between episodes.
What it can't tell usIt's a secondary analysis, and the whole benefit sat in one psychological subgroup. It doesn't show that maintenance care prevents new episodes.
Publication details & citation
Eklund et al. The Nordic maintenance care program: maintenance care reduces the number of days with pain in acute episodes and increases the length of pain free periods for dysfunctional patients with recurrent and persistent low back pain - a secondary analysis of a pragmatic randomized controlled trial. Chiropractic & Manual Therapies. 2020. DOI: 10.1186/s12998-020-00309-6.
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Spinal manipulation for the management of cervicogenic headache: A systematic review and meta-analysis
7 randomized trials comparing spinal manipulation with other manual therapies in people with cervicogenic headache.
What it foundSpinal manipulation gave small short-term benefits for pain intensity, headache frequency and disability, but not for headache duration. Long-term effects were not significant.
What it can't tell usThe authors note that high-quality evidence is lacking, and the comparison was other manual therapies, not no treatment.
Publication details & citation
Fernandez et al. Spinal manipulation for the management of cervicogenic headache: A systematic review and meta-analysis. European Journal of Pain. 2020. DOI: 10.1002/ejp.1632.
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Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up From a Randomized Controlled Trial
120 women with carpal tunnel syndrome at a tertiary public hospital, randomized to three sessions of physical therapy including manual therapy or carpal tunnel release surgery, both combined with home tendon and nerve gliding exercises.
What it foundPain, function, symptom severity and self-perceived improvement did not differ significantly between the groups at one year or four years, and surgery rates during the four years did not differ between the groups (15% manual therapy, 13% surgery).
What it can't tell usOnly women were included, the manual therapy was delivered as physical therapy rather than chiropractic care, and 81% completed the four-year follow-up. It didn't test chiropractic adjustment.
Publication details & citation
Fernández-de-Las-Peñas et al. Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up From a Randomized Controlled Trial. Physical Therapy. 2020. DOI: 10.1093/ptj/pzaa150.
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Effectiveness of deep tissue massage therapy, and supervised strengthening and stretching exercises for subacute or persistent disabling neck pain. The Stockholm Neck (STONE) randomized controlled trial
619 adults with subacute or persistent neck pain, assigned deep tissue massage, exercise, both, or advice to stay active.
What it foundDeep tissue massage led to more short-term improvement in neck pain than advice to stay active, and the treatment groups more often reported feeling recovered at every follow-up.
What it can't tell usMassage made no consistent difference to pain-related disability, and at one year none of the treatments was more effective than advice for pain. Exercise showed more improvement in pain at 26 weeks.
Publication details & citation
Skillgate et al. Effectiveness of deep tissue massage therapy, and supervised strengthening and stretching exercises for subacute or persistent disabling neck pain. The Stockholm Neck (STONE) randomized controlled trial. Musculoskeletal Science and Practice. 2020. DOI: 10.1016/j.msksp.2019.102070.
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Photobiomodulation therapy does not decrease pain and disability in people with non-specific low back pain: a systematic review
12 randomized trials with 1,046 people with non-specific low back pain, testing class I to III lasers and light-emitting diodes.
What it foundCompared with sham treatment, the effect on pain and disability was clinically unimportant, in recent and in long-lasting back pain alike.
What it can't tell usIt covers lower-power light only, not Class IV lasers, and some other outcomes rested on imprecise or low-quality evidence.
Publication details & citation
Tomazoni et al. Photobiomodulation therapy does not decrease pain and disability in people with non-specific low back pain: a systematic review. Journal of Physiotherapy. 2020. DOI: 10.1016/j.jphys.2020.06.010.
Read the publication recordThe safety of spinal manipulative therapy in children under 10 years: a rapid review
Case reports, case series, cohort studies and randomized trials from 1990 to 2019 on spinal manipulative therapy in children under 10, limited to studies of high or acceptable quality.
What it foundMost adverse events were mild, such as increased crying or soreness, with mild-event incidence between 0.3% and 22% across studies. One case report described a severe event, a rib fracture in a 21-day-old treated for fussiness and colic after a spring-activated device was used on the back, and another an indirect harm, a delayed diagnosis in a 4-month-old treated for a head tilt.
What it can't tell usThe risk of moderate and severe adverse events in children is unknown, and it's unclear whether spinal manipulation raises the risk of adverse events compared with other care.
Publication details & citation
Corso et al. The safety of spinal manipulative therapy in children under 10 years: a rapid review. Chiropractic & Manual Therapies. 2020. DOI: 10.1186/s12998-020-0299-y.
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No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews
41 systematic reviews and meta-analyses on spinal posture or physical exposure and low back pain, published 1990 to 2018.
What it foundBoth positive and null associations were reported for posture, sitting, standing, bending and heavy work. Reviews restricted to prospective studies were less able to reach consistent conclusions, and evidence that these factors precede first-time low back pain, or show a dose response, was lacking.
What it can't tell usA review of reviews inherits the definitions and the quality of the reviews it includes, which varied. It concerns low back pain, not neck pain.
Publication details & citation
Swain et al. No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. Journal of Biomechanics. 2020. DOI: 10.1016/j.jbiomech.2019.08.006.
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Chiropractic Care for Adults With Pregnancy-Related Low Back, Pelvic Girdle Pain, or Combination Pain: A Systematic Review
50 articles (18 systematic reviews, 30 randomized trials and 2 cohort studies) on care commonly used by chiropractors for pregnancy-related low back pain, pelvic girdle pain or both, limited to procedures that need no additional certification.
What it foundFor pregnancy low back pain the evidence for chiropractic care, exercise and support devices was rated favorable but inconclusive; for low back or pelvic girdle pain, multimodal care, education and physiotherapy were favorable but inconclusive.
What it can't tell usNo conclusion was conclusive, and spinal manipulation studied on its own was rated unclear rather than favorable.
Publication details & citation
Weis et al. Chiropractic Care for Adults With Pregnancy-Related Low Back, Pelvic Girdle Pain, or Combination Pain: A Systematic Review. Journal of Manipulative and Physiological Therapeutics. 2020. DOI: 10.1016/j.jmpt.2020.05.005.
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Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration
Adults with persistent tension-type or cervicogenic headache associated with neck pain; recommendations from a multidisciplinary panel based on systematic reviews.
What it foundConsider manual therapy (manipulation with or without mobilization) to the neck and upper back for cervicogenic headache lasting more than 3 months, and low-load endurance neck and shoulder-blade exercises for tension-type headache and for cervicogenic headache lasting more than 3 months. Do not offer neck manipulation as the only treatment for tension-type headache.
What it can't tell usIt covers persistent headaches with neck pain after other causes, including migraine, are ruled out, and it found no added benefit from combining manipulation, mobilization and exercise.
Publication details & citation
Côté et al. Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration. European Journal of Pain. 2019. DOI: 10.1002/ejp.1374.
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Chiropractic maintenance care - what's new? A systematic review of the literature
14 original research articles on chiropractic maintenance care published from 2007, four of them testing its effect on neck or back pain.
What it foundMaintenance care is defined as secondary or tertiary prevention for patients with earlier pain episodes who respond well to chiropractic care, and can be considered an evidence-based option for that group with low back pain, though not for every chiropractic patient.
What it can't tell usThe four effect studies had mixed results, only one selected patients using all existing evidence, and no cost-effectiveness studies were found. All three authors are chiropractors involved in the Nordic maintenance care program.
Publication details & citation
Axén, Hestbæk & Leboeuf-Yde Chiropractic maintenance care - what's new? A systematic review of the literature. Chiropractic & Manual Therapies. 2019. DOI: 10.1186/s12998-019-0283-6.
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The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial
252 adults from the Nordic maintenance care trial with recurrent or persistent low-back pain who responded well to initial chiropractic care, grouped by psychological profile.
What it foundPeople whose pain interfered most with daily life had 30 fewer days with pain on maintenance care with the same number of visits; adaptive copers had about 11 more days with pain and more visits; the interpersonally distressed group had no difference in days with pain and more visits.
What it can't tell usIt's a secondary analysis of one trial, and the profile came from a research questionnaire that isn't used routinely in practice. Five authors are paid employees of commercial companies, working as clinicians.
Publication details & citation
Eklund et al. The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial. PLOS ONE. 2019. DOI: 10.1371/journal.pone.0223349.
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Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials
47 randomized trials with 9,211 adults with chronic low back pain, with or without referred pain; trials only of sciatica were excluded.
What it foundModerate-quality evidence suggested spinal manipulation and mobilisation had similar effects to other recommended therapies for short-term pain relief, with a small, clinically better improvement in function over them, and seemed better than non-recommended treatments for function in the short term. Most reported side effects were musculoskeletal, short-lived and mild to moderate.
What it can't tell usEvidence against sham manipulation was low to very low quality, so that comparison is uncertain, and about half the trials looked at side effects, often without clear systematic recording. Two authors work as chiropractors and disclosed chiropractic-association funding.
Publication details & citation
Rubinstein et al. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019. DOI: 10.1136/bmj.l689.
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The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta-Analysis
6 randomized trials (677 people) of spinal manipulation for migraine, searched through April 2017.
What it foundSpinal manipulation was associated with fewer migraine days, a small effect, and lower migraine pain intensity.
What it can't tell usThe authors call the results preliminary: study quality varied, and one trial was left out of the main analysis because of high heterogeneity.
Publication details & citation
Rist et al. The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta-Analysis. Headache. 2019. DOI: 10.1111/head.13501.
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The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis
15 cross-sectional studies comparing forward head posture between people with and without neck pain, or correlating it with pain and disability.
What it foundAdults with neck pain showed more forward head posture than adults without it, and the posture correlated with pain intensity and disability in adults and older adults. In adolescents there was no such difference and no association with most neck pain measures.
What it can't tell usEvery included study was cross-sectional, so the review can't say whether the posture came before the pain or after it. Age confounded the relationship.
Publication details & citation
Mahmoud et al. The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis. Current Reviews in Musculoskeletal Medicine. 2019. DOI: 10.1007/s12178-019-09594-y.
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Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial
204 adults aged 35 to 70 with confirmed gluteal tendinopathy.
What it foundEducation with load management and exercise improved pain and global recovery more at eight weeks. Global improvement remained better than injection at 52 weeks.
What it can't tell usAt 52 weeks, pain didn't differ significantly from the injection group. These results are about gluteal tendinopathy, not all hip pain or hip arthritis.
Publication details & citation
Mellor et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ. 2018. DOI: 10.1136/bmj.k1662.
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The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain—A pragmatic randomized controlled trial
328 adults aged 18 to 65 with recurrent or persistent nonspecific low-back pain who had already responded favorably to initial care.
What it foundScheduled maintenance care was associated with about 13 fewer days of bothersome pain over one year than symptom-guided care, with more visits.
What it can't tell usThe trial was investigator- and assessor-blinded, but the main outcome was patients' own weekly text-message reports of bothersome days, and it only enrolled people who had already responded to care. It doesn't show a need for lifelong visits in healthy people, or any effect on immunity or disease prevention in general.
Publication details & citation
Eklund et al. The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain—A pragmatic randomized controlled trial. PLOS ONE. 2018. DOI: 10.1371/journal.pone.0203029.
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Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial
256 adults with chronic cervicogenic headache, assigned 0, 6, 12 or 18 sessions of chiropractic spinal manipulation over six weeks, with light massage at the other visits.
What it foundHeadache days fell as the number of manipulation visits rose. With 18 visits, headache days were reduced by about half, about 3 more days a month than the light-massage control. Headache intensity showed no important improvement.
What it can't tell usThe trial was open-label, so participants knew their group. Mild, short-lived side effects were reported by about 40% of those given manipulation and about 20% of the control group.
Publication details & citation
Haas et al. Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. The Spine Journal. 2018. DOI: 10.1016/j.spinee.2018.02.019.
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Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study
195 adults in Ontario, Canada, with an acute lumbar disc herniation needing an emergency department visit and surgery within eight weeks, from a population of more than 100 million person-years (1994 to 2004).
What it foundAcute disc herniations were strongly associated with both chiropractic and family-doctor visits, which the authors attribute to people with the early back pain of a developing herniation seeing both. They found no evidence that the risk after chiropractic visits was higher than after family-doctor visits.
What it can't tell usIt studied only herniations severe enough for early surgery, from records more than twenty years old, and it measured visits rather than what was done at them.
Publication details & citation
Hincapié et al. Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study. European Spine Journal. 2018. DOI: 10.1007/s00586-017-5325-y.
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Spinal manipulation and exercise for low back pain in adolescents: a randomized trial
185 adolescents aged 12 to 18 with chronic low back pain, given 12 weeks of spinal manipulation with exercise therapy or exercise therapy alone.
What it foundAdding spinal manipulation to exercise gave a larger reduction in back pain over a year. The difference was small at the end of treatment and larger at 26 and 52 weeks, and no serious treatment-related adverse events were reported.
What it can't tell usIt's a single trial in teenagers with long-lasting low back pain, and the authors say the findings need replicating. It doesn't apply to infants or young children, or to conditions outside the back.
Publication details & citation
Evans et al. Spinal manipulation and exercise for low back pain in adolescents: a randomized trial. Pain. 2018. DOI: 10.1097/j.pain.0000000000001211.
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Evidence for Dry Needling in the Management of Myofascial Trigger Points Associated With Low Back Pain: A Systematic Review and Meta-Analysis
11 randomized trials, 802 patients with low-back pain and myofascial trigger points.
What it foundDry needling of trigger points reduced pain intensity and disability more than other treatments immediately after treatment, and dry needling plus other treatment did better for pain than dry needling alone.
What it can't tell usModerate evidence for the post-treatment effect only. The authors called the superiority for disability, and the effects at follow-up, unclear.
Publication details & citation
Liu et al. Evidence for Dry Needling in the Management of Myofascial Trigger Points Associated With Low Back Pain: A Systematic Review and Meta-Analysis. Archives of Physical Medicine and Rehabilitation. 2018. DOI: 10.1016/j.apmr.2017.06.008.
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Foot orthoses for plantar heel pain: a systematic review and meta-analysis
19 randomized trials, 1,660 adults with plantar heel pain, comparing foot orthoses with sham orthoses or other care.
What it foundAt 7 to 12 weeks there was moderate-quality evidence that foot orthoses reduced pain more than sham orthoses, with no improvement in function. Customised and prefabricated orthoses showed no difference at any time point.
What it can't tell usThe authors call it uncertain whether the pain difference is clinically important. Before 6 weeks and after 12 weeks the evidence was very low quality and showed no benefit for pain or function. It doesn't describe any one brand of orthotic.
Publication details & citation
Whittaker et al. Foot orthoses for plantar heel pain: a systematic review and meta-analysis. British Journal of Sports Medicine. 2018. DOI: 10.1136/bjsports-2016-097355.
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Do schoolbags cause back pain in children and adolescents? A systematic review
69 studies involving 72,627 children and adolescents, including five prospective studies.
What it foundThe review found no convincing evidence that schoolbag weight, design or carrying method increased the risk of back pain.
What it can't tell usMost studies were cross-sectional or retrospective, and the prospective studies had moderate to high risk of bias. None of that makes a bag that hurts to carry something to ignore, or persistent pain in a child something that needs no assessment.
Publication details & citation
Yamato et al. Do schoolbags cause back pain in children and adolescents? A systematic review. British Journal of Sports Medicine. 2018. DOI: 10.1136/bjsports-2017-098927.
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Workplace interventions for reducing sitting at work
34 studies involving 3,397 workers in the June 2018 review.
What it foundLow-quality evidence suggested sit-stand desks reduced sitting time in the short and medium term. Results for several other workplace interventions were uncertain.
What it can't tell usThe review measured sitting time, and sitting less isn't the same as preventing back pain. This edition had no evidence on effects past one year, and the publisher links a later update.
Publication details & citation
Shrestha et al. Workplace interventions for reducing sitting at work. Cochrane Database of Systematic Reviews. 2018. DOI: 10.1002/14651858.CD010912.pub4.
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Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians
Adults with acute, subacute or chronic low-back pain considering noninvasive management.
What it foundThe guideline prioritizes non-drug options for chronic low-back pain, including exercise. Spinal manipulation is one of several options, supported by lower-quality evidence.
What it can't tell usA guideline pulls together existing evidence; it doesn't report a new experiment. It doesn't establish disc realignment, a cure for everyone, or superiority over all other care.
Publication details & citation
Qaseem et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2017. DOI: 10.7326/M16-2367.
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Complications of extracorporeal shockwave therapy in plantar fasciitis: Systematic review
39 studies, 2,493 patients with plantar fasciitis, receiving roughly 6,400 shock wave treatment sessions across a wide range of energy settings.
What it foundTwo complications were recorded in the whole series: precordial (chest) pain, and a superficial skin infection after regional anaesthesia. 225 patients reported pain during treatment and 247 reported transient red skin afterwards; transient pain, swelling, bruising, petechiae, altered sensation and severe headache were also reported.
What it can't tell usThe authors conclude shock wave therapy is likely safe for plantar fasciitis, with no complications expected at one year. Follow-up averaged 14.7 months and they call long-term complications unknown. The devices and doses varied widely; the result describes shock wave therapy for one condition, not StemWave or any single device.
Publication details & citation
Roerdink et al. Complications of extracorporeal shockwave therapy in plantar fasciitis: Systematic review. International Journal of Surgery. 2017. DOI: 10.1016/j.ijsu.2017.08.587.
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Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis
26 randomized trials of adults with low back pain of six weeks or less, treated with spinal manipulation in outpatient settings, plus observational studies for harms.
What it foundSpinal manipulation was associated with modest improvements in pain and function at up to six weeks (moderate-quality evidence). Minor, temporary effects such as increased pain, muscle stiffness and headache were reported in more than half of patients in large case series, and no trial reported a serious adverse event.
What it can't tell usResults varied a lot between trials, and the review covers only the first six weeks.
Publication details & citation
Paige et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017. DOI: 10.1001/jama.2017.3086.
Read the publication recordChiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial
104 people with migraine, assigned spinal manipulation, sham treatment or usual pharmacological management.
What it foundMigraine days decreased in all groups, with no significant between-group difference in the primary outcome. The authors considered the observed manipulation effect probably a placebo response.
What it can't tell usIt was a small trial. Its secondary outcomes don't overturn the main result, and a trial this size is too small to show how often rare serious harms happen.
Publication details & citation
Chaibi et al. Chiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial. European Journal of Neurology. 2017. DOI: 10.1111/ene.13166.
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The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis
13 randomized trials of dry needling performed by physical therapists for musculoskeletal pain, compared with sham, no treatment or another intervention.
What it foundIn the immediate to 12-week period, dry needling may reduce pain and raise pressure pain threshold compared with sham or no treatment. At 6 to 12 months the difference was not statistically significant, and it was not superior to other treatments for function.
What it can't tell usEvidence was rated very low to moderate quality. The trials were of physical therapists using mixed techniques across mixed conditions; the result does not describe every needle placed by every clinician.
Publication details & citation
Gattie et al. The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2017. DOI: 10.2519/jospt.2017.7096.
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Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration
13 eligible clinical practice guidelines for low back pain published 2005 to 2014, appraised with AGREE II; 10 had a low risk of bias.
What it foundAccording to the high-quality guidelines, everyone with low back pain should receive education, reassurance and self-management advice; people with acute low back pain should be encouraged to return to activity and may benefit from paracetamol, NSAIDs or spinal manipulation; chronic low back pain care may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture and multimodal rehabilitation.
What it can't tell usA review of guidelines, not of patients, and of guidelines for low back pain in general rather than only after traffic injuries. The authors say the guidelines need updating and that newer evidence challenges the paracetamol recommendation.
Publication details & citation
Wong et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Journal of Pain. 2017. DOI: 10.1002/ejp.931.
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Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs
200 randomized trial reports (177 pooled in meta-analyses) of conservative care for adults with shoulder impingement, searched to January 2017.
What it foundExercise reduced pain more than non-exercise control, and specific exercises more than generic ones. Manual therapy reduced pain more than placebo, and added to exercise it did better than exercise alone at the shortest follow-up. Laser did better than sham laser. Steroid injections did better than no treatment, and anti-inflammatory medicines better than placebo.
What it can't tell usThe authors rated the evidence very low in quality, and it is unclear how injections and medicines compare with exercise.
Publication details & citation
Steuri et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. British Journal of Sports Medicine. 2017. DOI: 10.1136/bjsports-2016-096515.
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Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain
5,511 workers who received compensation from the Ontario Workplace Safety and Insurance Board for back pain in 2005, grouped by the type of provider they saw first.
What it foundWorkers who first saw a chiropractor had shorter first episodes of full wage compensation than those who first saw a physician during the first 149 days, and those who first saw a physiotherapist had longer ones.
What it can't tell usWorkers chose their own first provider, so differences between the groups that the models didn't capture may explain part of the result, and the outcome is time on benefits rather than pain or function.
Publication details & citation
Blanchette et al. Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain. Journal of Occupational Rehabilitation. 2017. DOI: 10.1007/s10926-016-9667-9.
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Manual therapy and exercise for rotator cuff disease
60 randomized or quasi-randomized trials with 3,620 adults with rotator cuff disease, searched to March 2015; one high-quality trial of 120 people with chronic rotator cuff disease compared manual therapy and exercise together with a placebo.
What it foundIn that high-quality trial there was no clinically important difference between manual therapy with exercise and placebo in any outcome. Mild, short-term pain after treatment was reported by 31% of the manual therapy and exercise group and 8% of the placebo group. Low-quality evidence suggests the effects may be similar to those of a steroid injection or subacromial decompression surgery.
What it can't tell usNo meta-analysis was possible, only one trial tested the combination used in common practice against a placebo, and most other trials were high risk of bias with very low quality evidence.
Publication details & citation
Page et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database of Systematic Reviews. 2016. DOI: 10.1002/14651858.CD012224.
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Prevention of Low Back Pain: A Systematic Review and Meta-analysis
21 randomized trials involving 30,850 participants, examining interventions to prevent low-back pain.
What it foundExercise with education reduced the risk of a low-back-pain episode. Education alone, back belts and shoe insoles did not show a preventive effect.
What it can't tell usEvidence quality varied by intervention and outcome, and the search ended in 2014. It doesn't suggest every injury can be prevented, and it doesn't show that routine adjustments prevent back pain.
Publication details & citation
Steffens et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA Internal Medicine. 2016. DOI: 10.1001/jamainternmed.2015.7431.
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Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women
1,005,791 adults in 13 prospective cohort studies with data on daily sitting time and physical activity, followed for 2 to 18 years.
What it foundCompared with people who sat under 4 hours a day and were in the most active quarter, death rates were 59% higher in people who sat over 8 hours a day and were least active. In the most active quarter, sitting over 8 hours a day was not linked with higher mortality (hazard ratio 1.04, 95% CI 0.99 to 1.10); the authors put that activity level at about 60 to 75 minutes of moderate activity a day.
What it can't tell usSitting and activity were self-reported, and the main result is death from any cause. It's observational, so it shows which groups died sooner, not that sitting or activity caused it, and the highest activity level only partly offset the link with TV: in that group, watching 5 hours or more a day still went with a higher death rate.
Publication details & citation
Ekelund et al. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. The Lancet. 2016. DOI: 10.1016/S0140-6736(16)30370-1.
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Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in healthy active individuals: a systematic review
Studies of stretching before activity in healthy, physically active participants.
What it foundStretching can increase range of motion acutely. Longer static stretches immediately before performance had larger performance reductions than shorter holds; the surrounding warm-up mattered.
What it can't tell usThese are mostly immediate responses in healthy people. More range of motion doesn't automatically mean less pain, and the findings don't establish stretching as a treatment for an injured tendon, an unstable joint or an irritated nerve.
Publication details & citation
Behm et al. Acute effects of muscle stretching on physical performance, range of motion, and injury incidence in healthy active individuals: a systematic review. Applied Physiology, Nutrition, and Metabolism. 2016. DOI: 10.1139/apnm-2015-0235.
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Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis
48 randomized trials in adults with TMD comparing manual therapy or exercise with placebo, other treatments or standard care.
What it foundManual therapy, alone or combined with exercise, at the jaw or the neck showed promising effects. The review measured pain, range of motion and oral function, and most effect sizes were low to moderate.
What it can't tell usThe overall evidence was rated low, the trials had unclear or high risk of bias, and no high-quality evidence was found, so the authors concluded there's great uncertainty about how well these treatments work.
Publication details & citation
Armijo-Olivo et al. Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis. Physical Therapy. 2016. DOI: 10.2522/ptj.20140548.
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The Effectiveness of Mechanical Traction Among Subgroups of Patients With Low Back Pain and Leg Pain: A Randomized Trial
120 people with low-back pain and signs of lumbar nerve root compression, treated with extension-oriented exercise with or without mechanical traction, up to 12 visits over six weeks.
What it foundBoth groups improved, and adding traction made no difference to pain or disability at six weeks, six months or one year, including in the subgroup expected to respond.
What it can't tell usIt tested traction added to one exercise approach in physical therapy clinics, so it doesn't show how traction compares with no treatment at all.
Publication details & citation
Thackeray et al. The Effectiveness of Mechanical Traction Among Subgroups of Patients With Low Back Pain and Leg Pain: A Randomized Trial. Journal of Orthopaedic & Sports Physical Therapy. 2016. DOI: 10.2519/jospt.2016.6238.
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Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration
Adults with grades I to III neck pain and associated disorders of less than six months duration.
What it foundFor grade I to II neck pain of up to three months, clinicians may consider structured patient education combined with range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. It advises against a cervical collar and against education alone.
What it can't tell usIts recommendations are options a clinician 'may consider', not a ranking of one over another, and it covers only neck pain of up to six months.
Publication details & citation
Côté et al. Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Spine Journal. 2016. DOI: 10.1007/s00586-016-4467-7.
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The probability of spontaneous regression of lumbar herniated disc: a systematic review
31 studies of people with a lumbar disc herniation treated without surgery and imaged at least twice, nine of which used the standard herniation classification and were pooled.
What it foundDisc material regressed on follow-up imaging in 96% of sequestrations, 70% of extrusions, 41% of protrusions and 13% of bulges, and resolved completely in 43% of sequestrations and 15% of extrusions. Extrusions and sequestrations were significantly more likely to regress than bulges or protrusions.
What it can't tell usIt is about what the scans showed, not about pain, and the pooled figures rest on nine studies searched through March 2014.
Publication details & citation
Chiu et al. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clinical Rehabilitation. 2015. DOI: 10.1177/0269215514540919.
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Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial
86 people with chronic cervicogenic dizziness, average age 62, given 2 to 6 sessions over 6 weeks of sustained glides with self-applied glides, passive joint mobilisation with range-of-motion exercises, or a placebo.
What it foundAt 12 months both manual therapy groups had less frequent dizziness, lower Dizziness Handicap Inventory scores and better global perceived effect than placebo. No adverse effects were reported.
What it can't tell usDizziness intensity and pain did not differ from placebo at 12 months, each treatment came with a self-applied or range-of-motion exercise component, and the techniques were mobilisation, not high-velocity manipulation.
Publication details & citation
Reid et al. Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial. Manual Therapy. 2015. DOI: 10.1016/j.math.2014.08.003.
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Exercise for treating patellofemoral pain syndrome
31 trials with 1,690 adolescents and adults with patellofemoral pain, pain behind or around the kneecap.
What it foundExercise therapy may reduce pain and improve function, with some evidence that hip plus knee exercises may reduce pain more than knee exercises alone.
What it can't tell usThe evidence was very low quality, the trials varied a lot, and the review couldn't say which form of exercise works best or whether the result applies to everyone with this kind of pain.
Publication details & citation
van der Heijden et al. Exercise for treating patellofemoral pain syndrome. Cochrane Database of Systematic Reviews. 2015. DOI: 10.1002/14651858.CD010387.pub2.
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Systematic literature review of imaging features of spinal degeneration in asymptomatic populations
33 studies reporting imaging findings in 3,110 people without symptoms.
What it foundDegenerative findings were common in people without pain and became more frequent with age. A scan needs interpretation alongside symptoms and examination findings.
What it can't tell usThat doesn't make every disc finding harmless, or imaging never necessary. And a review like this can't identify what's causing one person's pain.
Publication details & citation
Brinjikji et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology. 2015. DOI: 10.3174/ajnr.A4173.
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- Center of the lower back
- Pain traveling into the leg
MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis
14 studies of 3,097 adults aged 50 or younger who had lumbar MRI: 1,193 without symptoms and 1,904 with low back pain, with or without leg symptoms.
What it foundDisc bulge (odds ratio 7.54, 95% CI 1.28 to 44.56), disc extrusion, disc protrusion, disc degeneration, Modic type 1 changes and spondylolysis were more common in people with back pain than in people without it. Annular fissures, any Modic change, central canal stenosis and spondylolisthesis were not associated with back pain.
What it can't tell usIt compares how often findings appear in two groups, so it shows association, not cause, and can't say which finding explains one person's pain. The bulge estimate has a very wide confidence interval, and it covers only adults 50 or younger.
Publication details & citation
Brinjikji et al. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. American Journal of Neuroradiology. 2015. DOI: 10.3174/ajnr.A4498.
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The efficacy of manual therapy for rotator cuff tendinopathy: a systematic review and meta-analysis
21 randomized trials comparing manual therapy with any other intervention in people with rotator cuff tendinopathy.
What it foundManual therapy reduced pain a little more than placebo or the treatment it was added to, and adding it to an exercise program reduced pain, by about one point on a ten-point scale, which may or may not be clinically important.
What it can't tell usMost trials had a high risk of bias, the evidence is low to moderate in quality, and it is unclear whether manual therapy improves function.
Publication details & citation
Desjardins-Charbonneau et al. The efficacy of manual therapy for rotator cuff tendinopathy: a systematic review and meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2015. DOI: 10.2519/jospt.2015.5455.
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Massage for low-back pain
25 randomized trials, 3,096 adults with non-specific low-back pain; one trial in acute pain, the rest in sub-acute or chronic pain.
What it foundMassage improved pain and function more than sham, waiting list or no treatment in the short term but not the long term. Against a pooled group of active treatments (manipulation, mobilization, TENS, acupuncture, traction, relaxation, physical therapy, exercise or self-care education) it reduced pain more in the short and long term, with no difference in function. No serious adverse events were reported.
What it can't tell usThe authors rated the evidence low to very low, mainly because participants and therapists couldn't be blinded, and said they had very little confidence that massage is an effective treatment for low-back pain.
Publication details & citation
Furlan et al. Massage for low-back pain. Cochrane Database of Systematic Reviews. 2015. DOI: 10.1002/14651858.CD001929.pub3.
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Interventions for preventing and treating low-back and pelvic pain during pregnancy
34 randomized trials with 5,121 pregnant women, 12 to 38 weeks when reported, with low back pain, pelvic pain or both; every intervention was added to usual prenatal care.
What it foundExercise may reduce pregnancy-related low back pain (low-quality evidence), and individual studies suggest a multi-modal program of manual therapy, exercise and education may also reduce pain and disability. Adverse effects, when reported, were minor and transient.
What it can't tell usEvidence ranged from moderate to low quality, the multi-modal evidence came from individual studies and was largely low quality, many results could not be pooled, and the searches ran to January 2015.
Publication details & citation
Liddle & Pennick Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database of Systematic Reviews. 2015. DOI: 10.1002/14651858.CD001139.pub4.
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Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis
47 studies of adults that measured sedentary time and allowed for physical activity, almost all of them prospective cohorts.
What it foundMore sedentary time went with higher risk of death from any cause (hazard ratio 1.24), death from and onset of cardiovascular disease (1.18 and 1.14), death from and onset of cancer (1.17 and 1.13) and type 2 diabetes (1.91), after allowing for physical activity. The links were generally stronger in people who were less active.
What it can't tell usSedentary time was self-reported in all but one study, and the studies measured it and activity in very different ways. These are associations from observational studies, so they can't show that sitting caused the outcomes.
Publication details & citation
Biswas et al. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Annals of Internal Medicine. 2015. DOI: 10.7326/M14-1651.
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Association of worker characteristics and early reimbursement for physical therapy, chiropractic and opioid prescriptions with workers' compensation claim duration, for cases of acute low back pain: an observational cohort study
1,442 Ontario Workplace Safety and Insurance Board claims for acute, uncomplicated low back pain approved in 2005, in workers still on full benefits four weeks after approval.
What it foundNeither physiotherapy nor chiropractic care reimbursed in the first four weeks was associated with how long the claim lasted. Early reimbursement for opioid prescriptions predicted longer claims.
What it can't tell usAn observational study that did not adjust for injury severity, limited to workers already off work more than four weeks. The authors say randomized trials are needed to establish cause.
Publication details & citation
Busse et al. Association of worker characteristics and early reimbursement for physical therapy, chiropractic and opioid prescriptions with workers' compensation claim duration, for cases of acute low back pain: an observational cohort study. BMJ Open. 2015. DOI: 10.1136/bmjopen-2015-007836.
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Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation
192 adults at two US research centers with back-related leg pain for at least four weeks, given 12 weeks of spinal manipulation plus home exercise and advice, or home exercise and advice alone.
What it foundAdding manipulation gave a clinically important advantage for leg pain at 12 weeks, and nearly all secondary outcomes improved more. At one year the leg pain difference was not statistically significant, while global improvement, satisfaction and lower medication use held up. No serious treatment-related adverse events occurred.
What it can't tell usPatients and providers could not be blinded, and the main leg pain advantage did not last to one year.
Publication details & citation
Bronfort et al. Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation. Annals of Internal Medicine. 2014. DOI: 10.7326/M14-0006.
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Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial
84 people with plantar heel pain of at least one month, given real or sham trigger point dry needling once a week for six weeks.
What it foundAt six weeks, real dry needling reduced first-step pain and foot pain more than sham needling. Minor, short-lived adverse events followed 32% of real needling appointments and under 1% of sham appointments.
What it can't tell usThe difference between the groups was smaller than the minimal important difference, and the therapist couldn't be blinded. The authors say the effect should be weighed against how often the minor adverse events happened.
Publication details & citation
Cotchett et al. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Physical Therapy. 2014. DOI: 10.2522/ptj.20130255.
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Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists
39 physiotherapists in Ireland trained in trigger point dry needling, recording 7,629 treatments over ten months.
What it foundMild adverse events followed 19% of treatments: bruising (7.6%), bleeding (4.7%), pain during treatment (3.0%) and pain afterwards (2.2%) were the common ones. No significant adverse event occurred, giving an estimated upper risk of 0.04% or less.
What it can't tell usOne training lineage, one country, and clinicians reporting on themselves. A survey that records no serious event over 7,629 treatments puts a ceiling on the risk; it doesn't show the risk is zero, and case reports elsewhere document serious harm.
Publication details & citation
Brady et al. Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. Journal of Manual & Manipulative Therapy. 2014. DOI: 10.1179/2042618613Y.0000000044.
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Exercise only, exercise with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule: a randomized clinical trial
86 people with neck pain and signs of cervical radiculopathy (arm symptoms from a neck nerve root), given four weeks of exercise alone, exercise with mechanical traction, or exercise with over-door traction.
What it foundAdding mechanical traction to exercise was followed by lower neck disability at six and twelve months than exercise alone, and lower than over-door traction at six months.
What it can't tell usIt's a single trial of 86 people with arm symptoms from the neck, and the twelve-month difference was less certain than the six-month one. It doesn't speak for neck pain without arm symptoms, or for traction without exercise.
Publication details & citation
Fritz et al. Exercise only, exercise with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule: a randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy. 2014. DOI: 10.2519/jospt.2014.5065.
Read the publication recordComprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial
172 people with grade I or II whiplash lasting more than three months.
What it foundAn intensive exercise program did not improve pain more than an advice session with telephone support at the measured follow-ups.
What it can't tell usIt compares two specific approaches to chronic whiplash. It isn't evidence that all exercise is useless, and it doesn't cover every acute injury.
Publication details & citation
Michaleff et al. Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. The Lancet. 2014. DOI: 10.1016/S0140-6736(14)60457-8.
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Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial
165 adults with lateral elbow pain lasting more than six weeks.
What it foundSteroid recipients had lower recovery and more recurrence at one year than placebo recipients. Physiotherapy did not significantly change one-year recovery or recurrence.
What it can't tell usThe results apply to these approaches to persistent lateral elbow pain. They don't show that chiropractic care is superior.
Publication details & citation
Coombes et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013. DOI: 10.1001/jama.2013.129.
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A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy
169 pregnant participants enrolled at 24 to 28 weeks, with outcomes assessed at 33 weeks.
What it foundManual therapy, stabilization exercise and education alongside obstetric care improved pain and disability compared with standard obstetric care alone.
What it can't tell usBecause the program combined several things, it can't separate out the effect of an adjustment. It doesn't show a benefit for delivery, fetal position or the baby's health. The publication record links a correction.
Publication details & citation
George et al. A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. American Journal of Obstetrics and Gynecology. 2013. DOI: 10.1016/j.ajog.2012.10.869.
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Effects of bracing in adolescents with idiopathic scoliosis
242 adolescents with the usual indications for bracing, in randomized and patient-preference groups.
What it foundIn the randomized group, 75% assigned bracing versus 42% assigned observation reached skeletal maturity without progression to a curve of at least 50 degrees.
What it can't tell usIt supports appropriate orthopedic assessment and bracing for selected adolescents. It gives no evidence that adjustments reverse scoliosis.
Publication details & citation
Weinstein et al. Effects of bracing in adolescents with idiopathic scoliosis. New England Journal of Medicine. 2013. DOI: 10.1056/NEJMoa1307337.
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A pilot study of a chiropractic intervention for management of chronic myofascial temporomandibular disorder
80 participants with chronic muscle-related TMD, assigned a dental splint, Activator Method chiropractic adjustment, a sham adjustment or self-care only, all with a self-care program.
What it foundPain went down by a similar amount in all four groups over six months, and the chiropractic group did not do better than the sham group.
What it can't tell usIt was a pilot built to test whether a larger trial could be run, not to compare the treatments, and only 52 people completed the six-month assessment.
Publication details & citation
DeVocht et al. A pilot study of a chiropractic intervention for management of chronic myofascial temporomandibular disorder. Journal of the American Dental Association. 2013. DOI: 10.14219/jada.archive.2013.0034.
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Is there relationship between temporomandibular disorders and head and cervical posture? A systematic review
17 studies on the association between head and neck posture and TMD.
What it foundThe relationship between TMD and head and neck posture remained controversial and unclear.
What it can't tell usMany of the studies had methodological flaws, and too few were of high quality to accept or rule out a link.
Publication details & citation
Rocha et al. Is there relationship between temporomandibular disorders and head and cervical posture? A systematic review. Journal of Oral Rehabilitation. 2013. DOI: 10.1111/joor.12104.
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Traction for low-back pain with or without sciatica
32 randomized trials involving 2,762 people with low-back pain, with or without sciatica, using manual or machine traction.
What it foundTraction, alone or added to other treatment, made little or no difference to pain, function or overall improvement. Seven trials reported adverse effects, including increased pain, worsening nerve signs and later surgery.
What it can't tell usThe evidence was searched through 2012, the trials were small and many had moderate to high risk of bias, and the review didn't test any one branded table.
Publication details & citation
Wegner et al. Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews. 2013. DOI: 10.1002/14651858.CD003010.pub5.
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Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State
1,885 Washington State workers with new workers' compensation time-loss claims for back injuries, surveyed about three weeks after the claim.
What it found9.2% had lumbar spine surgery within three years. Unadjusted, about 42.7% of workers who first saw a surgeon had surgery, against 1.5% of those who first saw a chiropractor; in a multivariate model that included injury severity and disability scores, a chiropractor as first provider was still linked with reduced odds of surgery.
What it can't tell usAn association in workers who chose their own first provider. It can't show that seeing a chiropractor first prevented surgery, because people who go to a surgeon first may have had injuries the model didn't fully capture.
Publication details & citation
Keeney et al. Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State. Spine. 2013. DOI: 10.1097/BRS.0b013e3182814ed5.
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Manipulative therapies for infantile colic
Six randomized trials with 325 infants under six months with colic, testing chiropractic, osteopathy or cranial manipulation.
What it foundFive of the six trials suggested a benefit, and the five that measured daily crying, combined, showed about 1 hour 12 minutes less crying a day. When only the trials that kept parents blinded were combined, the difference was not statistically significant.
What it can't tell usThe trials were small and prone to bias, so the reviewers could reach no definitive conclusion, and only one trial recorded adverse events, too few data to judge safety.
Publication details & citation
Dobson et al. Manipulative therapies for infantile colic. Cochrane Database of Systematic Reviews. 2012. DOI: 10.1002/14651858.CD004796.pub2.
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Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial
272 adults with nonspecific neck pain lasting 2 to 12 weeks.
What it foundManipulation performed better than medication at several follow-ups, but there was no important pain difference between manipulation and home exercise with advice.
What it can't tell usTreatment was unblinded. The study doesn't cover every cause of neck pain, instability after trauma, or an unexplained neurological problem.
Publication details & citation
Bronfort et al. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Annals of Internal Medicine. 2012. DOI: 10.7326/0003-4819-156-1-201201030-00002.
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Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature
Published reports, 1978 to 2009, of adverse events after spinal manipulation during pregnancy or postpartum: five articles describing seven people, plus two systematic reviews.
What it foundOnly a few adverse events were found in the literature, five of them in pregnant patients, ranging from pain that resolved within days to more severe injuries including fracture, stroke and epidural hematoma; the authors suggest such injuries may be relatively rare.
What it can't tell usCase reports cannot give a rate, and the authors call for better reporting of adverse events.
Publication details & citation
Stuber et al. Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature. Chiropractic & Manual Therapies. 2012. DOI: 10.1186/2045-709X-20-8.
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A randomised controlled trial of preventive spinal manipulation with and without a home exercise program for patients with chronic neck pain
98 chiropractic patients with chronic nonspecific neck pain, after a short course of treatment.
What it foundOver ten months, monthly spinal manipulation with or without home exercise made no difference compared with a chiropractor visit every two months to discuss symptoms; all groups held the level reached after initial care.
What it can't tell usIt's one modest trial with an attention-control comparison, so it can't separate specific from non-specific effects of a visit.
Publication details & citation
Martel et al. A randomised controlled trial of preventive spinal manipulation with and without a home exercise program for patients with chronic neck pain. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-41.
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Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?
60 people with chronic nonspecific low-back pain lasting at least six months, in a trial from a university rheumatology and rehabilitation department in Egypt.
What it foundBoth groups given a month of spinal manipulation improved more than sham at one month; only the group given maintenance manipulation every two weeks for nine more months showed more improvement at ten months, and the no-follow-up group returned near baseline.
What it can't tell usIt's a small trial, and it didn't select people who had responded to initial care, so it doesn't match how maintenance care is usually offered.
Publication details & citation
Senna & Machaly Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?. Spine. 2011. DOI: 10.1097/BRS.0b013e3181f5dfe0.
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A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial
401 adults with chronic nonspecific low-back pain.
What it foundStructural and relaxation massage both improved function and symptom bothersomeness at ten weeks compared with usual care.
What it can't tell usParticipants knew whether they received massage. Neither style was meaningfully superior, and benefits at one year were limited.
Publication details & citation
Cherkin et al. A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Annals of Internal Medicine. 2011. DOI: 10.7326/0003-4819-155-1-201107050-00002.
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Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study
40 people referred to spine surgeons with one-sided sciatica from a lumbar disc herniation that had not improved after at least three months of non-surgical care, assigned to chiropractic spinal manipulation or microdiscectomy, with crossover allowed after three months.
What it foundBoth groups improved. At one year an intention-to-treat analysis found no difference by the treatment people started with. Eight patients who crossed from manipulation to surgery improved as much as the surgical group; three who crossed from surgery to manipulation gained no further improvement.
What it can't tell usA very small trial, and the crossover after three months makes the one-year comparison harder to read. The lead author is a chiropractor.
Publication details & citation
McMorland et al. Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics. 2010. DOI: 10.1016/j.jmpt.2010.08.013.
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Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial
522 athletes aged 12 to 70 with a recent lateral ankle sprain, receiving usual care with or without an eight-week home balance program.
What it foundOver one year, 22% of the training group reported another sprain, compared with 33% of the usual-care group.
What it can't tell usRecurrences were self-reported. It backs rehabilitation after an ankle sprain, but it didn't test manipulation, and it doesn't show immediate pain relief.
Publication details & citation
Hupperets et al. Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial. BMJ. 2009. DOI: 10.1136/bmj.b2684.
Read the publication recordNo effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy
60 people with chronic low-back pain thought to come from the disc, in a graded activity program, given 20 sessions of IDD Therapy traction or a sham traction weight.
What it foundBoth groups improved in back pain, leg pain, disability and quality of life at 14 weeks, and active traction did no better than the sham on any of them.
What it can't tell usIt studied chronic low back pain, not sciatica, so it says nothing about leg pain from an irritated nerve root. It tested one protocol on one machine, and nothing in it backs claims of disc regeneration.
Publication details & citation
Schimmel et al. No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy. European Spine Journal. 2009. DOI: 10.1007/s00586-009-1044-3.
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Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health
54 epidemiological studies of the relationship between sagittal spinal curves (the side-on shape of the spine) and health outcomes, including spinal pain.
What it foundNo strong evidence of an association between sagittal spinal curves and any health outcome, including spinal pain. The included studies were generally of low methodological quality.
What it can't tell usPublished in 2008 and, being a review of observational studies, unable to say whether a curve causes anything even where an association was found.
Publication details & citation
Christensen & Hartvigsen Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. Journal of Manipulative and Physiological Therapeutics. 2008. DOI: 10.1016/j.jmpt.2008.10.004.
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A systematic literature review of nonsurgical treatment in adult scoliosis
Clinical studies of bracing, physical therapy, chiropractic care and injections in adult and degenerative scoliosis. Studies mainly of adolescents were excluded.
What it foundEvidence for every conservative option was indeterminate: Level IV on a five-level scale for physical therapy, chiropractic care and bracing, and Level III for injections. The authors concluded that conservative care in general may be a helpful option in adult deformity, but that evidence for this is lacking.
What it can't tell usIt's an older review built on low-level study designs, and it found too little research to recommend one conservative option over another.
Publication details & citation
Everett & Patel A systematic literature review of nonsurgical treatment in adult scoliosis. Spine. 2007. DOI: 10.1097/BRS.0b013e318134ea88.
Read the publication recordRead this research in context (1)
Surgery versus prolonged conservative treatment for sciatica
283 patients with severe sciatica lasting 6 to 12 weeks, assigned early surgery or prolonged conservative care with surgery if needed.
What it foundEarly surgery provided faster relief and recovery, while one-year outcomes were similar.
What it can't tell usAbout 39% of those first assigned conservative care went on to have surgery. It wasn't a chiropractic trial, and it doesn't show that any treatment shrinks discs or guarantees avoiding surgery.
Publication details & citation
Peul et al. Surgery versus prolonged conservative treatment for sciatica. New England Journal of Medicine. 2007. DOI: 10.1056/NEJMoa064039.
Read the publication recordChiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations
102 outpatients in Rome with acute back pain and sciatica with a disc protrusion and at least moderate pain, given active or simulated rapid-thrust manipulations by experienced chiropractors, five days a week up to 20 sessions.
What it foundMore of the manipulation group were free of radiating leg pain at the end of treatment (55% against 20%) and of local back pain (28% against 6%), with fewer days in pain and lower pain scores. Quality of life and psychosocial scores did not differ, and no adverse events were reported.
What it can't tell usOne trial in one city, with a daily schedule most practices do not use, and follow-up only to six months.
Publication details & citation
Santilli et al. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. The Spine Journal. 2006. DOI: 10.1016/j.spinee.2005.08.001.
Read the publication recordRead this research in context (2)
Short-term efficacy of Epley's manoeuvre: a double-blind randomised trial
66 people with confirmed posterior-canal benign paroxysmal positional vertigo (BPPV).
What it foundAt 24 hours, 80% receiving the Epley maneuver had neither vertigo nor nystagmus on positional testing, compared with 10% receiving the sham procedure.
What it can't tell usIt was a short-term test of one repositioning maneuver for one specific diagnosis. There's nothing in it that supports neck manipulation for unexplained dizziness.
Publication details & citation
von Brevern et al. Short-term efficacy of Epley's manoeuvre: a double-blind randomised trial. Journal of Neurology, Neurosurgery & Psychiatry. 2006. DOI: 10.1136/jnnp.2005.085894.
Read the publication recordDiagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests
48 patients assessed with clinical provocation tests and intra-articular anesthetic injections.
What it foundA cluster of pain-provoking tests was more useful than relying on a single finding to identify SI-joint pain in this sample.
What it can't tell usThe sample was small and selected. It's research on diagnosis, so it doesn't prove a pelvic misalignment or that any treatment works.
Publication details & citation
Laslett et al. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual Therapy. 2005. DOI: 10.1016/j.math.2005.01.003.
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Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study
101 patients with plantar fasciitis lasting at least ten months.
What it foundPlantar fascia-specific stretching improved worst pain and first-step pain more at eight weeks than Achilles stretching.
What it can't tell usOnly 82 patients came back for follow-up, and the two groups differed at the start in how long they'd had symptoms. Both groups also got insoles, medication and education, so the results can't be put down to stretching alone, or applied to every heel problem.
Publication details & citation
DiGiovanni et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. Journal of Bone and Joint Surgery. 2003. DOI: 10.2106/00004623-200307000-00013.
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A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache
200 people with cervicogenic headache, assigned to manipulation, specific exercise, both, or a control group.
What it foundManipulative therapy and exercise each reduced headache frequency and intensity, with benefits reported at 12 months.
What it can't tell usParticipants weren't blinded, and the combined approach wasn't significantly superior. The findings are about headache that starts in the neck (cervicogenic headache), not migraine in general.
Publication details & citation
Jull et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002. DOI: 10.1097/00007632-200209010-00004.
Read the publication recordRead this research in context (9)
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- Back of the head
- Upper neck
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