Immediate changes after manual therapy in resting-state functional connectivity as measured by functional magnetic resonance imaging in participants with induced low back pain

Biofield Therapies Clinical Research Landscape: A Scoping Review and Interactive Evidence Map

Background: Biofield Therapies, with a historical lineage spanning millennia and continuing relevance in contemporary practices, have been used to address various health conditions and promote wellbeing. The scientific study and adoption of these therapies have been hindered by cultural challenges and institutional barriers. In addition, the current research landscape for Biofield Therapies is insufficiently documented. Objectives: This scoping review aims to comprehensively document the peer-reviewed research landscape of Biofield Therapies. Furthermore, an online searchable and dynamic Evidence Map was created to serve as a publicly accessible tool for querying the evidence base, pinpointing research gaps, and identifying areas requiring further exploration. Methods: A systematic search of PubMed, Embase, CINAHL, and PsycInfo databases was conducted from inception through January 2024. Peer-reviewed interventional studies in English involving human participants receiving Biofield Therapy were included. Data on study design, population, intervention, comparator, outcomes, citation details, and direction of results reported were extracted and synthesized into two summary tables and three data tables. Results: In total, 353 studies in 352 published reports were included: 255 randomized controlled trials, 36 controlled clinical trials, and 62 pre-post study designs. Named biofield interventions included Reiki (n = 88), Therapeutic Touch (n = 71), Healing Touch (n = 31), intercessory prayer (n = 21), External Qigong (n = 16), Spiritual Healing/Spiritual Passé/Laying-on-of-hands (n = 14), "distant or remote healing" (n = 10), and Gentle Human Touch/Yakson Therapeutic Touch (n = 9). Also included were 56 studies in 55 reports involving bespoke, unknown, or other interventions, 20 studies involving multimodal interventions, and 17 studies involving multiple biofield interventions. Studies encompassed a wide variety of populations, most commonly healthy volunteers (n = 67), pain (n = 55), and cancer (n = 46). As reported in the Abstracts, nearly half of the studies (n = 172) reported positive results in favor of the Biofield Therapy for all outcomes being investigated, 95 reported mixed results, 71 reported nonsignificant results, 3 reported negative results, and 12 studies did not report the direction of results. Conclusions: Despite rising interest in Biofield Therapies among researchers, practitioners, and patients, the integration of these interventions into allopathic medical systems is hindered by challenges in researching these therapies and inconsistent reporting. These issues contribute to inconclusive findings, which limit our understanding of the efficacy of Biofield Therapies for specific conditions. The resulting scoping review and interactive Evidence Map aim to empower stakeholders to overcome these obstacles, thereby strengthening the evidence for the potential adoption of Biofield Therapies as future integrative care options in allopathic medicine.

The mechanisms of manual therapy: A living review of systematic, narrative, and scoping reviews

INTRODUCTION

Treatment mechanisms are the underlying process or pathway through which a treatment influences the body. This includes molecular, cellular and physiological processes or pathways contributing to treatment effect. Manual therapy (MT) evokes complex mechanistic responses across body systems, interacting with the individual patient and context to promote a treatment response. Challenges arise as mechanistic studies are spread across multiple professions, settings and populations. The purpose of this review is to summarize treatment mechanisms that have been reported to occur with MT application.

METHODS

Four electronic databases were searched (Medline, CINAHL, Cochrane Library, and PEDro) for reviews investigating mechanistic responses which occur during/post application of MT. This review was registered a priori with PROSPERO (CRD42023444839). Methodological quality (AMSTAR-2) and risk of bias (ROBIS) were assessed for systematic and scoping reviews. Data were synthesized by mechanistic domain.

RESULTS

Sixty-two reviews were included. Systematic reviews (n = 35), narrative reviews (n = 24), and scoping reviews (n = 4) of asymptomatic (n = 37), symptomatic (n = 43), non-specified human subjects (n = 7) and animals (n = 7) were included. Reviews of moderate quality supported neurovascular, neurological, and neurotransmitter/neuropeptide changes. Reviews of low quality supported neuroimmunce, neuromuscular, and neuroendocrine changes. Reviews of critically low quality support biomechanical changes.

CONCLUSIONS

Findings support critically low to moderate quality evidence of complex multisystem mechanistic responses occurring with the application of MT. Results support peripheral, segmental spinal, and supraspinal mechanisms occurring with the application of MT, which can be measured directly or indirectly. The clinical value of these findings has not been well established. While MT has proven to be an effective intervention to treat conditions such as pain, the current body of literature leaves uncertainty as to 'why' MT interventions work, and future research should look to better define which mechanisms (or combinations of mechanisms) are mediators of clinical response.

Verification of Pain-Related Neuromodulation Mechanisms of Calcitonin in Knee Osteoarthritis

Chronic pain represents the prevailing symptom among patients suffering from knee osteoarthritis (KOA). In KOA, peripheral sensitization is driven by disruptions in subchondral bone homeostasis, local inflammatory responses, and variations in neuropeptide and neurotransmitter levels. Calcitonin, a pivotal peptide involved in bone metabolism, additionally exhibits potent analgesic properties. This study aimed to elucidate the mechanisms underlying calcitonin's neuromodulatory effects related to pain in the treatment of KOA. Three experiments were conducted: (1) assessing calcitonin's therapeutic effects via histomorphology, nociceptive behavioral assessments, and Western blot analysis of proteins; (2) verification of the involvement of neurotransmitters and neuropeptides in calcitonin's action using the Signal Transduction PathwayFinder PCR Array, Bio-Plex suspension chip, and ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS); and (3) exploration of calcitonin's impact on brain function through functional magnetic resonance imaging (fMRI). Experiment 1 validated calcitonin's efficacy in KOA models. Experiment 2 demonstrated the involvement of the retinoic acid signaling pathway in calcitonin treatment, confirming that its analgesic efficacy is associated with the modulation of neuropeptides and neurotransmitters. Experiment 3 revealed that calcitonin treatment could reverse regional homogeneity and amplitude of low-frequency fluctuations in the hippocampus and tegmental nucleus. The study affirmed the critical role of pain-related neuromodulation mechanisms in calcitonin treatment, demonstrating that its analgesic effects are mediated through the modulation of neurotransmitters, neuropeptides, and brain function, as observed via fMRI. These findings provide a theoretical foundation for the clinical application of calcitonin in the treatment of KOA pain.

Assessing the transparency in reporting of clinical trials investigating manual therapy interventions for low back pain: A methodological review

RATIONALE

Low back pain (LBP) is a common condition with a significant societal burden. Manual therapy is an effective treatment for LBP and recommended in clinical practice guidelines. While the quantity of literature supporting the use of manual therapy is large, the methodological quality and transparency of this collective work are unclear.

AIMS AND OBJECTIVES

Explore the transparency in reporting of clinical trials assessing manual therapy interventions in patients with LBP by comparing planned components in the trial registration with what was reported in the published manuscript.

METHODS

Three databases were searched to identify trials assessing the treatment effect of manual therapy for LBP from January 2005 to May 2023. Studies were included if the manual therapy consisted of thrust manipulations, mobilizations or muscle energy techniques.

RESULTS

From 4462 studies initially identified, 167 studies remained in the final review after title, abstract and full-text review. Only 87 (52.1%) of the 167 studies were registered (n = 57 prospectively and n = 30 retrospectively). Primary outcomes in the publications were identical to the registration in 54 (62.1%) of the registered trials. Secondary outcomes in the publication were identical to the registration in 27 (31.0%) of the registered trials. The CONSORT reporting guideline was referenced in only 19 (21.8%) trials. Multiple discrepancies between registration and publication were noted for primary and secondary outcomes. All trials had eligibility criteria in the registration that matched their corresponding manuscript, while only four (4.6%) trial registrations addressed any type of statistical analysis plan.

CONCLUSION

Approximately half of the trials were not registered. Of those registered, only half were registered prospectively. Substantial discrepancies existed between registered and published outcomes that were never addressed by the authors, raising questions about potential bias. Transparency can be improved through more stringent requirements during manuscript submission to journals, and better reporting of the rationale for discrepancies between registration and publication.

Neuroplastic Responses to Chiropractic Care: Broad Impacts on Pain, Mood, Sleep, and Quality of Life

OBJECTIVES

This study aimed to elucidate the mechanisms of chiropractic care using resting electroencephalography (EEG), somatosensory evoked potentials (SEPs), clinical health assessments (Fitbit), and Patient-reported Outcomes Measurement Information System (PROMIS-29).

METHODS

Seventy-six people with chronic low back pain (mean age ± SD: 45 ± 11 years, 33 female) were randomised into control (n = 38) and chiropractic (n = 38) groups. EEG and SEPs were collected pre and post the first intervention and post 4 weeks of intervention. PROMIS-29 was measured pre and post 4 weeks. Fitbit data were recorded continuously.

RESULTS

Spectral analysis of resting EEG showed a significant increase in Theta, Alpha and Beta, and a significant decrease in Delta power in the chiropractic group post intervention. Source localisation revealed a significant increase in Alpha activity within the Default Mode Network (DMN) post intervention and post 4 weeks. A significant decrease in N30 SEP peak amplitude post intervention and post 4 weeks was found in the chiropractic group. Source localisation demonstrated significant changes in Alpha and Beta power within the DMN post-intervention and post 4 weeks. Significant improvements in light sleep stage were observed in the chiropractic group along with enhanced overall quality of life post 4 weeks, including significant reductions in anxiety, depression, fatigue, and pain.

CONCLUSIONS

These findings indicate that many health benefits of chiropractic care are due to altered brain activity.

The Effects of Osteopathic Manipulative Treatment on Brain Activity: A Scoping Review of MRI and EEG Studies

Osteopathic manipulative treatment (OMT) is a hands-on therapy aiming to achieve the global homeostasis of the patient. OMT focuses on treating the somatic dysfunctions characterized by tissue modifications, body asymmetry, and range-of-motion restrictions. The benefits related to OMT are thought to be associated with the interconnectedness of the body's systems and the inherent capacity for self-healing. However, whether OMT can influence brain activity, and, consequently, neurophysiological responses is an open research question. Our research investigates the literature to identify the effects of OMT on brain activity. The main purpose of the research question is: can OMT influence brain activity and consequently neurophysiological responses? A scoping review was conducted, searching the following databases: PubMed, Google Scholar, and OSTEOMED.DR (Osteopathic Medical Digital Repository), Scopus, Web of Science (WoS), and Science Direct. The initial search returned 114 articles, and after removing duplicates, 69 were considered eligible to be included in the final sample. In the end, eight studies (six randomized controlled trials, one pilot study, and one cross-over study) were finally included and analyzed in this review. In conclusion, OMT seems to have a role in influencing functional changes in brain activity in healthy individuals and even more in patients with chronic musculoskeletal pain. However, further RCT studies are needed to confirm these findings. Registration protocol: CRD42024525390.

Mulligan manual therapy added to exercise improves headache frequency, intensity and disability more than exercise alone in people with cervicogenic headache: a randomised trial

QUESTION

What is the effect of a 4-week regimen of Mulligan manual therapy (MMT) plus exercise compared with exercise alone for managing cervicogenic headache? Is MMT plus exercise more effective than sham MMT plus exercise? Are any benefits maintained at 26 weeks of follow-up?

DESIGN

A three-armed, parallel-group, randomised clinical trial with concealed allocation, blinded assessment of some outcomes and intention-to-treat analysis.

PARTICIPANTS

Ninety-nine people with cervicogenic headache as per International Classification of Headache Disorders (ICHD-3).

INTERVENTIONS

Participants were randomly allocated to 4 weeks of: MMT with exercise, sham MMT with exercise or exercise alone.

OUTCOME MEASURES

The primary outcome was headache frequency. Secondary outcomes were headache intensity, headache duration, medication intake, headache-related disability, upper cervical rotation range of motion, pressure pain thresholds and patient satisfaction. Outcome measures were collected at baseline and at 4, 13 and 26 weeks.

RESULTS

MMT plus exercise reduced headache frequency more than exercise alone immediately after the intervention (MD between groups in change from baseline: 2 days/month, 95% CI 2 to 3) and this effect was still evident at 26 weeks (MD 4 days, 95% CI 3 to 4). There were also benefits across all time points in several secondary outcomes: headache intensity, headache duration, headache-related disability, upper cervical rotation and patient satisfaction. Pressure pain thresholds showed benefits at all time points at the zygapophyseal joint and suboccipital areas but not at the upper trapezius. The outcomes in the sham MMT with exercise group were very similar to those of the exercise alone group.

CONCLUSIONS

In people with cervicogenic headache, adding MMT to exercise improved: headache frequency, intensity and duration; headache-related disability; upper cervical rotation; and patient satisfaction. These benefits were not due to placebo effects.

TRIAL REGISTRATION

CTRI/2019/06/019506.

Waste not, want not: call to action for spinal manipulative therapy researchers

BACKGROUND

Research waste is defined as research outcomes with no or minimal societal benefits. It is a widespread problem in the healthcare field. Four primary sources of research waste have been defined: (1) irrelevant or low priority research questions, (2) poor design or methodology, (3) lack of publication, and (4) biased or inadequate reporting. This commentary, which was developed by a multidisciplinary group of researchers with spinal manipulative therapy (SMT) research expertise, discusses waste in SMT research and provides suggestions to improve future research.

MAIN TEXT

This commentary examines common sources of waste in SMT research, focusing on design and methodological issues, by drawing on prior research and examples from clinical and mechanistic SMT studies. Clinical research is dominated by small studies and studies with a high risk of bias. This problem is compounded by systematic reviews that pool heterogenous data from varying populations, settings, and application of SMT. Research focusing on the mechanisms of SMT often fails to address the clinical relevance of mechanisms, relies on very short follow-up periods, and has inadequate control for contextual factors.

CONCLUSIONS

This call to action is directed to researchers in the field of SMT. It is critical that the SMT research community act to improve the way research is designed, conducted, and disseminated. We present specific key action points and resources, which should enhance the quality and usefulness of future SMT research.

Association between myofascial trigger point therapy and conditioned pain modulation

INTRODUCTION

Myofascial trigger point therapy (MTrP) is a widely used therapeutic approach, although the underlying mechanisms remain unclear. Mechanisms discussed include peripheral involvement of muscles as well as central pain modulating processes such as the conditioned pain modulation (CPM). The aim of this study was to investigate whether the analgesic response of MTrP and the analgesic response of CPM correlate in asymptomatic participants in order to identify shared underlying mechanisms of MTrP and CPM.

METHOD

Both, CPM and MTrP protocols consisted of heat-based test stimuli (heat pain thresholds before and after the intervention) and pressure-based (conditioning) stimuli. Asymptomatic participants (n = 94) were randomly assigned to receive either mild, intense or no pressure stimuli (between-group design) to both the fingernail and the MTrP of the infraspinatus muscle (within-group design). Pressure stimuli at both locations (fingernail, MTrP) were applied with a pressure algometer for 120 s and continuously adjusted to maintain a constant pain intensity of mild or intense pain. All thermal stimuli were applied on the lower leg with a thermal stimulator.

RESULTS

A significant correlation was shown between the analgesic effect of CPM and MTrP therapy for mild (r = 0.53, p = 0.002) and intensive stimuli (r = 0.73, p < 0.001). 17.3% of the variance of the MTrP effect were explained by CPM after mild stimulation, and 47.1% after intense stimulation. Pain-related characteristics did not explain the variance within the analgesic response using a regression analysis.

CONCLUSIONS

Between the analgesic responses following MTrP and CPM paradigms, a moderate to strong correlation was observed, suggesting shared underlying mechanisms.

The Alterations in the Brain Corresponding to Low Back Pain: Recent Insights and Advances

Low back pain (LBP) is a leading cause of global disabilities. Numerous molecular, cellular, and anatomical factors are implicated in LBP. Current issues regarding neurologic alterations in LBP have focused on the reorganization of peripheral nerve and spinal cord, but neural mechanisms of exactly what LBP impacts on the brain required further researches. Based on existing clinical studies that chronic pain problems were accompanying alterations in brain structures and functions, researchers proposed logical conjectures that similar alterations occur in LBP patients as well. With recent extensive studies carried out using noninvasive neuroimaging technique, increasing number of abnormalities and alterations has been identified. Here, we reviewed brain alterations including white matters, grey matters, and neural circuits between brain areas, which are involved in chronic LBP. Moreover, brain structural and functional connectivity abnormalities are correlated to the happening and transition of LBP. The negative emotions related to back pain indicate possible alterations in emotional brain regions. Thus, the aim of this review is to summarize current findings on the alterations corresponding to LBP in the brain. It will not only further our understanding of etiology of LBP and understanding of negative emotions accompanying with back pain but also provide ideas and basis for new accesses to the diagnosis, treatment, and rehabilitation afterward based on integral medicine.

Meta-epidemiologic review: blinding and sham treatment in clinical trial design for osteopathic manipulative treatment research

Objective

To analyze the consistency of study designs in osteopathic manipulative treatment (OMT) research, focusing on blinding protocols and the use of sham treatments.

Data Source and Study Selection

PubMed and CINAHL were searched in January 2022. A total of 83 research studies between 2009 and 2021 were selected based on the presence of a double- or single-blind study design and/or sham treatment.

Data Extraction and Analysis

Data regarding the primary outcome measures, blinding design, measures used to determine success of blinding, osteopathic technique used, and sham technique used for each eligible study were extracted and compared among different study designs.

Results

A total of 5968 subjects participated in the 83 trials. The study population mainly consisted of asymptomatic individuals (25%) and chronic back pain patients (19%). Light touch was employed most commonly (49%) as the sham treatment, followed by unrelated sham (20%) and incomplete maneuvers (20%). Most studies blinded the subjects (80%) or the outcome evaluator/data analyzer (71%), while only 20% studies blinded the osteopathic physicians.

Conclusions

Strict double-blinding is achievable for OMT clinical research by blinding the subjects and data collectors/analyzers rather than the osteopaths providing the actual treatment. The use of questionnaires to determine the success of blinding should be considered. Additionally, including OMT-naïve subjects is preferred to enhance blinding success. When designing a sham treatment, careful consideration should be given to blinding the data collector, accounting for the placebo effect, and incorporating an additional no-treatment control group to improve the rigor of the study design.

Inertial Sensors and Pressure Pain Threshold to Evaluate People with Primary Adhesive Capsulitis: Comparison with Healthy Controls and Effects of a Physiotherapy Protocol

Inertial sensors (IMUs) have been recently widely used in exercise and rehabilitation science as they can provide reliable quantitative measures of range of motion (RoM). Moreover, the pressure pain threshold (PPT) evaluation provides an objective measure of pain sensation in different body areas. The aim of this study was to evaluate the efficacy of physiotherapy treatment in people with adhesive capsulitis in terms of RoM and pain improvement measured by IMUs and the PPT. A combined prospective cohort/cross-sectional study was conducted. Nineteen individuals with adhesive capsulitis (10/19 females, 54 ± 8 years) and nineteen healthy controls (10/19 females, 51 ± 6 years) were evaluated for active glenohumeral joint RoM and PPT on shoulder body areas. Then, individuals with adhesive capsulitis were invited to 20 sessions of a physiotherapy protocol, and the assessments were repeated within 1 week from the last session. The range of motion in the flexion (p = 0.001) and abduction (p < 0.001) of the shoulder increased significantly after the physiotherapy protocol. Similarly, the PPT was found to increase significantly in all the assessed shoulder body areas, leading to no significant differences compared to the healthy controls. IMU and PPT assessments could be used to evaluate the efficacy of physical therapy in people with adhesive capsulitis.

Bibliometric Analysis of Functional Magnetic Resonance Imaging Studies on Manual Therapy Analgesia from 2002-2022

Background

Research on the brain mechanisms underlying manual therapy (MT)-induced analgesia has been conducted worldwide. However, no bibliometric analysis has been performed on functional magnetic resonance imaging (fMRI) studies of MT analgesia. To provide a theoretical foundation for the practical application of MT analgesia, this study examined the current incarnation, hotspots, and frontiers of fMRI-based MT analgesia research over the previous 20 years.

Methods

All publications were obtained from the Science Citation Index-Expanded (SCI-E) of Web of Science Core Collection (WOSCC). We used CiteSpace 6.1.R3 to analyze publications, authors, cited authors, countries, institutions, cited journals, references, and keywords. We also evaluated keyword co-occurrences and timelines, and citation bursts. The search was conducted from 2002-2022 and was completed within one day on October 7, 2022.

Results

In total, 261 articles were retrieved. The total number of annual publications showed a fluctuating but overall increasing trend. Author B. Humphreys had the highest number of publications (eight articles) and J. E. Bialosky had the highest centrality (0.45). The United States of America (USA) was the country with the most publications (84 articles), accounting for 32.18% of all publications. Output institutions were mainly the University of Zurich, University of Switzerland, and the National University of Health Sciences of the USA. The Spine (118) and the Journal of Manipulative and Physiological Therapeutics (80) were most frequently cited. The four hot topics in fMRI studies on MT analgesia were "low back pain", "magnetic resonance imaging", "spinal manipulation", and "manual therapy." The frontier topics were "clinical impacts of pain disorders" and "cutting-edge technical capabilities offered by magnetic resonance imaging".

Conclusion

fMRI studies of MT analgesia have potential applications. fMRI studies of MT analgesia have linked several brain areas, with the default mode network (DMN) garnering the most attention. Future research should include international collaboration and RCTs on this topic.

The Neurophysiological Lesion: A Scoping Review

Objective

The purpose of this study was to examine the extent of the literature on the neurophysiological lesion as referenced in functional neurology.

Methods

A literature search was performed within the period from 2010 to March 2021. Search terms included central sensitization, central sensitivity syndrome, nociplastic pain, cold hyperalgesia, heat hyperalgesia, mechanical hyperalgesia, dynamic mechanical allodynia, temporal summation, spatial summation, and descending inhibition. A qualitative synthesis summarized the research findings, including clinical conditions and effect of spinal manipulation.

Results

There were 30 studies, which included 7 high-level studies (meta-analysis or systematic reviews), 22 randomized controlled studies, and 1 scoping review. The findings suggest the existence of the changes in the central integrated state of a population of neurons with various disorders, experimentally induced stimulation, and treatment. The current literature suggests plasticity of the central integrative state (CIS) with the onset of pathologies and the changes in the CIS with different conservative nonpharmacologic treatments.

Conclusions

This review suggests changes in the resting state of the CIS of a population of neurons that exist in the physiologic lesion may change in response to various therapies, including manipulative therapy. The findings from this review provide support of the hypothesis that nonpharmacologic conservative care may affect the neurophysiological lesion. However, studies were heterogeneous and evidence was lacking in the translation of targeting the therapies to distinct neuronal areas for clinical outcomes to treat specific disease states.

The Immediate Hypoalgesic Effect of Low and High Force Thoracic Mobilizations in Asymptomatic Subjects as Measured by Pain Pressure Thresholds (PPT)

Physiotherapists commonly use mobilizations for treating patients with thoracic spine pain (TSP). There is evidence to suggest that spinal mobilizations can decrease pain. Different doses of mobilization treatment are applied, however there is a paucity of evidence on the influence of these dosage parameters. The effect of different forces of treatment remains unknown. This study aimed to investigate whether there was a difference in the hypoalgesic effect of high and low force thoracic mobilizations. This single-blinded, randomized, within-subject, repeated measures, cross-over design recruited 28 asymptomatic participants. Participants received the experimental conditions of high (200 N) and low force (30 N) mobilizations to T6 at least 48 h apart. Pressure pain thresholds (PPTs) were measured before and immediately after each experimental intervention at three different standardized sites. The results demonstrated that high force thoracic mobilizations caused a significant increase in PPT measures compared to low force mobilizations. This effect was detected at all PPT sites. This study suggests that high force thoracic PA mobilizations cause a significantly greater hypoalgesic response in asymptomatic participants than low force thoracic mobilizations. The hypoalgesic response seems to be elicited not only locally at the site of the intervention, but in a widespread manner.

The Current View on the Paradox of Pain in Autism Spectrum Disorders

Autism spectrum disorder (ASD) is a neurodevelopmental disorder, which affects 1 in 44 children and may cause severe disabilities. Besides socio-communicational difficulties and repetitive behaviors, ASD also presents as atypical sensorimotor function and pain reactivity. While chronic pain is a frequent co-morbidity in autism, pain management in this population is often insufficient because of difficulties in pain evaluation, worsening their prognosis and perhaps driving higher mortality rates. Previous observations have tended to oversimplify the experience of pain in autism as being insensitive to painful stimuli. Various findings in the past 15 years have challenged and complicated this dogma. However, a relatively small number of studies investigates the physiological correlates of pain reactivity in ASD. We explore the possibility that atypical pain perception in people with ASD is mediated by alterations in pain perception, transmission, expression and modulation, and through interactions between these processes. These complex interactions may account for the great variability and sometimes contradictory findings from the studies. A growing body of evidence is challenging the idea of alterations in pain processing in ASD due to a single factor, and calls for an integrative view. We propose a model of the pain cycle that includes the interplay between the molecular and neurophysiological pathways of pain processing and it conscious appraisal that may interfere with pain reactivity and coping in autism. The role of social factors in pain-induced response is also discussed. Pain assessment in clinical care is mostly based on subjective rather than objective measures. This review clarifies the strong need for a consistent methodology, and describes innovative tools to cope with the heterogeneity of pain expression in ASD, enabling individualized assessment. Multiple measures, including self-reporting, informant reporting, clinician-assessed, and purely physiological metrics may provide more consistent results. An integrative view on the regulation of the pain cycle offers a more robust framework to characterize the experience of pain in autism.

Chiropractic Spinal Adjustment Increases the Cortical Drive to the Lower Limb Muscle in Chronic Stroke Patients

This study aimed to investigate the effects of a single session of chiropractic spinal adjustment on the cortical drive to the lower limb in chronic stroke patients. In a single-blinded, randomized controlled parallel design study, 29 individuals with chronic stroke and motor weakness in a lower limb were randomly divided to receive either chiropractic spinal adjustment or a passive movement control intervention. Before and immediately after the intervention, transcranial magnetic stimulation (TMS)-induced motor evoked potentials (MEPs) were recorded from the tibialis anterior (TA) muscle of the lower limb with the greatest degree of motor weakness. Differences in the averaged peak-peak MEP amplitude following interventions were calculated using a linear regression model. Chiropractic spinal adjustment elicited significantly larger MEP amplitude (pre = 0.24 ± 0.17 mV, post = 0.39 ± 0.23 mV, absolute difference = +0.15 mV, relative difference = +92%, p &lt; 0.001) compared to the control intervention (pre = 0.15 ± 0.09 mV, post = 0.16 ± 0.09 mV). The results indicate that chiropractic spinal adjustment increases the corticomotor excitability of ankle dorsiflexor muscles in people with chronic stroke. Further research is required to investigate whether chiropractic spinal adjustment increases dorsiflexor muscle strength and walking function in people with stroke.

The Changes of Brain Function After Spinal Manipulation Therapy in Patients with Chronic Low Back Pain: A Rest BOLD fMRI Study

OBJECTIVE

To investigate the changes of regional homogeneity (Reho) values before and after spinal manipulative therapy (SMT) in patients with chronic low back pain (CLBP) through rest blood-oxygen-level-dependent functional magnetic resonance imaging (BOLD fMRI).

METHODS

Patients with CLBP (Group 1, n = 20) and healthy control subjects (Group 2, n = 20) were recruited. The fMRI was performed three times in Group 1 before SMT (time point 1, TP1), after the first SMT (time point 2, TP2), after the sixth SMT (time point 3, TP3), and for one time in Group 2, which received no intervention. The clinical scales were finished in Group 1 every time before fMRI was performed. The Reho values were compared among Group 1 at different time points, and between Group 1 and Group 2. The correlation between Reho values with the statistical differences and the clinical scale scores were calculated.

RESULTS

The bilateral precuneus and right mid-frontal gyrus in Group 1 had different Reho values compared with Group 2 at TP1. The Reho values were increased in the left precuneus and decreased in the left superior frontal gyrus in Group 1 at TP2 compared with TP1. The Reho values were increased in the left postcentral gyrus and decreased in the left posterior cingulate cortex and the superior frontal gyrus in Group 1 at TP3 compared with TP1. The ReHo values of the left precuneus in Group 1 at TP1 were negatively correlated with the pain degree at TP1 and TP2 (r = -0.549, -0.453; p = 0.012, 0.045). The Reho values of the middle temporal gyrus in Group 1 at TP3 were negatively correlated with the changes of clinical scale scores between TP3 and TP1 (r = 0.454, 0.559; p = 0.044, 0.01).

CONCLUSION

Patients with CLBP showed abnormal brain function activity, which was altered after SMT. The Reho values of the left precuneus could predict the immediate analgesic effect of SMT.

Evidence for increased neuromuscular drive following spinal manipulation in individuals with subacromial pain syndrome

BACKGROUND

Thoracic spinal manipulation can improve pain and function in individuals with shoulder pain; however, the mechanisms underlying these benefits remain unclear. Here, we evaluated the effects of thoracic spinal manipulation on muscle activity, as alteration in muscle activity is a key impairment for those with shoulder pain. We also evaluated the relationship between changes in muscle activity and clinical outcomes, to characterize the meaningful context of a change in neuromuscular drive.

METHODS

Participants with shoulder pain related to subacromial pain syndrome (n = 28) received thoracic manipulation of low amplitude high velocity thrusts to the lower, middle and upper thoracic spine. Electromyographic muscle activity (trapezius-upper, middle, lower; serratus anterior; deltoid; infraspinatus) and shoulder pain (11-point scale) was collected pre and post-manipulation during arm elevation, and normalized to a reference contraction. Clinical benefits were assessed using the Pennsylvania Shoulder Score (Penn) at baseline and 2-3 days post-intervention.

FINDINGS

A significant increase in muscle activity was observed during arm ascent (p = 0.002). Using backward stepwise regression analysis, a specific increase in the serratus anterior muscle activity during arm elevation explained improved Penn scores following post-manipulation (p < 0.05).

INTERPRETATION

Thoracic spinal manipulation immediately increases neuromuscular drive. In addition, increased serratus anterior muscle activity, a key muscle for scapular motion, is associated with short-term improvements in shoulder clinical outcomes.

Segmental Chiropractic Spinal Manipulation Does not Reduce Pain Amplification and the Associated Pain-Related Brain Activity in a Capsaicin-Heat Pain Model

Musculoskeletal injuries lead to sensitization of nociceptors and primary hyperalgesia (hypersensitivity to painful stimuli). This occurs with back injuries, which are associated with acute pain and increased pain sensitivity at the site of injury. In some cases, back pain persists and leads to central sensitization and chronic pain. Thus, reducing primary hyperalgesia to prevent central sensitization may limit the transition from acute to chronic back pain. It has been shown that spinal manipulation (SM) reduces experimental and clinical pain, but the effect of SM on primary hyperalgesia and hypersensitivity to painful stimuli remains unclear. The goal of the present study was to investigate the effect of SM on pain hypersensitivity using a capsaicin-heat pain model. Laser stimulation was used to evoke heat pain and the associated brain activity, which were measured to assess their modulation by SM. Eighty healthy participants were recruited and randomly assigned to one of the four experimental groups: inert cream and no intervention; capsaicin cream and no intervention; capsaicin cream and SM at T7; capsaicin cream and placebo. Inert or capsaicin cream (1%) was applied to the T9 area. SM or placebo were performed 25 min after cream application. A series of laser stimuli were delivered on the area of cream application (1) before cream application, (2) after cream application but before SM or placebo, and (3) after SM or placebo. Capsaicin cream induced a significant increase in laser pain (p < 0.001) and laser-evoked potential amplitude (p < 0.001). However, SM did not decrease the amplification of laser pain or laser-evoked potentials by capsaicin. These results indicate that segmental SM does not reduce pain hypersensitivity and the associated pain-related brain activity in a capsaicin-heat pain model.

Hypoalgesic Effects of Transcutaneous Electrical Nerve Stimulation Combined With Joint Manipulation: A Randomized Clinical Trial

OBJECTIVE

The objective of this study was to compare the hypoalgesic effects of isolated or combined use of transcutaneous electrical nerve stimulation (TENS) and cervical joint manipulation (JM) in asymptomatic participants.

METHODS

One hundred and forty-four healthy participants aged 18 to 30 years old were randomly assigned to 1 of 4 groups (n = 36 per group): active TENS + active JM, active TENS + placebo JM, placebo TENS + active JM, and placebo TENS + placebo JM. Active or placebo TENS was applied to the dominant forearm. JM was applied to the C6-7 segments. The pressure pain threshold was measured pre- and postintervention and after 20 minutes on the forearm and tibialis anterior of the dominant side.

RESULTS

Segmental hypoalgesia was greater in the group active TENS + active JM compared with active TENS + placebo JM (P = .002), placebo TENS + active JM (P < .0001), and placebo TENS + placebo JM (P < .0001). For the extrasegmental hypoalgesia, active TENS + active JM had greater hypoalgesic effect compared with active TENS + placebo JM (P = .033), placebo TENS + active JM (P = .002), and placebo TENS + placebo JM (P < .0001).

CONCLUSION

TENS and JM produced hypoalgesia when used alone and, when the treatments were combined, a higher segmental and extrasegmental hypoalgesic effect was obtained in asymptomatic participants.

Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain

Together, neck pain and back pain are the first cause of disability worldwide, accounting for more than 10% of the total years lived with disability. In this context, chiropractic care provides a safe and effective option for the management of a large proportion of these patients. Chiropractic is a healthcare profession mainly focused on the spine and the treatment of spinal disorders, including spine pain. Basic studies have examined the influence of chiropractic spinal manipulation (SM) on a variety of peripheral, spinal and supraspinal mechanisms involved in spine pain. While spinal cord mechanisms of pain inhibition contribute at least partly to the pain-relieving effects of chiropractic treatments, the evidence is weaker regarding peripheral and supraspinal mechanisms, which are important components of acute and chronic pain. This narrative review highlights the most relevant mechanisms of pain relief by SM and provides a perspective for future research on SM and spine pain, including the validation of placebo interventions that control for placebo effects and other non-specific effects that may be induced by SM. SIGNIFICANCE: Spinal manipulation inhibits back and neck pain partly through spinal segmental mechanisms and potentially through peripheral mechanisms regulating inflammatory responses. Other mechanisms remain to be clarified. Controls and placebo interventions need to be improved in order to clarify the contribution of specific and non-specific effects to pain relief by spinal manipulative therapy.

The effectiveness of manual therapy and proprioceptive neuromuscular facilitation compared to kinesiotherapy: a four-arm randomized controlled trial

BACKGROUND

Low back pain (LBP) has a negative impact on patients' life, not only from the physical point of view, but also in terms of psychic, social and economic wellbeing. The increasing costs of treatment and health care encourage the search for the most effective methods of treatment.

AIM

The aim of the study was to determine whether the use of combined therapy consisting of manual therapy and proprioceptive neuromuscular facilitation (PNF) is more effective than the use of manual therapy techniques, PNF or traditional kinesiotherapy as single methods in the treatment of LBP.

DESIGN

A four-arm RCT.

SETTING

Rehabilitation Department of Hospital in Parczew (Poland).

METHODS

The study was designed as four-arm randomized comparative controlled RCT and conducted on a group of 200 patients aged 27-55y. (44.9±9.2 years). The patients were randomly divided into four 50-person groups: 1) group A - manual therapy; 2) B - PNF; 3) C - manual therapy and PNF; and 4) group D - traditional kinesiotherapy and control group. Pain intensity was measured using VAS and Laitinen's questionnaire. Functional disability was assessed using Oswestry Disability Index (ODI) and Back Pain Functional Scale (BPFS).

RESULTS

There was a statistically significant difference in pain reduction (VAS Scale) between Group C (4.8 points) and Group D (3.9 points). In all the groups there was a statistically significant reduction in a degree of disability as measured by the ODI. A level of functional capabilities (BPFS) increased significantly only in Group C (8.8 points) as compared to Group D (5.7 points).

CONCLUSIONS

All the evaluated methods caused pain reduction which lasted for at least 2 weeks after the end of treatment. The degree of disability as measured by ODI lowered evenly in all groups. Patients' functional ability assessed with BPFS improved significantly in the group treated with combined therapy (manual therapy and PNF) as compared to the group of traditional kinesiotherapy.

CLINICAL REHABILITATION IMPACT

The therapy consisting of manual therapy and the PNF method seemed to be more effective than the traditional kinesitherapy in improving functioning of patients with non-specific low back pain.

Increased Salience Network Connectivity Following Manual Therapy is Associated with Reduced Pain in Chronic Low Back Pain Patients

Chronic low back pain (cLBP) has been associated with changes in brain plasticity. Nonpharmacological therapies such as Manual Therapy (MT) have shown promise for relieving cLBP. However, translational neuroimaging research is needed to understand potential central mechanisms supporting MT. We investigated the effect of MT on resting-state salience network (SLN) connectivity, and whether this was associated with changes in clinical pain. Fifteen cLBP patients, and 16 matched healthy controls (HC) were scanned with resting functional Magnetic Resonance Imaging (fMRI), before and immediately after a MT intervention (cross-over design with two separate visits, pseudorandomized, grades V 'Manipulation' and III 'Mobilization' of the Maitland Joint Mobilization Grading Scale). Patients rated clinical pain (0-100) pre- and post-therapy. SLN connectivity was assessed using dual regression probabilistic independent component analysis. Both manipulation (Pre: 39.43 ± 16.5, Post: 28.43 ± 16.5) and mobilization (Pre: 38.83 ± 17.7, Post: 31.76 ± 19.4) reduced clinical back pain (P < .05). Manipulation (but not mobilization) significantly increased SLN connectivity to thalamus and primary motor cortex. Additionally, a voxelwise regression indicated that greater MT-induced increase in SLN connectivity to the lateral prefrontal cortex was associated with greater clinical back pain reduction immediately after intervention, for both manipulation (r = -0.8) and mobilization (r = -0.54). Our results suggest that MT is successful in reducing clinical low back pain by both spinal manipulation and spinal mobilization. Furthermore, this reduction post-manipulation occurs via modulation of SLN connectivity to sensorimotor, affective, and cognitive processing regions. PERSPECTIVE: MT both reduces clinical low back pain and modulates brain activity important for the processing of pain. This modulation was shown by increased functional brain connectivity between the salience network and brain regions involved in cognitive, affective, and sensorimotor processing of pain.

Brain Connectivity Changes after Osteopathic Manipulative Treatment: A Randomized Manual Placebo-Controlled Trial

The effects of osteopathic manipulative treatment (OMT) on functional brain connectivity in healthy adults is missing in the literature. To make up for this lack, we applied advanced network analysis methods to analyze resting state functional magnetic resonance imaging (fMRI) data, after OMT and Placebo treatment (P) in 30 healthy asymptomatic young participants randomized into OMT and placebo groups (OMTg; Pg). fMRI brain activity measures, performed before (T0), immediately after (T1) and three days after (T2) OMT or P were used for inferring treatment effects on brain circuit functional organization. Repeated measures ANOVA and post-hoc analysis demonstrated that Right Precentral Gyrus (F (2, 32) = 5.995, p < 0.005) was more influential over the information flow immediately after the OMT, while decreased betweenness centrality in Left Caudate (F (2, 32) = 6.496, p < 0.005) was observable three days after. Clustering coefficient showed a distinct time-point and group effect. At T1, reduced neighborhood connectivity was observed after OMT in the Left Amygdala (L-Amyg) (F (2, 32) = 7.269, p < 0.005) and Left Middle Temporal Gyrus (F (2, 32) = 6.452, p < 0.005), whereas at T2 the L-Amyg and Vermis-III (F (2, 32) = 6.772, p < 0.005) increased functional interactions. Data demonstrated functional connectivity re-arrangement after OMT.

Efficacy of Physical Therapy on Nociceptive Pain Processing Alterations in Patients with Chronic Musculoskeletal Pain: A Systematic Review and Meta-analysis

INTRODUCTION

Chronic musculoskeletal pain is a major health, social, and economic problem. Most of the subjects who suffer from chronic musculoskeletal pain present processes of central sensitization. Temporal summation and conditioned pain modulation are the two most commonly used clinical measures of this. The objective of this review is to evaluate the effects of physical therapy on temporal summation (TS) and conditioned pain modulation (CPM) in patients with chronic musculoskeletal pain.

METHODS

This is a systematic review and meta-analysis. We searched the MEDLINE, EMBASE, CINAHL, EBSCO, PubMed, PEDro, Cochrane Collaboration Trials Register, Cochrane Database of Systematic Reviews, and SCOPUS databases. Different mesh terms and key words were combined for the search strategy, with the aim of encompassing all studies that have used any type of physical therapy treatment in patients with chronic musculoskeletal pain and have measured both TS and CPM.

RESULTS

Eighteen studies remained for qualitative analysis and 16 for quantitative analysis. Statistically significant differences with a 95% confidence interval (CI) were obtained for TS (-0.21, 95% CI = -0.39 to -0.03, Z = 2.50, P = 0.02, N = 721) and CPM (0.34, 95% CI = 0.12 to 0.56, Z = 2.99, P = 0.003, N = 680) in favor of physical therapy as compared with control. Manual therapy produces a slight improvement in TS, and physical therapy modalities in general improve CPM. No significant differences between the subgroups of the meta-analysis were found. The methodological quality of the studies was high.

CONCLUSIONS

Physical therapy produces a slight improvement in central sensitization (CS)-related variables, with TS decreased and CPM increased when compared with a control group in patients with CMP. Only significant differences in TS were identified in the manual therapy subgroup.

Functional Connectivity Analysis on Resting-State Electroencephalography Signals Following Chiropractic Spinal Manipulation in Stroke Patients

Stroke impairments often present as cognitive and motor deficits, leading to a decline in quality of life. Recovery strategy and mechanisms, such as neuroplasticity, are important factors, as these can help improve the effectiveness of rehabilitation. The present study investigated chiropractic spinal manipulation (SM) and its effects on resting-state functional connectivity in 24 subacute to chronic stroke patients monitored by electroencephalography (EEG). Functional connectivity of both linear and non-linear coupling was estimated by coherence and phase lag index (PLI), respectively. Non-parametric cluster-based permutation tests were used to assess the statistical significance of the changes in functional connectivity following SM. Results showed a significant increase in functional connectivity from the PLI metric in the alpha band within the default mode network (DMN). The functional connectivity between the posterior cingulate cortex and parahippocampal regions increased following SM, t (23) = 10.45, p = 0.005. No significant changes occurred following the sham control procedure. These findings suggest that SM may alter functional connectivity in the brain of stroke patients and highlights the potential of EEG for monitoring neuroplastic changes following SM. Furthermore, the altered connectivity was observed between areas which may be affected by factors such as decreased pain perception, episodic memory, navigation, and space representation in the brain. However, these factors were not directly monitored in this study. Therefore, further research is needed to elucidate the underlying mechanisms and clinical significance of the observed changes.

The Association Between Conditioned Pain Modulation and Manipulation-induced Analgesia in People With Lateral Epicondylalgia

OBJECTIVES

Conditioned pain modulation (CPM) and manipulation-induced analgesia (MIA) may activate similar neurophysiological mechanisms to mediate their analgesic effects. This study assessed the association between CPM and MIA responses in people with lateral epicondylalgia.

MATERIALS AND METHODS

Seventy participants with lateral epicondylalgia were assessed for CPM followed by MIA. A single assessor measured pressure pain thresholds (PPT) before, during, and after cold water immersion (10°C) of the asymptomatic hand and contralateral lateral glide (CLG) mobilization of the neck. For analyses, linear mixed models evaluated differences in CPM and MIA responses. Pearson partial correlations and regression analyses evaluated the association between CPM and MIA PPT.

RESULTS

There was a significant increase (CPM and MIA, P<0.001) in PPT from baseline during the interventions (CPM mean: 195.84 kPa for elbow and 201.87 kPa for wrist, MIA mean: 123.01 kPa for elbow and 126.06 kPa for wrist) and after the interventions (CPM mean: 126.06 kPa for elbow, 114.24 kPa for wrist, MIA mean: 123.50 kPa for elbow and 122.16 kPa for wrist). There were also significant moderate and positive partial linear correlations (r: 0.40 to 0.54, P<0.001) between CPM and MIA measures, controlling for baseline measures. Regression analyses showed that CPM PPT was a significant predictor of MIA PPT (P<0.001) and the models explained between 73% and 85% of the variance in MIA PPT.

DISCUSSION

This study showed that CPM and MIA responses were significantly correlated and that the CPM response was a significant predictor of MIA response.

Predictors of instanteous relief from spinal manipulation for non-specific low back pain: a delphi study

Background

There is some evidence and anecdotal reports that high-velocity low-amplitude (HVLA) spinal manipulation therapy (SMT) for non-specific low back pain (NSLBP) may immediately reduce pain in some patients. The mechanism for such a change remains unclear and the evidence is conflicting. The aim of this study was to seek consensus among a sample of expert manual therapists as to the possible clinical predictors that could help identify patients who are most likely to receive instant relief from NSLBP with SMT intervention.

Methods

Thirty-seven expert chiropractors and manipulative physiotherapists from around the world were invited to participate in a three round online Delphi questionnaire during the second half of 2018. Participants were provided with a list of 55 potential signs and symptoms as well as offering them the option of suggesting other factors in the first round. The variables were rated using a 4-point Likert likelihood scale and a threshold of 75% agreement was required for any item to progress to the next round.

Results

Of these 37 experts, 19 agreed to participate. Agreement as to the proportion of patients who receive instantaneous relief was minimal (range 10–80%). A total of 62 items were ranked over the 3 rounds, with 18 of these retained following the third round. The highest rated of the 18 was ‘A history including a good response to previous spinal manipulation’.

Discussion/conclusion

Five categories; patient factors, practitioner factors, signs and symptoms of NSLBP presentation, an instrument of measurement (FABQ), and the presence of cavitation following SMT best describe the overall characteristics of the factors. The 18 factors identified in this study can potentially be used to create an instrument of measurement for further study to predict those patients with NSLBP who will receive instantaneous relief post-SMT.

Ultrasound Shear Wave Elastography to Assess Osteopathic Manipulative Treatment on the Iliocostalis Lumborum Muscle: A Feasibility Study

OBJECTIVES

To investigate the feasibility of ultrasound shear wave elastography (SWE) in assessing iliocostalis lumborum muscle changes after osteopathic manipulative treatment (OMT).

METHODS

Using a linear array ultrasound transducer (4-9 MHz), we prospectively measured the shear wave velocity (SWV) of bilateral iliocostalis lumborum muscles in 20 patients with low back somatic dysfunction and in 9 age-matched healthy volunteers. The SWV was measured in muscle relaxation and contraction in all participants and immediately before and after OMT in patients. We developed a muscle SWV rate [SWV_contraction - SWV_relaxation )/SWV_relaxation ] and an SWV improvement index [(SWV_pre-OMT - SWV_post-OMT )/SWV_pre-OMT ] for quantifying muscle contractibility and changes in muscle stiffness after OMT. Statistical analyses included an unpaired t test to analyze the difference in the muscle SWV between muscle relaxation and contraction and between somatic dysfunction and nonsomatic dysfunction in patients and healthy volunteers, a paired t test to examine the difference in the SWV and SWV rate before and after OMT, the intraclass correlation coefficient to test intraobserver and interobserver reliability, and Spearman rank correlation to analyze the correlation of changes in the SWV with manual osteopathic assessments.

RESULTS

The mean ages of the patients with low back somatic dysfunction and the healthy volunteers were 28 and 26 years, respectively. The muscle SWV significantly differed between somatic dysfunction and nonsomatic dysfunction in patients and healthy volunteers, between muscle relaxation and contraction, and before and after OMT (P < .001). The SWV improvement index moderately correlated with manual osteopathic assessments (r = 0.68). The interobserver and intraobserver reliability for performing SWE was good (intraclass correlation coefficient, >0.8).

CONCLUSIONS

Our results suggest that SWE is feasible for quantifying the change in muscle stiffness and contractibility after OMT.

Evidence for decreased Neurologic Pain Signature activation following thoracic spinal manipulation in healthy volunteers and participants with neck pain

•

The use of brain-based models of pain were explored in two clinical studies.

•

Neurologic pain signature activation decreased following spinal manipulation.

•

Spinal manipulation altered the processing of pain-related brain activity.

•

We provide evidence for a centrally mediated therapeutic action of spinal manipulation.

•

Brain-based models have potential as objective clinical biomarkers of pain.

Background Context

Spinal manipulation (SM) is a common treatment for neck and back pain, theorized to mechanically affect the spine leading to therapeutic mechanical changes. The link between specific mechanical effects and clinical improvement is not well supported. SM's therapeutic action may instead be partially mediated within the central nervous system.

Purpose

To introduce brain-based models of pain for spinal pain and manual therapy research, characterize the distributed central mechanisms of SM, and advance the preliminary validation of brain-based models as potential clinical biomarkers of pain.

Study Design

Secondary analysis of two functional magnetic resonance imaging studies investigating the effect of thoracic SM on pain-related brain activity: A non-controlled, non-blinded study in healthy volunteers (Study 1, n = 10, 5 females, and mean age = 31.2 ± 10.0 years) and a randomized controlled study in participants with acute to subacute neck pain (Study 2, n = 24, 16 females, mean age = 38.0 ± 15.1 years).

Methods

Functional magnetic resonance imaging was performed during noxious mechanical stimulation of the right index finger cuticle pre- and post-intervention. The effect of SM on pain-related activity was studied within brain regions defined by the Neurologic Pain Signature (NPS) that are predictive of physical pain.

Results

In Study 1, evoked mechanical pain (p < 0.001) and NPS activation (p = 0.010) decreased following SM, and the changes in evoked pain and NPS activation were correlated (r_RM² = 0.418, p = 0.016). Activation within the NPS subregions of the dorsal anterior cingulate cortex (dACC, p = 0.012) and right secondary somatosensory cortex/operculum (rS2_Op, p = 0.045) also decreased following SM, and evoked pain was correlated with dACC activity (r_RM² = 0.477, p = 0.019). In Study 2, neck pain (p = 0.046) and NPS (p = 0.033) activation decreased following verum but not sham SM. Associations between evoked pain, neck pain, and NPS activation, were not significant and less clear, possibly due to inadequate power, methodological limitations, or other confounding factors.

Conclusions

The findings provide preliminary evidence that SM may alter the processing of pain-related brain activity within specific pain-related brain regions and support the use of brain-based models as clinical biomarkers of pain.

Unravelling functional neurology: does spinal manipulation have an effect on the brain? - a systematic literature review

Background

A recent hypothesis purports that spinal manipulation may cause changes at a brain level. Functional Neurology, a mainly chiropractic approach, promotes the use of spinal manipulation to improve ‘brain function’ as if it were a proven construct. No systematic review has been performed to investigate how well founded this hypothesis is.

Objective

To investigate whether spinal manipulation has an effect on ‘brain function’ that is associated with any clinical benefits.

Method

In this systematic review, the literature was searched in PubMed, Embase, and PEDro (final search February 2018). We included randomized or non-randomized controlled studies, in which spinal manipulation was performed to any region of the spine, applied on either symptomatic or asymptomatic humans, and compared to a sham or to another type of control. The outcome measures had to be stated as direct or proxy markers of ‘brain function’. Articles were reviewed blindly by at least two reviewers, using a quality checklist designed for the specific needs of the review. Studies were classified as of ‘acceptable’, ‘medium’, or ‘low’ methodological quality. Results were reported in relation to (i) control intervention (sham, ‘inactive control’, or ‘another physical stimulus’) and (ii) study subjects (healthy, symptomatic, or with spinal pain” subjects/spinal pain”), taking into account the quality. Only results obtained from between-group or between-intervention comparisons were considered in the final analysis.

Results

Eighteen of 1514 articles were included. Studies were generally of ‘low’ or ‘medium’ methodological quality, most comparing spinal manipulation to a control other than a sham. Thirteen out of the 18 studies could be included in the final analysis. Transitory effects of different types of ‘brain function’ were reported in the three studies comparing spinal manipulation to sham (but of uncertain credibility), in “subclinical neck/spinal pain” subjects or in symptomatic subjects. None of these three studies, of ‘medium’ or ‘acceptable’ quality, investigated whether the neurophysiological effects reported were associated with clinical benefits. The remaining 10 studies, generally of ‘low’ or ‘medium’ quality, compared spinal manipulation to ‘inactive control’ or ‘another physical stimulus’ and similarly reported significant between-group differences but inconsistently.

Conclusion

The available evidence suggests that changes occur in ‘brain function’ in response to spinal manipulation but are inconsistent across and - sometimes - within studies. The clinical relevance of these changes is unknown. It is therefore premature to promote the use of spinal manipulation as a treatment to improve ‘brain function’.

Electronic supplementary material

The online version of this article (10.1186/s12998-019-0265-8) contains supplementary material, which is available to authorized users.

No difference in pressure pain threshold and temporal summation after lumbar spinal manipulation compared to sham: A randomised controlled trial in adults with low back pain

BACKGROUND

Changes in quantitative sensory tests have been observed after spinal manipulative therapy (SMT), particularly in pressure pain thresholds (PPT) and temporal summation (TS). However, a recent systematic review comparing SMT to sham found no significant difference in PPT in patients with musculoskeletal pain. The sham-controlled studies were generally low quality, and conclusions about other quantitative sensory tests could not be made.

OBJECTIVES

We aimed to perform a sham-controlled study with the specific objective of investigating changes in PPT and TS short-term after lumbar SMT compared to sham manipulation in people with low back pain.

METHODS

This was a double-blind randomised controlled trial comparing high-velocity low-amplitude lumbar SMT against sham manipulation in participants with low back pain. Primary outcome measures were PPT at the calf, lumbar spine and shoulder, and TS at the hands and feet. These were measured at baseline, then immediately, 15 min and 30 min post-intervention.

RESULTS

Eighty participants (42 females) were included in the analyses (mean age 37 years), with 40 participants allocated to each intervention group. Significant between-group differences were only observed for calf PPT, which could be explained by a decrease in PPT (increased sensitivity) after SMT and an increase after sham. Feet TS decreased significantly over time after both SMT and sham, and any other changes over time were inconsistent.

CONCLUSIONS

Our results suggest that lumbar SMT does not have a short-term hypoalgesic effect, as measured with PPT and TS, when compared to sham manipulation in people with low back pain.

Neurophysiological Effects of High Velocity and Low Amplitude Spinal Manipulation in Symptomatic and Asymptomatic Humans: A Systematic Literature Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To summarize the evidence of neurophysiological effects of spinal manipulative therapy (SMT) with a high velocity low amplitude thrust (HVLA-SMT) in asymptomatic and symptomatic humans.

SUMMARY OF BACKGROUND DATA

HVLA-SMT is effective in reducing back pain, but its mode of action is not fully understood.

METHODS

A systematic literature search (until July 2018) was conducted by a professional librarian in seven databases (Medline (OvidSP), Premedline (PubMed), EMBASE, Cochrane, CINAHL, PEDro, and Scopus). Two authors selected the studies according to the a priori described criteria and scored study quality. Only controlled studies of at least moderate quality were included. Effects of HVLA-SMT on a particular outcome measure were defined as more than one study showing a significantly greater effect of HVLA-SMT compared with the control intervention.

RESULTS

From the 18 studies included (932 participants in total), there was evidence only for an association between HVLA-SMT and changes in the autonomic nervous system, reflected in changes in heart rate variability and skin conductance. Most studies focused on healthy volunteers and none related neurophysiologic changes to pain reduction.

CONCLUSION

This systematic review points to HVLA-SMT affecting the autonomic nervous system. The effects seem to depend on the spinal level of HVLA-SMT application and might differ between healthy volunteers and pain patients. There is a need for high-quality studies that include patients, well characterized for pain duration and outcome measure baseline values, and address the relation between changes in neurophysiology and pain.

LEVEL OF EVIDENCE

2.

Does Osteopathic Manipulative Treatment Make a Neuropsychological Difference in Adults With Pain? A Rationale for a New Approach

Cognitive impairment is common in patients with pain. While symptoms of pain are effectively treated with osteopathic manipulative treatment (OMT), the cognitive complaint is vastly ignored. Pain-induced cognitive dysfunction can be severe and is particularly apparent in working memory and attention. There is good reason to expect cognitive responsiveness to OMT. Previous research has reported the effects of OMT on related psychiatric outcomes, including relief from depression and anxiety, suggesting that OMT may produce more cortical benefits than is currently thought. The rationale to link OMT to cognition comes from the tenets of osteopathic medicine: body unity, homeostasis, and the structure-function relationship. The present article provides background evidence to support the hypothetical link between OMT and cognitive benefits and proposes a physiological mechanism of how OMT could exert its effect on cognition. Research strategies are discussed to test the hypotheses that are generated from the proposed theoretical framework.

Experimental Pain Is Alleviated by Manual Traction Itself Rather than Subjective Bias in the Knee: A Signal Detection Analysis

BACKGROUND

Manual traction is used for pain relief, but it is not clear whether the pain relief effect of manual traction is due to sensitivity or to subjective bias. The differences between manual traction and touch have also been unclear.

OBJECTIVES

We used signal detection theory to investigate whether manual traction and touch were effective for pain relief, and we compared the pain relief effect between manual traction and touch.

DESIGN

Repeated measures and single blinding.

METHODS

Twenty healthy adult volunteers performed an intensity judgment task immediately before and after each intervention. The intervention was either manual traction or touch for 10 minutes. We measured the intensity judgment task's signal detection measures of hit rates, false alarm rates, sensitivity (d'), and response bias (C) in an Aδ fiber-mediated pain condition and C fiber-mediated pain condition.

RESULTS

Manual traction did not provide a significant level of change, but its effect sizes differed. In our comparison of the effect sizes, manual traction tended to reduce the hit rate and altered the sensitivity value rather than the response bias in Aδ fiber-mediated pain. There was no significant difference in the amount of change in the hit rate between touch and manual traction regarding Aδ fiber-mediated pain and C fiber-mediated pain.

CONCLUSIONS

In terms of effect sizes, manual traction was effective for the pain relief of the first pain by producing a change in pain sensitivity rather than by subjective bias. Manual traction reduced the first pain, whereas touch reduced the first pain and second pain.

The effects of chiropractic spinal manipulation on central processing of tonic pain - a pilot study using standardized low-resolution brain electromagnetic tomography (sLORETA)

The objectives of the study were to investigate changes in pain perception and neural activity during tonic pain due to altered sensory input from the spine following chiropractic spinal adjustments. Fifteen participants with subclinical pain (recurrent spinal dysfunction such as mild pain, ache or stiffness but with no pain on the day of the experiment) participated in this randomized cross-over study involving a chiropractic spinal adjustment and a sham session, separated by 4.0 ± 4.2 days. Before and after each intervention, 61-channel electroencephalography (EEG) was recorded at rest and during 80 seconds of tonic pain evoked by the cold-pressor test (left hand immersed in 2 °C water). Participants rated the pain and unpleasantness to the cold-pressor test on two separate numerical rating scales. To study brain sources, sLORETA was performed on four EEG frequency bands: delta (1–4 Hz), theta (4–8 Hz), alpha (8–12 Hz) and beta (12–32 Hz). The pain scores decreased by 9% after the sham intervention (p < 0.05), whereas the unpleasantness scores decreased by 7% after both interventions (p < 0.05). sLORETA showed decreased brain activity following tonic pain in all frequency bands after the sham intervention, whereas no change in activity was seen after the chiropractic spinal adjustment session. This study showed habituation to pain following the sham intervention, with no habituation occurring following the chiropractic intervention. This suggests that the chiropractic spinal adjustments may alter central processing of pain and unpleasantness.

Cerebral Perfusion Changes After Osteopathic Manipulative Treatment: A Randomized Manual Placebo-Controlled Trial

Osteopathic Manipulative Treatment (OMT) is a therapeutic approach aimed at enhancing the body's self-regulation focusing on somatic dysfunctions correction. Despite evidence of OMT effectiveness, the underlying neurophysiological mechanisms, as well as blood perfusion effects, are still poorly understood. The study aim was to address OMT effects on cerebral blood flow (CBF) in asymptomatic young volunteers as measured by Magnetic Resonance Arterial Spin Labeling (ASL) method. Thirty blinded participants were randomized to OMT or placebo, and evaluated with an MRI protocol before manual intervention (T0), immediately after (T1), and 3 days later (T2). After T0 MRI, participants received 45 min of OMT, focused on correcting whole body somatic dysfunctions, or placebo manual treatment, consisting of passive touches in a protocolled order. After treatment, participants completed a de-blinding questionnaire about treatment perception. Results show significant differences due to treatment only for the OMT group (OMTg): perfusion decreased (compared to T0) in a cluster comprising the left posterior cingulate cortex (PCC) and the superior parietal lobule, while increased at T2 in the contralateral PCC. Furthermore, more than 60% of participants believed they had undergone OMT. The CBF modifications at T2 suggest that OMT produced immediate but reversible effects on CBF.

A randomized clinical trial comparing non-thrust manipulation with segmental and distal dry needling on pain, disability, and rate of recovery for patients with non-specific low back pain

Objective: The purpose of this study was to examine the within and between-group effects of segmental and distal dry needling (DN) without needle manipulation to a semi-standardized non-thrust manipulation (NTM) targeting the symptomatic spinal level for patients with non-specific low back pain (NSLBP). Methods: Sixty-five patients with NSLBP were randomized to receive either DN (n = 30) or NTM (n = 35) for six sessions over 3 weeks. Outcomes collected included the oswestry disability index (ODI), patient specific functional scale (PSFS), numeric pain rating scale (NPRS), and pain pressure thresholds (PPT). At discharge, patients perceived recovery was assessed. Results: A two-way mixed model ANOVA demonstrated that there was no group*time interaction for PSFS (p = 0.26), ODI (p = 0.57), NPRS (p = 0.69), and PPT (p = 0.51). There was significant within group effects for PSFS (3.1 [2.4, 3.8], p = 0.018), ODI (14.5% [10.0%, 19.0%], p = 0.015), NPRS (2.2 [1.5, 2.8], p = 0.009), but not for PPT (3.3 [0.5, 6.0], p = 0.20). Discussion: The between-group effects were neither clinically nor statistically significant. The within group effects were both significant and exceeded the reported minimum clinically important differences for the outcomes tools except the PPT. DN and NTM produced comparable outcomes in this sample of patients with NSLBP. Level of evidence: 1b.

Association Between Sensorimotor Impairments and Functional Brain Changes in Patients With Low Back Pain: A Critical Review

Low back pain (LBP) coincides with sensorimotor impairments, for example, reduced lumbosacral tactile and proprioceptive acuity and postural control deficits. Recent functional magnetic resonance imaging studies suggest that sensorimotor impairments in LBP may be associated with brain changes. However, no consensus exists regarding the relationship between functional brain changes and sensorimotor behavior in LBP. Therefore, this review critically discusses the available functional magnetic resonance imaging studies on brain activation related to nonnociceptive somatosensory stimulation and motor performance in individuals with LBP. Four electronic databases were searched, yielding nine relevant studies. Patients with LBP showed reduced sensorimotor-related brain activation and a reorganized lumbar spine representation in higher-order (multi)sensory processing and motor regions, including primary and secondary somatosensory cortices, supplementary motor area, and superior temporal gyrus. These results may support behavioral findings of sensorimotor impairments in LBP. In addition, patients with LBP displayed widespread increased sensorimotor-evoked brain activation in regions often associated with abnormal pain processing. Overactivation in these regions could indicate an overresponsiveness to sensory inputs that signal potential harm to the spine, thereby inducing overgeneralized protective responses. Hence, functional brain changes could contribute to the development and recurrence of LBP. However, future studies investigating the causality between sensorimotor-related brain function and LBP are imperative.

Intervertebral kinematics of the cervical spine before, during, and after high-velocity low-amplitude manipulation

BACKGROUND CONTEXT

Neck pain is one of the most commonly reported symptoms in primary care settings, and a major contributor to health-care costs. Cervical manipulation is a common and clinically effective intervention for neck pain. However, the in vivo biomechanics of manipulation are unknown due to previous challenges with accurately measuring intervertebral kinematics in vivo during the manipulation.

PURPOSE

The objectives were to characterize manual forces and facet joint gapping during cervical spine manipulation and to assess changes in clinical and functional outcomes after manipulation. It was hypothesized that patient-reported pain would decrease and intervertebral range of motion (ROM) would increase after manipulation.

STUDY DESIGN/SETTING

Laboratory-based prospective observational study.

PATIENT SAMPLE

12 patients with acute mechanical neck pain (4 men and 8 women; average age 40 ± 15 years).

OUTCOME MEASURES

Amount and rate of cervical facet joint gapping during manipulation, amount and rate of force applied during manipulation, change in active intervertebral ROM from before to after manipulation, and numeric pain rating scale (NPRS) to measure change in pain after manipulation.

METHODS

Initially, all participants completed a NPRS (0-10). Participants then performed full ROM flexion-extension, rotation, and lateral bending while seated within a custom biplane radiography system. Synchronized biplane radiographs were collected at 30 images/s for 3 seconds during each movement trial. Next, synchronized, 2.0-milliseconds duration pulsed biplane radiographs were collected at 160 images/s for 0.8 seconds during the manipulation. The manipulation was performed by a licensed chiropractor using an articular pillar push technique. For the final five participants, two pressure sensors placed on the thumb of the chiropractor (Novel pliance system) recorded pressure at 160 Hz. After manipulation, all participants repeated the full ROM movement testing and once again completed the NPRS. A validated volumetric model-based tracking process that matched subject-specific bone models (from computed tomography) to the biplane radiographs was used to track bone motion with submillimeter accuracy. Facet joint gapping was calculated as the average distance between adjacent articular facet surfaces. Pre- to postmanipulation changes were assessed using the Wilcoxon signed-rank test.

RESULTS

The facet gap increased 0.9 ± 0.40 mm during manipulation. The average rate of facet gapping was 6.2 ± 3.9 mm/s. The peak force and rate of force application during manipulation were 65 ± 4 N and 440 ± 58 N/s. Pain score improved from 3.7 ± 1.2 before manipulation to 2.0 ± 1.4 after manipulation (p <. 001). Intervertebral ROM increased after manipulation by 1.2° (p = .006), 2.1° (p = .01), and 3.9° (p = .003) at the C4/C5, C5/C6, and C6/C7 motion segments, respectively, during flexion-extension; by 1.5° (p = .028), 1.9° (p = .005), and 1.3° (p = .050) at the C3/C4, C4/C5, and C5/C6 motion segments, respectively, during rotation; and by 1.3° (p = .034) and 1.1° (p = .050) at the C4/C5 and C5/C6 motion segments, respectively, during lateral bending. Global head ROM relative to the torso increased after manipulation by 8º (p = .023), 10º (p = .002), and 13º (p = .019) during lateral bending, axial rotation and flexion-extension, respectively, after manipulation.

CONCLUSIONS

This study is the first to measure facet gapping during cervical manipulation on live humans. The results demonstrate that target and adjacent motion segments undergo facet joint gapping during manipulation and that intervertebral ROM is increased in all three planes of motion after manipulation. The results suggest that clinical and functional improvement after manipulation may occur as a result of small increases in intervertebral ROM across multiple motion segments. This study demonstrates the feasibility of characterizing in real time the manual inputs and biological responses that comprise cervical manipulation, including clinician-applied force, facet gapping, and increased intervertebral ROM. This provides a basis for future clinical trials to identify the mechanisms behind manipulation and to optimize the mechanical factors that reliably and sufficiently impact the key mechanisms behind manipulation.

Brain Mechanisms of Anticipated Painful Movements and Their Modulation by Manual Therapy in Chronic Low Back Pain

Heightened anticipation and fear of movement-related pain has been linked to detrimental fear-avoidance behavior in chronic low back pain (cLBP). Spinal manipulative therapy (SMT) has been proposed to work partly by exposing patients to nonharmful but forceful mobilization of the painful joint, thereby disrupting the relationship among pain anticipation, fear, and movement. Here, we investigated the brain processes underpinning pain anticipation and fear of movement in cLBP, and their modulation by SMT, using functional magnetic resonance imaging. Fifteen cLBP patients and 16 healthy control (HC) subjects were scanned while observing and rating video clips depicting back-straining or neutral physical exercises, which they knew they would have to perform at the end of the visit. This task was repeated after a single session of spinal manipulation (cLBP and HC group) or mobilization (cLBP group only), in separate visits. Compared with HC subjects, cLBP patients reported higher expected pain and fear of performing the observed exercises. These ratings, along with clinical pain, were reduced by SMT. Moreover, cLBP, relative to HC subjects, demonstrated higher blood oxygen level-dependent signal in brain circuitry that has previously been implicated in salience, social cognition, and mentalizing, while observing back straining compared with neutral exercises. The engagement of this circuitry was reduced after SMT, and especially the spinal manipulation session, proportionally to the magnitude of SMT-induced reduction in anticipated pain and fear. This study sheds light on the brain processing of anticipated pain and fear of back-straining movement in cLBP, and suggests that SMT may reduce cognitive and affective-motivational aspects of fear-avoidance behavior, along with corresponding brain processes. PERSPECTIVE: This study of cLBP patients investigated how SMT affects clinical pain, expected pain, and fear of physical exercises. The results indicate that one of the mechanisms of SMT may be to reduce pain expectancy, fear of movement, and associated brain responses.

Subclinical recurrent neck pain and its treatment impacts motor training-induced plasticity of the cerebellum and motor cortex

The cerebellum processes pain inputs and is important for motor learning. Yet, how the cerebellum interacts with the motor cortex in individuals with recurrent pain is not clear. Functional connectivity between the cerebellum and motor cortex can be measured by a twin coil transcranial magnetic stimulation technique in which stimulation is applied to the cerebellum prior to stimulation over the motor cortex, which inhibits motor evoked potentials (MEPs) produced by motor cortex stimulation alone, called cerebellar inhibition (CBI). Healthy individuals without pain have been shown to demonstrate reduced CBI following motor acquisition. We hypothesized that CBI would not reduce to the same extent in those with mild-recurrent neck pain following the same motor acquisition task. We further hypothesized that a common treatment for neck pain (spinal manipulation) would restore reduced CBI following motor acquisition. Motor acquisition involved typing an eight-letter sequence of the letters Z,P,D,F with the right index finger. Twenty-seven neck pain participants received spinal manipulation (14 participants, 18–27 years) or sham control (13 participants, 19–24 years). Twelve healthy controls (20–27 years) also participated. Participants had CBI measured; they completed manipulation or sham control followed by motor acquisition; and then had CBI re-measured. Following motor acquisition, neck pain sham controls remained inhibited (58 ± 33% of test MEP) vs. healthy controls who disinhibited (98 ± 49% of test MEP, P<0.001), while the spinal manipulation group facilitated (146 ± 95% of test MEP, P<0.001). Greater inhibition in neck pain sham vs. healthy control groups suggests that neck pain may change cerebellar-motor cortex interaction. The change to facilitation suggests that spinal manipulation may reverse inhibitory effects of neck pain.

Unraveling the Mechanisms of Manual Therapy: Modeling an Approach

Synopsis Manual therapy interventions are popular among individual health care providers and their patients; however, systematic reviews do not strongly support their effectiveness. Small treatment effect sizes of manual therapy interventions may result from a "one-size-fits-all" approach to treatment. Mechanistic-based treatment approaches to manual therapy offer an intriguing alternative for identifying patients likely to respond to manual therapy. However, the current lack of knowledge of the mechanisms through which manual therapy interventions inhibit pain limits such an approach. The nature of manual therapy interventions further confounds such an approach, as the related mechanisms are likely a complex interaction of factors related to the patient, the provider, and the environment in which the intervention occurs. Therefore, a model to guide both study design and the interpretation of findings is necessary. We have previously proposed a model suggesting that the mechanical force from a manual therapy intervention results in systemic neurophysiological responses leading to pain inhibition. In this clinical commentary, we provide a narrative appraisal of the model and recommendations to advance the study of manual therapy mechanisms. J Orthop Sports Phys Ther 2018;48(1):8-18. doi:10.2519/jospt.2018.7476.

Comparison of 2 Lumbar Manual Therapies on Temporal Summation of Pain in Healthy Volunteers

The purpose of this study was to compare the immediate change in temporal summation of heat pain (TSP) between spinal manipulation (SMT) and spinal mobilization (MOB) in healthy volunteers. Ninety-two volunteers (24 male; 23.8 ± 5.3 years) were randomized to receive SMT, MOB, or no treatment (REST) for 1 session. Primary outcomes were changes in TSP, measured at the hand and foot, immediately after the session. A planned subgroup analysis investigated effects across empirically derived TSP clusters. For the primary outcome there were no differences in the immediate change in TSP measured at the foot between SMT and MOB, however, both treatments were superior to the REST condition. In the subgroup analysis the response to a standard TSP protocol was best characterized by 3 clusters: 52% no change (n = 48, 52%); facilitatory response (n = 24, 26%), and inhibitory response (n = 20, 22%). There was a significant Time × Treatment group × Cluster interaction for TSP measured at the foot. The inhibitory cluster showed the greatest attenuation of TSP after SMT and MOB compared with REST. These data suggest lumbar manual therapies of different velocities produce a similar localized attenuation of TSP, compared with no treatment. Attenuation of localized pain facilitatory processes by manual therapies was greatest in pain-free individuals who show an inhibitory TSP response.

PERSPECTIVE

The attenuation of pain facilitatory measures may serve an important underlying role in the therapeutic response to manual therapies. Identifying patients in pain who still have an inhibitory capacity (ie, an inhibitory response subgroup) may be useful clinically in identifying the elusive "manual therapy" responder.

Contextually Aided Recovery (CARe): a scientific theory for innate healing

BACKGROUND

The chiropractic profession emerged when scientific explanations for causes of health and disease were still in infancy and the co-existence of notions such as innate healing and vitalism were perhaps admissible within such a historical context. Notwithstanding, within the scientific culture of the 21^st Century all healthcare paradigms require evidential support which in regard these early concepts are in large part, absent. Nevertheless, a large body of emerging scientific evidence supports the existence of innate healing phenomena that may explain a plethora of clinical outcomes observed during chiropractic care. However, in contrast to the notion that removing the putative subluxation constitutes the mechanism by which this healing is initiated, the evidentially supported explanation is one that invokes the impact of contextual factors inherent in the skilful care and authority of the healthcare provider. This perspective is presented here as the scientific model of Contextually Aided Recovery (CARe).

MAIN BODY

This paper contends that;Contextual effects are powerful and desirable and are triggered by contextual factors present in all therapeutic encounters including those encountered in chiropractic practice.These factors can elicit large clinical effects with substantive evidence supporting pain, immune and motor modulation.The compartmentalisation of specific and non-specific effects is a biologically and scientifically false dichotomy, erroneously invoked to de-legitimise treatment approaches that expertly construct contextual healing scenarios.The use of factors to construct contextual healing scenarios that maximise positive (placebo) and minimize negative (nocebo) effects is a skilful clinical art within the multimodal approach that describes modern chiropractic care and should be presented and defended as a legitimate component of orthodox healthcare Clinical improvement during chiropractic care, beyond any biologically specific treatment effects of manipulation and other modalities, may be largely understood considering contextual factors as described by a Contextually Aided Recovery (CARe) model.