Benefits and Harms of Spinal Manipulative Therapy for Treating Recent and Persistent Nonspecific Neck Pain: A Systematic Review With Meta-analysis

Development and validation of a quick screening tool for predicting neck pain patients benefiting from spinal manipulation: a machine learning study

BACKGROUND

Neck pain (NP) ranks among the leading causes of years lived with disability worldwide. While spinal manipulation is a common physical therapy intervention for NP, its variable patient responses and inherent risks necessitate careful patient selection. This study aims to develop and validate a machine learning-based prediction model to identify NP patients most likely to benefit from spinal manipulation.

METHODS

This multicenter study analyzed 623 NP patients in a retrospective cohort and 319 patients from a separate hospital for external validation, with data collected between May 2020 and November 2024. Treatment success was defined as achieving ≥ 50% reduction in Numerical Rating Scale (NRS) and ≥ 30% reduction in Neck Disability Index (NDI) after two weeks of spinal manipulation. We compared data imputation methods through density plots, and conducted δ-adjusted sensitivity analysis. Then employed both Boruta algorithm and LASSO regression to select relevant predictors from 40 initial features, and four feature subsets (Boruta-selected, LASSO-selected, intersection, and union) were evaluated to determine the optimal combination. Nine machine learning algorithms were tested using internal validation (70% training, 30% testing) and external validation. Performance metrics included Area Under the Receiver Operating Characteristic Curve (AUC), accuracy, F1-score, sensitivity, specificity, and predictive values. The SHAP framework enhanced model interpretability. Youden's Index was applied to determine the optimal predictive probability threshold for clinical decision support, and a web-based application was developed for clinical implementation.

RESULTS

The combined LASSO and Boruta algorithms identified nine optimal predictors, with the union feature set achieving superior performance. Among the algorithms tested, the Multilayer Perceptron (MLP) model demonstrated optimal performance with an AUC of 0.823 (95% CI 0.750, 0.874) in the test set, showing consistency between training (AUC = 0.829) and test performance. External validation confirmed robust performance (AUC: 0.824, accuracy: 0.765, F1 score: 0.76) with satisfactory calibration (Brier score = 0.170). SHAP analysis highlighted the significant predictive value of clinical measurements and patient characteristics. Based on Youden's Index, the optimal predictive probability threshold was 0.603, yielding a sensitivity of 0.762 and specificity of 0.802. The model was implemented as a web-based application providing real-time probability calculations and interactive SHAP force plots.

CONCLUSION

Our machine learning model demonstrates robust performance in identifying suitable candidates for spinal manipulation among neck pain patients, offering clinicians an evidence-based practical tool to optimize patient selection and potentially improve treatment outcomes.

Effects of Multimodal Interventions on Patients with Neck Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the impact of multimodal therapy on patients with neck pain.

METHODS

A comprehensive search was conducted in PubMed, Cochrane Library, Web of Science, and Embase databases from their inception until April 2024. Randomized controlled trials involving multimodal therapy for neck pain were included. Two researchers independently screened the literature, extracted data, and assessed the quality of the included studies. Meta-analysis was performed using RevMan 5.4 software.

RESULTS

A total of 10 studies were included. The meta-analysis results showed that multimodal therapy significantly reduced the Visual Analog Scale scores for neck pain [standardized mean difference = -2.96, 95% confidence interval (CI): -4.21 to -1.71, P < 0.001] and the Neck Disability Index scores [mean difference (MD) = -6.15, 95% CI: -10.25 to -2.04, P < 0.01], decreased kinesiophobia [MD = -18.48, 95% CI: -29.22 to -2.74, P < 0.001], and increased the pressure pain threshold [left trapezius: MD = 0.48, 95% CI: 0.20 to 0.77, P < 0.01; right trapezius: MD = 0.50, 95% CI: 0.22 to 0.79, P < 0.01]. Subgroup analysis revealed that when the intervention duration was greater than 4 weeks, multimodal therapy significantly improved neck function [MD = -5.97, 95% CI: -11.52 to -0.42, P = 0.04].

CONCLUSIONS

Multimodal therapy can effectively reduce pain severity, improve kinesiophobia and pain thresholds in patients with neck pain, and significantly improve neck function when the intervention duration exceeds 4 weeks. Future studies with larger sample sizes and higher quality are needed for further exploration.

The Effects of Cervical Manipulation Compared with a Conventional Physiotherapy Program for Patients with Acute Whiplash Injury: A Randomized Controlled Trial

Whiplash injuries (WLs) are the most frequent cause of emergency room visits after motor vehicle collisions. In clinical practice, massage, electrotherapy, mobilization, or therapeutic exercise are used. As part of manual therapy, high-velocity, low-amplitude manipulative techniques can also be used. Objectives: To evaluate the effect of the cervical Specific Adjustment Technique (SAT) in adults affected by whiplash on pain, functionality, cervical mobility, and radiological changes in cervical curvature through a prospective, single-blind, randomized clinical trial. Methods: One hundred and nineteen patients with grade II acute WL were randomly assigned to either the manipulation group (MAN group = 59) or the rehabilitation group (RHB group = 60) to receive 3 or 20 sessions of treatment, respectively. Both groups were measured at baseline and 15, 30, and 120 days after starting treatment. Results: Statistically significant differences were found in the MAN group in flexion (p = 0.041) and left-side bending (p = 0.022); similar statistical values were found in the other measures. According to the interaction treatment-time effect, statistical significance for the Cobb angle was obtained in the MAN group (p = 0.047). Conclusions: the effects of SAT were comparable in terms of pain, functionality, and mobility of the cervical spine. Although further research is needed on its effects in the acute phase, due to its effectiveness and lower associated cost, SAT could be considered a useful technique, at least during the first 3 months after a traffic collision.

Effectiveness of Manual Joint Mobilization Techniques in the Treatment of Nonspecific Neck Pain: Systematic Review With Meta-Analysis and Meta-Regression of Randomized Controlled Trials

OBJECTIVE: The purpose of this study was to investigate the effects of cervical joint mobilization techniques (JMTs) on pain and disability in adults with nonspecific neck pain. DESIGN: This study is an intervention systematic review with meta-analysis and meta-regression of randomized controlled trials (RCTs). LITERATURE SEARCH: We searched MEDLINE, Cochrane CENTRAL, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database, and Web of Science databases, including references from other reviews or clinical practice guidelines up to October 16, 2024. STUDY SELECTION CRITERIA: Eligible RCTs evaluated JMTs compared to routine physiotherapy, minimally active interventions, or no treatment. The primary outcome was pain; secondary outcomes were disability, Global Perceived Effect (GPE), quality of life, psychosocial status, and adverse events. DATA SYNTHESIS: Meta-analyses and meta-regression were conducted for pain, disability, and GPE. The risk of bias was assessed with Cochrane RoB 2.0 Tool; the certainty of the evidence was assessed with the Grading of Recommendations, Assessment, Development, and Evaluations approach. We used The Template for the Intervention Description and Replication checklist to evaluate the quality of reporting of interventions delivered. RESULTS: Results from 16 RCTs were pooled (n = 1,157 participants), reporting nonclinically positive results on pain reduction (mean difference [MD] = -0.86 (95% confidence interval [-1.35, -0.36])), disability (MD=-2.11 [-3.31, -0.91]), and GPE (standardized mean difference = 0.11 ([-0.15, 0.37]) and high heterogeneity. The meta-regressions did not identify any covariates associated with the treatment effects. Minor side effects (increased neck pain and headache) were reported. CONCLUSION: There was very low certainty evidence supporting the efficacy of JTMs for reducing pain and improving disability in people with NSNP. J Orthop Sports Phys Ther 2025;55(3):1-20. Epub 12 February 2025. doi:10.2519/jospt.2025.12836.

The Effectiveness of Spinal Manipulative Therapy in Treating Spinal Pain Does Not Depend on the Application Procedures: A Systematic Review and Network Meta-analysis

OBJECTIVE: To assess whether spinal manipulative therapy (SMT) application procedures (ie, target, thrust, and region) impacted changes in pain and disability for adults with spine pain. DESIGN: Systematic review with network meta-analysis. LITERATURE SEARCH: We searched PubMed and Epistemonikos for systematic reviews indexed up to February 2022 and conducted a systematic search of 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. We included randomized controlled trials (RCTs) from recent systematic reviews and newly identified RCTs published during the review process and employed artificial intelligence to identify potentially relevant articles not retrieved through our electronic database searches. STUDY SELECTION CRITERIA: We included RCTs of the effects of high-velocity, low-amplitude SMT, compared to other SMT approaches, interventions, or controls, in adults with spine pain. DATA SYNTHESIS: The outcomes were spinal pain intensity and disability measured at short-term (end of treatment) and long-term (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. Results were presented as network plots, evidence rankings, and league tables. RESULTS: We included 161 RCTs (11 849 participants). Most SMT procedures were equal to clinical guideline interventions and were slightly more effective than other treatments. When comparing inter-SMT procedures, effects were small and not clinically relevant. A general and nonspecific rather than a specific and targeted SMT approach had the highest probability of achieving the largest effects. Results were based on very low- to low-certainty evidence, mainly downgraded owing to large within-study heterogeneity, high RoB, and an absence of direct comparisons. CONCLUSION: There was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients' preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant. J Orthop Sports Phys Ther 2025;55(2):1-14. Epub 7 January 2025. https://doi.org/10.2519/jospt.2025.12707.

Effects of Breathing Exercises on Neck Pain Management: A Systematic Review with Meta-Analysis

Background: Given the relationship between reduced pulmonary and respiratory muscle function in neck pain, incorporating breathing exercises into neck pain management may be beneficial. Purpose: The purpose of this study was to investigate the benefits of breathing exercises for treating neck pain. Methods: We searched PubMed (MEDLINE), PEDro, CINAHL, Scopus, and EMBASE databases, up to the 28 of February 2024. Randomized controlled trials evaluating the impact of breathing exercises on reducing pain and disability in both persistent and recent neck pain were selected. A meta-analysis was conducted for each outcome of interest; however, if quantitative methods were not possible, a qualitative synthesis approach was used. The risk of bias was assessed using the Cochrane RoB 2.0 Tool (version 22 August 2019). We used the GRADE approach to judge the certainty of the evidence. Results: Five studies were included. Meta-analysis showed a statistically significant reduction in pain (standardized mean difference (SMD), -10.16; 95% CI: -14.82, -5.50) and disability (SMD, -0.80; 95% CI: -1.49, -0.11), in favor of breathing exercises. Qualitative synthesis for pulmonary functional parameters resulted in a statistically significant improvement for FVC, MIP, MEP, and MVV, in favor of breathing exercises. Conclusions: Breathing exercises showed significant short-term effects in reducing pain and disability for persistent neck pain. They also provided benefits for functional respiratory parameters. However, the evidence certainty is low.

Integrating Chiropractic Care and Tai Chi Training for the Treatment of Chronic Nonspecific Neck Pain in Nurses: A Single-Arm Mixed-Methods Pilot Trial

Objectives: Chronic nonspecific neck pain (CNNP) is prevalent among health care workers, with particularly high rates among nurses. Nurses experiencing CNNP often report decreased job satisfaction, increased absenteeism, and reduced productivity. In recent years, nonpharmacologic approaches have gained attention as effective treatments for the management of CNNP, with exercise and manual therapies representing two of the most common. Early evidence shows that multimodal treatments may be more effective than unimodal strategies. The purpose of this current study was to assess the feasibility and observe the clinical outcomes of combined multimodal chiropractic care (MCC) and Tai Chi (TC) for CNNP in nurses. Methods: A single-arm mixed-methods pilot trial was conducted including 16 weeks of MCC and TC in nurses with self-reported CNNP. Feasibility outcomes were recruitment, retention, and adherence to the interventions. Clinical outcomes of interest included neck pain and related disabilities. Secondary outcomes of interest were functional, affective, and work-related performance. Qualitative interviews were also conducted. Results: Of the 59 screened, 36 met the eligibility criteria, and 21 were enrolled. The retention rate was 71.4%, and adherence rates were 85.3% for MCC and 62.5% for TC classes. Multiple pain and disability-related outcomes exhibited modest improvement from baseline to 16-week follow-up. Qualitative analysis identified six emergent themes: (1) neck pain being an inherent part of nursing, (2) nurses push through their pain, (3) MCC relieves pain and is instructive for preventing pain, (4) TC provides overall relaxation, (5) both interventions increased body awareness and improved posture, and (6) scheduling difficulties were a key obstacle for participating. Conclusions: Observed reductions in neck pain and disability suggest the potential utility of combined MCC and TC interventions for managing CNNP. Along with qualitative feedback regarding facilitators and barriers to participation, the findings support and inform a future randomized trial evaluating the combined benefits of MCC and TC for CNNP in nurses. Clinical Trial Registration #NCT06523036.

Comparison of Short-Term Effects of Different Spinal Manipulations in Patients with Chronic Non-Specific Neck Pain: A Randomized Controlled Trial

Spinal manipulations for chronic non-specific neck pain (CNNP) include cervical, cervicothoracic junction, and thoracic spine (CCT) manipulations as well as upper cervical spine (UCS) manipulations. This study aimed to compare the short-term effects of UCS manipulation versus a combination of CCT spine manipulations on pain intensity, disability, and cervical range of motion (CROM) in CNNP patients. In a private physiotherapy clinic, 186 participants with CNNP were randomly assigned to either the UCS (n = 93) or CCT (n = 93) manipulation groups. Neck pain, disability, and CROM were measured before and one week after the intervention. No significant differences were found between the groups regarding pain intensity and CROM. However, there was a statistically significant difference in neck disability, with the CCT group showing a slightly greater decrease (CCT: 16.9 ± 3.8 vs. UCS: 19.5 ± 6.8; p = 0.01). The findings suggest that a combination of manipulations in the CCT spine results in a slightly more pronounced decrease in self-perceived disability compared to UCS manipulation in patients with CNNP after one week. However, no statistically significant differences were observed between the groups in terms of pain intensity or CROM.

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.

Specific and shared mechanisms associated with treatment for chronic neck pain: study protocol for the SS-MECH trial

BACKGROUND

Treatment mechanisms involve the steps or processes through which an intervention unfolds and produces change in an outcome variable. Treatment mechanisms can be specific to the intervention provided (i.e. pain modulation) or shared with other treatments (i.e. reduced fear of movement). Whether specific and shared treatment mechanisms are different across interventions and whether they lead to the outcomes seen in trials is largely unknown. The management of individuals with chronic neck pain routinely include manual therapy (MT) and resistance exercise (RE), as both approaches are included in clinical practice guidelines and both yield similar outcomes.

OBJECTIVES

Our study plans to answer two research questions: 1) what are the specific mechanisms associated with MT versus interventions (and are these different), and 2) what are the shared mechanisms associated with these interventions, and do specific or shared mechanisms mediate clinical outcomes?

METHODS

This study will involve a 2-group parallel (1:1) single-blinded randomized trial to compare the specific and potential shared treatment mechanisms between these two approaches. We will enroll individuals with a history of chronic neck pain and evaluate whether specific or shared mechanisms mediate clinical outcomes.

RESULTS

We hypothesize that MT and RE approaches will both exhibit different specific treatment mechanisms, and that both approaches will exhibit shared treatment mechanisms, which will notably influence outcomes at both discharge and 6-months.

CONCLUSIONS

This study is important because it will help identify what specific or shared treatment mechanisms are associated with different interventions and, how different treatment mechanisms influence clinical outcomes.

Relationship between Athletes' Big Five Model of Personality and Athletic Performance: Meta-Analysis

Academic interest in athletic performance is ongoing. To examine the correlation between athletic performance and athletes' personality types, data extraction in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was completed in October 2021, and a meta-analysis was performed using 180 data from 18 selected papers using the "meta" package version 4.8-4 of R Studio 3.3.3. As a result, these selected studies proved to have reliable quality in proceeding with this study via quality assessment. The overall effect of personality on athletic performance (AP) was ESr = 0.124, p < 0.01. Furthermore, only conscientiousness (ESr = 0.178, p < 0.001) and extroversion (ESr = 0.145, p < 0.01), among the five personality types, showed statistically significant results, and these two personality types had a positive correlation with performance. In the publication bias test, this study found that (a) agreeableness had a publication bias; but, with an additional test using trim-and-fill, (b) the effect was not significant enough to be considered. In addition, the analysis of the moderating effects was conducted in four aspects, and all moderating effect analyses showed statistically significant differences between the groups, demonstrating the heterogeneity of this study. Therefore, this study found a significant relationship between personality and athletic performance and showed the importance of conscientiousness and extroversion.