Ghasabmahaleh, Seyedezahra Hosseini et. Al. “Spinal Manipulation for Subacute and

Chronic Lumbar Radiculopathy: A Randomized Controlled Trial.” The American Journal

of Medicine. Vol 134, Issue 1, Jan 2021. Page 135-141.

 “Only the manipulation group showed significantly favorable results in the

Oswestry scores and the straight leg raise test. All ranges of motion increased

significantly with manipulation. Between-group analyses showed significantly

better outcomes for manipulation in all measurements with large effect

sizes…Spinal manipulation improves the results of physiotherapy over a period

of 3 months for patients with subacute or chronic lumbar radiculopathy.

 Our results showed that manipulation was more successful in pain palliation and

disability reduction than non-manipulation strategy. Moreover, the manipulation

group experienced better outcomes in increasing ROM and improving the results

of the straight leg raise test. The favorable outcomes remained for at least 3

months….Spinal manipulation leads to more success in pain control and

disability reduction for the management of subacute or chronic lumbar

radiculopathy. The favorable outcomes remained for at least 3 months following

the cessation of the treatment. We conclude that manipulation improved the

results of physiotherapy over a period of 3 months for patients with subacute or

chronic lumbar radiculopathy.

Conde-Vazquez, Orlando et. Al. “The Effectiveness of Manual Therapy in People with

Chronic non-Specific Low Back Pain: An Umbrella Review with Meta-Analysis.” Annals

of Physical and Rehabilitation Medicine. 69 (2026).

 “Manual Therapy (MT) outperforms other interventions regarding pain and

disability in the short term and this effect diminishes over time. MT offers

significant short term benefits in reducing pain and disability in individuals with

chronic non-specific low back pain. Like most interventions for CNLBP, the

effects of MT tend to diminish over time.

Spinal manipulative treatment (SMT, thrust) and mobilization (non-thrust) have

been shown to be effective in reducing pain and improving function in persons

with CNLBP, with manipulation showing slightly greater effects, although not

always statistically significant. Spinal manipulation has been found to be

comparable to other recommended treatments, such as NSAIDs and exercise….

Manipulation offers small short-term benefits (up to 12 weeks) for pain and

function but long term effects may diminish, suggesting a potential need for

ongoing treatment. Myofascial Release has shown potential benefits for CNLBP,

particularly in reducing disability, though its effects on pain are less consistent

across studies. Evidence suggests that MFR significantly improves disability

outcomes with benefits observed after multiple sessions and even following a

single application…Moreover, combining MFR with other interventions, such as

physical therapy or exercise, may enhance its therapeutic impact.

The findings of this UR and meta-analysis indicate that MT has a statistically

significant effect on reducing pain intensity and disability in individuals with

CNLBP in the short term…indicating a significant reduction in pain levels.

Similarly, disability outcomes, suggesting moderate improvement…These

findings highlight that, as with most treatments for CNLBP, the benefits of MT are

more pronounced within the first 3 months, gradually diminishing over time.

Lo, Chi Ngai et. Al. “The effectiveness of neuromuscular spinal manipulation- an

updated systematic review and meta-analysis.” International Journal of Osteopathic

Medicine.” Vol 54, December 2024.

“This updated systematic review and meta-analysis provides the latest summary

of evidence that supports the effectiveness of NSM for improving short-term

isometric muscle strength in asymptomatic subjects.

Aetna Website

Minetama and co-workers (2018) stated that the efficacy of PT for patients with

lumbar spinal stenosis (LSS) has been reported only for the short-term, and few

reports have compared outcomes of surgical treatment with non-surgical

treatment after PT.  These researchers evaluated 2-year outcomes of LSS

patients treated with surgery or under follow-up observation after PT for 6

weeks.  Patients presenting with neurogenic claudication, radiologically-

confirmed central LSS affecting both legs and refractory symptoms to

pharmacotherapy of more than 3 months were enrolled.  Patients were treated

with MT, stretching and strengthening exercises, and body weight-supported

treadmill walking once-weekly for 6 weeks.  Clinical outcomes were measured

using the Zurich Claudication Questionnaire (ZCQ), VAS of LBP, leg pain, and

numbness, the Japanese Orthopedic Association Back Pain Evaluation

Questionnaire and the SF-36.  Two years after PT, patients were classified into

the observation group (Group I) or the surgery group (Group II), whose patients

failed to respond to PT and wanted to undergo surgery.  A total of 38 patients

were enrolled; 28 had complete data at 2 years: 21 and 7 in Groups I and II,

respectively.  Group II had a higher body mass index (BMI) than Group I.  There

were no significant differences in clinical outcomes at baseline.  Six weeks after

PT, Group I had significantly better outcomes for symptom severity and physical

function on the ZCQ subscales, physical functioning and bodily pain on the SF-

36 subscales.  These outcomes in Group I were maintained or improved and did

not differ significantly between groups at 2-years.  However, the physical function

on the ZCQ subscales was improved in Group II more than those in Group I (MD

of -0.6; 95 % CI: -1.2 to -0.03, p < 0.05) at 2 years.  The authors concluded that

at 2 years, the outcomes except for the change in physical function score in the

ZCQ subscale did not differ significantly between patients who had undergone

surgery and those who avoided surgery

Pelvic Misalignment, Sacroiliac Joint Dysfunction and Hip Pain/Dysfunction

Posluszny, Michal O. and Malgorzata M. Waszak. “The influence of sacroiliac joint

manipulation on changes in the values of the center of pressure in the process of

maintaining static body balance.” Journal of Manipulative and Physiological

Therapeutics.” Vol 44, Issue 5. June 2021. Pages 408-419.

“A statistically significant difference between before and after treatment was

found in the experimental group in terms of COP pathway, COP pathway area

and average COP speed. Furthermore, the groups differed in before-treatment

values of these parameters in favor of the control group, but after treatment

measurement revealed normalization of the levels of these characteristics in the

experimental group to the level of the control group. .. As a result of SIJ

manipulation, parameters related to the ability to maintain balance improved in

the experimental group.

However, the most common dysfunctions in this region (SIJ disorders) are

compensatory mobility disorders int eh form of hyper or hypomobility …SIJ

dysfunction can also lead to uneven loading of the lower limbs and asymmetry of

muscle tensions, revealed by deficits in balance and postural control.

Aetna Website

In a retrospective, chart-review study, Galleher and colleagues (2017) evaluated

the benefit of adding manual therapy (MT) to PT care in pediatric patients with

anterior hip pain; assessed the relative risk of adverse reactions when MT was

used; and reported the types of MT used.  This study included patients who were

treated in a hospital-based sports medicine clinic.  The charts of 201 patients

(mean age of 14.23 ± 2.15 years) met the inclusion criteria and were reviewed.

 Patients were grouped into those who received MT during their episode of care,

and those who did not.  Pain efficiency (change in pain/number of visits), number

and type of adverse reactions, as well as frequency and type of manual therapy

interventions used, were the main health outcomes.  The mean pain efficiency

was significantly less if MT was carried out (MT = 0.60 [95 % CI: 0.47 to 0.72], no

MT = 0.80 [95 % CI: 0.71 to 0.90] p = 0.01).  There was no significant difference

between groups in risk of adverse reactions (MT = 5, no MT = 5).  The number of

visits was significantly different between groups (MT = 9.43 ± 3.9 sessions, and

no MT = 7.6 ± 5.2 sessions).  The authors concluded that MT did not increase the

risk of an adverse reaction in pediatric patients with anterior hip pain.  However,

while it appeared to be a safe intervention, it did not improve pain efficiency or

patient adherence.  They stated that future research should be performed to

evaluate the effectiveness of MT, when performed by skilled therapists, in

pediatric patients with hip pain in a controlled manner.  Level of Evidence = IIIb.

 Mansell and associates (2018) noted that arthroscopic hip surgery has risen 18-

fold in the past decade; however, there is a dearth of clinical trials comparing

surgery with non-operative management.  In a RCT, these researchers

determined the comparative effectiveness of surgery and physical therapy for

femoro-acetabular impingement (FAI) syndrome.  Patients were recruited from a

large military hospital after referral to the orthopedic surgery clinic and were

eligible for surgery.  Of 104 eligible patients, 80 elected to participate, and the

majority were active-duty service members (91.3 %).  No patients withdrew

because of adverse events (AEs).  These investigators randomly selected

patients to undergo either arthroscopic hip surgery (surgery group) or PT

(rehabilitation group).  Patients in the PT group began a 12-session supervised

clinic program within 3 weeks, and patients in the surgery group were scheduled

for the next available surgery at a mean of 4 months after enrollment.  Patient-

reported outcomes of pain, disability, and perception of improvement over a 2-

year period were collected.  The primary outcome was the Hip Outcome Score

(HOS; range of 0 to 100 [lower scores indicating greater disability]; 2 subscales:

activities of daily living and sport).  Secondary measures included the

International Hip Outcome Tool (iHOT-33), Global Rating of Change (GRC), and

return to work at 2 years.  The primary analysis was on patients within their

original randomization group.  Statistically significant improvements were seen in

both groups on the HOS and iHOT-33, but the mean difference was not

significant between the groups at 2 years (HOS activities of daily living, 3.8 [95 %

CI: -6.0 to 13.6]; HOS sport, 1.8 [95 % CI: -11.2 to 14.7]; iHOT-33, 6.3 [95 % CI: -

6.1 to 18.7]).  The median GRC across all patients was that they felt about the

same (GRC = 0).  Two patients assigned to the surgery group did not undergo

surgery, and 28 patients in the PT group ended up undergoing surgery.  A

sensitivity analysis of actual surgery to no surgery did not change the

outcome; 20 (33.3 %) patients who underwent surgery and 4 (33.3 %) who did

not undergo surgery were medically separated from military service at 2 years. 

The authors concluded that there was no significant difference between the

groups at 2 years.  Most patients perceived little to no change in status at 2

years, and 1/3 of military patients were not medically fit for duty at 2 years.

 Drawbacks of this study included a single hospital, a single surgeon, and a high

rate of cross-over.  Level of Evidence = I.