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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. 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. 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. 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.

Introduction: Older adults often experience incomplete recovery after a hip fracture. Rehabilitation programs with progressive resistance training are associated with improved functional recovery. This systematic review and meta-analysis with meta-regression a) evaluated resistance training characteristics reported in hip fracture rehabilitation programs, b) performed meta-analysis of resistance training impact on strength (primary outcome), gait and physical activity (secondary outcomes), and c) explored resistance training program characteristics associated with improved outcomes using meta-regression. Materials and Methods: Medline, EMBASE, CINAHLPLUS, and Web of Science Core Collection databases were searched (January2000–February2021). Randomized controlled trials including progressive resistance training rehabilitation programs after hip fracture surgery in adults ≥50 years old were included. Meta-analyses and exploratory meta-regression were performed. Results: Meta-analysis showed significant increases in strength (10 trials-728 participants; Standardized Mean Difference (SMD) [95%CI]; .40 [.02, .78]) immediately following program completion in intervention relative to control participants. Meta-analysis on 5 trials (n = 384) with extended follow up found no significant group differences (SMD = .47 [-.28, 1.23]) in strength. Center-based relative to home-based programs were associated with significantly greater improvements in strength (P < .05) as were programs where resistance training intensity was prescribed using one-repetition maximum relative to other exercise prescription methods (P < .05). In gait meta-analysis (n = 10 trials-704 participants), gait speed in intervention participants immediately after the program was significantly higher than control (SMD = .42 [.08, .76]) but this finding was not maintained in extended follow-up (n = 5 trials-240 participants; SMD = .6 [-.26, .38]). Higher resistance training intensity was associated with significant improvements in gait speed (P < .05). No meta-analysis was performed for the 3 heterogeneous studies reporting physical activity. Discussion: Progressive resistance training improved muscle strength and gait speed after hip fracture surgery in adults ≥50years old immediately after the program ended, but the longer-term impact may be more limited. Conclusions: Higher resistance training intensity and center-based programs may be associated with more improvement, but require further research.

Spinal and peripheral joint manipulation (MAN) and mobilization (MOB) are widely used for managing musculoskeletal conditions. Although adverse events (AE) have been reported following these interventions, there is no universally accepted definition and classification system. This study aimed to establish an inter-professional and international standardized definition and severity classification for AE following MAN and MOB. This sequential mixed-methods study included an electronic Delphi process (e-Delphi) followed by focus groups. Inter-professional and international expert stakeholders participated in 3 e-Delphi rounds: Round 1 included open-ended questions on participants’ working AE definition and severity classification; Round 2, level of agreement with statements generated from Round 1 and a previous scoping review; and Round 3, level of agreement with statements achieving consensus in Round 2. Focus groups explored e-Delphi findings. Consensus was reached for severity categories (i.e., mild, moderate, severe and catastrophic) and on 2 domains to differentiate these categories (i.e., symptom intensity and impact on patient). Consensus was not reached for a standardized AE definition following MAN and MOB. Focus group discussions centered on “unfavourable”, “unexpected” and “undesired” terms and differences between “serious” and “catastrophic” severity classification categories. Findings contribute to advancing patient safety and AE knowledge across professions and informing further safety research and practice.

Spinal and peripheral joint manipulation and mobilization are interventions used by many healthcare providers to manage musculoskeletal conditions. Although there are many reports of adverse events (or undesirable outcomes) following such interventions, there is no common definition for an adverse event or clarity on any severity classification. This impedes advances of patient safety initiatives and practice. This scoping review mapped the evidence of adverse event definitions and classification systems following spinal and peripheral joint manipulation and mobilization for musculoskeletal conditions in adults. An electronic search of the following databases was performed from inception to February 2021: MEDLINE, EMBASE, CINAHL, Scopus, AMED, ICL, PEDro, Cochrane Library, Open Grey and Open Theses and Dissertations. Studies including adults (18 to 65 years old) with a musculoskeletal condition receiving spinal or peripheral joint manipulation or mobilization and providing an adverse event definition and/or classification were included. All study designs of peer-reviewed publications were considered. Data from included studies were charted using a standardized data extraction form and synthesised using narrative analysis. From 8248 identified studies, 98 were included in the final synthesis. A direct definition for an adverse event and/or classification system was provided in 69 studies, while 29 provided an indirect definition and/or classification system. The most common descriptors to define an adverse event were causality, symptom severity, onset and duration. Twenty-three studies that provided a classification system described only the end anchors (e.g., mild/minor and/or serious) of the classification while 26 described multiple categories (e.g., moderate, severe). A vast array of terms, definition and classification systems were identified. There is no one common definition or classification for adverse events following spinal and peripheral joint manipulation and mobilization. Findings support the urgent need for consensus on the terms, definition and classification system for adverse events related to these interventions.

Background Spinal pain is a highly prevalent condition affecting a large part of the population. Chiropractic maintenance care (MC) is a management strategy intended to prevent spinal pain recurrent episodes and deterioration by treating patients at pre-planned intervals. A previous study showed that patients identified as a dysfunctional subgroup by the West Haven-Yale Multidimensional Pain Inventory (MPI) and receiving MC had fewer days with bothersome LBP. This suggests MC may have superior effectiveness in this subgroup of patients. The MPI, however, is not practical for daily clinical practice, prompting the development of the MAINTAIN instrument. This study aims to (1) assess the effectiveness and cost-effectiveness of stratified MC using the MAINTAIN instrument, and (2) assess the fidelity and procedure compliance of implementing the MAINTAIN instrument. Methods This pragmatic randomized clinical trial will recruit 225 consecutive patients (18–65 years old) with significant (> 30 days in the past 12 months) recurrent spinal pain presenting to chiropractic clinics. After the initial 3 weeks (6 visits) of chiropractic care, patients will be randomized to receive either Stratified MC or Standard Chiropractic Care. Stratified MC: patients will complete the MAINTAIN instrument and be stratified to MC or symptom-guided care (clinicians’ judgment). Patients in the Standard Chiropractic Care arm will receive standard treatment based on the chiropractor’s judgment. The primary outcome is the total number of days with activity-limiting pain measured at 12 months. Secondary outcomes include the number of missed working days and loss of work productivity due to pain, pain intensity, disability, health-related quality of life, perceived improvement, and implementation of MAINTAIN instrument outcomes. An intention-to-treat protocol and generalized estimating equations (GEE) linear regression models will be used for analysis. Discussion This study investigates the impact of using a clinical instrument to identify patients with recurrent spinal pain to target those who benefit most from a chiropractic MC approach. Strict inclusion criteria should ensure a suitable target group, and frequently collected repeated measures should provide accurate outcome assessment. The study is pragmatic and includes standard clinical procedures facilitating the generalizability and transferability of the results into clinical practice. Trial registration ClinicalTrials.gov NCT05350254. Prospectively registered on April 22, 2022, last modified on December 08, 2023. The first patient was randomized into the study on December 21, 2023.

This prospective, community-based, active surveillance study aimed to report the incidence of moderate, severe, and serious adverse events (AEs) after chiropractic (n = 100) / physiotherapist (n = 50) visit in offices throughout North America between October-2015 and December-2017. Three content-validated questionnaires were used to collect AE information: two completed by the patient (pre-treatment [T 0 ] and 2–7 days post-treatment [T 2 ]) and one completed by the provider immediately post-treatment [T 1 ]. Any new or worsened symptom was considered an AE and further classified as mild, moderate, severe or serious. From the 42 participating providers (31 chiropractors; 11 physiotherapists), 3819 patient visits had complete T 0 and T 1 assessments. The patients were on average 50±18 years of age and 62.5% females. Neck/back pain was the most common presenting condition (70.0%) with 24.3% of patients reporting no condition/preventative care. From the patients visits with a complete T 2 assessment (n = 2136 patient visits, 55.9%), 21.3% reported an AE, of which: 7.9% were mild, 6.2% moderate, 3.7% severe, 1.5% serious, and 2.0% had missing severity rating. The most common symptoms reported with moderate or higher severity were discomfort/pain, stiffness, difficulty walking and headache. This study provides valuable information for patients and providers regarding incidence and severity of AEs following patient visits in multiple community-based professions. These findings can be used to inform patients of what AEs may occur and future research opportunities can focus on mitigating common AEs.

Background Literature on low back pain (LBP) treatment suggests not all LBP is the same and patients with extension- or flexion-related LBP may benefit from different strategies. This study’s objective was to evaluate the effect of participant positioning when delivering spinal manipulation on reported immediate comfort, in individuals with LBP. Methods This a randomized crossover trial. Volunteer adult participants with LBP were recruited from a chiropractic college campus clinic to receive two procedures in random order: 1. Standard side posture lumbopelvic manipulation (SPLM) and 2. Modified flexed lumbopelvic manipulation. The modified position was similar to the standard, but with increased hip and lumbopelvic flexion. Participants were not blinded. The primary outcome of self-reported comfort was recorded using a 0–10 scale. Paired t-tests were used to compare mean comfort scores, and a minimal clinically important difference of 2.0 was used. Secondary analysis examined correlations between comfort during active range of motion (AROM) and the two SPLM procedures. An exploratory analysis comparing within-participant differences was examined. All reported harms were mild in nature (e.g. discomfort). Results Forty participants were recruited (mean 25.5 years of age, 75% female). 20 participants started with the Standard SPLM and 20 started with the Modified Flexed SPLM. No differences in comfort were found between the Standard SPLM (N = 40) versus Modified flexed SPLM (N = 40), (mean (SD) = − 0.01 (2.3), Effect Size Cohen’s d  = − 0.004 95% CI (− 0.32, 0.32)). No correlations were found between the comfort during AROM and the two SPLM procedures. Observing within-participant differences for individual comfort, 14 participants had a clinically significant difference ≥ 2. Specifically, 6 participants had lower scores with Standard SPLM and 8 participants had lower scores with Modified flexed SPLM. Conclusion Comparing comfort during a Modified flexed SPLM to the Standard one revealed no difference for a population with LBP. However, some individuals did demonstrate a comfort preference for a Standard versus a Modified flexed position. Future studies should examine other variations of manipulation and particular subgroups of individuals with LBP (e.g. direction related) that experience discomfort during manipulation.

Background Spinal manipulation (MAN) and mobilization (MOB) are biomechanically different yet both elicit pain reduction and increased range of motion. Previous investigations have focused on quantifying kinetics (e.g., applied forces) or, recipient kinematics (i.e., movements) during MAN and MOB. While these studies provide valuable information, they do not report on the strategies adopted by providers when performing the complex motor tasks of MAN and MOB. This review sought to synthesise the literature reporting on provider kinematics during the delivery of MAN and MOB. Methods This scoping literature review is reported following the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) statement. MEDLINE (Ovid), PsychINFO, Cochrane Library, Web of Science, Embase, Scopus, PEDro, ICL and CINAHL databases were searched from inception to September 2023 for terms relating to provider kinematics during the delivery of MAN and MOB. Data were extracted and reported descriptively, including: general study characteristics, number and characteristics of individuals who delivered/received MAN and/or MOB, region treated, equipment used and kinematic parameters of the individual delivering the procedure. Results Of 4,844 records identified, five (0.1%) fulfilled the eligibility criteria and were included in the analysis. Of these, provider kinematics were reported for the delivery of MAN in four (80%) and for the delivery of MOB in one (20%) article. Practitioners applied the procedure in all (100%) and students in one (20%) study. Spinal regions treated were: lumbar ( n  = 4), thoracic ( n  = 2) and cervical ( n  = 1). Data were reported heterogeneously but were most commonly captured using either video or motion capture equipment ( n  = 4, 80%). The direction of applied force was fully reported in one (20%) and only partially reported (one spinal region) in another study. Conclusions There are a small number of studies reporting heterogeneously on provider kinematics during the delivery of MAN and MOB. Clear reporting of the procedure from a biomechanical perspective and of the measurement equipment used could enable future meta-analysis of provider kinematic data, the use of provider kinematic data in the development of technique skills curricula and could feasibly be used to mitigate risk of injury for providers.

Background Leg length inequality (LLI) greater than 20 mm has been associated with low back pain (LBP) and its correction is clinically recommended. Much less is known about the biomechanical effects that LLI below 15 mm has on pelvis orientation. Methods Twenty-two adult participants (8 female) aged between 18 and 30 years without LBP were enrolled in the study and completed a series of sit-to-stand trials with no heel-lift (0 mm baseline) and heel-lifts of varying heights (5, 9 and 12 mm) placed in their right shoe. Three-dimensional kinematic data were obtained from the lower extremities, pelvis and thorax. Additional kinematic data were obtained from the left and right sides of the pelvis. The global orientation of the whole pelvis and relative orientation between the left and right sides of the pelvis were obtained in upright standing immediately upon completion of the sit-to-stand movement. Repeated measures ANOVAs were used to detect differences in sample means across the different levels of heel-lift (0, 5, 9, and 12 mm). The tests for within-subject effects determined overall significant differences between the means at the different levels of heel-lift induced LLI. Partial Eta-Squared was used to express the size for the main effect of heel-lift height. For each level of heel-lift, the estimated marginal mean and 95% confidence interval (95%CI) values of pelvis angles were illustrated graphically. Results Left frontal plane rotation of the pelvis increased (p = 0.001), that is, the left side of the pelvis was lower than the right side of the pelvis, and anterior tilt of the pelvis decreased (p = 0.020) with a heel-lift height (applied on the right) as low as 5 mm. A significant main effect of heel-lift was only observed for the norm of rotations about all three axes for relative-pelvis orientation (p = 0.034). Post-hoc analyses did not reveal any statistically significant differences between the heel-lifts and the 0 mm baseline (p≥0.072). Conclusion These findings suggest that correcting leg length inequality below the recommended threshold of 20 mm may influence pelvic orientation. Future work can investigate the effects of the altered orientations on spine loading and the clinical effects of corrections to minor leg length inequality.

Background Manual therapy, including spinal manipulative therapy (SMT), is a core component of chiropractic education. Simulation tools such as the Human Analogue Mannequin (HAM ® ) have been developed and coupled with force-sensing technology to support safe and structured training of SMT force-time characteristics. However, it remains unclear whether motor skills acquired using these tools are transferable to real-world scenarios. Methods This sequential explanatory mixed-methods observational study investigated whether chiropractic students, proficient at applying a set of pre-specified SMT force-time characteristics to the HAM ® , could replicate those same characteristics in humans. Quantitative data measured SMT force-time characteristics (preload force, peak impulse force, time to peak impulse force) applied on the HAM ® . Participants meeting the predefined force-time criteria in 4 out of 5 trials proceeded to apply SMTs to a human. Qualitative data from a survey with open-ended questions explored participants’ perceptions of their ability to replicate the SMT and differences between the HAM ® and humans. Results Ninety-five students participated (56% female, median age: 25 years), and 50 (53%) met the criteria on the HAM ® . Thirty-seven (74%) of the participants who met the criteria on the HAM ® also met the criteria on humans. No significant differences in participant characteristics were found between those who met or did not meet the criteria when applying SMT on humans. Participants who did not meet SMT force-time criteria on either the HAM ® or humans often under-applied preload force. Time to peak impulse force criteria was usually met across all trials. Qualitatively, participants perceived that internal factors (e.g., previous experience, emotions, tactile feel) and differences between the HAM ® and humans (e.g., stiffness, breathing) influenced their ability to replicate the SMT force-time criteria on humans. Conclusion Most students who successfully applied SMT force-time characteristics on a mannequin were able to replicate them on humans. Not meeting the SMT proficiency criteria (particularly in preload force) and the influence of non-biomechanical factors highlights the complexity of manual therapy motor skill development.