Table 1 Study characteristics

Brantingham et al (2003)[22]

Osteoarthritis of the hip (n = 8)

I1: hip manipulations (4)

Sham manipulation with deactivated Activator Instrument a spring loaded piston activated instrument to posterior superior iliac spine, iliac crest and greater trochanter

Pain (NRS)

Final treatment

MT may have noteworthy short term clinical benefit over sham.

I2: sham manipulation of the hip (4)

Disability (WOMAC)

Pain: I1: 18.8 (4); I2: 48.8 (4)

Chiropractic

Mean age:

Hip function (ROM)

Disability: I1: 7.3 (4); I2 37.5 (4)

I1: 60 ± 4; I2: 57 ±12

Six treatments over 3 weeks and a one month follow-up visit

ROM flexion: I1: 109.5 (4); I2: 94.3 (4)

Follow-up 7 weeks

ROM extension: I1: 10.0 (4); I2: 6.3 (4)

7 weeks follow-up

Pain: I1: 15.0 (4); I2: 36.6 (4)

Disability: I1: 7.4 (4); I2: 31.4 (4)

Cleland et al (2005)[23]

Mechanical neck pain (n = 36)

I1: thoracic spine manipulation (19)

Participants in the exact same position as the MT group, deep inhalation and then exhale; no high-velocity low amplitude thrust .

Pain (VAS)

Immediate

A statistical significant improvement in pain in the MT group.

I2: sham manipulation (17)

Pain: I1: 26.1 ± 17.2 (19); I2: 43.5 ± 19.5 (17); WMD: -17.4 (-29.8 to -5)

Physical therapy

Mean age:

I1: 36 ± 8.5;

One intervention

I2: 35 ± 11.3

5 minutes post treatment

Ghroubi et al (2007)[24]

Chronic low back pain (n = 64)

I1: spinal manipulation (32)

Sham manipulations under the same conditions as for I1 without the manipulative thrust

Pain (VAS)

1 month follow-up

Patients receiving the manipulations showed improvement in pain and disability.

Four interventions

Disability

Pain: I1: 49.4 ± 16.8 (32); I2: 58.4 ± 28.8 (32); WMD: -9 (-20.8 to 2.8)

Physical therapy

Mean age:

I2: sham manipulation (32)

(Oswestry)

2 months follow-up

I1: 39.1 ±11.1; I2: 37.4 ±7.5

One intervention

Pain: I1: 48.1 ± 22.8 (32); I2: 54.4 ± 25.8 (32); WMD: -6.3 (-18.5 to 5.9)

Follow-up at 1 and 2 months

Disability: I1: 12.3 ± 5.7 (32); I2: 12.1 ± 5.6 (32); WMD: 0.2 (-2.6 to 3)

Hawk et al (2002)[25]

Chronic Pelvic Pain, (n = 39)

I1: lumbar spine flexion-distraction and trigger point therapy (20)

Sham manipulation with a hand-held adjusting instrument combined with light effleurage

Pain (VAS) Disability (PDI) Quality of life (SF-36)

Median change scores [range] (n)

Mean change scores were not consistent across sites so results were not combined and overall effect sizes were not estimated

Chiropractic

Mean age:

I2: sham manipulation and effleurage (19)

6 weeks follow-up:

I1: 34.7 ± 7.6; I2: 33.7 ± 7.6

Six weeks of treatment with three visits a week for 2 weeks and twice a week for 4 weeks (total14 treatments at 3 different sites/practices)

Pain: I1 site 1: 36 [0, 76] (9); I1 site 2: 20 [-16,50] (6); I1 site 3: -63 [-70, -3.0] (3); I2: site 1: 14 [-12,34] (7); I2 site 2: 11 [-5,60] (6); I2 site 3: 13 [-17,28] (5)

Follow-up 12 weeks

Disability: I1 site 1: 9 [1,20] (9); I1 site 2: 7 [-5,21] (6); I1 site 3: 1 [-30,22] (3)

I2: site 1: 4 [-18,32] (7); I2 site 2: 8 [2,15] (6); I2 site 3: 14 [1,28] (5)

12 weeks follow-up:

Pain: I1 site 1: 36 [-6, 76] (9); I1 site 2: 23 [-40,51] (6); I1 site 3: -23 [-49,2] (3)

I2: site 1: 11 [-29,35] (7); I2 site 2: 4 (-14,38) (6); I2 site 3: 3 (-35,39) (5)

Disability: I1 site 1: 9 [0,27] (9); I1 site 2: 9.5 [-14,16] (6); I1 site 3: 2 [-39,25] (3); I2: site 1: 7 [-10,46] (7); I2 site 2: 10.5 [0,19] (6); I2 site 3: 5 [1,20] (5)

Hawk et al (2005)[26]

Subacute (4-12 weeks) or chronic low back pain (more than 12 weeks), (n = 111)

I1: lumbar spine flexion-distraction and trigger point therapy (54)

Sham manipulation with a hand-held adjusting instrument combined with light effleurage

Improvement of symptoms

Improvement symptoms

Patients in both groups improved on RMQ but there were no significant differences

I2: sham manipulation and effleurage (57)

Disability (RMQ)

I1: n = 29; I2: n = 20 RD: 0.19 (0.0 to 0.37)

Chiropractic

Mean age:

Eight treatment over 3 weeks

Quality of life (SF-36)

3 weeks follow-up

I1: 51 ± 14.2; I2: 53 ±15.2

Follow-up 3 weeks

Disability:

I1: 1.6 ±3.2 (n = 54); I2: 2.1 ± 3.3 (n = 52)

WMD: -0.5 (-1.8 to 0.8)

Hondras et al (1999)[27]

Primary dysmenorrhea, (n = 138)

I1: spinal manipulation (69)

The low force mimic maneuver consisted of positioning the subject on one side with bilateral flexion of the hip and knee joints.

Pain (VAS)

Mean pre- post change cycle 2

There are no statistically significant differences between the two interventions.

Chiropractic

I2: low force mimic (69)

Pain: I1: 10.1 ± 14.8 (68); I2: 8.0 ± 16.6 (69)

Mean age:

Treatment took place on day 1of cycles 2, 3 and 4.

WMD: 2.1 (-3.2 to 7.4)

I1: 31.1; I1: 29.7

Follow-up after each of 4 menstrual cycles.

Kokjohn et al (1992)[28]

Primary dysmenorrhea, (n = 45)

I1: spinal manipulation (24)

Positioning the subject on one side with bilateral flexion of the knee and hip joint; to minimize the mechanical effect

Pain (VAS)

Mean differences

MT is effective in relieving pain

I2: sham manipulation (21)

Abdominal pain: I1: 20.91 ± 23.0 (23); I2: 8.1 ±15.0 (21); WMD: 12.8 (0.9 to 24.7)

Mean age: 30.3

One intervention, Post-treatment

Back pain: I1: 18.7 ±19.4 (23); I2: 7.8 ± 15.7 (21); WMD: 10.9 (0.09 to 21.7)

Learman et al (2009)[29]

Chronic low back pain, (n = 33)

I1: first spinal manipulation second sham procedure(17)

Sham procedure was done in de manipulative position to simulate a manual technique

Pain (VAS) Trunk proprioception (Biodex system 3)

No data

MT had minimal immediate effect on trunk proprioception.

Physical therapy

Mean age:

Two interventions

I1: 37.4 ±9.21; I2: 37.25 ±8.65

I2: first sham procedure second spinal manipulation third sham (16)

Crossover design

Three interventions

Intervention took place in a period of one week.

Post treatment and 1 week follow-up

Licciardone et al (2003)[30]

Chronic low back pain, (n = 91)

I1: osteopathic manipulative treatment (48)

Subject receiving manipulation as a simulated osteopathic manipulative techniques

Pain (VAS) Disability (RMQ)

No data

Both groups scored better than the control group. No significant benefits were measured.

Osteopathic

Mean age:

Seven interventions

I1: 49 ±12; I2: 52 ±12; I3: 49 ±12

I2: sham manipulation (23)

Seven interventions

I3: no intervention (20)

Follow-up at 1, 3 months

Mansilla-Ferragut et al (2009)[31]

Mechanical neck pain, (n = 37)

I1: spinal manipulation of the atlanto-occipital joint (18)

Manual contact intervention similar to cervical thrust manipulation. Head was rotated and maintained for 30 sec.

Pressure pain threshold (Mechanical pressure algometer, kg/cm²)

Pressure pain threshold

MT group scored better on pressure pain and active mouth opening

Mean age:

One intervention

Function: (Active mouth opening in mm)

I1: 0.9 ± 0.3 (18)

Physical therapy

I1: 36 ±7; I2: 34 ± 8

I2: manual contact sham intervention (19)

I2: 0.7 ± 0.4 (19)

One intervention

WMD: 0.2 (-0.04 to 0.4)

Function

I1: 38.8 ± 4.5 (18)

I2: 35.9 ± 4.3 (19)

MD: 2.9 (-0.1 to 5.9)

5 minutes post-treatment

Nielsen et al (1995)[32]

Chronic asthma, (n = 31)

I1: Active chiropractic spinal manipulation followed by sham (16)

A drop table was used. Gentle pressure over the spinal contact point with one hand was applied, while the other hand trusted on the drop section with the purpose of releasing it.

Perceived recovery (VAS) Pulmonary functions (FEV1, FCV)

Mean change from baseline

No significant differences between MT and sham in perceived recovery and lung functions.

Chiropractic

Mean age: 28.6 ±7.2

I2: Sham chiropractic spinal manipulation followed by active spinal manipulation (15)

Recovery: I1: - 5.93 (16); I2: - 8.46 (15)

Crossover study

Started with twice a week for a 4-week period. Two weeks cross over.

FEV ₁ : I1: 0.05 (16); I2: 0.09 (15)

FVC: I1: 0.13 (16); I2: 0.12 (15)

Noll et al (2008)[33]

Elderly patients with obstructive pulmonary disease, (n = 35)

I1: seven osteopathic manipulative techniques 'commonly used for respiratory disorders’ (18)

Light touch at the same anatomic regions in the same position as the manipulative group

Pulmonary functions (FEV1, FVC, RAW, residual volume)

Post-treatment

Overall worsing of air trapping immediate after manipulation compared to sham.

Osteopathic

I2: sham manipulative techniques (17)

FEV1: I1: 1.18 ±0.62 (18); I2: 1.28 ± 0.63 (17); WMD: -0.1 (-0.5 to 0.3)

Mean age:

FVC; I1: 2.36 ± 0.93 (18); I2: 2.66 ± 0.92 (17); WMD: -0.3 (-0.94 to 0.34)

I1: 69.6 ± 6.6; I2: 72.2 ± 7.1

One intervention.

FEF25-75 L/sec; I1: 0.43 ± 0.31 (18)

Post treatment and 1 day follow-up with a survey

I2: 0.55 ± 0.43 (17); WMD: 0.12 (-0.14 to 0.38)

RAW: I1: 6.15 ± 5.22 (18); I2: 7.71 ± 6.09 (17); WMD: -1.6 (-5.5 to 2.3)

Residual volume; I1: 5.02 ± 3.06 (18)

I2: 4.84 ± 1.84 (17); WMD: 0.18 (-1.6 to 2.0)

Sanders et al (1990)[34]

Acute low back pain < 2 weeks, (n = 18)

I1: MT L4/L5-S1 region (6)

Light physical contact/touch at the L4/L5-S1 region of the spine

Pain (VAS)

No data

Significant reduction of pain in de manipulation group, not in the other groups. No between group analyses.

Chiropractic

I2: sham manipulation L4/L5-S1 (6)

Mean age:

I3: no treatment or physical contact (6)

Males 41 ± 13.9; Female 33 ± 8.6

One intervention. 5 and 30 minutes post treatment

Santilli et al (2006)[35]

Acute low back pain and sciatica with disc protrusion on resonance imaging, (n = 102)

I1: soft tissue manipulations and rotational MT (53)

Soft muscle pressing similar to MT but not following any specific patterns and not involving rapid thrusts

Pain (number of patients pain-free) at end of follow-up Quality of life (SF-36)

180 days follow-up

Active manipulations are more effective than sham on percentage pain-free cases, not on SF-36 scores

Chiropractic

I2: soft muscle pressing (49)

Pain: low back pain; I1: n = 15; I2: n = 3

Mean age: 43.1

Maximum of 20 sessions, 5 days per week

RD: 0.22 (0.08 to 0.36)

Follow-up 15-30-45-90-180 days after first visit

Referred pain; I1: n = 29 (48); I2: n = 10 (48) RD: 0.34 (0.17 to 0.52)

Quality of life; I1: 53.8 ±16.8 (53)

I2: 57.5 ± 20 (49)

WMD: -3.7 (-10.9 to 3.5)

Senna and Machaly (2011)[36]

Chronic nonspecific low back pain, (n = 93)

I1: maintained MT and ROM exercise (26)

Manually applied force of diminished magnitude, aimed purposely to avoid treatable areas of the spine.

Pain (VAS) Disability (Oswestry)

1 month follow-up

After 1 and 10 months the subjects receiving maintenance MT had lower pain and disability scores and higher quality of life scores compared to sham.

Mean age:

I2: sham manipulation and ROM exercise (40)

Quality of life (SF-36)

Pain: I1: 29.4 ± 5.5 (25); I2: 33.2 ± 7.3 (37); I3: 29.5 ± 6.1 (26)

Physician

I1: 41.6 ±11; I2: 42.4 ±9.7; I3: 40.3 ± 11.7

I3: non-maintained MT and ROM exercise (27)

WMD (I1 vs I2): -3.8 (-7.2 to -0.4)

I2 and I3 12 treatments of MT or sham MT over 1 month period in I2 and I3.

Disability: I1: 24.6 ± 8.0 (25); I2: 32.5 ± 12.8 (37); I3: 24.1 ± 9.2 (26)

I1 received the same treatments of MT as I3 and additional MT every two weeks for the next 9 months.

WMD (I1 vs I2): -7.9 (-13.7 to – 2.1)

Follow-up 1,4,7,10 months

Quality of life: I1: 32.1 ± 7.0 (25); I2: 27.1 ± 7.9 (37); I3: 31.6 ± 8.2 (26)

WMD (I1 v I2): 5.0 (1.1 to 8.9)

10 months Pain: I1: 23.5 ± 8.0 (25); I2: 38.3 ± 12.8 (37); I3: 38.5 ± 12.8 (26)

WMD (I1 vs I2): -14.8 (-20.6 to -9.0)

Disability: I1: 20.6 ± 7.5 (25); I2: 37.4 ± 13.4 (37); I3: 34.9 ± 12.2 (26)

WMD (I1 vs I2): -16.8 (-22.7 to -10.9)

Quality of life: I1: 33.7 ± 7.0 (25); I2: 25.9 ± 7.9 (37); I3: 27.7 ± 8.2 (26)

WMD (I1 v I2): 7.8 (3.9 to 11.7)

Vernon et al (2009)[37]

Tension type headache, (n = 20)

I1: amitriptyline and MT (4)

A treatment table with a head piece that was capable of a small downward displacement (drop-piece). Drop-piece was quickly engaged simulating the thrust. Before brief preparatory soft tissue massage.

Days of headache reduction in the last 28 days of the trial (headache diary)

I1: -8.4 ± 7.5 (4)

Combined treatment of chiropractic and amitriptyline showed significant and clinical relevant results in headache reduction

I2: amitriptyline and sham MT (5)

I2: 3.1 ± 5.4 (5)

Chiropractic

Mean age:

I3: sham amitriptyline and MT (6)

I3: 2.0 ± 6.3 (6)

I1: 29 ± 9.8; I2: 29.4 ± 10.1; I3: 34 ± 11.6; I4: 43 ± 4.5

I4: sham amitriptyline and sham MT (5)

WMD (I1 v I2): -11.5 (-21.6 to – 1.4)

Chiropractic MTafter 4 weeks of amitriptyline, 3 times/week for 6 weeks and then once per week for 4 weeks.

Follow-up 4, 10, 14 weeks

Waagen et al (1986)[38]

Chronic low back pain (> 3 weeks), (n = 29)

I1: MT (11)

Lumbar drop-piece on the chiropractic adjusting table to minimal tension. Adjustment by applying gentle pressure over posterior superior iliac spines.

Pain (VAS) Function: lumbar spine function tests

Pain: immediate (mean differences between pre-post)

MT is effective for relieving pain compared to sham MT

I2: sham MT (18)

I1: 13 (9); I2: 7 (10)

Chiropractic

Two of three times weekly for 2 weeks

2 weeks; Pain: I1: 23 (9); I2: 6 (10)

Mean age:

Follow-up after 2 weeks

ASLR: I1: 6 ± 8.7 (9); I2: -13.5 ± 10.3 (8); WMD: 19.5 (9.7 to 29.4)

I1: 25.2; I2: 24.3

Flexion; I1: 0.34 ± 0.9 (9); I2: 0.95 ± 2.2 (8); MD: -0.6 (-2.3 to 1.1)

Extension; I1: 1.2 ± 1.2 (9); I2: -0.5 ± 2.1 (8); WMD: 1.7 (-0.04 to 3.4)

Walsh and Polus (1999)[39]

Premenstrual syndrome (PMS), (n = 45)

I1: first high velocity, low amplitude MT plus soft tissue therapy second sham treatment (28)

The sham treatment used a Activator Adjusting Instrument (Activator Methods Inc., Phoenix, Ariz)

PMS symptoms (PMS-cator disc)

PMS symptoms

For the total group, there was a decrease in the mean global scores in the treatment phase compared with both the baseline and the sham phases

Crossover study

Mean age:

I2: first sham treatment second high velocity, low amplitude MT plus soft tissue therapy (17)

I1: 34.9 ± 25.3 (25)

Chiropractic

I1: 35 ±7.4; I2: 36 ±7.0

I2: 43.11 ± 26.2 (25)

Three times over a period of ten days. Follow-up after 3 menstrual cycles.

WMD: -8.2 (-22.8 to 6.4)

Whittingham and Nilsson (2001)[40]

Cervicogenic headache, (n = 105)

I1: first manipulation, second no treatment, third sham manipulation (56)

Sham manipulation was delivered with a deactivated pettibon instrument

Active cervical ROM (goniometer)

6 weeks Right Rotation

Spinal manipulation of the cervical spine increases active range of motion

Mean age:

I2: first sham manipulation, second manipulation, third no treatment (49)

I1: 67 ± 9.0 (56); I2: 57 ± 9.8 (49)

Crossover study

I1:39.4 ±11.6; I2:41.9 ±12.5

WMD: 10.0 (6.4 to 13.6)

Chiropractic

4 study phases in 12 weeks

Left Rotation; I1: 67 ± 9.0 (56); I2: 56 ± 9.8 (49) WMD: 11.0 (7.4 to 14.6)

Follow-up 3, 6, 9 and 12 weeks

Right lateral flexion; I1: 46 ± 8.2 (56)

I2: 39 ± 7.7 (49); WMD: 7.0 (3.9 to 10.1); Left lateral flexion; I1: 44 ± 9.0 (56); I2: 39 ± 9.1 (49); WMD: 5.0 (1.5 to 8.5)

12 weeks Right Rotation

I1: 70 ± 8.0 (53); I2: 73 ± 9.1 (49)

WMD: -3 (-6.4 to 0.4)

Left Rotation; I1: 69 ± 8.0 (53)

I2: 72 ± 11.2 (49); WMD: -3 (-6.8 to 0.8); Right Lateral Flexion; I1: 47 ± 8.0 (53); I2: 40 ± 9.8 (49); WMD: 7.0 (3.5 to 10.5); Left Lateral Flexion; I1: 45 ± 8.0 (53); I2: 47 ± 9.1 (49); WMD: -2.0 (-5.4 to 1.4)