Skip to main content

Table 1 Study characteristics

From: Is manipulative therapy more effective than sham manipulation in adults?: a systematic review and meta-analysis

Author (year) profession Patient population Intervention (n) follow-up Sham specification Outcome (instrument) Results mean, sd (n) and WMD with 95% CI or n and RD with 95 CI Author’s conclusion
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)
  1. MT: manipulative therapy, CI: confidence interval, RD: risk difference, ROM: range of motion, VAS-score: visual analogue scale (100 mm), I1: intervention one, I2: intervention two, I3: intervention three, I4: intervention 4, WMD: weighted mean difference, LFM: low force mimic, NRS: numeric rating scale, FEV1: forced expiratory volume 1 second, FVC: forced vial capacity, RAW: airway resistance, ODI: Oswestry Disability Index, PMS: premenstrual syndromes, WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index, SF-36: Short Form Health Survey, RMQ: Roland Morris Back Pain Questionnaire, ASLR: Active Straight Leg Raising test.