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Table 1 Evidence table of included studies, in alphabetical order

From: The effects of spinal manipulation on performance-related outcomes in healthy asymptomatic adult population: a systematic review of best evidence

Authors, Year Subjects & Setting; # enrolled; Design Interventions; # subjects Comparisons; # subjects Follow-Up Outcomes Key Findings Mean change (95% CI)
Physiological Outcomes
 Budgell B and Polus B, 2006 [30] No current neck or upper back pain; 18–45 years; n = 28;
Japan; Controlled crossover trial, 1 week apart.
PA thrust SMT to upper thoracic spine (1–4 vertebral levels) dependent on motion restriction. (cross-bilateral or combination SMT). Sham: hands over the scapulae bilaterally, with a single light brief impulse simultaneously with both hands. Immediately post intervention. ECG recording for 5-min blocks pre-SMT and post-SMT. Adverse events. Mean differences between groups SMT-Sham:
HR: − 0.24 bpm (− 4.15, 3.67)
LFab: − 50.5 (− 126.09, 25.09)
LFn: − 4.99 (− 11.54, 1.56)
HFab: 122.2 (− 242.49, 486.89)
HFn: 4.43 (− 2.22, 11.08)
LF/HF: − 0.2578 (− 0.61, 0.09)
Adverse events: Sham: 1 subject, 3.8/10 on VAS. SM: 2 subjects, 1.3 and 1.4/10 on VAS.
 Da Silva et al., 2013 [33] Healthy university students, no regular physical activity; 20–30 years; Brazil; n = 67; Single-blind placebo-controlled clinical trial. Cervical SMT group: supine rotary SMT of C3. n = 15
Thoracic SMT group: side-lying rotary thrust of T12. n = 15
Cervical and thoracic SMT group: cervical SMT followed by thoracic SM. n = 15
Anterior tibiotarsal mobilization: AP glide of the tibia on the talus. n = 14 Immediately post intervention. Maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), total lung capacity (TLC) and residual volume (RV). N.S. between-group differences between groups.
*Unable to calculate mean change and 95% CI.
 Ward J, 2013 [47] Apparently healthy chiropractic students; 20–29 years; Texas, USA; n = 20. Single-blind, RCT. Side-posture mammillary push at L3, performed bilaterally. n = 10 No SMT. n = 10 HR and Rate of Perceived Exertion (RPE): at the conclusion of each 3 min exercise test stage; Blood lactate concentration (BLC): conclusion of the exercise test. Time to exhaustion: at conclusion of the test. HR (bpm), RPE (Borg scale), BLC, time to perceived exertion and VO2 max (calculated from time to perceived exertion) during the Bruce treadmill protocol. Velocity response 4 mmol/L: 0.1 mph (−0.27, 0.46)
Velocity response 8 mmol/L: 0.1 mph (− 0.36, 0.57)
HR 4 mmol/L: 2.9 bpm (− 8.81, 2.91)
HR 8 mmol/L: 4.8 bpm (− 4.18, 13.88)
RPE 5mph: − 0.3 (− 1.99, 1.39)
RPE 6mph: − 0.1 (− 2.22, 2.02)
RPE 7mph: 0.1 (− 2.59, 2.79)
RPE 8mph: − 1 (− 6.07, 4.07)
Biomechanical Outcomes: Electromyography/Muscle Activation
 Christiansen et al., 2018 [31] Elite level Taekwondo athletes with subclinical neck pain; 17–50 years; Auckland, New Zealand; n = 12; Within-subject randomized controlled crossover trial, 1 week apart. SMT HVLA thrust to areas of segmental dysfunction throughout entire spine and SIJs. n = 11 Head and spine moved passively and actively similar to SMT without HVLA thrust. Immediately, 30 min and 60 min post intervention. Surface EMG of plantarflexors during maximum voluntary contraction (MVC) (% change). MVC between group % change SMT-Sham:
Immediately post: 11.09% (3.63, 18.55)
30 min post: 13.68% (4.51, 22.85)
60 min post: 9.74% (0.79, 18.59)
 Dunning et al., 2009 [35] Asymptomatic, physiotherapy and nursing students; 18–40 years; Birmingham, UK; n = 54; Crossover RCT with 8 min of washout. HVLA rotary SMT to the right C5/6 segment. Sham SMT to the right C5/6 segment.
Control: no manual contact for 30 s.
Immediately post intervention. Resting EMG (rEMG) of the biceps brachii muscles (mean % change). Between group mean % change:
Right:
SMT-control: 98.38% (84.08,112.68)
SMT-sham: 73.08% (59.43, 86.73)
Sham-control: 25.30% (19.63, 30.97)
Left:
SMT-control: 82.19% (67.06, 97.33)
SMT-sham: 62.89% (49.18–76.59)
Sham-control: 19.31% (10.10–28.52)
S.S. greater change of the right compared to the left:
(14.16%)
 Grindstaff et al., 2009 [38] Healthy adults, asymptomatic last 6 months; 18–37 years; USA; n = 42; RCT. Supine lumbopelvic SMT (high grade mobilization). n = 15 Side-lying lumbar mid-range flexion/extension PROM for 1 min, lower grade joint mobilization. n = 13.
Lying prone on elbows for 3 min, sham treatment. n = 13.
Immediately after and 20, 40, and 60 min post-intervention. Quadriceps maximal voluntary isometric contraction (MVIC) (% change) and central activation ratio (CAR) (% change). MVIC:
SMT-PROM = 8.1% (5.52, 19.44)
SMT-Prone extension = 12.1% (1.36, 15.28)
CAR:
SMT-PROM = 5.0% (0.37, 9.92)
SMT-Prone extension = 6.5% (1.34, 10.90)
N.S. change in % change MVIC or CAR from baseline at 20, 40 or 60 min.
*Unable to calculate mean change and 95% CI
 Pollard et al., 1996 [13] Healthy chiropractic students; 18–40 years; Sydney NSW; n = 30; Controlled before/after intervention study. Lumbar roll position with SMT of the right L3/4 segment. n = 15 Sham: Simulated SMT to the left side of the L3/4 motion segment while in the lumbar roll position. n = 15 Immediate after SMT Average of the force of two maximal isometric contractions of the quadriceps femoris (N). Between group difference SMT-Control:
5.1 N (− 3.67, 13.87)
 Sanders et al., 2015 [46] Healthy, asymptomatic, never received SMT; 20–35 years; Kentucky, USA; n = 21; Randomized, controlled, single-blind crossover design. Bilateral side-lying lumbar and/or SIJ SMT to identified restrictions. n = 21 Sham: use of drop piece and non-specific thrust through lumbar paraspinals. n = 21 Within 5 min post-treatment, and again after 20 min. Maximal voluntary isometric contractions (MVIC) of extension and flexion at 60° knee flexion. Isokinetic, concentric MVIC of knee extension and flexion at 60°s and 180°/s (% change). Between group SMT-Sham % change extension & flexion at 60° knee flexion:
2.8% (− 2.23, 7.83)
Between group SMT-Sham % change isokinetic contractions at 60°/s:
− 3.7% (− 10.93, 3.53)
Between group SMT-Sham % change isokinetic contractions at 180°/s:
4.1% (− 6.64, 14.84)
Biomechanical Outcomes: Range of Motion
 Galindez-Ibarbengoetxea et al., 2017 [36] Asymptomatic participants, 18–40 years; Spain; n = 36; Prospective, randomized controlled pilot study. AMC5 group: HVLA to right C5. n = 12
MT group: Joint dysfunction of cervical and thoracic spine evaluated and HVLA as needed. n = 12
ST group: same protocol as AMC5 but 3 rotation movements without reaching barrier. n = 12 Immediately post intervention. Cervical spine ROM (°), cervical flexion isometric peak force (N), surface EMG of SCM (mV), cervical erector spinae and biceps brachii (mV).
Adverse events.
Cervical extension ROM:
AMC5-MT: 2.5° (− 3.87, 8.87)
AMC5-ST: 7.3° (1.02, 13.58,)
MT-ST: 9.8° (5.18, 14.42)
Cervical flexion ROM:
AMC5-MT: 0.09° (− 5.94, 6.12)
AMC5-ST: 2.41° (− 3.73, 8.55)
MT-ST: 2.5° (− 3.58, 8.58)
Cervical right lateral flexion ROM:
AMC5-MT: 1.25° (− 3.89, 6.39)
AMC5-ST:- 0.91° (− 7.01, 5.19)
MT-ST: 29.8° (24.36, 35.24,)
Cervical left lateral flexion ROM:
AMC5-MT: 1.83° (− 3.3, 6.96)
AMC5-ST: − 1.83° (− 7.49, 3.83)
MT-ST: 0° (− 4.79, 4.79)
Cervical right rotation ROM:
AMC5-MT: − 2.83° (− 9.07, 3.41)
AMC5-ST: 4° (− 1.62, 9.62)
MT-ST: 1.17° (− 3.58, 5.92)
Cervical left rotation ROM:
AMC5-MT: 3.66° (− 1.94, 9.26)
AMC5-ST: 0.1° (− 5.97, 6.17)
MT-ST: 3.76° (− 1.10, 8.62)
Cervical flexion isometric peak force:
AMC5-MT: − 2.76 N (− 8.1, 2.58)
AMC5-ST: 0.47 N (− 4.22, 5.16)
MT-ST: 3.23 N (− 2.63, 9.09)
Biceps brachii EMG at rest:
AMC5-MT: Right − 35.07 mV (− 80.85, 10.71)
Left − 3.76 mV (− 53.64, 46.12)
AMC5-ST: Right − 36.9 mV (− 90.91, 17.11)
Left 121.68 mV (56.00, 187.36)
MT-ST: Right − 1.83 mV (− 60.55,56.89)
Left 125.44 mV (59.94, 190.94)
SCM during cranio-cervical flexion test:
AMC5-MT: Right − 7.2 mV (− 18.91, 4.51)
Left 2.47 mV (− 10.25, 15.19)
AMC5-ST: Right 8.69 mV (− 4.95, 22.33)
Left 4.35 mV (− 8.51,17.21)
MT-ST: Right 15.89 mV (1.79, 29.99)
Left 1.88 mV (− 11.51, 15.27)
No adverse events.
 Gavin D, 1999 [37] Asymptomatic; 22–44 years; USA; n = 78; Single-blind RCT. Group 3: SMT group, supine or seated SMT to hypomobile segments of the thoracic spine and ribs. n = 26 Group 1: control group, waited 4 min in a separate room with the manipulating therapist. n = 26
Group 2: mobility group, prone segmental mobility test from T3-T8. n = 26
Immediately post intervention. Thoracic spine (T3-T8) seated AROM (°) in forward bend, right & left side bend. Forward bending ROM:
Control-Palpation: − 1.1 ° (− 2.50, 0.30)
SMT-Control: 1.0° (− 0.47, 2.47)
SMT-Palpation: − 0.1° (− 1.83, 1.63)
Right-side bend ROM:
Control-Palpation: − 0.3° (− 2.09, 1.49)
SMT-Control: 1.5° (0.17, 3.17)
SMT-Palpation: 1.2° (− 0.64, 3.04)
Left-side bend ROM:
Control-Palpation: − 0.7° (− 2.13, 0.73)
SMT-Control: 2.2° (0.91, 3.49)
SMT-Palpation: 1.5° (− 0.18, 3.18)
 Hanney et al., 2017 [39] Students, faculty or staff of University of Central Florida; 18–50 years; Florida, USA; n = 102; Randomized controlled trial. Bilateral cervicothoracic thrust manipulation.
n = 34
Manual stretching: supine with passive flexion, lateral flexion away and rotation of head towards stretched side until barrier was met for 30 s, 2x/side. n = 34
No treatment: seated for 3–5 min. n = 34
Immediately after intervention. Cervical ROM (flexion, extension, bilateral lateral flexion and rotation) (°). S.S. group x time interaction: cervical extension ROM and bilateral lateral flexion.
Extension ROM:
SMT-Control: 3.76° (− 0.37, 7.15)
SMT-Stretch: − 4.29° (− 7.72, − 0.86)
Control-Stretch: − 8.05° (− 11.42, − 4.68)
L lateral flexion ROM:
SMT-Control: 2.82° (0.18, 5.46)
SMT-Stretch: 0.35° (− 2.06, 2.76)
Control-Stretch: − 2.47° (− 5.26, 0.32)
R lateral flexion ROM:
SMT-Control: 3.76° (0.94, 6.58)
SMT-Stretch: − 0.47° (− 3.31, 2.37)
Control-Stretch: − 4.23° (− 7.26, − 1.20)
Cervical flexion ROM:
SMT-Control: 3.61° (0.16, 7.06)
SMT-Stretch: − 0.65° (− 3.86, 2.56)
Control-Stretch: − 4.26° (− 7.58, − 0.94)
Left cervical rotation ROM:
SMT-Control: 3.0° (0.38, 5.62)
SMT-Stretch: 0.53° (− 1.70, 2.76)
Control-Stretch: − 2.47° (− 5.04, − 0.10)
Right cervical rotation ROM:
SMT-Control: 1.88° (− 0.70, 4.46)
SMT-Stretch: 0.88° (− 1.23, 2.99)
Control-Stretch: − 1.0° (− 3.77, 1.77)
Biomechanical Outcomes: Other
 Ditcharles et al., 2017 [34] Right-handed young healthy adults; 24–32 years; France; n = 22; Randomized controlled trial. Standing “lift-off” technique HVLA SMT to T9. n = 11 Sham: same experimental protocol as HVLA group using “light touch methodology”, without compression or traction. n = 11 Immediately post intervention. Gait initiation variables: anticipatory postural adjustments (APA) duration (sec), peak of anticipatory backward center of pressure (COP) displacement (m), center of gravity (COG) velocity at toe-off (TO) (m/s), mechanical efficiency of APA (ratio), peak of COG velocity (m/s), step length (m), and swing phase duration (msec); thoracic spine ROM (°). N.S. main effect of group x condition for spine ROM, except thoracic flexion.
Thoracic flexion: S.S. main effect of group x condition
(F1,21 = 14.55).
S.S. greater forward flexion post-SMT.
S.S. main effect of group, condition and group x condition on every gait initiation variable.
S.S. lower post-SMT than pre-SMT.
N.S. change in sham group.
*Unable to calculate mean change and 95% CI.
 Learman et al., 2009 [41] History of chronic low back pain with minimal to no pain at the time of testing; 18–65 years; USA; n = 33; Randomized, controlled, unbalanced crossover design, 1-week washout. SMT: side-lying lumbar SMT at level of identified dysfunction.
n = 33
Sham: side-lying position mimicking SMT held for 15 s.
n = 33
Immediately and 1 week after intervention. Trunk joint position sense (JPS), threshold to detect passive motion (TTDPM), direction of motion (DM) and force reproduction (FR). JPS:
S.S. period effect in SMT group (F = 3.026).
1-week residual effect: mean error reduction of 1.05° (98.33%
CI = 0.16, 1.94).
S.S. immediate treatment effect for sham group (t = 3.247).
Mean error reduction: 0.82° (99% CI = 0.08°, 1.56°).
TTDPM:
S.S. group-period effect (F = 4.048, p = 0.013)
SMT: 0.317° (98.33% CI = 0.04, 0.60)
N.S. difference for DM or FR.
*Unable to calculate mean change or 95% CI
 Méndez-Sánchez et al. 2014 [14] Asymptomatic men and women; 18–30 years; Spain; n = 62. Double-blind RCT. Bilateral HVLA to SIJs plus placebo technique. n = 31 Placebo technique: mobilization without tension of the hips in the supine position. n = 31 Immediately after SMT. Baropodometric analysis of surface (mm2), weight (kg) and percentage of load (%) on each forefoot, hindfoot and each foot in its entirety, and the location of the maximum pressure point on the plantar support. Between group differences HVLA-placebo:
Surface variable:
Left foot: 0.06 mm2 (− 6.19, 6.31)
Right foot: − 0.9 mm2 (− 8.96, 7.16)
% of load:
Left foot: 2.39% (− 0.15, 4.93)
Right foot: − 2.39% (− 4.93, 0.15)
Weight variable:
Left foot: 1.84 kg (0.14, 3.54)
Right foot: − 1.84 kg (− 3.54, − 0.14)
Forefoot (FF) and Hindfoot (HF) measures:
Surface variable:
LFF: 0.93 mm2 (− 2.25, 4.11)
RFF: 2.0 mm2 (− 2.45, 6.45)
LHF: 1.71 mm2 (− 0.51, 3.93)
RHF: 0.04 mm2 (− 2.83, 2.91)
% of load:
LFF: 0.32% (− 1.49, 2.13)
RFF: − 0.39% (− 2.71, 1.93)
LHF: 2.71% (0.53, 4.89)
RHF: − 2.13% (− 3.79, − 0.47)
 Puentedura et al., 2011 [43] Healthy individuals from university faculty and students; 21–34 years; Las Vegas, US; n = 35; Single-blinded crossover RCT, 1-week washout. Side-lying lumbar thrust joint SMT to the right side. n = 35 Sham: side-lying position Maitland grade I oscillation for lumbar rotation over 30 s bilaterally. n = 35 Immediate after condition. Thickness of the transversus abdominus (TA) muscle during the abdominal drawing in maneuver (cm). Between group differences SMT-Sham:
Rest: − 0.014 cm (− 0.04, 0.01)
Contracted: − 0.007 cm (− 0.05, 0.04)
 Rosa et al., 2013 [44] Asymptomatic; 19–28 years; Brazil; n = 55; Controlled before/after intervention laboratory study. Seated thoracic SMT. n = 24 Sham: same position and procedure, without the high-velocity thrust. n = 21 Immediately after the intervention.
SMT: n = 3 lost due to no cavitation
Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH), scapular plane abduction kinematics to determine scapulohumeral rhythm (GH:scapulothoracic ratio).
Adverse events.
Between group differences, during different degrees of arm elevation:
30°-120°: 0.45 (− 0.79, 1.69)
30°-60°: − 0.05 (− 0.39, 0.29)
60°-90°: − 0.05 (− 0.15, 0.32)
90°-120°: 0.36 (− 0.11, 0.83)
No adverse events.
Sport-Specific Outcomes
 Costa et al., 2009 [32] Golfers with handicap 0 to 15, practicing at least 4 h 1x/week, 18–55 years; Brazil; n = 43; RCT. Group 2: same standardized stretch program as Group 1 plus SMT. SMT provided to dysfunctional joints of the neck, thoracic spine and low back. 1x/week, 4 weeks. n = 23 Group 1: standardized stretch program. Static stretches were performed for 20 s bilaterally, including forearm flexors, deltoids, brachioradialis, biceps, forearm extensors, levator scapulae, gastrocnemius, soleus, quadriceps, hamstrings and gluteal muscles. n = 20 Immediately post intervention weekly. Trial distance of 3 full swing maneuvers with driver club (average of 3 distances in meters). Mean differences between groups (Group 2-Group 1):
Immediately post-intervention week 1: 9.82 m (−3.58, 23.22)
Immediately post-intervention week 2: 11.04 m (− 0.05, 22.13)
Immediately post-intervention week 3: 4.39 m (− 5.54, 14.32)
Immediately post-intervention week 4: 7.73 m (− 1.48, 16.94)
 Humphries et al. 2013 [40] Asymptomatic male recreational basketball players, completing at least 5/10 free throws; 16–37 years; Texas, USA; n = 24; RCT pilot study. Left cervical SMT at C5/C6. n = 12 Sham: Activator set to zero force n = 12 Immediately after SMT. Dominant handgrip isometric strength (kg) and free throw completion (20 free throws) (% completed).
Adverse events.
Handgrip strength between SMT-placebo:
1.2 kg (−4.46, 6.86)
Free throw accuracy between SMT-placebo:
2.4% (0.656, 4.14)
No adverse events.
 Olson et al., 2014 [42] Asymptomatic cyclists; 29–43 years; Texas; n = 20; Blinded, randomized, crossover, controlled study, 1 week between interventions. Condition A: bilateral HVLA side-posture SMT mammillary push at L3 with 15 min wait. n = 6 Condition B: 15 min bilateral sham acupuncture to arbitrary points on or near GB-34, SP-6, CV-6, Shenmen.n = 6 Control arm: no intervention. n = 8 15 min post intervention. Sit and reach test (cm), time to completion of a 0.5 km cycle ergometer sprint against 4-kp resistance (sec), maximum exercise heart rate (bpm) and rate of perceived exertion (Borg 6–20 scale). Between group differences HVLA-Sham Acupunctur:
0.5 km sprint time: 0.8 s (− 10.82, 12.42)
Mean RPE: 0.2 (− 1.16, 1.56)
Mean max HR: − 0.3 bpm (− 10.08, 9.48)
Mean sit-and-reach test: − 0.6 cm (− 6.19, 4.99)
N.S. training effect or test acclimation in the control group.
 Sandell et al., 2008 [45] Healthy, male junior running athletes training in middle distance; 17–20 years; Sweden; n = 17; Prospective, randomized, controlled experimental pilot study. Side posture SIJ SMT, hip joint adjustment (prone posterior to anterior glide) chosen based on restrictions and same stretching program as control group. 1x/week for 3 weeks. n = 8 Control group: passive and active stretching, using hip flexor stretch, as part of their usual training activities. 2–3 times during the study period. n = 9 Within 3 days after 3-week intervention Hip extension (°) and running velocity (30 m) (sec). Hip extension between group differences SMT-Control:
Right: − 3.8° (− 5.73, − 1.87)
Left: − 2.9° (− 4.95, − 0.85)
Running velocity between group differences SMT-Control:
− 0.062 s (− 0.13, 0.002)
  1. AP Anteroposterior, ECG Electrocardiogram, FU Follow-up, HR Heart rate, HF High frequency, HVLA High velocity low amplitude, LF Low frequency, N.S. Non-significant, PA Posteroanterior, SIJ Sacroiliac joint, ROM Range of motion, SMT Spinal manipulative therapy, S.S. Statistically significant, VAS Visual analog scale