Can pre-treatment verbal suggestions influence the short-term effects of spinal manipulation in young adults with chronic non-specific low back pain? A randomized controlled trial

Musculoskeletal Science and Practice · 2025-10-10 · 1 citations

To investigate whether pre-treatment verbal suggestions (positive, neutral, or negative) modulate the short-term effects of lumbar spinal manipulation in young adults with chronic non-specific low back pain (CNSLBP). Three-arm, triple-blind randomized controlled trial. Sixty-six participants (mean age 21 years ± 2,96; 76% women) with CNSLBP were randomly assigned to a positive, neutral, or negative verbal suggestion before a standardized lumbar spinal manipulation. Outcomes were assessed at baseline (t0), immediately post-intervention (t1), and 24 hours later (t2). The primary outcome was pain intensity (NPRS-11). Secondary outcomes included stress (SNRS-11, PSS-10), pressure pain threshold (PPT), disability, kinesiophobia, sleepiness, expectations, tissue temperature, lumbar active range of motion (AROM), and blood biomarkers. All groups improved in pain at t1 and t2 (p < 0.05). The positive verbal instruction group showed greater pain reduction compared to the negative verbal instruction group at t1 (mean difference [MD] = –1.41; p = 0.004) and t2 (MD = –2.18; p = 0.001). Stress levels were significantly lower in the positive verbal instruction group compared to the negative verbal instruction group at t2 (MD = –2.46; p = 0.001). PPT increased significantly in the positive verbal instruction group compared to the negative verbal instruction group at L5 (t1: MD = 0.47; p = 0.001) and L3 (t2: MD = 0.48; p = 0.001). No significant between-group differences were found for disability, kinesiophobia, sleepiness, lumbar AROM, tissue temperature, or blood biomarkers. Verbal suggestions modulate the short-term effects of spinal manipulation in young adults with CNSLBP. • Positive suggestions improved short-term clinical effects of spinal manipulation • Negative suggestions reduced benefits; neutral ones produced intermediate effects • Verbal framing may influence pain intensity, stress, and pressure sensitivity • Clinicians should consider wording to optimize therapeutic outcomes • Findings may not generalize due to young female sample and 24h follow-up limit

American Physical Therapy Association Clinical Practice Guideline Facilitated Shared Decision Making for Patients With Low Back Pain: Feasibility and Acceptability in Outpatient Physical Therapy

Physical Therapy · 2025-12-19

IMPORTANCE: The feasibility and acceptability of integrating shared decision making (SDM) for patients receiving physical therapy for low back pain (LBP) is unclear. OBJECTIVE: This study assessed feasibility and acceptability of integrating SDM for intervention selection facilitated by American Physical Therapy Association clinical practice guidelines for patients with LBP. DESIGN: This was a non-randomized pilot feasibility study. SETTING: This study was conducted in outpatient physical therapy clinics. PARTICIPANTS: Physical therapists (n = 10) and patients receiving care for LBP (n = 40) participated. INTERVENTION: Physical therapists were non-randomly allocated to not receive (-SDM, n = 4) or receive (+SDM, n = 6) training to integrate SDM for patients with LBP. MAIN OUTCOMES AND MEASURES: Feasibility of study procedures was assessed through recruitment, enrollment, and retention rates. Acceptability was assessed with standard measures for treatment acceptability (Short Assessment of Patient Satisfaction, SAPS), credibility-expectancy (Credibility-Expectancy Questionnaire, CEQ), therapeutic alliance (Work Alliance Inventory Short-Revised, WAI-SR), SDM occurrence (collaborRATE, and 9-item Shared Decision Making Questionnaire, SDM-Q-9) at 4 weeks. Patient-reported outcomes were described for pain intensity and interference (Pain, Enjoyment, General Activity, PEG), pain self-efficacy (4-item Pain Self Efficacy Questionnaire, PSEQ-4), and LBP disability (Oswestry Disability Index, ODI). RESULTS: Of 68 patients that were eligible, 43 (63.2%) communicated with study coordinator, 40 (93.0%) were enrolled, and 24 (60.0%) completed 4-week follow-up. Patient acceptability outcome median scores for SAPS (-SDM = 24.0, +SDM = 24.0), CEQ-credibility (25.0, 26.0), CEQ-expectancy (21.0, 23.0), WAI-SR goal (20.0, 18.0), WAI-SR task (17.0, 18.0), and WAI-SR bond (16.0, 19.0) were observed. Top score rates for collaboRATE (-SDM = 53.8%, +SDM = 72.7%) and SDM-Q-9 (38.5%, 54.5%) were observed. Median within-participant change in PEG (-SDM = -0.7 points, +SDM = -2.0 points), PSEQ-4 (0.0, +2.0), and ODI (-4.0, -12.0) scores were observed with minimal important change rates for PEG (-SDM = 23.1%, +SDM = 54.5%), PSEQ-4 (30.8%, 63.7%), and ODI (38.5%, 63.6%) described. CONCLUSIONS: Feasibility findings will inform future efficacy study planning with respect to recruitment, enrollment, and retention procedures. Future studies should consider assessing SDM from both patient and physical therapist perspectives while also evaluating how clinical practice guidelines may be used as resources to facilitate SDM for people with LBP. RELEVANCE: These study findings have implications for SDM as a strategy to incorporate patient preferences into evidence-based clinical decision making for patients with LBP in outpatient physical therapy settings, however, larger scale studies are needed.

Manual Therapy

2025-07-22

The manual therapies are a very old discipline that developed in parallel in many cultures across the world. Muscle-biased techniques, for example, have been represented in foundational documents of traditional Chinese medicine and Sanskrit writings from India. Early texts by Hippocrates describe the use of joint- and muscle-biased techniques. More recent history saw the development of osteopathy and chiropractic philosophies and theories. Today, there is a staggering variety of practices within manual therapy used by many different professions to manage musculoskeletal disorders. These therapies include techniques biased toward the joints, the soft tissues (including muscle and fascia), and neurovascular structures. Manual therapy is embedded within the inception of the physical therapy profession and is described in the profession’s early literature. 1 Specifically, the physical therapy profession evolved during World War I with the rehabilitation needs of wounded soldiers, and massage was considered an integral component for the management of these patients. Historically, physical therapists were trained in manual therapy by physicians. 2 , 3 Well-known physical therapists in the field of manual therapy, such as Freddy Kaltenborn, Geoffrey Maitland, Stanley Paris, Gregory Grieve, and David Lamb, all trained under or were influenced by orthopedic physicians such as James Mennell, James Cyriax, and Allan Stoddard. 1 Subsequently, the early physical therapy clinical decision-making approach to manual therapy was heavily influenced by osteopathic and orthopaedic physicians. In this chapter, the present traditional and more current theories regarding why manual therapy is effective for some patients presenting with musculoskeletal disorders will be presented, along with the general principles for the successful implementation of manual therapy into clinical practice. The evidence specific to the risk and general efficacy of manual therapy will be presented along with the modern definition of the broader context of how Orthopedic Manual Physical Therapy is described today.

The mechanisms of manual therapy: A living review of systematic, narrative, and scoping reviews

PLoS ONE · 2025-03-18 · 45 citations

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

A Mechanistic-Based Approach to the Physical Therapy Management for a Patient With the Diagnosis of Pseudogout: A Case Study

JOSPT Cases · 2025-05-23

BACKGROUND: Pseudogout is an inflammatory arthritis typically affecting the knee. Consensus-based recommendations for physical therapy management approaches for patients presenting with pseudogout are lacking, requiring additional frameworks to guide the clinical decision-making process. A pain mechanistic-based approach can direct the physical therapy management approach for conditions such as pseudogout in which an established evidence base is lacking. CASE PRESENTATION: A 66-year-old male was referred by his physiatrist to physical therapy with bilateral anterior knee pain. The physician diagnosed pseudogout from the blood work and linked the increase in knee pain to this condition, prompting a referral for physical therapy. The patient was presumed to have a nociceptive pain presentation. Treatment focused on exercises directed at the peripheral source of pain and pain-relieving modalities. OUTCOME AND FOLLOW-UP: The patient was seen for 30 visits over a 19-week period. Lower Extremity Functional Scale score improved by 20, Patient-Specific Functional Scale score improved by 3.67/10, numeric pain-rating scale score improved by 3.67, and performance on the 5× Sit-to-Stand Test improved by 16 seconds. DISCUSSION: This case describes the application of a mechanistic-based approach to physical therapy management of a patient with pseudogout, for which research evidence is lacking. JOSPT Cases 2025;5(3):156-160. Epub 23 May 2025. doi:10.2519/josptcases.2025.0021

Limited association between central pain processing and clinical outcomes in non-specific chronic neck pain after a manual therapy intervention: A secondary analysis

Musculoskeletal Science and Practice · 2025-04-01

BACKGROUND: Non-specific chronic neck pain (NSCNP) is a prevalent condition causing significant disability. While manual therapy is recommended, its clinical benefits are limited. The relationship between central pain processing and treatment outcomes in NSCNP remains unclear. OBJECTIVES: To assess whether central pain processing measures could predict manual therapy outcomes in NSCNP patients. DESIGN: Pre-planned secondary analysis. METHODS: Sixty-three NSCNP patients underwent a four-week manual therapy regimen. Central pain processing mechanisms were assessed using Pressure Pain Threshold (PPT), Temporal Summation of Pain (TSP), and Conditioned Pain Modulation (CPM). Clinical outcomes were measured using the Neck Disability Index (NDI), pain intensity, and the Global Rating of Change Scale (GRoC). Univariate and multivariate regression models explored associations between baseline variables and treatment outcomes. RESULTS: Multivariate analysis identified baseline CPM and neck pain duration as significant predictors of treatment outcome based on GRoC. A weak negative association was found between CPM and GRoC (p < 0.05), suggesting that patients with lower CPM response reported better perceived outcomes. Baseline NDI was inversely associated with changes in disability (p < 0.01). Baseline pain intensity (p < 0.01) and duration (p < 0.05) were inversely related to pain reduction, while baseline CPM narrowly missed significance. No significant associations were found between TSP, PPT, and clinical outcomes. CONCLUSION: The findings suggest a limited association between pre-treatment central pain processing status and manual therapy outcomes in NSCNP patients. The lower CPM response was modestly predictive of better outcomes, contrary to expectations. Routine use of QST measures to guide treatment decisions in this population is not supported by current data.

Foundational Principles of Treatment

2025-07-22

The physical therapist’s management of a patient’s injury or pain condition has evolved in recent years. Today’s physical therapist understands the science of pain in greater detail and uses an active approach grounded in appropriately dosed exercise, compared to the emphasis on passive care that existed years ago. Passive interventions such as manual therapy and other modalities have a role in contemporary care. That role is short-lived 1 and should be primarily used to create pain reduction early in the course of care, allowing for a window of opportunity for well-tolerated loading programs. Moreover, an early decrease in symptoms can enhance the patient’s belief that the care will be effective. Early improvement in pain ratings can enhance the therapeutic alliance between the patient and therapist and improve adherence and patient-reported outcomes.

Patient and physical therapist perspectives on spinal manipulative therapy for low back pain and associated clinical outcomes: protocol for a prospective, single-arm intervention study

BMJ Open · 2025-07-01 · 1 citations

INTRODUCTION: Spinal manipulative therapy (SMT) is a common manual therapy intervention provided by healthcare providers for patients with low back pain (LBP). Responses to SMT are influenced by interactions between the patient and provider. Contextual factors may be specific to the patient, provider, patient-provider relationship or environment in which treatment is provided, with all capable of influencing clinical outcomes. The overall goal of this study is to gain a deeper understanding of contextual factors associated with manual therapy utilisation, perception and outcomes, from both patient and provider perspectives. A better understanding of modifiable contextual factors will inform future studies testing the impact on how SMT is delivered to patients influences clinical outcomes that could potentially advance the clinical science of manual therapy. METHODS AND ANALYSIS: A prospective, single-arm study design with follow-up measures assessed up to 26 weeks after initiation of physical therapy for LBP will be used to assess relationships between physical therapy clinical outcomes and contextual factors related to the patient (preference, expectation, pain beliefs, pain associated distress and prior manual therapy experiences), the provider (equipoise, expectation, pain beliefs and clinical experience) and the interaction between the two (therapeutic alliance). Multimodal treatment approach of SMT (required during initial three treatment sessions within a 2week period), exercise and education supported by recent clinical practice guidelines will be encouraged for this study. ETHICS AND DISSEMINATION: Ethics approval for the study was obtained from the University of Florida Institutional Review Board. Informed consent is required for physical therapist and patient participant enrolment in this project. The results of this study will be disseminated at professional scientific conferences and submitted for publication in peer-reviewed journals. Reference or approval number: IRB#: IRB202301700 TRIAL REGISTRATION NUMBER: NCT06590116.

Editorial: The role of expectations on treatment outcomes: from the experimental context to the clinical practice

Frontiers in Psychology · 2025-03-27 · 1 citations

The first contribution by Predatu et al. 4 examines how response expectancy impacts the efficacy of gratitude interventions in a randomized controlled trial. This study emphasizes that the effects of optimism on treatment outcomes are moderated by different levels of expectancy, particularly in enhancing positive emotions. The findings provide significant insights into how psychological interventions like gratitude journaling can be optimized through the careful management of response expectations, making this study relevant for both experimental psychologists and clinicians looking to enhance patient well-being through non-pharmacological means.Moving to the clinical setting, Wessels et al. 5 focus on the role of open-label placebo (OLP) in reducing preoperative anxiety in patients undergoing gynecological laparoscopic surgery. The Preoperative Anxiolysis and Treatment Expectation (PATE) trial explores how openly administered placebos, alongside positive expectation-enhancing videos, can significantly alleviate anxiety and postoperative pain. This innovative approach challenges traditional perceptions of placebo use and provides an ethical, non-deceptive option for improving surgical outcomes.In a narrative review, Wilhelm et al. 6 highlight the ways in which homeopathy leverages patient expectations to drive therapeutic success, despite the absence of active ingredients in its remedies. This review argues that while homeopathy operates primarily through placebo mechanisms, conventional medicine can learn from its success in managing patient expectations. By incorporating patient-centred communication styles and optimising treatment rituals, evidence-based medicine can further enhance treatment outcomes.The next article expands the discussion of expectations from lab and clinical settings to healthcare organisations themselves. Poulter et al 7 explore how neglecting patient expectations can induce nocebo effects, resulting in dissatisfaction, poor adherence, and negative clinical outcomes. They advocate for healthcare institutions to foster positive patient expectations at every stage of the care pathway. This article goes beyond the patient-provider interaction, emphasising that an organizationwide commitment to managing expectations is essential for avoiding nocebo-induced harm.Asan et al. 8 contribute an observational study that examines the impact of media coverage on nocebo effects during the COVID-19 pandemic. Specifically, they investigate how reports linking the AstraZeneca vaccine to rare cases of cerebral venous sinus thrombosis (CVST) led to a surge in emergency department visits for headache complaints. This study underscores the broader societal implications of health communication and calls for greater vigilance in media reports to prevent unnecessary panic and strain on healthcare systems.The power of observational learning (OL) in shaping treatment expectations is explored in the sixth article. Klau&#223; et al. 9 conduct a systematic review to examine how OL can induce placebo and nocebo effects. The findings suggest that watching others&#39; treatment experiences can significantly modulate one&#39;s own expectations and outcomes, with implications for both clinical practice and patient education. This review highlights the need for future research on how to optimize OL to maximise therapeutic benefits while minimising harm.Finally, Cormack and Rossettini 10 present an opinion piece on the influence of nocebo effects in exercise therapy for musculoskeletal (MSK) pain. They argue that clinicians often unintentionally create nocebo effects through their language and behaviour, leading to reduced patient engagement with prescribed exercises. This article calls for clinicians to become more mindful of how their communication can impact patient expectations and outlines strategies to mitigate nocebo effects, thereby enhancing the efficacy of exercise-based interventions.The insights from this Research Topic suggest that clinicians, researchers, and healthcare organizations need to consider expectations as modifiable and measurable variables in treatment protocols. Managing these expectations -whether to harness placebo effects or prevent nocebo effects -has the potential to improve patient outcomes across a wide range of medical fields. As more attention is directed toward expectation-based interventions, the future of patient care will likely see a greater focus on psychological factors as a complement to traditional medical approaches. These articles collectively pave the way for innovative practices that enhance the efficacy of treatments by addressing the psychological underpinnings of patient experience.

Integrated manual therapies: IASP taskforce viewpoint

PAIN Reports · 2024-10-29 · 15 citations

Introduction: Manual therapy refers to a range of hands-on interventions used by various clinical professionals, such as osteopaths, osteopathic physicians, chiropractors, massage therapists, physiotherapists, and physical therapists, to treat patients experiencing pain. Objectives: To present existing evidence of mechanisms and clinical effectiveness of manual therapy in pain. Methods: This Clinical Update focuses on the 2023 International Association for the Study of Pain Global Year for Integrative Pain Care. Current models of manual therapy and examples of integrative manual therapy are discussed. Results: The evolution of concepts in recent years are presented and current gaps in knowledge to guide future research highlighted. Mechanisms of manual therapy are discussed, including specific and contextual effects. Findings from research on animal and humans in manual therapy are presented including on inflammatory markers, fibrosis, and behaviours. There is low to moderate levels of evidence that the effect sizes for manual therapy range from small to large for pain and function in tension headache, cervicogenic headache, fibromyalgia, low back pain, neck pain, knee pain, and hip pain. Conclusion: Manual therapies appear to be effective for a variety of conditions with minimal safety concerns. There are opportunities for manual therapies to integrate new evidence in its educational, clinical, and research models. Manual therapies are also well-suited to fostering a person-centred approach to care, requiring the clinician to relinquish some of their power to the person consulting. Integrated manual therapies have recently demonstrated a fascinating evolution illustrating their adaptability and capacity to address contemporary societal challenges.