The effect of unimodal manual therapy on patients with spinal pain: an umbrella review

The effect of unimodal manual therapy on patients with spinal pain: an umbrella review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review The effect of unimodal manual therapy on patients with spinal pain: an umbrella review Lau Yan Hei, Chun Hei Matthew Lo, Kwan Shu Ng, Tin Long Yip, Wing Yan Yu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6487750/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Spinal pain, including neck pain (NP) and low back pain (LBP), is a leading cause of global disability. Manual therapy is recommended as a non-pharmacological adjunct, but its standalone effects are not well understood. The objective of this review was to synthesize and critically evaluate the systematic reviews and meta-analyses that have investigated the effectiveness of unimodal manual therapy for managing spinal pain. Methods: This umbrella review of systematic reviews and meta-analyses searched seven databases from inception to March 2024, focusing on unimodal manual therapy. Two independent reviewers assessed methodological quality using AMSTAR 2 and ROBIS tools, and reporting quality using PRISMA 2020. Data regarding treatment techniques, pain and functional outcomes, and spinal conditions were extracted. The citation overlap was calculated using the Corrected Covered Area (CCA) index. Results: Sixteen reviews met inclusion criteria. Evidence suggests limited effectiveness of unimodal manual therapy compared to sham, placebo, or other interventions for NP and LBP across all follow-up periods. Mobilization demonstrated short-term benefits in NP reduction and functional improvement, though long-term effectiveness remains uncertain. Methodological quality was generally low, with only one high-quality review. CCA values were 6.3% for NP and 19% for LBP reviews. Conclusion: Unimodal manual therapy may be more beneficial when integrated into multimodal approaches, particularly for short-term relief. Future research should prioritize methodological rigor and standardized reporting to better establish long-term effectiveness in managing spinal pain. Umbrella review Spinal pain Manual therapy Mobilisation Neck pain Low back pain Figures Figure 1 Figure 2 Figure 3 Introduction Spinal pain significantly impairs global quality of life and productivity, manifesting as lower back, neck, and thoracic pain. 13,49 Lower back pain (LBP) is a leading cause of disability, prevalent in central and eastern Europe and Australia, with lower rates in East Asia. 14 Its incidence increases with age, and sacral pain complicates chronic LBP cases. 12,14 Neck pain (NP) is also widespread, with a global prevalence rate of 2,696.5 per 100,000 in 2019. 79 In the USA, NP incidence ranges from 10.4% to 21.3% annually. 9 Thoracic pain, though less common, affects children, adolescents, and older populations. 6,46 Effective management is crucial, with guidelines recommending non-pharmacological interventions such as manual therapy, which defined as hands-on techniques applied to joints and vertebrae. 16,81 Mobilization and manipulation are key components, involving passive joint movement and fast thrusts, respectively. 72,76 While numerous systematic reviews and meta-analyses have evaluated manual therapy's effectiveness for spinal pain, their findings have been heterogeneous, 21,59,72 making it challenging for clinicians and policymakers to draw definitive conclusions. This variation in reported outcomes may be attributed to differences in methodological quality, inclusion criteria, intervention definitions, and outcome measures across reviews. 10 Additionally, the isolated effects of manual therapy are often difficult to determine, as it is frequently delivered as part of a multimodal treatment approach. 17 Systematic reviews synthesize research findings to inform clinical practice based on evidence and the risk of bias. 87 Previous overviews of systematic reviews on the effectiveness of manual therapy might not reflect current evidence due to evolving methodologies and new studies. 25,69 There is a gap in reviews focusing solely on manual therapy as a treatment for spinal pain, often included as part of multimodal strategies. 5,16 To ensure review integrity, contemporary tools like Assessment of Multiple Systematic Reviews II (AMSTAR 2), 78 Risk Of Bias In Systematic reviews (ROBIS) 88 , and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist 2020 63 have been developed for assessments and reporting. This umbrella review aims to synthesize and critically evaluate the existing evidence from systematic reviews and meta-analyses focusing specifically on unimodal manual therapy interventions for spinal pain. Methods This umbrella review protocol was registered with PROSPERO. Deviations are presented in Additional file 1, and the review followed the PRIOR checklist. 33 Search strategy A comprehensive search was conducted across seven databases, including Medline, CINAHL, EMBASE, Cochrane, SCOPUS, Web of Science, and Epistemoniko. Additionally, we searched the PROSPERO registry of systematic reviews. The search encompassed records from the inception to Mach 10, 2024. The search aimed to identify reviews on unimodal manual therapy for spinal conditions, developed with a health librarian. Details are in Additional file 2. Eligibility criteria This study included systematic reviews and meta-analyses based on PICOS (Population, Intervention, Comparison, Outcome, and Study design) framework. Table 1 summarises the eligibility criteria. Population : Adults aged 18-65 with spinal pain, excluding non-musculoskeletal or asymptomatic conditions. Both acute/subacute (12 weeks) spinal pain were included. Intervention : Unimodal manual therapies, such as spinal mobilization and manipulation, administered by qualified clinicians. 43 Exclusions were made for techniques like soft tissue massage, trigger point therapy, and stabilization exercises. Comparator : Any conservative treatments not involving manual therapy, including usual care, sham, placebo, or other non-manual approaches. Outcome: Pain and/or functional limitation assessments using standardized scales like visual analogue scale, numerical pain rating scale, 39 Neck Disability Index, and Oswestry Disability Index. 36 Study design : English-published reviews incorporating randomized controlled trials (RCTs), as which are the benchmark for assessing healthcare interventions. 37 Non-RCTs and non-peer-reviewed reviews were excluded. Study selection Articles were imported into EndNote X20 software. Two independent reviewers (LYH, LCHM, NKS, YTL, and YWY) applied the eligibility criteria in two stages: 1) screening titles and abstracts, and 2) reviewing full texts. Any disagreements were resolved through discussion among the reviewers and the corresponding author. Data extraction A pair of reviewers (XXX) independently extracted data using a standardized template, resolving discrepancies through discussion with the corresponding author. A pilot extraction in 5% of studies ensured consistency before full extraction. We included the most recent reviews when updates were available. Data focused on review information rather than primary RCTs, following Cochrane recommendations for overviews of reviews. 68 Collected data included author, publication year, population characteristics, number of studies, intervention details, outcome measures, and main findings. Methodological quality assessments A pair of trained reviewers (LYH, LCHM, NKS, YTL, and YWY) independently assessed the methodological quality of the included reviews using the AMSTAR 2 tool. 78 The tool has 16 items, seven (2, 4, 7, 9, 11, 13, 15) of which are critical for assessing methodological soundness. Each item was rated as "Yes," "Partial Yes," or "No." 78 Items 11, 12, and 15 were not applicable to reviews. An overall confidence rating was assigned to each review, categorized as "High," "Moderate," "Low," or "Critically Low," based on the presence of major flaws in critical and non-critical items. 78 Disagreements were resolved through in-depth discussions with the corresponding author. Risk of bias assessments A pair of trained reviewers (LYH, LCHM, NKS, YTL, and YWY) independently assessed the risk of bias in the included reviews using the ROBIS tool, 88 which is structured into three phases: (1) assessing relevance, (2) identifying concerns about the review process, and (3) risk of bias judgment. Phase 2 includes 21 signaling items across four domains: study eligibility criteria, identification and selection of studies, data collection and study appraisal, and synthesis and findings. Responses to signaling items are "yes," "probably yes," "probably no," "no," or "no information." Phase 3 uses three signaling items to determine the overall risk of bias, rated as "low," "high," or "unclear." Discrepancies were resolved through discussions with the corresponding author. Reporting quality assessment A pair of trained reviewers (LYH, LCHM, NKS, YTL, and YWY) independently assessed the reporting quality of the included reviews using the 27-item PRISMA checklist 2020. 63 Each item was rated as "yes," "partially yes," or "no," indicating complete, partial, or no reporting. Discrepancies were resolved through team discussions with the corresponding author. Data analysis A PRISMA flowchart 54 was created to depict the study selection process. The characteristics and results were presented using graphs and tables. Data were categorized by the type of manual therapy and the type of spinal pain. Effect sizes and p-values from the meta-analyses comparing unimodal manual therapy to other therapies were extracted and reported. Results were labelled as "mixed" if the chronicity of pain or follow-up time was unspecified. Effects were pooled by follow-up period into immediate (up to 24 hours), short-term (1 day to 6 weeks), and long-term (≥ 6 weeks). 2 To assess the extent of citation overlap among the primary RCTs included in the reviews, a citation matrix was constructed. The Corrected Covered Area (CCA) index was calculated using the formula: 40 where N is the total count of primary RCTs in the included reviews (including double-counting), r is the number of unique publications, and c is the number of reviews. Overlap was classified as "slight" (0%-5%), "moderate" (6%-10%), "high" (11%-15%), or "very high" (above 15%). 67 Reviews with RCTs entirely included in more recent reviews were excluded. The extracted data was visually represented using bubble maps created on the Canva platform. The bubbles depict the effects of unimodal manual therapy across various follow-up duration: Bubble size: Represents the number of reviews for a specific comparison group. Bubble colour: Indicates the type of manual therapy (manipulation and/or mobilization). X-axis: Categorizes outcomes as "favours comparison," "no significant difference," "mixed effect," and "favours spinal manual therapy (SMT)". Y-axis: Categorizes follow-up periods as "immediate," "short," "long," or "not specified." Results Our search yielded 4,473 citations. After removing 2,074 duplicates, we reviewed the titles and abstracts of 2,399 citations, selecting 168 articles for full-text assessments. Ultimately, 38 reviews 2,7,8,17-20,22,26,27,30,31,34,35,41,42,47,51-53,55-57,61,66,70,71,73-75,77,80,82,84-86,89,90 (including 325 RCTs) met our inclusion criteria. After excluding reviews with 100% overlapping RCTs, we included 16 reviews 7,17,18,35,41,47,55,61,66,71,73,75,82,84,86,89 in the final analysis. The detailed selection process is depicted in the PRISMA flowchart (Fig. 1 ) . An exhaustive list of excluded reviews, along with reasons for exclusion, is provided in Additional file 3. Study characteristics Of the 16 included reviews, eight 17,18,35,55,66,73,75,82 were meta-analyses , and 6 had registered protocols. 35,55,66,71,75,82 Table 2 summarizes the main characteristics of the included reviews. Regarding the populations studied, eight reviews focused on patients with LBP, 17,41,47,61,66,73,75,89 seven only on NP, 18,35,55,71,82,84,86 and one included patients with both NP and LBP. 7 Various risk of bias assessment tools were used, including the Cochrane Risk of Bias, PEDro scale, and JADAD scale. Table 3 details the AMSTAR 2 ratings, one review was rated as high quality, 73 three moderate, 35,71,75 three low, 41,47,82 and nine critically low. 7,17,18,55,61,66,84,86,89 . Approximately 56%of the included reviews did not register their protocol or justify their deviations from the original protocols. None explained their selection of study designs. Over half did not provide justifications for excluding studies. Only one review 73 reported funding sources. Additionally, 44% did not account for risk of bias in their interpretation of findings, and 38% did not explain heterogeneity in results. Table 4 details the risk of bias as evaluated by the ROBIS tool. For phase 1 (assessing relevance), all reviews demonstrated low risk. In phase 2, 88% of reviews had low risk for study eligibility criteria, 94% for identification and selection, 81% for data collection and study appraisal, and 75% for synthesis and findings. In phase 3 (risk of bias in the review), 81% of reviews had low risk. Table 5 details the reporting quality using the PRISMA checklist. Generally, there were deficiencies in the reporting process. Few reviews provided adequate information in the abstract (18.8% compliance). Only two reviews 35,73 comprehensively reported information sources (12.5%), and six 35,66,73,75,84,86 search strategies for all databases (37.5%). Only one review 73 adequately discussed managing missing data (6.3%). Most items on data synthesis were poorly reported, including handling missing data (25%), exploring heterogeneity (62.5%), and conducting sensitivity analyses (43.8%). More than half did not assess confidence in the evidence (50%). Less than half provided lists of excluded references with reasons (43.8%). More than half reported risk of bias (56.3%), heterogeneity sources (56.3%), and evidence quality (56.3%). One-third conducted sensitivity analyses (37.5%). Over a third registered their protocols (43.8%), provided the protocol before conducting the review (43.8%), or described deviations from the original protocol (12.6%). Over a third reported sources of financial or non-financial support (43.8%). Half reported competing interests (56.3%). None provided complete data, codes, or other materials (0%). Neck pain Six included reviews focused on manipulation in patients with NP.=, 7,18,35,71,82,86 five on mobilisation, 7,18,35,71,84 and three on manipulation/mobilisation. 7,55,86 Detailed comparisons are illustrated in bubble maps (Fig. 2) and Additional file 4. Manipulation Acute NP : One review 7 did not find any significant benefit of manipulation over no treatment for immediate and short-term pain relief, with no evaluations on functional outcomes. Chronic NP : Three included reviews 18,35,82 examined immediate pain relief, with six out of seven comparisons showing no significant advantage of manipulation over no treatment, placebo, medication, kinesio-taping, or low-voltage electrical acupuncture, except one showing superiority over placebo. For short-term pain, four reviews 7,18,71,82 provided five comparisons. Three showed no significant difference between manipulation and placebo or kinesio-taping. One found manipulation superior to sham treatment, while another was inferior to high-tech exercises (cardiovascular, isotonic, and isokinetic exercises). In long-term pain outcomes, three reviews 7,35,86 presented nine comparisons. Seven showed no significant advantage of manipulation over high-tech exercises, medication, or acupuncture. One found manipulation superior to medication, while another found it inferior to acupuncture. For function, two reviews 18,35 found no immediate significant differences, with one indicating manipulation was inferior to kinesio-taping. Regarding short-term function, two reviews 18,71 showed favouring manipulation over sham treatment, with no difference against kinesio-taping. For long-term function, two reviews 35,86 indicated that manipulation was not significantly better than medication or acupuncture, with one showing inferior results against acupuncture. Mixed chronicity NP : One review 7 found manipulation inferior to physiotherapy for immediate pain relief, while another 35 showed no significant short-term difference compared to low-level laser therapy. For the long term, two reviews 7,35 indicated that manipulation was superior to exercise therapy in one comparison but inferior to physiotherapy. No reviews assessed the effect of manipulation on function in this context. Mobilisation Acute NP : No reviews assessed mobilisation effects on pain or function in acute NP. Chronic NP : Two reviews 18,35 found no immediate pain relief advantage of mobilisation over no treatment or therapeutic ultrasound. For short-term pain effects, two reviews 18,71 indicated mobilisation was superior to sham treatment and neurodynamic exercises. One review 71 reported improved short-term function with mobilisation over sham treatment. Comprehensive assessments of short- and long-term effects on pain and function are lacking. Mixed chronicity NP : Two reviews 35,84 with four comparisons investigated immediate effects of mobilisation on pain reduction. Two comparisons showed no superiority of mobilisation over sham mobilisation or massage, one indicated mobilisation was superior to no treatment, and one showed placebo mobilisation was superior to mobilisation. No reviews were identified for the short-term effects of mobilisation on pain and function. For long-term pain outcomes, two reviews 7,35 provided seven comparisons, with five showing mobilisation more effective than physiotherapy or general medical care. However, two comparisons indicated no significant difference between mobilisation and general medical care or acupuncture. For function, one review 35 found no significant immediate difference between mobilisation and massage and no significant long-term difference between mobilisation and acupuncture. Manipulation/mobilisation Acute NP : No reviews reported on the effects of manipulation/mobilisation on pain or function. Chronic NP : No reviews summarized the effects on pain. Additionally, there are no reviews assessing their impact on function in the immediate or short term. For long-term function, one review 7 found manipulation/mobilisation superior to physiotherapy and general medical care in four out of five comparisons, while one showed no significant difference against physiotherapy. A meta-analysis 55 also found manipulation/mobilisation superior to physiotherapy for improving function, though follow-up duration was unspecified. Low back pain Six included reviews focused on manipulation, 7,17,41,66,75,89 five on mobilisation, 7,17,47,61,89 and three on manipulation/mobilisation. 7,17,73 Detailed findings are illustrated in a bubble map (Fig. 3) and Additional file 4. Manipulation Acute LBP : One review 89 found no significant immediate difference in pain reduction between manipulation and sham treatment. Short-term effects from two reviews 66,89 with six comparisons showed no significant difference between manipulation and sham, multimodal treatments (shortwave diathermy, therapeutic ultrasound, and exercises), or non-steroidal anti-inflammatory drugs (NSAIDs) on pain reduction. Long-term effects from two reviews 41,89 with three comparisons found no significant differences compared to intensive exercise programs (strengthening and endurance exercises) or general medical care in reducing pain, except one comparison showing manipulation superior to sham manipulation. For function, no immediate effects were evaluated. Two reviews 66,89 found no significant differences between manipulation and sham manipulation, enhanced care, McKenzie exercises, or booklet. One review with five comparisons found no significant differences on function between manipulation and various treatments. 89 Chronic LBP : One review 17 encompassing two comparisons found no immediate pain improvement differences. Two reviews 41,89 significant short-term pain reduction compared to sham manipulation, NSAIDs, or acupuncture. Long-term effects showed manipulation more effective than sham manipulation. 41 For function, one review 17 found no immediate significant differences compared to minimal conservative medical care. Two reviews 41,89 showed significant short-term functional improvements compared to sham manipulation, NSAIDs, or acupuncture, while one review 17 found no significant functional difference against minimal conservative medical care. For long-term effects, one review 41 found manipulation to be more effective than sham manipulation in improving function. Mixed chronicity LBP : Two reviews 7,89 showed mixed immediate pain results. One review 89 indicated superiority over placebo massage, while the other 7 found no significant difference compared to physiotherapy. For short-term pain effects, two reviews 75,89 with eight comparisons revealed that six found manipulation was significantly more effective than sham manipulation, placebo treatment, placebo massage, chemonucleolysis, or a back-school education program. However, one comparison showed no significant short-term difference on pain between manipulation and McKenzie exercises, while another review indicated inferiority of manipulation against the back-school education program. In terms of long-term effect in pain, two reviews 7,89 with six comparisons found no significant differences between manipulation and McKenzie exercises, physiotherapy, or chemonucleolysis, although one review 89 found manipulation superior to chemonucleolysis. For function, one review 7 indicated no significant immediate differences between manipulation and physiotherapy in a cohort of patients with diverse LBP chronicity. For the short-term on function, one review 89 with three comparisons reported significant effects of manipulation over chemonucleolysis or the back school program, while one comparison highlighted that the back school program is more effective than manipulation. For the long-term effects on function, two reviews 7,89 reported no significant differences between manipulation and physiotherapy or chemonucleolysis. Mobilisation Acute LBP: One review 47 found no significant pain reduction difference between mobilisation and sham mobilisation. For short-term functional outcomes, one review 89 indicated mobilisation superior to flexion exercises, while another 47 found no better effect over sham mobilisation for mixed follow-ups. Chronic LBP : One review 17 encompassing three comparisons found no significant immediate pain reduction effects compared to active trunk exercises, stabilizing training, or minimal conservative care. The same review indicated no significant long-term differences in pain outcomes. For function, one review 17 with two comparisons showed no significant immediate differences between mobilization and active trunk exercises or stabilizing training, while one demonstrated the superiority of mobilization over minimal conservative care Long-term outcomes from two reviews 7,17 with eight comparisons indicated mobilisation was favoured over no treatment or physical agents like hot packs, TENS, or therapeutic ultrasound in two comparisons. Three comparisons showed no significant difference between mobilisation and active trunk exercises or minimal conservative care, while three indicated that mobilisation was inferior to high-tech or stabilizing exercises. Mixed chronicity LBP : One review 61 found a significant short-term effect of mobilisation on the improvements of pain and function compared to flexion exercises in the prone position. Manipulation/mobilisation Acute LBP : No reviews reported the immediate effects on pain or function. One review 73 found no short-term pain reduction advantage over sham treatments, physiotherapy, or exercises, while one comparison favoured manipulation/mobilisation over an internet-based educational booklet. For long-term pain outcomes, one comparison favoured manipulation/mobilisation over the educational booklet, while two showed no difference against physiotherapy or exercises. 73 For function, no significant differences were found in short- or long-term outcomes. Chronic LBP : One review 17 found no immediate differences in pain and function compared to general or motor control exercises. No reviews assessed the short-term effects on pain or function in individuals with chronic LBP. For long-term effects, one review 17 found no significant differences in pain reduction and functional improvements compared to general or motor control exercises. Mixed chronicity LBP : One review 7 found no significant short- or long-term differences in pain or function compared to soft tissue treatments or educational back school programs. The CCA values for NP and LBP were calculated, with NP-related reviews at 6.3% and LBP-related reviews at 19%. Detailed citation matrices are in Additional file 5. Discussion This umbrella review offers insights into the effectiveness of unimodal manual therapy, including manipulation, mobilisation, and manipulation/mobilization, for managing spinal pain. Mixed findings emerged, with generally not demonstrating a significant advantage over sham, placebo, or other treatments for NP and LBP across immediate, short-, and long-term pain and function outcomes. Mobilisation showed some short-term benefits in reducing NP and improving function, but its long-term effects on pain remain unclear due to insufficient evaluation. The evidence for manipulation/mobilization is limited, with no clear benefits observed for pain intensity or function in either the short- or long-term. These results highlight the need for further high-quality reviews to better understand the specific effects of manual therapy, particularly on long-term outcomes. The lack of consistent, clinically meaningful benefits suggests a limited role for unimodal manual therapy in spinal pain management, necessitating careful consideration by clinicians and policymakers when developing evidence-based guidelines. SMT, including manipulation and mobilisation, is commonly used for NP and LBP. 11 However, its effectiveness can vary due to several factors. Benefits may stem from non-specific effects like placebo responses 15 , the therapeutic relationship, and patient expectations rather than specific physiological changes. 24,45 Misdiagnosis, inappropriate application, and variability in technique and practitioner skill can also hinder effectiveness, further complicated by a lack of standardization in practice. 23,38,83 Pain is a complex experience influenced by biological, psychological, and social factors 32 , which manual therapy may not adequately address 29 . While manual therapy may provide short-term relief, it often does not address long-term issues or underlying causes, necessitating a comprehensive treatment plan for sustained benefits 16,60 . Despite these limitations, SMT can still play a valuable role in a multimodal approach for some patients by reducing spinal stiffness and activating paraspinal muscles, facilitating exercise training and rehabilitation 4 . This underscores the importance of thorough assessment by healthcare professionals to determine its appropriateness for individual conditions. 48 The quality of the included reviews reveals significant shortcomings, raising concerns about the reliability and validity of their findings. Of the 16 included reviews, 7,17,18,35,41,47,55,61,66,71,73,75,82,84,86,89 only one was rated as high quality, 73 one as moderate quality, 71 three as low quality, 41,47,82 and the majority as critically low quality. 7,17,18,35,55,61,66,75,82,84,86,89 This indicates a pressing need for methodological improvements in systematic reviews and meta-analyses. This aligns with previous umbrella reviews on other conditions, highlighting the generally low methodological quality of systematic reviews on manual therapy interventions. 3,28 Notably, over half of the reviews failed to register their protocols before conducting the review, and none adequately justified deviations from their initial protocols, undermining transparency and reproducibility. 54,65 . Evidence from related guidelines supports these concerns. 1,50 Koensgen et al. 50 found that almost all (92.5%) of the non-Cochrane systematic reviews differed from their published protocols, with half having a major difference. However, the final review publications only reported 10% of these differences, and only 7% provided an explanation. 50 Allers et al. 1 noted that while the number of published systematic review protocols increased, many reviews remained unpublished after several years, suggesting widespread issues with protocol registration and transparency. Furthermore, the lack of comprehensive reporting on excluded studies in nearly half of the reviews highlights critical gaps in the evaluation process. 62 Incomplete reporting of study exclusions and inadequate risk of bias assessments can lead to biased conclusions and limit confidence in the review findings. 58 The reporting quality, assessed by the PRISMA checklist, was poor, with only 63.7% of included studies adhering to the 27-item checklist, consistent with a prior overview of a random 200 reviews published in rehabilitation journals. 44 Generally, poor reporting in systematic reviews is a well-documented problem, with studies finding that less than half fully adhere to PRISMA guidelines. 64 These deficiencies compromise the integrity of the reviews and hinder clinicians and researchers from drawing meaningful conclusions from the existing literature. There is an urgent need for future reviews to adhere more closely to PRISMA guidelines and improve methodological rigor to enhance the overall quality of evidence for the effectiveness of manual therapy for spinal pain. Strengths and limitations This umbrella review's strength lies in its comprehensive and methodologically rigorous evaluation of unimodal manual therapy for spinal pain. It systematically searched seven major databases and employed a robust selection process, ensuring broad inclusion of relevant studies. The use of multiple quality assessment tools, including AMSTAR 2, ROBIS, and the PRISMA 2020 checklist, added thoroughness and credibility to the evaluation. The meticulous data extraction and synthesis processes, categorizing findings by treatment technique, outcome measures, and follow-up duration, provided a clear understanding of the effects of unimodal manual therapy. The inclusion of a citation overlap analysis using the CCA index further strengthened the review by highlighting primary study overlap, ensuring conclusions are based on a distinct and comprehensive body of evidence. This level of detail and rigor supports the validity of the review's conclusions and offers valuable insights for clinicians, patients, and policymakers in making informed decisions about manual therapy for spinal conditions. However, this umbrella review has limitations. It included only systematic reviews and meta-analyses published in English, potentially limiting the generalizability of the results. The exclusion of non-peer-reviewed studies and those not in English might have omitted valuable data. The reliance on published reviews, which often report significant or positive results, could introduce publication bias. The variation in quality among included reviews, with many rated as critically low or low quality, could affect the reliability of the synthesized evidence. The review's reliance on secondary data means it depends on the quality and comprehensiveness of primary sources, carrying over any limitations or biases. Additionally, the review did not account for potential heterogeneity in study populations, interventions, and outcomes, affecting generalizability and applicability. Future research should address these limitations by improving methodological rigor and focusing on high-quality trials. Implications for clinical practice The mixed results from the umbrella review suggest that unimodal SMT can be as effective as other interventions for managing spinal pain, primarily targeting the physical component and potentially overlooking psychological or social contributors. 29 Manual therapy can be a viable option within a broader, multimodal treatment plan, as recommended by current clinical guidelines. 16,60 Clinicians should be aware of the variability in the effectiveness of different manual therapy techniques. While some may offer short-term benefits, their long-term efficacy remains unclear. Treatment plans should be tailored to individual patient needs, considering factors such as the type and chronicity of spinal pain, patient preferences, and contraindications. This personalized approach can maximize therapeutic benefits while minimizing potential risks. The review underscores the importance of ongoing professional development and training for clinicians providing manual therapy. Standardized protocols and well-trained healthcare providers can improve the consistency and effectiveness of interventions. Clinicians should stay informed about the latest research and guidelines to integrate new evidence into their practice, improving care quality for patients with spinal pain. Implication for future studies The findings highlight several implications for future systematic reviews and meta-analyses in manual therapy for spinal pain. There is a need for higher-quality reviews adhering strictly to established methodological guidelines like AMSTAR 2, ROBIS, and the PRISMA checklist. Future reviews should ensure comprehensive literature searches, transparent reporting of study selection processes, and thorough risk of bias assessments. Registering protocols in advance and justifying deviations are crucial for enhancing transparency and reproducibility. Future reviews should address heterogeneity observed in included studies, standardizing definitions and classifications of interventions, outcomes, and patient populations. Detailed reporting on study characteristics will help clarify contexts in which manual therapy is most effective. More rigorous primary research is needed to fill gaps in existing literature. Future RCTs should explore long-term impacts on pain and function. By addressing these gaps and improving evidence quality, future reviews can provide more definitive guidance for clinicians, patients, and policymakers on manual therapy for spinal pain. Conclusion This umbrella review highlights the mixed effectiveness of unimodal manual therapy for managing spinal pain, suggesting it can be as effective as other interventions but not consistently superior. It underscores the need for higher-quality research to understand specific contexts where manual therapy is most effective. Future studies should focus on improving methodological rigor, standardizing intervention protocols, and exploring long-term outcomes to provide more definitive clinical guidance. While unimodal manual therapy remains valuable in managing spinal pain, clinicians should integrate it within a broader, evidence-based treatment plan tailored to individual patient needs, optimizing patient outcomes and healthcare resource use. Declarations Clinical trial number: not applicable . Acknowledgements We sincerely acknowledge the health librarian who helped validating the search strategies. Author contributions LYH, LCHM, NKS, YTL, YWY, and FAZ conceived and designed the study. LYH, LCHM, NKS, YTL, YWY, and FAZ had full access to all data in the study and take responsibility for the integrity of the data. FAZ did the literature searches. LYH, LCHM, NKS, YTL, YWY, and FAZ interpreted the data and wrote the first draft of the manuscript. LYH, LCHM, NKS, YTL, YWY, SA, OE, AYLW, and FAZ wrote the final draft of the manuscript. All authors contributed to critical revision of the report for important intellectual content. LYH, LCHM, NKS, YTL, and YWY contributed equally to this paper. FAZ is the submitting and corresponding author and the guarantor. Data availability All the data extracted from the included studies are included in the tables, appendices, and figures. Ethics approval and consent to participate The study does not require ethical approval.. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Systematic review registration The protocol was registered in PROSPERO database with a registration number: CRD42023469017. 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Eligibility criteria Inclusion criteria Exclusion criteria Population Adults (≥ 18 and < 65 years old) Pain in the following spinal regions (cervical, thoracic, lumbar, sacral or coccygeal pain) Acute pain (Less than 12 weeks), Chronic pain (More than 12 weeks) Any nationality or gender < 18 years old or ≥ 65 years old Temporomandibular joint (TMJ) pain Cervicogenic headache Cervicobrachial pain Cancer Asymptomatic disorders (e.g. scoliosis, kyphosis, degeneration, upper cross syndrome) Pregnancy-related spinal pain Intervention Manipulation, mobilization, or manual traction Unimodal intervention group Techniques conducted by professional clinician (e.g. physiotherapist, chiropractor, osteopath) Multimodal intervention group (e.g. manipulation with exercise vs usual care) Manual therapy not included in our criteria (e.g. Tuina, soft tissue massage, myofascial release, mechanical traction, trigger point therapy, bone setting, stretching, lymph drainage, cranial sacral therapy, occipital release and stabilization exercise) Techniques conducted by non- professionals Comparison Sham therapy, placebo or none Usual care Other forms of therapies Outcome Pain Function Timing Treatment period of any duration Follow-up of any duration Design Systematic reviews Meta-analysis (Includes at least 2 RCTs) RCTs, Controlled clinical trial (CCT), Umbrella reviews Observational studies, Pilot studies, Doctoral projects, Thesis Others English language Non-English language Adverse effects reporting studies without comparison Table 2 To 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table2.docx Table3.docx Table4.docx Table5.docx Additionalfile1.docx Additionalfile2.docx Additionalfile3.docx Additionalfile4.docx Additionalfile5.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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productivity, manifesting as lower back, neck, and thoracic pain.\u003csup\u003e13,49\u003c/sup\u003e Lower back pain (LBP) is a leading cause of disability, prevalent in central and eastern Europe and Australia, with lower rates in East Asia.\u003csup\u003e14\u003c/sup\u003e Its incidence increases with age, and sacral pain complicates chronic LBP cases.\u003csup\u003e12,14\u003c/sup\u003e Neck pain (NP) is also widespread, with a global prevalence rate of 2,696.5 per 100,000 in 2019.\u003csup\u003e79\u003c/sup\u003e In the USA, NP incidence ranges from 10.4% to 21.3% annually.\u003csup\u003e9\u003c/sup\u003e Thoracic pain, though less common, affects children, adolescents, and older populations.\u003csup\u003e6,46\u003c/sup\u003e \u003c/p\u003e\n\u003cp\u003eEffective management is crucial, with guidelines recommending non-pharmacological interventions such as manual therapy, which defined as hands-on techniques applied to joints and vertebrae.\u003csup\u003e16,81\u003c/sup\u003e Mobilization and manipulation are key components, involving passive joint movement and fast thrusts, respectively.\u003csup\u003e72,76\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWhile numerous systematic reviews and meta-analyses have evaluated manual therapy's effectiveness for spinal pain, their findings have been heterogeneous,\u003csup\u003e21,59,72\u003c/sup\u003e making it challenging for clinicians and policymakers to draw definitive conclusions. This variation in reported outcomes may be attributed to differences in methodological quality, inclusion criteria, intervention definitions, and outcome measures across reviews.\u003csup\u003e10\u003c/sup\u003e Additionally, the isolated effects of manual therapy are often difficult to determine, as it is frequently delivered as part of a multimodal treatment approach.\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSystematic reviews synthesize research findings to inform clinical practice based on evidence and the risk of bias.\u003csup\u003e87\u003c/sup\u003e Previous overviews of systematic reviews on the effectiveness of manual therapy might not reflect current evidence due to evolving methodologies and new studies.\u003csup\u003e25,69\u003c/sup\u003e There is a gap in reviews focusing solely on manual therapy as a treatment for spinal pain, often included as part of multimodal strategies.\u003csup\u003e5,16\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure review integrity, contemporary tools like Assessment of Multiple Systematic Reviews II (AMSTAR 2),\u003csup\u003e78\u003c/sup\u003e Risk Of Bias In Systematic reviews (ROBIS)\u003csup\u003e88\u003c/sup\u003e, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist 2020\u003csup\u003e63\u003c/sup\u003e have been developed for assessments and reporting. This umbrella review aims to synthesize and critically evaluate the existing evidence from systematic reviews and meta-analyses focusing specifically on unimodal manual therapy interventions for spinal pain.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis umbrella review protocol was registered with PROSPERO. Deviations are presented in\u0026nbsp;Additional file 1, and the review followed the PRIOR checklist.\u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSearch strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive search was conducted across seven databases, including Medline, CINAHL, EMBASE, Cochrane, SCOPUS, Web of Science, and Epistemoniko. Additionally, we searched the PROSPERO registry of systematic reviews. The search encompassed records from the inception to Mach 10, 2024. The search aimed to identify reviews on unimodal manual therapy for spinal conditions, developed with a health librarian. Details are in\u0026nbsp;Additional file 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study included systematic reviews and meta-analyses based on PICOS (Population, Intervention, Comparison, Outcome, and Study design) framework. Table 1 summarises the eligibility criteria.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e: Adults aged 18-65 with spinal pain, excluding non-musculoskeletal or asymptomatic conditions. Both acute/subacute (\u0026lt;12 weeks) and chronic (\u0026gt;12 weeks) spinal pain were included.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIntervention\u003c/em\u003e: Unimodal manual therapies, such as spinal mobilization and manipulation, administered by qualified clinicians.\u003csup\u003e43\u003c/sup\u003e Exclusions were made for techniques like soft tissue massage, trigger point therapy, and stabilization exercises.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eComparator\u003c/em\u003e: Any conservative treatments not involving manual therapy, including usual care, sham, placebo, or other non-manual approaches.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOutcome:\u003c/em\u003e Pain and/or functional limitation assessments using standardized scales like visual analogue scale, numerical pain rating scale,\u003csup\u003e39\u003c/sup\u003e Neck Disability Index, and Oswestry Disability Index.\u003csup\u003e36\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy design\u003c/em\u003e: English-published reviews incorporating randomized controlled trials (RCTs), as which are the benchmark for assessing healthcare interventions.\u003csup\u003e37\u003c/sup\u003e Non-RCTs and non-peer-reviewed reviews were excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eArticles were imported into EndNote X20 software. Two independent reviewers (LYH, LCHM, NKS, YTL, and YWY) applied the eligibility criteria in two stages: 1) screening titles and abstracts, and 2) reviewing full texts. Any disagreements were resolved through discussion among the reviewers and the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData extraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA pair of reviewers (XXX) independently extracted data using a standardized template, resolving discrepancies through discussion with the corresponding author. A pilot extraction in 5% of studies ensured consistency before full extraction. We included the most recent reviews when updates were available. Data focused on review information rather than primary RCTs, following Cochrane recommendations for overviews of reviews.\u003csup\u003e68\u003c/sup\u003e Collected data included author, publication year, population characteristics, number of studies, intervention details, outcome measures, and main findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodological quality assessments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA pair of trained reviewers (LYH, LCHM, NKS, YTL,\u0026nbsp;and\u0026nbsp;YWY) independently assessed the methodological quality of the included reviews using the AMSTAR 2 tool.\u003csup\u003e78\u003c/sup\u003e The tool has 16 items, seven (2, 4, 7, 9, 11, 13, 15) of which are critical for assessing methodological soundness. Each item was rated as \u0026quot;Yes,\u0026quot; \u0026quot;Partial Yes,\u0026quot; or \u0026quot;No.\u0026quot;\u003csup\u003e78\u003c/sup\u003e Items 11, 12, and 15 were not applicable to reviews. An overall confidence rating was assigned to each review, categorized as \u0026quot;High,\u0026quot; \u0026quot;Moderate,\u0026quot; \u0026quot;Low,\u0026quot; or \u0026quot;Critically Low,\u0026quot; based on the presence of major flaws in critical and non-critical items.\u003csup\u003e78\u003c/sup\u003e Disagreements were resolved through in-depth discussions\u0026nbsp;with the corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk of bias assessments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA pair of trained reviewers (LYH, LCHM, NKS, YTL,\u0026nbsp;and\u0026nbsp;YWY) independently assessed\u0026nbsp;the risk of bias in the included reviews using the ROBIS tool,\u003csup\u003e88\u003c/sup\u003e which is structured into three phases: (1) assessing relevance, (2) identifying concerns about the review process, and (3) risk of bias judgment. Phase 2 includes 21 signaling items across four domains: study eligibility criteria, identification and selection of studies, data collection and study appraisal, and synthesis and findings. Responses to signaling items are\u0026nbsp;\u0026quot;yes,\u0026quot;\u0026nbsp;\u0026quot;probably yes,\u0026quot;\u0026nbsp;\u0026quot;probably no,\u0026quot;\u0026nbsp;\u0026quot;no,\u0026quot;\u0026nbsp;or\u0026nbsp;\u0026quot;no information.\u0026quot;\u0026nbsp;Phase 3 uses three signaling items to determine the overall risk of bias, rated as\u0026nbsp;\u0026quot;low,\u0026quot;\u0026nbsp;\u0026quot;high,\u0026quot;\u0026nbsp;or\u0026nbsp;\u0026quot;unclear.\u0026quot;\u0026nbsp;Discrepancies were resolved through discussions with the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReporting quality assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA pair of trained reviewers (LYH, LCHM, NKS, YTL,\u0026nbsp;and\u0026nbsp;YWY) independently assessed the reporting quality of the included reviews using the 27-item PRISMA checklist 2020.\u003csup\u003e63\u003c/sup\u003e Each item was rated as\u0026nbsp;\u0026quot;yes,\u0026quot;\u0026nbsp;\u0026quot;partially yes,\u0026quot;\u0026nbsp;or\u0026nbsp;\u0026quot;no,\u0026quot;\u0026nbsp;indicating complete, partial, or no reporting. Discrepancies were resolved through team discussions with the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA PRISMA flowchart\u003csup\u003e54\u003c/sup\u003e was created to depict the study selection process. The characteristics and results were presented using graphs and tables. Data were categorized by the type of manual therapy and the type of spinal pain. Effect sizes and p-values from the meta-analyses comparing unimodal manual therapy to other therapies were extracted and reported. Results were labelled as \u0026quot;mixed\u0026quot; if the chronicity of pain or follow-up time was unspecified. Effects were pooled by follow-up period into immediate (up to 24 hours), short-term (1 day to 6 weeks), and long-term (\u0026ge; 6 weeks).\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eTo assess the extent of citation overlap among the primary RCTs included in the reviews, a citation matrix was constructed. The Corrected Covered Area (CCA) index was calculated using the formula:\u003csup\u003e40\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/p\u003e\n\u003cp\u003ewhere \u003cem\u003eN\u003c/em\u003e is the total count of primary RCTs in the included reviews (including double-counting), \u003cem\u003er\u003c/em\u003e is the number of unique publications, and \u003cem\u003ec\u003c/em\u003e is the number of reviews. Overlap was classified as \u0026quot;slight\u0026quot; (0%-5%), \u0026quot;moderate\u0026quot; (6%-10%), \u0026quot;high\u0026quot; (11%-15%), or \u0026quot;very high\u0026quot; (above 15%).\u003csup\u003e67\u003c/sup\u003e Reviews with RCTs entirely included in more recent reviews were excluded. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe extracted data was visually represented using bubble maps created on the Canva platform. The bubbles depict the effects of unimodal manual therapy across various follow-up duration:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eBubble size: Represents the number of reviews for a specific comparison group.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBubble colour: Indicates the type of manual therapy (manipulation and/or mobilization). \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eX-axis: Categorizes outcomes as \u0026quot;favours comparison,\u0026quot; \u0026quot;no significant difference,\u0026quot; \u0026quot;mixed effect,\u0026quot; and \u0026quot;favours spinal manual therapy (SMT)\u0026quot;.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eY-axis: Categorizes follow-up periods as \u0026quot;immediate,\u0026quot; \u0026quot;short,\u0026quot; \u0026quot;long,\u0026quot; or \u0026quot;not specified.\u0026quot;\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Results","content":"\u003cp\u003eOur search yielded 4,473 citations. After removing 2,074 duplicates, we reviewed the titles and abstracts of 2,399 citations, selecting 168 articles for full-text assessments. Ultimately, 38 reviews\u003csup\u003e2,7,8,17-20,22,26,27,30,31,34,35,41,42,47,51-53,55-57,61,66,70,71,73-75,77,80,82,84-86,89,90\u003c/sup\u003e (including 325 RCTs) met our inclusion criteria. After excluding reviews with 100% overlapping RCTs, we included 16 reviews\u003csup\u003e7,17,18,35,41,47,55,61,66,71,73,75,82,84,86,89\u003c/sup\u003e in the final analysis. The detailed selection process is depicted in the PRISMA flowchart (Fig. 1\u003cstrong\u003e)\u003c/strong\u003e. An exhaustive list of excluded reviews, along with reasons for exclusion, is provided in\u0026nbsp;Additional file 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 16 included reviews, eight\u003csup\u003e17,18,35,55,66,73,75,82\u003c/sup\u003e were meta-analyses , and 6 had registered protocols.\u003csup\u003e35,55,66,71,75,82\u003c/sup\u003e Table 2 summarizes the main characteristics of the included reviews. Regarding the populations studied, eight reviews focused on patients with LBP,\u003csup\u003e17,41,47,61,66,73,75,89\u003c/sup\u003e seven only on NP,\u003csup\u003e18,35,55,71,82,84,86\u003c/sup\u003e and one included patients with both NP and LBP.\u003csup\u003e7\u003c/sup\u003e Various risk of bias assessment tools were used, including the Cochrane Risk of Bias, PEDro scale, and JADAD scale.\u003c/p\u003e\n\u003cp\u003eTable 3 details the AMSTAR 2 ratings, one review was rated as high quality,\u003csup\u003e73\u003c/sup\u003e three moderate,\u003csup\u003e35,71,75\u003c/sup\u003e three low,\u003csup\u003e41,47,82\u003c/sup\u003e and nine critically low.\u003csup\u003e7,17,18,55,61,66,84,86,89\u003c/sup\u003e. Approximately 56%of the included reviews did not register their protocol or justify their deviations from the original protocols. None explained their selection of study designs. Over half did not provide justifications for excluding studies. Only one review\u003csup\u003e73\u003c/sup\u003e reported funding sources. Additionally, 44% did not account for risk of bias in their interpretation of findings, and 38% did not explain heterogeneity in results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4 details the risk of bias as evaluated by the ROBIS tool. For phase 1 (assessing relevance), all reviews demonstrated low risk. In phase 2, 88% of reviews had low risk for study eligibility criteria, 94% for identification and selection, 81% for data collection and study appraisal, and 75% for synthesis and findings. In phase 3 (risk of bias in the review), 81% of reviews had low risk.\u003c/p\u003e\n\u003cp\u003eTable 5 details the reporting quality using the PRISMA checklist. Generally, there were deficiencies in the reporting process. Few reviews provided adequate information in the abstract (18.8% compliance). Only two reviews\u003csup\u003e35,73\u003c/sup\u003e comprehensively reported information sources (12.5%), and six\u003csup\u003e35,66,73,75,84,86\u003c/sup\u003e search strategies for all databases (37.5%). Only one review\u003csup\u003e73\u003c/sup\u003e adequately discussed managing missing data (6.3%). Most items on data synthesis were poorly reported, including handling missing data (25%), exploring heterogeneity (62.5%), and conducting sensitivity analyses (43.8%). More than half did not assess confidence in the evidence (50%). Less than half provided lists of excluded references with reasons (43.8%). More than half reported risk of bias (56.3%), heterogeneity sources (56.3%), and evidence quality (56.3%). One-third conducted sensitivity analyses (37.5%). Over a third registered their protocols (43.8%), provided the protocol before conducting the review (43.8%), or described deviations from the original protocol (12.6%). Over a third reported sources of financial or non-financial support (43.8%). Half reported competing interests (56.3%). None provided complete data, codes, or other materials (0%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNeck pain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSix included reviews focused on manipulation in patients with NP.=,\u003csup\u003e7,18,35,71,82,86\u003c/sup\u003e five on mobilisation,\u003csup\u003e7,18,35,71,84\u003c/sup\u003e and three on manipulation/mobilisation.\u003csup\u003e7,55,86\u003c/sup\u003e Detailed comparisons are illustrated in bubble maps (Fig. 2) and Additional file 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManipulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eAcute NP\u003c/u\u003e\u003c/em\u003e: One review\u003csup\u003e7\u003c/sup\u003e did not find any significant benefit of manipulation over no treatment for immediate and short-term pain relief, with no evaluations on functional outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eChronic NP\u003c/u\u003e\u003c/em\u003e: Three included reviews\u003csup\u003e18,35,82\u003c/sup\u003e examined immediate pain relief, with six out of seven comparisons showing no significant advantage of manipulation over no treatment, placebo, medication, kinesio-taping, or low-voltage electrical acupuncture, except one showing superiority over placebo. For short-term pain, four reviews\u003csup\u003e7,18,71,82\u003c/sup\u003e provided five comparisons. Three showed no significant difference between manipulation and placebo or kinesio-taping. One found manipulation superior to sham treatment, while another was inferior to high-tech exercises (cardiovascular, isotonic, and isokinetic exercises). In long-term pain outcomes, three reviews\u003csup\u003e7,35,86\u003c/sup\u003e presented nine comparisons. Seven showed no significant advantage of manipulation over high-tech exercises, medication, or acupuncture. One found manipulation superior to medication, while another found it inferior to acupuncture.\u003c/p\u003e\n\u003cp\u003eFor function, two reviews\u003csup\u003e18,35\u003c/sup\u003e found no immediate significant differences, with one indicating manipulation was inferior to kinesio-taping. Regarding short-term function, two reviews\u003csup\u003e18,71\u003c/sup\u003e showed favouring manipulation over sham treatment, with no difference against kinesio-taping. For long-term function, two reviews\u003csup\u003e35,86\u003c/sup\u003e indicated that manipulation was not significantly better than medication or acupuncture, with one showing inferior results against acupuncture.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eMixed chronicity NP\u003c/u\u003e\u003c/em\u003e: One review\u003csup\u003e7\u003c/sup\u003e found manipulation inferior to physiotherapy for immediate pain relief, while another\u003csup\u003e35\u003c/sup\u003e showed no significant short-term difference compared to low-level laser therapy. For the long term, two reviews\u003csup\u003e7,35\u003c/sup\u003e indicated that manipulation was superior to exercise therapy in one comparison but inferior to physiotherapy.\u003c/p\u003e\n\u003cp\u003eNo reviews assessed the effect of manipulation on function in this context.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMobilisation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eAcute NP\u003c/u\u003e\u003c/em\u003e: No reviews assessed mobilisation effects on pain or function in acute NP.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eChronic NP\u003c/u\u003e\u003c/em\u003e: Two reviews\u003csup\u003e18,35\u003c/sup\u003e found no immediate pain relief advantage of mobilisation over no treatment or therapeutic ultrasound. For short-term pain effects, two reviews\u003csup\u003e18,71\u003c/sup\u003e indicated mobilisation was superior to sham treatment and neurodynamic exercises.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne review\u003csup\u003e71\u003c/sup\u003e reported improved short-term function with mobilisation over sham treatment. Comprehensive assessments of short- and long-term effects on pain and function are lacking.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eMixed chronicity NP\u003c/u\u003e\u003c/em\u003e: Two reviews\u003csup\u003e35,84\u003c/sup\u003e with four comparisons investigated immediate effects of mobilisation on pain reduction. Two comparisons showed no superiority of mobilisation over sham mobilisation or massage, one indicated mobilisation was superior to no treatment, and one showed placebo mobilisation was superior to mobilisation. No reviews were identified for the short-term effects of mobilisation on pain and function. For long-term pain outcomes, two reviews\u003csup\u003e7,35\u003c/sup\u003e provided seven comparisons, with five showing mobilisation more effective than physiotherapy or general medical care. However, two comparisons indicated no significant difference between mobilisation and general medical care or acupuncture.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor function, one review\u003csup\u003e35\u003c/sup\u003e found no significant immediate difference between mobilisation and massage and no significant long-term difference between mobilisation and acupuncture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManipulation/mobilisation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eAcute NP\u003c/u\u003e\u003c/em\u003e: No reviews reported on the effects of manipulation/mobilisation on pain or function.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eChronic NP\u003c/u\u003e\u003c/em\u003e: No reviews summarized the effects on pain. Additionally, there are no reviews assessing their impact on function in the immediate or short term. For long-term function, one review\u003csup\u003e7\u003c/sup\u003e found manipulation/mobilisation superior to physiotherapy and general medical care in four out of five comparisons, while one showed no significant difference against physiotherapy. A meta-analysis\u003csup\u003e55\u003c/sup\u003e also found manipulation/mobilisation superior to physiotherapy for improving function, though follow-up duration was unspecified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLow back pain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSix included reviews focused on manipulation,\u003csup\u003e7,17,41,66,75,89\u003c/sup\u003e five on mobilisation,\u003csup\u003e7,17,47,61,89\u003c/sup\u003e and three on manipulation/mobilisation.\u003csup\u003e7,17,73\u003c/sup\u003e Detailed findings are illustrated in a bubble map (Fig. 3) and Additional file 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManipulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eAcute LBP\u003c/u\u003e\u003c/em\u003e: One review\u003csup\u003e89\u003c/sup\u003e found no significant immediate difference in pain reduction between manipulation and sham treatment. Short-term effects from two reviews\u003csup\u003e66,89\u003c/sup\u003e with six comparisons showed no significant difference between manipulation and sham, multimodal treatments (shortwave diathermy, therapeutic ultrasound, and exercises), or non-steroidal anti-inflammatory drugs (NSAIDs) on pain reduction. Long-term effects from two reviews\u003csup\u003e41,89\u003c/sup\u003e with three comparisons found no significant differences compared to intensive exercise programs (strengthening and endurance exercises) or general medical care in reducing pain, except one comparison showing manipulation superior to sham manipulation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor function, no immediate effects were evaluated. Two reviews\u003csup\u003e66,89\u003c/sup\u003e found no significant differences between manipulation and sham manipulation, enhanced care, McKenzie exercises, or booklet. One review with five comparisons found no significant differences on function between manipulation and various treatments.\u003csup\u003e89\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eChronic LBP\u003c/u\u003e\u003c/em\u003e: One review\u003csup\u003e17\u003c/sup\u003e encompassing two comparisons found no immediate pain improvement differences. Two reviews\u003csup\u003e41,89\u003c/sup\u003e significant short-term pain reduction compared to sham manipulation, NSAIDs, or acupuncture. Long-term effects showed manipulation more effective than sham manipulation.\u003csup\u003e41\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eFor function, one review\u003csup\u003e17\u003c/sup\u003e found no immediate significant differences compared to minimal conservative medical care. Two reviews\u003csup\u003e41,89\u003c/sup\u003e showed significant short-term functional improvements compared to sham manipulation, NSAIDs, or acupuncture, while one review\u003csup\u003e17\u003c/sup\u003e found no significant functional difference against minimal conservative medical care. For long-term effects, one review\u003csup\u003e41\u003c/sup\u003e found manipulation to be more effective than sham manipulation in improving function.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eMixed chronicity LBP\u003c/u\u003e\u003c/em\u003e: Two reviews\u003csup\u003e7,89\u003c/sup\u003e showed mixed immediate pain results. One review\u003csup\u003e89\u003c/sup\u003e indicated superiority over placebo massage, while the other\u003csup\u003e7\u003c/sup\u003e found no significant difference compared to physiotherapy. For short-term pain effects, two reviews\u003csup\u003e75,89\u003c/sup\u003e with eight comparisons revealed that six found manipulation was significantly more effective than sham manipulation, placebo treatment, placebo massage, chemonucleolysis, or a back-school education program. However, one comparison showed no significant short-term difference on pain between manipulation and McKenzie exercises, while another review indicated inferiority of manipulation against the back-school education program. In terms of long-term effect in pain, two reviews\u003csup\u003e7,89\u003c/sup\u003e with six comparisons found no significant differences between manipulation and McKenzie exercises, physiotherapy, or chemonucleolysis, although one review\u003csup\u003e89\u003c/sup\u003e found manipulation superior to chemonucleolysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor function, one review\u003csup\u003e7\u003c/sup\u003e indicated no significant immediate differences between manipulation and physiotherapy in a cohort of patients with diverse LBP chronicity. For the short-term on function, one review\u003csup\u003e89\u003c/sup\u003e with three comparisons reported significant effects of manipulation over chemonucleolysis or the back school program, while one comparison highlighted that the back school program is more effective than manipulation. For the long-term effects on function, two reviews\u003csup\u003e7,89\u003c/sup\u003e reported no significant differences between manipulation and physiotherapy or chemonucleolysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMobilisation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eAcute LBP:\u0026nbsp;\u003c/u\u003e\u003c/em\u003eOne review\u003csup\u003e47\u003c/sup\u003e found no significant pain reduction difference between mobilisation and sham mobilisation. For short-term functional outcomes, one review\u003csup\u003e89\u003c/sup\u003e indicated mobilisation superior to flexion exercises, while another\u003csup\u003e47\u003c/sup\u003e found no better effect over sham mobilisation for mixed follow-ups.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eChronic LBP\u003c/u\u003e\u003c/em\u003e: One review\u003csup\u003e17\u003c/sup\u003e encompassing three comparisons found no significant immediate pain reduction effects compared to active trunk exercises, stabilizing training, or minimal conservative care. The same review indicated no significant long-term differences in pain outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor function, one review\u003csup\u003e17\u003c/sup\u003e with two comparisons showed no significant immediate differences between mobilization and active trunk exercises or stabilizing training, while one demonstrated the superiority of mobilization over minimal conservative care Long-term outcomes from two reviews\u003csup\u003e7,17\u003c/sup\u003e with eight comparisons indicated mobilisation was favoured over no treatment or physical agents like hot packs, TENS, or therapeutic ultrasound in two comparisons. Three comparisons showed no significant difference between mobilisation and active trunk exercises or minimal conservative care, while three indicated that mobilisation was inferior to high-tech or stabilizing exercises.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eMixed chronicity LBP\u003c/u\u003e\u003c/em\u003e: One review\u003csup\u003e61\u003c/sup\u003e found a significant short-term effect of mobilisation on the improvements of pain and function compared to flexion exercises in the prone position.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManipulation/mobilisation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eAcute LBP\u003c/u\u003e\u003c/em\u003e: No reviews reported the immediate effects on pain or function. One review\u003csup\u003e73\u003c/sup\u003e found no short-term pain reduction advantage over sham treatments, physiotherapy, or exercises, while one comparison favoured manipulation/mobilisation over an internet-based educational booklet. For long-term pain outcomes, one comparison favoured manipulation/mobilisation over the educational booklet, while two showed no difference against physiotherapy or exercises.\u003csup\u003e73\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor function, no significant differences were found in short- or long-term outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eChronic LBP\u003c/u\u003e\u003c/em\u003e: One review\u003csup\u003e17\u003c/sup\u003e found no immediate differences in pain and function compared to general or motor control exercises. No reviews assessed the short-term effects on pain or function in individuals with chronic LBP. For long-term effects, one review\u003csup\u003e17\u003c/sup\u003e found no significant differences in pain reduction and functional improvements compared to general or motor control exercises.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eMixed chronicity LBP\u003c/u\u003e\u003c/em\u003e: One review\u003csup\u003e7\u003c/sup\u003e found no significant short- or long-term differences in pain or function compared to soft tissue treatments or educational back school programs.\u003c/p\u003e\n\u003cp\u003eThe CCA values for NP and LBP were calculated, with NP-related reviews at 6.3% and LBP-related reviews at 19%. Detailed citation matrices are in\u0026nbsp;Additional file 5.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis umbrella review offers insights into the effectiveness of unimodal manual therapy, including manipulation, mobilisation, and manipulation/mobilization, for managing spinal pain. Mixed findings emerged, with generally not demonstrating a significant advantage over sham, placebo, or other treatments for NP and LBP across immediate, short-, and long-term pain and function outcomes. Mobilisation showed some short-term benefits in reducing NP and improving function, but its long-term effects on pain remain unclear due to insufficient evaluation. The evidence for manipulation/mobilization is limited, with no clear benefits observed for pain intensity or function in either the short- or long-term. These results highlight the need for further high-quality reviews to better understand the specific effects of manual therapy, particularly on long-term outcomes. The lack of consistent, clinically meaningful benefits suggests a limited role for unimodal manual therapy in spinal pain management, necessitating careful consideration by clinicians and policymakers when developing evidence-based guidelines.\u003c/p\u003e\n\u003cp\u003eSMT, including manipulation and mobilisation, is commonly used for NP and LBP.\u003csup\u003e11\u003c/sup\u003e However, its effectiveness can vary due to several factors. Benefits may stem from non-specific effects like placebo responses\u003csup\u003e15\u003c/sup\u003e, the therapeutic relationship, and patient expectations rather than specific physiological changes.\u003csup\u003e24,45\u003c/sup\u003e Misdiagnosis, inappropriate application, and variability in technique and practitioner skill can also hinder effectiveness, further complicated by a lack of standardization in practice.\u003csup\u003e23,38,83\u003c/sup\u003e Pain is a complex experience influenced by biological, psychological, and social factors \u003csup\u003e32\u003c/sup\u003e, which manual therapy may not adequately address \u003csup\u003e29\u003c/sup\u003e. While manual therapy may provide short-term relief, it often does not address long-term issues or underlying causes, necessitating a comprehensive treatment plan for sustained benefits \u003csup\u003e16,60\u003c/sup\u003e. Despite these limitations, SMT can still play a valuable role in a multimodal approach for some patients by reducing spinal stiffness and activating paraspinal muscles, facilitating exercise training and rehabilitation \u003csup\u003e4\u003c/sup\u003e. This underscores the importance of thorough assessment by healthcare professionals to determine its appropriateness for individual conditions.\u003csup\u003e48\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe quality of the included reviews reveals significant shortcomings, raising concerns about the reliability and validity of their findings. Of the 16 included reviews,\u003csup\u003e7,17,18,35,41,47,55,61,66,71,73,75,82,84,86,89\u003c/sup\u003e only one was rated as high quality,\u003csup\u003e73\u003c/sup\u003e one as moderate quality,\u003csup\u003e71\u003c/sup\u003e three as low quality,\u003csup\u003e41,47,82\u003c/sup\u003e and the majority as critically low quality.\u003csup\u003e7,17,18,35,55,61,66,75,82,84,86,89\u003c/sup\u003e This indicates a pressing need for methodological improvements in systematic reviews and meta-analyses. This aligns with previous umbrella reviews on other conditions, highlighting the generally low methodological quality of systematic reviews on manual therapy interventions.\u003csup\u003e3,28\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eNotably, over half of the reviews failed to register their protocols before conducting the review, and none adequately justified deviations from their initial protocols, undermining transparency and reproducibility.\u003csup\u003e54,65\u003c/sup\u003e. Evidence from related guidelines supports these concerns.\u003csup\u003e1,50\u003c/sup\u003e Koensgen et al.\u003csup\u003e50\u003c/sup\u003e found that almost all (92.5%) of the non-Cochrane systematic reviews differed from their published protocols, with half having a major difference. However, the final review publications only reported 10% of these differences, and only 7% provided an explanation.\u003csup\u003e50\u003c/sup\u003e Allers et al.\u003csup\u003e1\u003c/sup\u003e noted that while the number of published systematic review protocols increased, many reviews remained unpublished after several years, suggesting widespread issues with protocol registration and transparency.\u003c/p\u003e\n\u003cp\u003eFurthermore, the lack of comprehensive reporting on excluded studies in nearly half of the reviews highlights critical gaps in the evaluation process.\u003csup\u003e62\u003c/sup\u003e Incomplete reporting of study exclusions and inadequate risk of bias assessments can lead to biased conclusions and limit confidence in the review findings.\u003csup\u003e58\u003c/sup\u003e The reporting quality, assessed by the PRISMA checklist, was poor, with only 63.7% of included studies adhering to the 27-item checklist, consistent with a prior overview of a random 200 reviews published in rehabilitation journals.\u003csup\u003e44\u003c/sup\u003e Generally, poor reporting in systematic reviews is a well-documented problem, with studies finding that less than half fully adhere to PRISMA guidelines.\u003csup\u003e64\u003c/sup\u003e These deficiencies compromise the integrity of the reviews and hinder clinicians and researchers from drawing meaningful conclusions from the existing literature. There is an urgent need for future reviews to adhere more closely to PRISMA guidelines and improve methodological rigor to enhance the overall quality of evidence for the effectiveness of manual therapy for spinal pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis umbrella review's strength lies in its comprehensive and methodologically rigorous evaluation of unimodal manual therapy for spinal pain. It systematically searched seven major databases and employed a robust selection process, ensuring broad inclusion of relevant studies. The use of multiple quality assessment tools, including AMSTAR 2, ROBIS, and the PRISMA 2020 checklist, added thoroughness and credibility to the evaluation. The meticulous data extraction and synthesis processes, categorizing findings by treatment technique, outcome measures, and follow-up duration, provided a clear understanding of the effects of unimodal manual therapy. The inclusion of a citation overlap analysis using the CCA index further strengthened the review by highlighting primary study overlap, ensuring conclusions are based on a distinct and comprehensive body of evidence. This level of detail and rigor supports the validity of the review's conclusions and offers valuable insights for clinicians, patients, and policymakers in making informed decisions about manual therapy for spinal conditions.\u003c/p\u003e\n\u003cp\u003eHowever, this umbrella review has limitations. It included only systematic reviews and meta-analyses published in English, potentially limiting the generalizability of the results. The exclusion of non-peer-reviewed studies and those not in English might have omitted valuable data. The reliance on published reviews, which often report significant or positive results, could introduce publication bias. The variation in quality among included reviews, with many rated as critically low or low quality, could affect the reliability of the synthesized evidence. The review's reliance on secondary data means it depends on the quality and comprehensiveness of primary sources, carrying over any limitations or biases. Additionally, the review did not account for potential heterogeneity in study populations, interventions, and outcomes, affecting generalizability and applicability. Future research should address these limitations by improving methodological rigor and focusing on high-quality trials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for clinical practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mixed results from the umbrella review suggest that unimodal SMT can be as effective as other interventions for managing spinal pain, primarily targeting the physical component and potentially overlooking psychological or social contributors.\u003csup\u003e29\u003c/sup\u003e Manual therapy can be a viable option within a broader, multimodal treatment plan, as recommended by current clinical guidelines.\u003csup\u003e16,60\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eClinicians should be aware of the variability in the effectiveness of different manual therapy techniques. While some may offer short-term benefits, their long-term efficacy remains unclear. Treatment plans should be tailored to individual patient needs, considering factors such as the type and chronicity of spinal pain, patient preferences, and contraindications. This personalized approach can maximize therapeutic benefits while minimizing potential risks.\u003c/p\u003e\n\u003cp\u003eThe review underscores the importance of ongoing professional development and training for clinicians providing manual therapy. Standardized protocols and well-trained healthcare providers can improve the consistency and effectiveness of interventions. Clinicians should stay informed about the latest research and guidelines to integrate new evidence into their practice, improving care quality for patients with spinal pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Implication for future studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings highlight several implications for future systematic reviews and meta-analyses in manual therapy for spinal pain. There is a need for higher-quality reviews adhering strictly to established methodological guidelines like AMSTAR 2, ROBIS, and the PRISMA checklist. Future reviews should ensure comprehensive literature searches, transparent reporting of study selection processes, and thorough risk of bias assessments. Registering protocols in advance and justifying deviations are crucial for enhancing transparency and reproducibility.\u003c/p\u003e\n\u003cp\u003eFuture reviews should address heterogeneity observed in included studies, standardizing definitions and classifications of interventions, outcomes, and patient populations. Detailed reporting on study characteristics will help clarify contexts in which manual therapy is most effective. More rigorous primary research is needed to fill gaps in existing literature. Future RCTs should explore long-term impacts on pain and function. By addressing these gaps and improving evidence quality, future reviews can provide more definitive guidance for clinicians, patients, and policymakers on manual therapy for spinal pain.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis umbrella review highlights the mixed effectiveness of unimodal manual therapy for managing spinal pain, suggesting it can be as effective as other interventions but not consistently superior. It underscores the need for higher-quality research to understand specific contexts where manual therapy is most effective. Future studies should focus on improving methodological rigor, standardizing intervention protocols, and exploring long-term outcomes to provide more definitive clinical guidance. While unimodal manual therapy remains valuable in managing spinal pain, clinicians should integrate it within a broader, evidence-based treatment plan tailored to individual patient needs, optimizing patient outcomes and healthcare resource use.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely acknowledge the health librarian who helped validating the search strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLYH, LCHM, NKS, YTL, YWY, and FAZ conceived and designed the study. LYH, LCHM, NKS, YTL, YWY, and FAZ had full access to all data in the study and take responsibility for the integrity of the data. FAZ did the literature searches. LYH, LCHM, NKS, YTL, YWY, and FAZ interpreted the data and wrote the first draft of the manuscript. LYH, LCHM, NKS, YTL, YWY, SA, OE, AYLW, and FAZ wrote the final draft of the manuscript. All authors contributed to critical revision of the report for important intellectual content. LYH, LCHM, NKS, YTL, and YWY contributed equally to this paper. FAZ is the submitting and corresponding author and the guarantor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the data extracted from the included studies are included in the tables, appendices, and figures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study does not require ethical approval..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSystematic review registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol was registered in PROSPERO database with a registration number: CRD42023469017.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAllers K, Hoffmann F, Mathes T, Pieper D. 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Chapter V: Overviews of Reviews. \u003cem\u003eCochrane Handbook for Systematic Reviews of Interventions\u003c/em\u003e. 2021.\u003c/li\u003e\n\u003cli\u003ePosadzki P. Is spinal manipulation effective for pain? An overview of systematic reviews. \u003cem\u003ePain Med\u003c/em\u003e. Jun 2012;13(6):754-61. doi:10.1111/j.1526-4637.2012.01397.x\u003c/li\u003e\n\u003cli\u003eRajadurai V, Murugan K, Vikas College of Physiotherapy UCMICLSHHMBPCOOXRWUKvyc. Spinal manipulative therapy for low back pain: a systematic review. \u003cem\u003ePhysical Therapy Reviews\u003c/em\u003e. 2009 2009;14(4):260-271. \u003c/li\u003e\n\u003cli\u003eRiley SP, Shaffer SM, Flowers DW, Hofbauer MA, Swanson BT. Manual therapy for non-radicular cervical spine related impairments: establishing a \u0026apos;Trustworthy\u0026apos; living systematic review and meta-analysis. \u003cem\u003eJ Man Manip Ther\u003c/em\u003e. Aug 2023;31(4):231-245. doi:10.1080/10669817.2023.2201917\u003c/li\u003e\n\u003cli\u003eRubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. \u003cem\u003eBmj\u003c/em\u003e. Mar 13 2019;364:l689. doi:10.1136/bmj.l689\u003c/li\u003e\n\u003cli\u003eRubinstein SM, Terwee CB, Assendelft WJJ, De Boer MR, Van Tulder MW. Spinal manipulative therapy for acute low back pain: An update of the cochrane review. Article. \u003cem\u003eSpine\u003c/em\u003e. 2013;38(3):E158-E177. doi:10.1097/BRS.0b013e31827dd89d\u003c/li\u003e\n\u003cli\u003eRubinstein SM, Van Middelkoop M, Assendelft WJJ, De Boer MR, Van Tulder MW. Spinal manipulative therapy for chronic low-back pain: An update of a cochrane review. Review. \u003cem\u003eSpine\u003c/em\u003e. 2011;36(13):E825-E846. doi:10.1097/BRS.0b013e3182197fe1\u003c/li\u003e\n\u003cli\u003eRuddock JK, Sallis H, Ness A, Perry RE. Spinal Manipulation Vs Sham Manipulation for Nonspecific Low Back Pain: A Systematic Review and Meta-analysis. \u003cem\u003eJ Chiropr Med\u003c/em\u003e. Sep 2016;15(3):165-83. doi:10.1016/j.jcm.2016.04.014\u003c/li\u003e\n\u003cli\u003eSandoz R. The significance of the manipulative crack and of other articular noises. \u003cem\u003eAnn Swiss Chiropract Assoc\u003c/em\u003e. 1969;4:47-68. \u003c/li\u003e\n\u003cli\u003eSchroeder J, Kaplan L, Fischer DJ, Skelly AC. The outcomes of manipulation or mobilization therapy compared with physical therapy or exercise for neck pain: a systematic review. \u003cem\u003eEvid Based Spine Care J\u003c/em\u003e. Apr 2013;4(1):30-41. doi:10.1055/s-0033-1341605\u003c/li\u003e\n\u003cli\u003eShea BJ, Reeves BC, Wells G, et al. 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Aug 2014;22(3):141-53. doi:10.1179/2042618613y.0000000043\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Eligibility criteria\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5698%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5698%;\"\u003e\n \u003cp\u003ePopulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAdults (\u0026ge; 18 and \u0026lt; 65 years old)\u003c/li\u003e\n \u003cli\u003ePain in the following spinal regions (cervical, thoracic, lumbar,\u0026nbsp;sacral or coccygeal pain)\u003c/li\u003e\n \u003cli\u003eAcute pain (Less than 12 weeks),\u0026nbsp;Chronic pain (More than 12 weeks)\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAny nationality or gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026lt; 18 years old or \u0026ge; 65 years old\u003c/li\u003e\n \u003cli\u003eTemporomandibular joint (TMJ) pain\u003c/li\u003e\n \u003cli\u003eCervicogenic headache\u003c/li\u003e\n \u003cli\u003eCervicobrachial pain\u003c/li\u003e\n \u003cli\u003eCancer \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAsymptomatic disorders (e.g. scoliosis, kyphosis, degeneration, upper cross syndrome)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePregnancy-related spinal pain\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5698%;\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eManipulation, mobilization, or manual traction\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eUnimodal intervention group\u003c/li\u003e\n \u003cli\u003eTechniques conducted by professional clinician (e.g. physiotherapist, chiropractor, osteopath)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eMultimodal intervention group (e.g. manipulation with exercise vs usual care)\u003c/li\u003e\n \u003cli\u003eManual therapy not included in our criteria (e.g. Tuina, soft tissue massage, myofascial release, mechanical traction, trigger point therapy, bone setting, stretching, lymph drainage, cranial sacral therapy, occipital release and stabilization exercise)\u003c/li\u003e\n \u003cli\u003eTechniques conducted by non- professionals\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5698%;\"\u003e\n \u003cp\u003eComparison\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSham therapy, placebo or none\u003c/li\u003e\n \u003cli\u003eUsual care\u003c/li\u003e\n \u003cli\u003eOther forms of therapies\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5698%;\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePain\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFunction\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5698%;\"\u003e\n \u003cp\u003eTiming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eTreatment period of any duration\u003c/li\u003e\n \u003cli\u003eFollow-up of any duration\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5698%;\"\u003e\n \u003cp\u003eDesign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSystematic reviews\u003c/li\u003e\n \u003cli\u003eMeta-analysis (Includes at least 2 RCTs)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eRCTs, Controlled clinical trial (CCT), Umbrella reviews\u003c/li\u003e\n \u003cli\u003eObservational studies, Pilot studies, Doctoral projects, Thesis\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.5698%;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eEnglish language\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42.2151%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-English language\u003c/li\u003e\n \u003cli\u003eAdverse effects reporting studies without comparison\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 2 To 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Umbrella review, Spinal pain, Manual therapy, Mobilisation, Neck pain, Low back pain","lastPublishedDoi":"10.21203/rs.3.rs-6487750/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6487750/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Spinal pain, including neck pain (NP) and low back pain (LBP), is a leading cause of global disability. Manual therapy is recommended as a non-pharmacological adjunct, but its standalone effects are not well understood. The objective of this review was to synthesize and critically evaluate the systematic reviews and meta-analyses that have investigated the effectiveness of unimodal manual therapy for managing spinal pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis umbrella review of systematic reviews and meta-analyses searched seven databases from inception to March 2024, focusing on unimodal manual therapy. Two independent reviewers assessed methodological quality using AMSTAR 2 and ROBIS tools, and reporting quality using PRISMA 2020. Data regarding treatment techniques, pain and functional outcomes, and spinal conditions were extracted. The citation overlap was calculated using the Corrected Covered Area (CCA) index.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eSixteen reviews met inclusion criteria. Evidence suggests limited effectiveness of unimodal manual therapy compared to sham, placebo, or other interventions for NP and LBP across all follow-up periods. Mobilization demonstrated short-term benefits in NP reduction and functional improvement, though long-term effectiveness remains uncertain. Methodological quality was generally low, with only one high-quality review. CCA values were 6.3% for NP and 19% for LBP reviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eUnimodal manual therapy may be more beneficial when integrated into multimodal approaches, particularly for short-term relief. Future research should prioritize methodological rigor and standardized reporting to better establish long-term effectiveness in managing spinal pain.\u003c/p\u003e","manuscriptTitle":"The effect of unimodal manual therapy on patients with spinal pain: an umbrella review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-24 18:53:04","doi":"10.21203/rs.3.rs-6487750/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"72e2e86f-afe0-44d2-96d8-2580122ef665","owner":[],"postedDate":"September 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-24T18:53:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-24 18:53:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6487750","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6487750","identity":"rs-6487750","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}