Joint mobilization associated or not to other therapies reduces chronic musculoskeletal pain: a systematic review

Thiago dos Santos Sousa Abner Maria Ivone Oliveira Dantas Isabela Freire Azevedo-Santos Josimari Melo DeSantana About the authors

ABSTRACT

BACKGROUND AND OBJECTIVES:

Joint mobilization is a non-pharmacological technique used to treat chronic musculoskeletal pain. However, it is controversial due to a lack of studies comparing its effects on this painful condition. The objective of this study was to assess the risk of bias in clinical trials investigating the effect of joint mobilization on chronic musculoskeletal pain.

CONTENTS:

A systematic search on Pubmed, Cochrane Library, ScienceDirect, Scielo, PEDro, CINAHL, SPORTDiscus, LILACS, BVS, PsycINFO, Web of Science, and Scopus was performed on September 2019 from the combination of three keywords: Musculoskeletal Manipulations AND Chronic Pain AND Musculoskeletal Pain. Randomized controlled clinical trials that evaluated the use of joint mobilization associated or not to other therapies in chronic musculoskeletal pain treatment were included. Five thousand five hundred eighty-seven articles were screened, and 14 studies were analyzed, including 812 participants, with a mean age of 54 years, and female being the most affected. According to these articles, joint mobilization promoted the reduction of pain intensity in short and long terms, increase in range of motion, strength and function when used alone or in association with conventional physiotherapy. Regarding methodological quality, most of the studies were classified with low risk for selection, performance, detection and reporting bias. In the “other bias” item, which considered therapists experience time and types of treatment applied, only one study presented low risk and other study presented an unclear risk.

CONCLUSION:

Joint mobilization seems to be an effective technique for the treatment of chronic musculoskeletal pain. However, it is still necessary to investigate and compile studies with greater methodological quality, thus promoting greater support to evidence-based practice.

Keywords:
Chronic pain; Musculoskeletal manipulations; Musculoskeletal pain

RESUMO

JUSTIFICATIVA E OBJETIVOS:

Mobilização articular é uma técnica não farmacológica usada no tratamento da dor musculoesquelética crônica. No entanto, é controverso devido à falta de estudos que comparem seus efeitos sobre essa condição de dor. O objetivo deste estudo foi avaliar o risco de viés em ensaios clínicos que investigam o efeito da mobilização articular na dor musculoesquelética crônica.

CONTEÚDO:

Foi realizada uma busca sistematizada no Pu-bmed, Cochrane Library, ScienceDirect, Scielo, PEDro, CINAHL, SPORTDiscus, LILACS, BVS, PsycINFO, Web of Science e Scopus em setembro de 2019 com a combinação de três palavras-chave: Musculoskeletal Manipulations AND Chronic Pain AND Musculoskeletal Pain. Ensaios clínicos controlados e aleatorizados que avaliaram o uso de mobilização articular associada ou não a outras terapias no tratamento da dor muscu-loesquelética crônica foram incluídos. Foram encontrados 5587 artigos e analisados 14 estudos, incluindo 812 participantes, com idade média de 54 anos, sendo o sexo feminino o mais afetado. Nestes, a mobilização articular promoveu redução da dor em curto e longo prazo, amplitude de movimento, força e melhora da função quando utilizado isoladamente ou em associação à fisioterapia convencional. Em relação à qualidade metodológica, a maioria dos estudos foi classificada com baixo risco para seleção, desempenho, detecção e viés de relato. No item “other bias”, que considerou terapeutas com tempo de experiência e tipos de tratamento aplicados, apenas um estudo apresentou baixo risco e outro estudo apresentou risco incerto.

CONCLUSÃO:

Mobilizaç ão articular parece ser uma técnica eficaz para o tratamento da dor musculoesquelética crônica. No entanto, é necessário realizar estudos com maior qualidade metodológica, promovendo maior apoio à prática baseada em evidências.

Descritores:
Dor crônica; Dor musculoesquelética; Manipulações musculoesqueléticas

INTRODUCTION

Chronic musculoskeletal pain (CMP) is defined as a painful condition associated with dysfunction in muscles, ligaments, tendons, bones, and/or adjacent structures that lasts for more than three months11 Sampath KK, Mani R, Miyamori T, Tumilty S. The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and meta-analysis. Clin Rehabil. 2016;30(12):1141-55.,22 Sahrmann S, Azevedo DC, Dillen LV. Diagnosis and treatment of movement system impairment syndromes. Braz J Phys Therapy. 2017;21(6):391-9.. Musculoskeletal conditions are the main cause of disability worldwide, with a prevalence ranging from 13.5 to 47% of the general population33 Blyth FM, Noguchi N. Chronic musculoskeletal pain and its impact on older people. Best Pract Res Clin Rheumatol. 2017;31(2):160-8.. The main risk factors for this condition are advanced age, female sex, smoking, low schooling, sedentary lifestyle, poor social interaction, depression and anxiety44 Cimmino MA, Ferrone C, Cutolo M. Epidemiology of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol. 2011;25(2):173-83..

This type of pain has a multifactorial etiology, which may have a definite cause (traumatic, ischemic, tumor, inflammatory, overload, overuse) or non-specific causes55 Toye F, Seers K, Allcock N, Briggs M, Carr E, Andrews J, et al. Patients' experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review. Br J Gen Pract. 2013;63(617):e829-e41.,66 Gerdle B, Ghafouri B, Ernberg M, Larsson B. Chronic musculoskeletal pain: review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique. J Pain Res. 2014;7:313.. Several characteristics may be present in these patients, as generalized, diffuse and/or local muscle pain, physical and mental fatigue, a decrease of muscle strength, demotivation, sleep disorders, among others66 Gerdle B, Ghafouri B, Ernberg M, Larsson B. Chronic musculoskeletal pain: review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique. J Pain Res. 2014;7:313.

7 Crofford LJ. Chronic pain: where the body meets the brain. Trans Am Clin Climatol Assoc. 2015;126:167.
-88 Clauw DJ. Diagnosing and treating chronic musculoskeletal pain based on the underlying mechanism(s). Best Pract Res Clin Rheumatol. 2015;29(1):6-19., which may lead to increased health costs and reduced quality of life99 Hirase T, Kataoka H, Inokuchi S, Nakano J, Sakamoto J, Okita M. Factors associated with chronic musculoskeletal pain in Japanese community-dwelling older adults: A cross-sectional study. Medicine. 2017;96(23):e7069..

The treatment of CMP can be performed by a multiprofessional team and consists of pharmacological and/or non-pharmacologi-cal therapies1010 Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;4:CD011279.. The most used drugs are analgesics, non-steroidal anti-inflammatories, antidepressants, neuroleptics, anticonvulsants and myorelaxants1111 Ushida T. Burdensome problems of chronic musculoskeletal pain and future prospects. J Orthop Sci. 2015;20(6):958-66.. Some non-pharmacological therapies involve physiotherapeutic techniques such as acupuncture, kine-siotherapy, electrotherapy, thermotherapy, phototherapy, spinal manipulation and massage therapy which aim to reduce pain and improve the quality of life of these patients22 Sahrmann S, Azevedo DC, Dillen LV. Diagnosis and treatment of movement system impairment syndromes. Braz J Phys Therapy. 2017;21(6):391-9.,1212 Rajapakse D, Liossi C, Howard RF. Presentation and management of chronic pain. Arch Dis Child. 2014;99(5):474-80..

Currently, these non-pharmacological treatments are being prioritized because of the lower risk of adverse effects. Manual therapy (MT) is one of these non-pharmacological techniques most widely used in the treatment of dysfunctions affecting the musculoskeletal system. It consists of a physiotherapeutic treatment that includes therapeutic massage, joint mobilization (JM), manipulation, among others22 Sahrmann S, Azevedo DC, Dillen LV. Diagnosis and treatment of movement system impairment syndromes. Braz J Phys Therapy. 2017;21(6):391-9..

JM is a technique used to treat musculoskeletal pain in the axial and appendicular skeletons. It is indicated to reduce pain, muscle spasms, reversible joint hypomobility, positioning/subluxation failure, progressive limitation, and functional immobility1313 Krekoukias G, Gelalis ID, Xenakis T, Gioftsos G, Dimitriadis Z, Sakellari V. Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. J Man Manip Ther. 2017;25(2):66-73.. However, this technique has limitations and/or contraindications that consist of irreversible hypomobility, joint effusion and inflammation. The neurophysiological and mechanical effects caused by the use of joint mobilizations provide analgesia in patients with CMP1313 Krekoukias G, Gelalis ID, Xenakis T, Gioftsos G, Dimitriadis Z, Sakellari V. Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. J Man Manip Ther. 2017;25(2):66-73.,1414 Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Booth MS, et al. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J. 2018;18(5):866-79..

Studies suggest1313 Krekoukias G, Gelalis ID, Xenakis T, Gioftsos G, Dimitriadis Z, Sakellari V. Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. J Man Manip Ther. 2017;25(2):66-73.,1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,1616 Wyke B, Polacek P. Articular neurology: the present position. J Joint Bone Surg. 1975;57(3):401. that JM activates the dorsal area of periaqueductal gray matter (PAG) of the brain, and this influences on pain perception. Studies show an immediate reduction of pain and an increase in sympathetic nervous system activity, suggesting an indirect relationship with the dorsal area of PAG and association between increased stimulation of sympathetic nervous system and reduction of mechanical pain thre-shold1313 Krekoukias G, Gelalis ID, Xenakis T, Gioftsos G, Dimitriadis Z, Sakellari V. Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. J Man Manip Ther. 2017;25(2):66-73.,1717 Taylor AM, Phillips K, Patel KV, Turk DC, Dworkin RH, Beaton D, et al. Assessment of physical function and participation in chronic pain clinical trials: IMMPACT/ OMERACT recommendations. Pain. 2016;157(9):1836-50.

18 Seroussi R. Chronic pain assessment. Phys Med Rehabil Clin N Am. 2015;26(2):185-99.
-1919 Kingston L, Claydon L, Tumilty S. The effects of spinal mobilizations on the sympathetic nervous system: a systematic review. Man Ther. 2014;19(4):281-7.. An experimental study has shown an analgesic response accompanied by sympathetic nervous system activation after the electrical stimulation of the midbrain, originating in PAG2020 Lovick T. Interactions between descending pathways from the dorsal and ventrolateral periaqueductal gray matter in the rat. The midbrain periaqueductal gray matter: Springer; 1991. 101-20p.. Other clinical studies have shown a sympathetic-excitatory change combined with a hypoalgesic response after spinal JM, with increased skin conductance2121 Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Man Ther. 2001;6(2):72-81.

22 Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexci-tatory effects of mobilization with movement for lateral epicondylalgia. Phys Ther. 2003;83(4):374-83.

23 Slater H, Vicenzino B, Wright A. 'Sympathetic Slump': the effects of a novel manual therapy technique on peripheral sympathetic nervous system function. J Man Manip Ther. 1994;2(4):156-62.

24 Perry J, Green A, Singh S, Watson P. A randomised, independent groups study investigating the sympathetic nervous system responses to two manual therapy treatments in patients with LBP. Man Ther. 2015;20(6):861-7.

25 Tsirakis V, Perry J. The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on sympathetic outflow to the lower limbs. Man Ther. 2015;20(1):103-8.

26 Piekarz V, Perry J. An investigation into the effects of applying a lumbar Maitland mobilisation at different frequencies on sympathetic nervous system activity levels in the lower limb. Man Ther. 2016;23(1):83-9.

27 Moutzouri M, Perry J, Billis E. Investigation of the effects of a centrally applied lumbar sustained natural apophyseal glide mobilization on lower limb sympathetic nervous system activity in asymptomatic subjects. J Manipulative Physiol Ther. 2012;35(4):286-94.

28 Cleland J, Durall C, Scott SA. Effects of slump long sitting on peripheral sudomotor and vasomotor function: a pilot study. J Man Manip Ther. 2002;10(2):67-75.
-2929 Navarro-Santana MJ, Gómez-Chiguano GF, Somkereki MD, Fernández-de-las-Peñas C, Cleland JA, Plaza-Manzano G. Effects of joint mobilisation on clinical manifestations of sympathetic nervous system activity: a systematic review and meta-analysis. Physiotherapy. 2019. Epub ahead print), respiratory and heart rate3030 Vicenzino B, Cartwright T, Collins D, Wright A. Cardiovascular and respiratory changes produced by lateral glide mobilization of the cervical spine. Man Ther. 1998;3(2):67-71., and decreased skin temperature3131 La Touche R, París-Alemany A, Mannheimer JS, Angulo-Díaz-Parreño S, Bishop MD, Lopéz-Valverde-Centeno A, et al. Does mobilization of the upper cervical spine affect pain sensitivity and autonomic nervous system function in patients with cervi-co-craniofacial pain?: A randomized-controlled trial. Clin J Pain. 2013;29(3):205-15.,3232 Roy RA, Boucher JP, Comtois AS. Paraspinal cutaneous temperature modification after spinal manipulation at L5. J Manipulative Physiol Ther. 2010;33(4):308-14.. Changes in central sympathetic activity may be directly related to modulation response during therapeutic intervention2929 Navarro-Santana MJ, Gómez-Chiguano GF, Somkereki MD, Fernández-de-las-Peñas C, Cleland JA, Plaza-Manzano G. Effects of joint mobilisation on clinical manifestations of sympathetic nervous system activity: a systematic review and meta-analysis. Physiotherapy. 2019. Epub ahead print) and it is also hypothesized that JM initiates the inhibitory mechanisms in the dorsal region of the PAG1313 Krekoukias G, Gelalis ID, Xenakis T, Gioftsos G, Dimitriadis Z, Sakellari V. Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. J Man Manip Ther. 2017;25(2):66-73..

Using grade III JM in an experimental model of ankle joint inflammation, showed action through spinal blockade of serotonergic (5HT1) receptors, found in nucleus raphe magnus (NRM) and noradrenergic (alpha 2), located mainly in a small nucleus in the gray matter of the pons, the locus coeruleus. However, blockade of GABA or opioid receptors had no influence on the analgesic effect produced by joint mobilization3333 Skyba D, Radhakrishnan R, Rohlwing J, Wright A, Sluka K. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain. 2003;106(1-2):159-68.. These data may suggest that MA reduces CNS pain through non-opioid descending inhibitory pathways from the rostral ventromedial medulla and dorsolateral pontine tegmentum. More recently, the role of the nociceptive adenosinergic system has been shown to mediate the antihyperalgesic effect of MA by activating A1 adenosiner-gic receptors that predominantly mediate the effects of synaptic transmission in the superficial region of the dorsal horn3434 Martins DF, Mazzardo-Martins L, Cidral-Filho FJ, Stramosk J, Santos AR. Ankle joint mobilization affects postoperative pain through peripheral and central adenosine A1 receptors. Phys Ther. 2013;93(3):401-12..

There are several studies on the use of MT in diseases and other conditions, such as chronic spinal pain and osteoarthritis (OA)1010 Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;4:CD011279.,1313 Krekoukias G, Gelalis ID, Xenakis T, Gioftsos G, Dimitriadis Z, Sakellari V. Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. J Man Manip Ther. 2017;25(2):66-73.. A recently published meta-analysis about manipulation and mobilization, specifically for the treatment of chronic low back pain, has shown that both therapies appear to be safe and that there is moderate quality in the studies that support the use of these techniques to reduce this type of pain1414 Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Booth MS, et al. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J. 2018;18(5):866-79..

Another meta-analysis addressed the use of manual therapy, exercise therapy (ET), or combined treatment for adults with cervicalgia. Quality of included studies was moderate and the authors concluded that combined treatment consisting of MT and ET does not appear to be more effective in reducing the intensity of resting neck pain, cervical spine disability, or quality of life improvement in adult patients with cervicalgia when compared to only ET3535 Fredin K, Loras H. Manual therapy, exercise therapy or combined treatment in the management of adult neck pain - a systematic review and meta-analysis. Musculos-kelet Sci Pract. 2017;31:62-71.. Although it presents moderate scientific evidence according to the previously published studies, the use of JM in patients with CMP still presents controversies due to the lack of studies that directly compare its effects in this painful condition. Therefore, there is an even greater need for studies with methodological quality that is rigorous enough to indicate treatments in this area. Thus, in order to verify the existence of clinical trials related to this topic, this systematic review aimed to investigate and evaluate the effect of protocols for JM application associated or not to other therapies in the treatment of pain and motor performance in patients with CMP.

CONTENTS

As a PICO strategy, randomized trials with a control or placebo group that evaluated the use of JM associated or not with other therapies in CMP treatment were included in this review. The studies that presented participants older than 18 years old with chronic pain related to musculoskeletal dysfunction for time >3 months and who were treated with JM associated or not with other therapies were selected.

Clinical trials comparing any type of JM with placebo or sham intervention, with no other type of treatment, mobilization as an isolated therapy or in combination with other conservative therapies have been included. Clinical trials comparing different protocols of JM (e.g., different degrees, series, repetitions, and/or body sites/segments) were also included.

The exclusion criteria were studies with participants who presented oncological pain, headache, temporomandibular dysfunction (TMD), other painful conditions. It was also excluded studies with patients who were undergone to other modalities of therapies and/or mobilization under anesthesia or performed by machines as forms of treatment, use of JM only outside the site of pain, studies that did not report how long considered the pain condition as chronic and cross-over clinical trials. Studies that had no full-text accessible, and that was not possible to contact the authors, were also excluded.

The primary outcomes evaluated were pain measured by a validated pain score scale, such as the visual analog scale (VAS) and numerical rating scale (NRS) and pressure pain threshold (PPT), measured by digital pressure algometer. As secondary outcomes were considered: the range of motion data (ROM) accessed through universal goniometer or inclinometer, muscle strength measured indirectly or directly through the isokinetic dynamometer and manual tests, functionality measured by validated functional tests, quality of life through validated questionnaires, such as SF-36 and QoL for general measures, adherence to treatment measured by the number of sessions that the individual performed and patient expectation /satisfaction measured through the patient’s report and the Likert scale.

Protocol and register

This research protocol was registered in the International Registry of Systematic Reviews PROSPERO (CRD 42016046029). The inclusion criteria and analyses of studies were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane Handbook for Systematic Reviews of Interventions.

Search strategy

The studies were screened in the following electronic databases: Pubmed, Cochrane Library, ScienceDirect, Scielo, PEDro, CINAHL, SPORTDiscus, LILACS, BVS, PsycINFO, Web of Science, Scopus and Google Scholar. There were no restrictions on language or year of publication. The search was performed in September 2019 by combining the following descriptors: Manual Therapy/ Musculoskeletal Manipulations (“Musculoskeletal Manipulations” [mesh terms] OR (manipulations, musculoskeletal) OR (manual therapies) OR (manual therapy) OR (therapies, manual) OR (therapy, manual) OR (manipulation therapy) OR (manipulation therapies) OR (therapies, manipulation) OR (manipulative therapies) OR (manipulative therapy) OR (therapies, manipulative) OR (therapy, manipulative) OR (therapy, manipulation)), Chronic Pain (“Chronic Pain”[mesh terms] OR (Chronic Pains) OR (Pains, Chronic) OR (Pain, Chronic) OR (Widespread Chronic Pain) OR (Chronic Pain, Widespread) OR (Chronic Pains, Widespread); (Pain, Widespread Chronic) OR (Pains, Widespread Chronic) OR (Widespread Chronic Pains)) e Musculoskeletal Pain (“Musculoskeletal Pain” [mesh terms] OR (Musculoskeletal Pains) OR (Pain, Musculoskeletal) OR (Pains, Musculoskeletal)).

Searches were remade immediately before the final analyses and additional studies were retrieved for inclusion. The reference lists of all primary studies were checked, and all articles were revised for additional references. Data collection and analyses were performed in accordance with the methods set out in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane Handbook for Systematic Reviews of Interventions.

Data selection and extraction

Two authors independently extracted data from all studies included using an Excel spreadsheet. This worksheet included extracting information about characteristics of studies, participants, methodological aspects, interventions, comparisons, primary and secondary outcomes, results, chronic pain condition, mobilization type, and association with other interventions. At this stage of the study, disagreements among reviewers were discussed with a third investigator.

Quality assessment

The risk of bias was assessed using the Cochrane Collaboration tool by two reviewers independently. Thus, six domains were evaluated: selection bias (random sequence generation and allocation concealment), performance bias (participants blinding), detection bias (evaluators blinding), attrition bias (results with incomplete data), reporting bias (selective reporting of outcomes) and other biases. For the judgment of this last type of bias (Other bias) the following aspects were considered: the number of physiotherapists who applied the protocols and their years of experience in the area (over one year), mobilization type (with different characteristics and/or combination with other therapies, presence of control group), no validated placebo for mobilization; compared with different therapies and with different application objectives.

Each of these biases was classified as low risk, high risk, or unclear risk. Review Manager 5.3 was used for all quantitative analyses. The searches were remade immediately before the final analyses in September 2019 and additional studies were retrieved for inclusion in order to ensure the selection of the largest possible number of studies.

Included studies

The database search recovered 5587 potentially relevant references: Pubmed (258), PEDro (28), CINAHL (32), Cochrane Library (39), LILACS (0), Scielo (2), ScienceDirect (4412), Scopus (343), SPORTDiscus (19), Web of Science (145), PsycINFO (15), BVS (194) e Google Scholar (100). The search retrieved 5587 records of trials after removal duplicates, of which 30 articles were selected for full-text evaluation and 11 clinical trials met the inclusion criteria. Hand search on the reference lists of all primary studies was performed and further three clinical trials were selected; thus, 14 clinical trials were included for qualitative synthesis. Figure 1 shows the flowchart of the search and selection process in this review.

Figure 1
Flow of the studies through the review

Included clinical trials examining the JM intervention associated or not with other therapies in the treatment of CMP were published between 2008 and 2018. The total sample from 14 studies was 812 participants, ranging from 28 to 120 participants in each study. Of these, eleven (n=11) performed the sample calculation to estimate the number of subjects included3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.

37 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.

38 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.

39 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.

40 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.

43 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.

44 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.

45 Villafañe JH, Langford D, Alguacil-Diego IM, Fernández-Carnero J. Management of trapeziometacarpal osteoarthritis pain and dysfunction using mobilization with movement technique in combination with kinesiology tape: a case report. J Chir Med. 2013;12(2):79-86.
-4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.. The mean age of participants was approximately 54 years, ranging from 18 to 90 years. On average, a higher number of female participants were found (60,98%).

Some studies (25%) considered chronic pain after three months. Of these, two were about cervicalgias4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.,4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31. and one about rotator cuff injuries3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.. Two studies (16,66%) had as inclusion criteria patients with pain for more than 10 years4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7.. In another study (8,33%), chronic epicondylitis as of six months were considered for inclusion1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.. Table 1 summarizes the characteristics of the included studies.

Table 1
Characteristics of the included studies

PRIMARY OUTCOMES

Pain intensity

The majority of included trials (11 of 14) measured pain intensity only at rest1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.

39 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.

40 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.

43 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.

44 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.
-4545 Villafañe JH, Langford D, Alguacil-Diego IM, Fernández-Carnero J. Management of trapeziometacarpal osteoarthritis pain and dysfunction using mobilization with movement technique in combination with kinesiology tape: a case report. J Chir Med. 2013;12(2):79-86.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.. One study measured the intensity of pain during movement (39), and one study evaluated pain intensity on movement and at rest3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.. Five studies evaluated the intensity of pain through the visual analog scale (VAS)1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.
-4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43. and other four studies used the numerical rating scale (NRS)3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.

39 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.
-4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.. One study evaluated pain through the McGill Pain Questionnai-re4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.. In study4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53. VAS was used to evaluate pain intensity associated with nociceptive flexion reflex test4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53..

All studies have shown significant short- and/or long-term reduction of pain intensity following JM combined or not with other therapies1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.

39 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.

40 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.

43 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.

44 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.
-4545 Villafañe JH, Langford D, Alguacil-Diego IM, Fernández-Carnero J. Management of trapeziometacarpal osteoarthritis pain and dysfunction using mobilization with movement technique in combination with kinesiology tape: a case report. J Chir Med. 2013;12(2):79-86.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95..

Pressure pain threshold (PPT)

Some studies have evaluated PPT as a primary outco-me4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.,4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.,4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53.. This variable was measured through a digital pressure algometer at different points, according to pain location. The study4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53. evaluated PPT in patients with chronic cervical disorders related to whiplash injury. Three measurements were conducted in the C6 spinous process at the median nerve trunk bilaterally elbow and the tibialis anterior muscles bilaterally at two times before and after therapy4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53..

The study4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56. collected the measurements of PPT in the carpometacarpal joint at the bottom of the anatomical snuffbox and tubercle of the scaphoid bone. Three measurements were performed in the dominant hand of subjects with a one-minute interval, four times before treatment, 5 minutes after the treatment, 1 and 2 weeks after therapy.

On study4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20. the PPT was measured three times, with a rest interval of one minute between measurements, in bones connected to trapeziometacarpal joint, of scaphoid bone apophysis and hama-to bone in four moments (baseline, immediately after treatment, one and two weeks after treatment) on symptomatic hand with OA carpometacarpal.

Another study4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7. consisted of a secondary analysis that focused on the contralateral hand (asymptomatic). The PPT was evaluated three times with a rest interval of one minute between measurements on the carpometacarpal joint of the contralateral thumb and the symptomatic hand with carpometacarpal OA, on scaphoid bone tubercle and hamato bone process in four moments (baseline, immediately after treatment, one and two weeks after treatment).

On study4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52. PPT measurements were performed three times, with an interval of 10 seconds between measurements in the following points: close to spinous process of cervical spine at medullary level treated on right side, with participant in pronated position, upper right trapezius muscle, between C7 and acromion, with sitting participant and trunk of the right median nerve at the elbow, medial to the biceps tendon, with the elbow at approximately 30° flexion, with forearm resting on a support and participant sitting in three moments (before, after and follow-up). The study4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72. performed three PPT measurements with a 30-second interval between each application at the pain site in patients with plantar fasciitis. Algometry was measured twice (baseline and at the end of all care sessions).

Five of six studies4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.,4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.,4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.

45 Villafañe JH, Langford D, Alguacil-Diego IM, Fernández-Carnero J. Management of trapeziometacarpal osteoarthritis pain and dysfunction using mobilization with movement technique in combination with kinesiology tape: a case report. J Chir Med. 2013;12(2):79-86.
-4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56. demonstrated a significant increase in short and/or long-term pressure pain threshold after JM application, associated or not with other therapies. Only one study4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53. showed no significant difference after the use of this therapy.

SECONDARY OUTCOMES

Range of motion

Five of the included studies performed ROM measure-ment3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.,4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.
-4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.. Among studies that evaluated ROM with a universal goniometer, one article evaluated only active mobility4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31., and two other studies did not specified3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.. Active ROM was still evaluated through the inclinometer in a study4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72. and through the cervical range of motion instrument4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52..

Four articles showed a significant increase of ROM at cervical4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31., shoulder4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95., hip3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5., and foot4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72. joints after JM application associated or not with other therapies. One study4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52. did not find any significant difference for cervical ROM after therapy.

Muscle strength

Five studies evaluated muscle strength1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.

47 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7.
-4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.. In the study3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756., the isometric strength of the symptomatic shoulder was assessed for abduction, internal and external rotation through the Nicholas Manual Muscle Tester (Lafayette, EUA) performed with a dynamometer. After the demonstration and training test, participants were asked to push as much as possible against the dynamometer for 4 seconds while the evaluator provided a verbal stimulus3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756..

The study 4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95. used muscle testing procedures by Daniels and Wor-thingham to assess the strength of the major shoulder muscles. In this system, muscle strength is marked with a numerical rating ranging from zero, indicating no muscle activation, to 5 for the best possible response to manual resistance in a reduced range of the muscle group that performs the movement.

Other studies1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7. used the hand dynamometer to measure the strength of patients with chronic lateral epicondylitis and thumb metacarpal OA, respectively1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7.. The studies from4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7. also used the tweezer dynamometer to evaluate thumb strength4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7.. Increased muscle strength after JM application associated or not to other therapies was observed in three studies3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.. Three other studies found no changes in strength after therapy1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7..

Functionality Ten studies that were included investigated hip, shoulder, knee, and foot functionality. Nine of them used questionnaires3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.

40 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.
-4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53. and one used functional tests3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5., all with validation.

The study3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5. on the immediate effects of mobilization in patients with hip OA was the only that evaluated the functional indexes of patients through validated tests3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.. The Timed Up and Go test (TUG), which simulates some functional activities of daily living (from sitting to standing, walking and standing to sitting) 3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.; the 30s Chair Stand Test (CST), which assesses function and strength of the lower limbs3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5. and the 40m Self Placed Walk Test (SPWT), which measures the time required to walk on short distances3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.. The other studies used the following questionnaires: Shoulder Pain and Disability Index (SPADI) to evaluate shoulder function in patients with chronic rotator cuff lesions3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.; Knee Injury and Osteoarthritis Outcome Score (KOOS) to evaluate knee function/performance in activities of daily living (ADL) in patients with patellofemoral OA3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.; the Neck Disability Index (NDI) was used to assess pain and disability of cervical spine in patients with chronic neck pain, cervicalgia and chronic whiplash injury disorders, respectively4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.
-4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53.; the Upper Extremity Motor Activity Log Modified to measure upper limb functionality in patients with frozen shoulder4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.; the Lower Extremity Functional Scale (LEFS) for assessing the functionality of lower limbs of patients with plantar fasciitis4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.; the Oswestry Disability Index (ODI) that was used in patients with chronic low back pain to measure pain-related disability in the lumbar spine3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7. and the Patient Rated Tennis Elbow Evaluation (PRTEE), which evaluated the functional outcomes related to pain and disability in patients with chronic lateral epicondylitis1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88..

Improvement of functionality was observed in seven stu-dies3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.

37 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.
-3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.,4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.
-4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95. after JM application associated or not with other therapies. There was no significant difference in functionality in three studies3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53. after JM application.

Quality of life

Three studies assessed quality of life (AQoL)3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43., using different instruments, such as the Medical Outcomes Study 36-item shor-t-form (SF-36)3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756., the Assessment of Quality of Life (AQoL)3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756., the ADL subscale of Knee injury and Osteoarthritis Outcome Score (KOOS)3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64. and the 12-item health survey (SF-12)4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43..

Only one study3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756. showed a significant increase in the quality of life parameters after JM application. Two studies3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.

40 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.
-4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43. did not show any significant difference in this outcome after therapy.

Adherence to treatment

Only two studies evaluated adherence of participants through medical records, considering the number of visits performed and the total number of visits that were pre-established in the study protocol3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.. Both studies showed good patient adherence to JM treatment, but no significant difference was observed between treatment and control groups.

Expectation/satisfaction

Three studies evaluated the expectations before the intervention, relating to their respective satisfactions after intervention3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43. A five-point Likert scale was used (1 = much worse, 2 = slightly worse, 3 = no change, 4 = slightly better, 5 = much better)3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64., this data was registered in each patient’s medical records. The study4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43. evaluated the expectation before treatment from the concepts chosen by the patient: complete recovery, great improvement, partial relief or no expectation of relief. All three studies reported that most participants reported satisfaction and improvement with JM treatment performed.

Adverse events

Only three studies reported adverse events3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.. In the stu-dy4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,16.3% of patients treated with transcutaneous electrical nerve stimulation (TENS) (n=7) and 6.4% of those treated with manual therapy (n=3) reported treatment-related adverse effects. Three of them presented increased pain in the treated area and one showed the general physical condition of the group treated with TENS. Of those who received manual therapy, one patient reported clinical worsening during the first few days and the others did not specify symptoms4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43..

Study3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756. reported that during the intervention period, 17 participants out of 55 (31%) from the active group had adverse effects that included increased short-term pain during or after treatment (n=3), increase in short-term pain with home workouts (n=12) and slight irritation to tape used for postural taping (n=2). In the placebo group, five participants out of 61 (8%) reported adverse events involving increased short-term pain during or after treatment. During the follow-up period, 7 of 49 patients (14%) from the active group reported adverse events and included increased short-term pain with home exercise3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756..

In the study3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64. adverse events were observed in seven participants who undergone exercise, education, manual therapy, taping intervention (skin reaction to the use of tape (n = 2)); edema after treatment (n = 2); pain in other areas after exercise (lumbar n =1; ankle n=1; another knee n=1). All adverse events were mild, with no need for medical intervention or treatment discontinuation (some bandage adjustments were performed and/or exercises were done by the physiotherapist).

Thus, most of the adverse effects caused slight damages to the patients in included studies, were generally related to the increase of local pain immediately after the technique application, but without lasting for a long time.

Other variables

All studies recorded demographic data (sex, age, body mass index, height, among others). Other variables were also considered in some studies, such as thermal pain threshold4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53., nociceptive flexion reflex and pain related to this test4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53., pain catastrophizing3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7., level of anxiety, and depression4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53. and use of drugs during treat-ment3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.. Two studies evaluated the levels of depression and anxiety in the participants through the Goldberg Depression and Anxiety Scale (GHQ-28). In one study, it was evidenced that 42.6% of the participants treated with manual therapy presented anxiety and depression4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43., and the other study showed that all individuals had high levels of anxiety and depression4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53..

The study4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53. evaluated the thermal threshold, nociceptive flexion reflex and the pain associated with this test and showed that there was an increase in the nociceptive reflex flexion threshold in the group treated with JM and that there was no significant difference in pain during the reflex test nociceptive flexion and at the threshold of thermal pain. On sutdy3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7. catastrophizing evaluation of patients with chronic low back pain was performed and pain catastrophizing interference was observed in the treatment of these patients Three studies reported the use of drugs during treatment3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.. The study3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64. evidenced similar use of analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), glucosamines, and fish oil.

The study4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31. use of pain medication was registered in five patients of both groups, and there was no significant difference between them. The study4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43. details the periodicity of the consumption of NSAIDs, analgesics and muscle relaxants. In the group treated with manual therapy, 4.3% of patients took these drugs every day, while 12.8% reported weekly or monthly consumption.

Risk of bias

The studies were evaluated for the risk of bias (low, high, or unclear) in relation to six domains. Figure 2 summarizes the results of individual studies.

Figure 2
Risk of bias

One study adequately described all domains and was considered as a low risk of bias3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.. One study presented a high risk for the selection bias by using an open randomization process (random list of numbers)4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53.. Two studies presented an unclear risk for the performance bias because they did not present information about the blindness of participants and researchers4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53.. All studies had a low risk of reporting bias1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.

37 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.

38 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.

39 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.

40 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.

43 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.
-4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.

47 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7.

48 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.
-4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53..

In the domain “other bias,” 12 studies presented a high risk of bias1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.

40 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.

43 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.

44 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.

45 Villafañe JH, Langford D, Alguacil-Diego IM, Fernández-Carnero J. Management of trapeziometacarpal osteoarthritis pain and dysfunction using mobilization with movement technique in combination with kinesiology tape: a case report. J Chir Med. 2013;12(2):79-86.
-4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53.. Six reported that more than one therapist performed the mobilization1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95., seven performed different types and techniques of JM without specifying the type of mobilization and/or combined with other therapies1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.,4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95., and 11 articles used different treatment controls, such as TENS, therapeutic ultrasound, laser, stretching or patient educa-tion1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.

40 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.

43 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.
-4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7.

48 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.
-4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53.. Three studies did not report the experience of the therapists who performed treatments3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53.. One study was considered to be at an unclear risk because it did not report the number of therapists who performed the mobilization techniques and the time of clinical experience in the area3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7..

In general, the methodological quality of studies was considered a low risk of bias. The values referring to the percentage of articles classified in each degree of risk of bias are represented in(figure 3.

Figure 3
Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included studies

DISCUSSION

According to the studies analyzed, JM seems to have better results in the management of chronic musculoskeletal conditions when it was used alone or in combination with conventional physiotherapy. From the 14 articles included, seven used JM interventions alone compared to a control group using simulated placebo therapy3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.,3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5., other interventions with appliances switched off or in non-therapeutic doses4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.,4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7., manual contact4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53. or without treatment3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7. and seven used JM in association with therapeutic resources used in conventional physiotherapy (TENS, TUS, strengthening, patient education and home exercises) compared to the same therapy without JM1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.,4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.. This shows the scarcity of clinical trials that use only JM as treatment, which makes it difficult to know the efficacy of this technique alone in various types of musculoskeletal disorders. In addition, the lack of validated placebo techniques for JM also difficult the discovery of new evidence about technique effect.

For primary outcomes (pain intensity and pressure pain threshold), JM promoted short-term3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.,3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.,4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4747 Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7. and long-term4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52. pain reduction in different types of musculoskeletal pain when only mobilization was used as treatment. When applied in combination with other therapies in musculoskeletal lower limb dysfunctions (patellofemoral OA and plantar fasciitis) and spine (chronic neck pain chronic disorders related to whiplash injury and chronic low back pain), the studies showed a reduction of pain after treatment3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.,4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53.. In upper limb dysfunctions (rotator cuff injury, frozen shoulder, lateral epicondylitis and thumb carpometacarpal OA), some studies have reported pain reduction1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56., and others did not observe any differences between groups3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.. Most of the articles also showed improvement of ROM, strength and function after JM treatment1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.

37 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.
-3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.,4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.
-4242 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.,4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.. Based on these studies, most of them with good methodological quality, JM can be considered an effective therapeutic resource in reducing pain and improving the functionality of patients with CMP. There is insufficient evidence to determine the effect of JM on quality of life, adherence and patient expectancy in the treatment of CMP Previous reviews and meta-analyses show chronic musculoskeletal conditions studied separately and involving manual therapy as a set or combination of manual techniques (neck pain3535 Fredin K, Loras H. Manual therapy, exercise therapy or combined treatment in the management of adult neck pain - a systematic review and meta-analysis. Musculos-kelet Sci Pract. 2017;31:62-71.,5050 Hidalgo B, Hall T, Bossert J, Dugeny A, Cagnie B, Pitance L. The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review. J Back Musculoskelet Rehabil. 2017;30(6):1149-69., lower back pain1414 Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Booth MS, et al. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J. 2018;18(5):866-79.,5151 Hidalgo B, Detrembleur C, Hall T, Mahaudens P, Nielens H. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. J Man Manip Ther. 2014;22(2):59-74., patellofemoral pain5252 Jayaseelan DJ, Scalzitti DA, Palmer G, Immerman A, Courtney CA. The effects of joint mobilization on individuals with patellofemoral pain: a systematic review. Clin Rehabil. 2018;32(6):722-33., impingement syndrome5353 Haik M, Alburquerque-Sendín F, Moreira R, Pires E, Camargo P. Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials. Br J Sports Med. 2016:bjsports-2015-095771., hip OA11 Sampath KK, Mani R, Miyamori T, Tumilty S. The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and meta-analysis. Clin Rehabil. 2016;30(12):1141-55., or using a particular technique of JM for pain treatment5454 Stathopoulos N, Dimitriadis Z, Koumantakis GA. Effectiveness of Mulligan's Mobilization with Movement techniques on pain and disability of peripheral joints: A systematic review with meta-analysis between 2008-2017. Physiotherapy. 2018.. In addition, it presents restrictions on language and publication period of selected articles, and the search was performed in a small number of databases, which makes these studies limited. Differently, the present review performed the search on 12 databases, without year and publication language restrictions, which reduces the risk of loss of some article at screening and, consequently, provides greater access to the data extracted from studies already published about this theme.

The prevalence of common musculoskeletal conditions has a strong relationship with age, being directly proportional to aging, with an increase of painful complaints due to the wear of the musculoskeletal system33 Blyth FM, Noguchi N. Chronic musculoskeletal pain and its impact on older people. Best Pract Res Clin Rheumatol. 2017;31(2):160-8.. In this review, neck pain was more prevalent among included studies4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.
-4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72., in contrast to the number of back pain studies in the literature, who had only one study included3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.. This may have been caused by not meeting the inclusion criteria in this review or the fact that manipulation seems to be the most appropriate technique for low back pain according to current re-visions1414 Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Booth MS, et al. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J. 2018;18(5):866-79.. Later appear the injuries that affect the shoulders, such as rotator cuff disease3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756. and frozen shoulder4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95. and to a less extent, diseases such as lateral epicondylagia1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88. and plantar fasciitis4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.. OA is a common condition shown in studies in different body regions and patellofemoral1717 Taylor AM, Phillips K, Patel KV, Turk DC, Dworkin RH, Beaton D, et al. Assessment of physical function and participation in chronic pain clinical trials: IMMPACT/ OMERACT recommendations. Pain. 2016;157(9):1836-50., carpometacarpal4444 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.

45 Villafañe JH, Langford D, Alguacil-Diego IM, Fernández-Carnero J. Management of trapeziometacarpal osteoarthritis pain and dysfunction using mobilization with movement technique in combination with kinesiology tape: a case report. J Chir Med. 2013;12(2):79-86.
-4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56. and hip1616 Wyke B, Polacek P. Articular neurology: the present position. J Joint Bone Surg. 1975;57(3):401..

Autors5151 Hidalgo B, Detrembleur C, Hall T, Mahaudens P, Nielens H. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. J Man Manip Ther. 2014;22(2):59-74. in a systematic review (SR) about JM and exercise efficacy for different stages of non-specific low back pain, found that JM (being the high speed and low amplitude manipulation of the pelvic loin region that presents evidence of moderate support compared to mobilization and soft tissue techniques including “myofascial,” “miotensive” or “harmonic” techniques in this same body region), in combination with specific and/or general exercises, or usual medical care, are better than any of these isolated interventions.

In agreement, study1414 Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Booth MS, et al. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J. 2018;18(5):866-79. in a meta-analysis on manipulation and mobilization in the treatment of chronic low back pain, have observed that the manipulation of high speed and low amplitude (thrust) is the most recommended. However, the search conducted in this SR showed year restriction (January 2000 to April 2013), language (only articles in English), and a few electronic databases (Medline, Cochrane Register of Controlled Trials, PEDro, CINAHL, PsycINFO, and ICL). In this meta-analysis, a specific population was not defined since there was no homogeneity in the causes of low back pain, which implies a greater heterogeneity of studies and consequently a higher methodological bias and less applicability of these data in clinical practice. In an SR about the use of exercise in mechanical neck pain, stu-dy5555 Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015;1:CD004250. concluded that there was no evidence of high quality, indicating that there is still uncertainty about the efficacy of specific strengthening and resistance exercises for neck pain. Study5050 Hidalgo B, Hall T, Bossert J, Dugeny A, Cagnie B, Pitance L. The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review. J Back Musculoskelet Rehabil. 2017;30(6):1149-69., in SR about JM efficacy and exercise for nonspecific cervical pain, emphasized the importance of performing combined treatment (JM plus exercises), being better compared to JM or exercises alone. The authors also showed that JM does not need to be applied at the symptomatic level to improve pain and can then be applied at adjacent levels according to the irritability status5050 Hidalgo B, Hall T, Bossert J, Dugeny A, Cagnie B, Pitance L. The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review. J Back Musculoskelet Rehabil. 2017;30(6):1149-69.. These reviews also show that manipulation is less indicated in cervical disorders, recommending that the thoracic manipulation or mobilization should be performed. This agrees with results found in studies included in this SR4141 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.
-4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53., who considered mobilization as a treatment with good results in patients with nonspecific mechanical neck pain and with whiplash injury-related cervical disorders, applied either alone or in association with conventional therapy. In studies about chronic pain, pain intensity is considered the primary outcome in most clinical trials5656 May M, Junghaenel DU, Ono M, Stone AA, Schneider S. Ecological Momentary Assessment Methodology in Chronic Pain Research: A Systematic Review. J Pain. 2018;19(7):699-716. and should be investigated both at rest and during movement. From the included studies, 12 evaluated only pain at rest1515 Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.,3737 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.,3838 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.,4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.

41 Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.

42 Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.

43 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.

44 Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.

45 Villafañe JH, Langford D, Alguacil-Diego IM, Fernández-Carnero J. Management of trapeziometacarpal osteoarthritis pain and dysfunction using mobilization with movement technique in combination with kinesiology tape: a case report. J Chir Med. 2013;12(2):79-86.
-4646 Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53., one study assessed only pain in motion3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64., and only one has evaluated pain at rest and during movement3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.. Both the intensity of pain in rest and during movement must be evaluated because there are pain conditions that do not occur or have lower intensity at rest, which may mask the evaluation and generate a bias in the study.

Therefore, it is very important to perform pain assessment in these two conditions in order to have more reliable data about the pain of a population.

In the reviews cited above, positive results were also observed for the reduction of pain associated with the use of manual therapy/ mobilization and combinations with exercises5050 Hidalgo B, Hall T, Bossert J, Dugeny A, Cagnie B, Pitance L. The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review. J Back Musculoskelet Rehabil. 2017;30(6):1149-69.. In a previous SR about the use of physiotherapeutic treatment in subacromial pain, it has been shown that exercise therapy should be the best treatment for pain reduction and improvement of function and range of motion. However, the addition of joint mobilizations to exercise can accelerate the reduction of short-term pain5353 Haik M, Alburquerque-Sendín F, Moreira R, Pires E, Camargo P. Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials. Br J Sports Med. 2016:bjsports-2015-095771.. The same can be observed in studies included in this SR that combine the use of JM with conventional physiotherapy3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,3030 Vicenzino B, Cartwright T, Collins D, Wright A. Cardiovascular and respiratory changes produced by lateral glide mobilization of the cervical spine. Man Ther. 1998;3(2):67-71.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.. People with chronic pain present reduced functionality, and this loss can be evaluated through functional index instruments1818 Seroussi R. Chronic pain assessment. Phys Med Rehabil Clin N Am. 2015;26(2):185-99.. Of the 14 included studies, only seven assessed functionality3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.

37 Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.

38 Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.

39 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.
-4040 Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.,4848 Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.,4949 Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53., which shows a deficiency in studies regarding the evaluation of this variable. This is evidenced by the Initiative on Methods, Measurement and Evaluation of Pain in Clinical Trials (IMMPACT) and Outcome Measures in Rheumatology (OME-RACT), which bring the importance of assessing both pain and functionality of patients1717 Taylor AM, Phillips K, Patel KV, Turk DC, Dworkin RH, Beaton D, et al. Assessment of physical function and participation in chronic pain clinical trials: IMMPACT/ OMERACT recommendations. Pain. 2016;157(9):1836-50..

A systematic review investigated the risks of manual treatment on the vertebral segment and concluded that serious adverse events are rare, the most common are mild, and these are associated with a greater amount of spinal manipulation5757 Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Therap. 2017;25:37.. Although some studies included in this SR3636 Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.,3939 Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.,4343 Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43. have investigated adverse events as a secondary outcome and have reported as minimum, there are not enough data to prove this variable due to heterogeneity of the studies.

This review presented some strength points, including the development of the question and the population table, intervention, control/comparison and result (PICO strategy), use of a systematic, explicit and transparent methodology, incorporating internal validity evaluation (risk of bias), independent methodological evaluation by a third reviewer for each of the technical steps involved in the review phases, and a comprehensive survey in most databases, without restrictions. None of the authors reported any conflict of interest.

Nevertheless, there are some limitations in this systematic review that make it impossible to conduct a meta-analysis. Although most of the included studies present low risk of bias, there was a significant heterogeneity regarding the protocol of JM application (different degrees of mobilization, series, repetitions, body segments, type of mobilization - Mulligan, Maitland, Kalten-born and passive), duration of the chronic condition, treatment performed by more than one professional with different experiences and training times, compared to control groups or placebo using other techniques or treatments that are not related to manual therapy and outcomes assessed in different ways.

From that, future clinical trials should aim to use only the JM technique in experimental groups to standardize the application protocols of the techniques and validate placebo techniques with the use of manual therapy. Based on that, studies can be performed with greater methodological accuracy regarding the application of the technique and can generate greater and more reliable results.

CONCLUSION

According to the results of this review, JM seems to be an effective technique for CMP, when applied alone or in association with other interventions, once it causes pain intensity decrease, improvement on range of motion, strength, functionality, quality of life, with good patient adherence/satisfaction and low adverse events. Based on this review, no specific clinical recommendations can be made on the optimal dose of treatment through JM. Future clinical trials should investigate mobilization types and the dose of treatment according to different musculoskeletal diseases.

REFERENCES

  • 1
    Sampath KK, Mani R, Miyamori T, Tumilty S. The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and meta-analysis. Clin Rehabil. 2016;30(12):1141-55.
  • 2
    Sahrmann S, Azevedo DC, Dillen LV. Diagnosis and treatment of movement system impairment syndromes. Braz J Phys Therapy. 2017;21(6):391-9.
  • 3
    Blyth FM, Noguchi N. Chronic musculoskeletal pain and its impact on older people. Best Pract Res Clin Rheumatol. 2017;31(2):160-8.
  • 4
    Cimmino MA, Ferrone C, Cutolo M. Epidemiology of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol. 2011;25(2):173-83.
  • 5
    Toye F, Seers K, Allcock N, Briggs M, Carr E, Andrews J, et al. Patients' experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review. Br J Gen Pract. 2013;63(617):e829-e41.
  • 6
    Gerdle B, Ghafouri B, Ernberg M, Larsson B. Chronic musculoskeletal pain: review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique. J Pain Res. 2014;7:313.
  • 7
    Crofford LJ. Chronic pain: where the body meets the brain. Trans Am Clin Climatol Assoc. 2015;126:167.
  • 8
    Clauw DJ. Diagnosing and treating chronic musculoskeletal pain based on the underlying mechanism(s). Best Pract Res Clin Rheumatol. 2015;29(1):6-19.
  • 9
    Hirase T, Kataoka H, Inokuchi S, Nakano J, Sakamoto J, Okita M. Factors associated with chronic musculoskeletal pain in Japanese community-dwelling older adults: A cross-sectional study. Medicine. 2017;96(23):e7069.
  • 10
    Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;4:CD011279.
  • 11
    Ushida T. Burdensome problems of chronic musculoskeletal pain and future prospects. J Orthop Sci. 2015;20(6):958-66.
  • 12
    Rajapakse D, Liossi C, Howard RF. Presentation and management of chronic pain. Arch Dis Child. 2014;99(5):474-80.
  • 13
    Krekoukias G, Gelalis ID, Xenakis T, Gioftsos G, Dimitriadis Z, Sakellari V. Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. J Man Manip Ther. 2017;25(2):66-73.
  • 14
    Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Booth MS, et al. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J. 2018;18(5):866-79.
  • 15
    Richer N, Marchand AA, Descarreaux M. Management of chronic lateral epicondylitis with manual therapy and local cryostimulation: a pilot study. J Chiropr Med. 2017;16(4):279-88.
  • 16
    Wyke B, Polacek P. Articular neurology: the present position. J Joint Bone Surg. 1975;57(3):401.
  • 17
    Taylor AM, Phillips K, Patel KV, Turk DC, Dworkin RH, Beaton D, et al. Assessment of physical function and participation in chronic pain clinical trials: IMMPACT/ OMERACT recommendations. Pain. 2016;157(9):1836-50.
  • 18
    Seroussi R. Chronic pain assessment. Phys Med Rehabil Clin N Am. 2015;26(2):185-99.
  • 19
    Kingston L, Claydon L, Tumilty S. The effects of spinal mobilizations on the sympathetic nervous system: a systematic review. Man Ther. 2014;19(4):281-7.
  • 20
    Lovick T. Interactions between descending pathways from the dorsal and ventrolateral periaqueductal gray matter in the rat. The midbrain periaqueductal gray matter: Springer; 1991. 101-20p.
  • 21
    Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Man Ther. 2001;6(2):72-81.
  • 22
    Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexci-tatory effects of mobilization with movement for lateral epicondylalgia. Phys Ther. 2003;83(4):374-83.
  • 23
    Slater H, Vicenzino B, Wright A. 'Sympathetic Slump': the effects of a novel manual therapy technique on peripheral sympathetic nervous system function. J Man Manip Ther. 1994;2(4):156-62.
  • 24
    Perry J, Green A, Singh S, Watson P. A randomised, independent groups study investigating the sympathetic nervous system responses to two manual therapy treatments in patients with LBP. Man Ther. 2015;20(6):861-7.
  • 25
    Tsirakis V, Perry J. The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on sympathetic outflow to the lower limbs. Man Ther. 2015;20(1):103-8.
  • 26
    Piekarz V, Perry J. An investigation into the effects of applying a lumbar Maitland mobilisation at different frequencies on sympathetic nervous system activity levels in the lower limb. Man Ther. 2016;23(1):83-9.
  • 27
    Moutzouri M, Perry J, Billis E. Investigation of the effects of a centrally applied lumbar sustained natural apophyseal glide mobilization on lower limb sympathetic nervous system activity in asymptomatic subjects. J Manipulative Physiol Ther. 2012;35(4):286-94.
  • 28
    Cleland J, Durall C, Scott SA. Effects of slump long sitting on peripheral sudomotor and vasomotor function: a pilot study. J Man Manip Ther. 2002;10(2):67-75.
  • 29
    Navarro-Santana MJ, Gómez-Chiguano GF, Somkereki MD, Fernández-de-las-Peñas C, Cleland JA, Plaza-Manzano G. Effects of joint mobilisation on clinical manifestations of sympathetic nervous system activity: a systematic review and meta-analysis. Physiotherapy. 2019. Epub ahead print)
  • 30
    Vicenzino B, Cartwright T, Collins D, Wright A. Cardiovascular and respiratory changes produced by lateral glide mobilization of the cervical spine. Man Ther. 1998;3(2):67-71.
  • 31
    La Touche R, París-Alemany A, Mannheimer JS, Angulo-Díaz-Parreño S, Bishop MD, Lopéz-Valverde-Centeno A, et al. Does mobilization of the upper cervical spine affect pain sensitivity and autonomic nervous system function in patients with cervi-co-craniofacial pain?: A randomized-controlled trial. Clin J Pain. 2013;29(3):205-15.
  • 32
    Roy RA, Boucher JP, Comtois AS. Paraspinal cutaneous temperature modification after spinal manipulation at L5. J Manipulative Physiol Ther. 2010;33(4):308-14.
  • 33
    Skyba D, Radhakrishnan R, Rohlwing J, Wright A, Sluka K. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain. 2003;106(1-2):159-68.
  • 34
    Martins DF, Mazzardo-Martins L, Cidral-Filho FJ, Stramosk J, Santos AR. Ankle joint mobilization affects postoperative pain through peripheral and central adenosine A1 receptors. Phys Ther. 2013;93(3):401-12.
  • 35
    Fredin K, Loras H. Manual therapy, exercise therapy or combined treatment in the management of adult neck pain - a systematic review and meta-analysis. Musculos-kelet Sci Pract. 2017;31:62-71.
  • 36
    Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ. 2010;340:c2756.
  • 37
    Tavares FA, Chaves TC, Silva ED, Guerreiro GD, Gonçalves JF, Albuquerque AA. Immediate effects of joint mobilization compared to sham and control intervention for pain intensity and disability in chronic low back pain patients: randomized controlled clinical trial. Rev Dor. 2017;18(1):2-7.
  • 38
    Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: a randomised controlled trial. Man Ther. 2016;22:80-5.
  • 39
    Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy M, Ozturk H, et al. Exercise, education, manual-therapy and taping compared to education for patello-femoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457-64.
  • 40
    Shashua A, Flechter S, Avidan L, Ofir D, Melayev A, Kalichman L. The effect of additional ankle and midfoot mobilizations on plantar fasciitis: a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(4):265-72.
  • 41
    Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. J Orthop Sports Phys Ther. 2014;44(3):141-52.
  • 42
    Farooq MN, Mohseni-Bandpei MA, Gilani SA, Ashfaq M, Mahmood Q. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31.
  • 43
    Mayor EE, Pérez GL, Martín YP, del Barco ÁA, Fuertes RR, Requejo CS, et al. Ensayo clínico aleatorizado en pacientes con cervicalgia mecánica en atención primaria: terapia manual frente a electroestimulación nerviosa transcutánea. Aten Primaria. 2008;40(7):337-43.
  • 44
    Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2012;35(2):110-20.
  • 45
    Villafañe JH, Langford D, Alguacil-Diego IM, Fernández-Carnero J. Management of trapeziometacarpal osteoarthritis pain and dysfunction using mobilization with movement technique in combination with kinesiology tape: a case report. J Chir Med. 2013;12(2):79-86.
  • 46
    Villafañe JH, Silva GB, Diaz-Parreño SA, Fernandez-Carnero J. Hypoalgesic and motor effects of kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Manipulative Physiol Ther. 2011;34(8):547-56.
  • 47
    Villafañe JH, Cleland JA, Fernandez-De-Las-Peñas C. Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Ther. 2013;36(4):232-7.
  • 48
    Horst R, Maicki T, Trąbka R, Albrecht S, Schmidt K, Mçtel S, et al. Activity-vs. struc-tural-oriented treatment approach for frozen shoulder: a randomized controlled trial. Clin Rehabil. 2017;31(5):686-95.
  • 49
    Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: a pilot randomised controlled trial. Man Ther. 2010;15(2):149-53.
  • 50
    Hidalgo B, Hall T, Bossert J, Dugeny A, Cagnie B, Pitance L. The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review. J Back Musculoskelet Rehabil. 2017;30(6):1149-69.
  • 51
    Hidalgo B, Detrembleur C, Hall T, Mahaudens P, Nielens H. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. J Man Manip Ther. 2014;22(2):59-74.
  • 52
    Jayaseelan DJ, Scalzitti DA, Palmer G, Immerman A, Courtney CA. The effects of joint mobilization on individuals with patellofemoral pain: a systematic review. Clin Rehabil. 2018;32(6):722-33.
  • 53
    Haik M, Alburquerque-Sendín F, Moreira R, Pires E, Camargo P. Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials. Br J Sports Med. 2016:bjsports-2015-095771.
  • 54
    Stathopoulos N, Dimitriadis Z, Koumantakis GA. Effectiveness of Mulligan's Mobilization with Movement techniques on pain and disability of peripheral joints: A systematic review with meta-analysis between 2008-2017. Physiotherapy. 2018.
  • 55
    Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015;1:CD004250.
  • 56
    May M, Junghaenel DU, Ono M, Stone AA, Schneider S. Ecological Momentary Assessment Methodology in Chronic Pain Research: A Systematic Review. J Pain. 2018;19(7):699-716.
  • 57
    Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Therap. 2017;25:37.

Publication Dates

  • Publication in this collection
    27 Feb 2020
  • Date of issue
    Jan-Mar 2020

History

  • Received
    19 Nov 2019
  • Accepted
    02 Jan 2020
Sociedade Brasileira para o Estudo da Dor Av. Conselheiro Rodrigues Alves, 937 Cj2 - Vila Mariana, CEP: 04014-012, São Paulo, SP - Brasil, Telefones: , (55) 11 5904-2881/3959 - São Paulo - SP - Brazil
E-mail: dor@dor.org.br