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Effects of Joint Mobilizations and Manipulations

Effects of Joint Mobilizations and Manipulations

The effects of joint mobilizations and manipulations on kinematics and muscular changes. Identifying the use of joint mobs and manips on the cervical, thoracic, and lumbar spine, and the effects on range of motion, pain, nervous system response, and motion at the neck, shoulder, hip, knee, ankle. Research showing these effects are not placebo.

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Course Description: Effects of Joint Mobilizations and Manipulations

Physical rehabilitation professionals, including physical therapists, osteopaths, and chiropractors, have been refining joint mobilizations and joint manipulations for 100s of years. There are even depictions of joint mobilization treatment that are 1000s of years old. Joint mobilization strategies have been published for chronic pain of the low back, hand pain, extremity joint issues, and various sports injuries. Some practitioners have noted the effect of joint mobilizations and joint manipulations on muscle activity and have integrated these techniques into routines for muscle weakness, muscle strains, and recurring pain relief for active trigger points.

The neurophysiological and mechanical effects of mobilizations and manipulations are actually quite complex. However, the simplest and most effective recommendation for their use is the intent to reduce joint stiffness for specific joints that have been assessed as exhibiting a reduction in joint play (arthrokinematic motion). Despite outcome studies demonstrating the efficacy of this approach to using these techniques, it would be presumptive to imply that there is a single, or a simple reason, that these techniques are effective. Some studies even imply mechanisms that are similar to deep tissue massage, massage guns, and other muscle tissue and connective tissue techniques, that are related to nerve endings involved in neuromuscular reflexes like autogenic inhibition (relaxation response), and altered cortisol concentrations (stress hormone), and central nervous system mediated pain relief which may be particularly effective for the treatment of chronic pain.

We hope this course helps to build a foundation of knowledge regarding the effects of joint intended technique from a very large body of research and rich clinical history. Further, this course is pre-approved for credits toward the Integrated Manual Therapist (IMT) Certification, and pre-approved for continuing education credits for sports medicine professionals and health care providers (physical therapists, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.).

Pre-approved credits for:

Pre-approved for Continuing Education Credits for:

This Course Includes:

  • AI Tutor
  • Webinar
  • Study Guide
  • Text and Illustrations
  • Audio Voice-over
  • Research Review
  • Practice Exam
  • Pre-approved Final Exam

Brookbush Institute's Position Statement

Mobilizations and manipulations result in kinematic, neurophysiological, and muscular changes that have been correlated with the improvement of various subjective and objective patient outcomes, both short-term and long-term. Further, these changes have been demonstrated in randomized placebo/nocebo-controlled trials, implying the effects are not attributable to placebo or patient perceptions/expectations.

What this Course Covers

  • Myth Busting
    • The Effects Are Not Placebo
  • Kinematics
    • Joint Motion During Mobilization and Manipulation
    • Factors affecting force during mobilization and manipulations.
    • Factors Affecting Joint Stiffness
    • Effect on Structures
  • Nervous System
    • H-reflex, M-wave, and V-wave Response
    • Central Nervous System (CNS) Mediated Changes
    • Sympatho-excitatory Effects
    • Analgesia
  • Muscle Activity
    • Spine
    • Extremities
    • Additional Considerations

Course Study Guide: Effects of Joint Mobilizations and Manipulations

Course Webinar: Effects of Joint Mobilizations and Manipulations

Introduction

Research Summary

Myth Busting: The Effects are Not Placebo

Kinematics: Joint Motion During Mobilizations and Manipulations
5 Sub Sections

Kinematics: Factors Affecting Joint Stiffness
2 Sub Sections

Kinematics: Factors Affecting Force During Mobilizations and Manipulations
2 Sub Sections

Nervous System
4 Sub Sections

Muscle Activity
3 Sub Sections

Bibliography

Bibliography

Cervical Spine Kinematics

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  6. Williams, J. M., & Cuesta-Vargas, A. I. (2013). An investigation into the kinematics of 2 cervical manipulation techniques. Journal of manipulative and physiological therapeutics, 36(1), 20-26.
    • Manipulation results in less ROM than Active ROM
  7. Van Geyt, B., Dugailly, P. M., Klein, P., Lepers, Y., Beyer, B., & Feipel, V. (2017). Assessment of in vivo 3D kinematics of cervical spine manipulation: Influence of practitioner experience and occurrence of cavitation noise. Musculoskeletal Science and Practice, 28, 18-24.
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    • Cervical Mobilization
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    • Lumbar
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    • Spine Manipulation Kinematics and Outcomes
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    • Shoulder
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    • Movement of Adjacent Segments
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    • Effect on Structures
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    • Amount of Force Necessary for Failure of Tissue
  38. Sran, M. M., Khan, K. M., Zhu, Q., McKay, H. A., & Oxland, T. R. (2004). Failure characteristics of the thoracic spine with a posteroanterior load: investigating the safety of spinal mobilization. Spine, 29(21), 2382-2388.
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    • Toe and Creep
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    • Direction of Force during mobilization
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    • Fascia
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    • Support from investing structures
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    1. Position of the Spine, Pelvis, and Rib Cage
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    • Physical Characteristics
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    • Muscle Activity's Effect on Stiffness
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    • Hand Position and Grip
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    • Gender
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    • Experience
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    • Practitioners Can Alter Force
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    • Comparing Techniques
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    • Manual Fixation
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    • Additional Variables Affecting Force During Practice and Research
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    • Local analgesic effects
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    • Distal Analgesic Effects
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  98. George, S. Z., Bishop, M. D., Bialosky, J. E., Zeppieri, G., & Robinson, M. E. (2006). Immediate effects of spinal manipulation on thermal pain sensitivity: an experimental study. BMC Musculoskeletal disorders, 7(1), 68.
  99. Bialosky, J. E., Bishop, M. D., Robinson, M. E., Barabas, J. A., & George, S. Z. (2008). The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects. BMC Musculoskeletal Disorders, 9(1), 19.
  100. Yang J, Lee B, Kim C. Changes in proprioception and pain in patients with neck pain after upper thoracic manipulation. J Phys Ther Sci. 2015;27(3):795-8.
  101. Fernández-De-Las-Peñas, C., Pérez-De-Heredia, M., Brea-Rivero, M., & Miangolarra-Page, J. C. (2007). Immediate effects on pressure pain threshold following a single cervical spine manipulation in healthy subjects. Journal of Orthopaedic & Sports Physical Therapy, 37(6), 325-329.
  102. Fernández-Carnero, J., Fernández-de-las-Peñas, C., & Cleland, J. A. (2008). Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. Journal of manipulative and physiological therapeutics, 31(9), 675-681.
  103. Fernández-Carnero, J., Cleland, J. A., & Arbizu, R. L. T. (2011). Examination of motor and hypoalgesic effects of cervical vs thoracic spine manipulation in patients with lateral epicondylalgia: a clinical trial. Journal of manipulative and physiological therapeutics, 34(7), 432-440.
  104. Vicenzino, B., Collins, D., Benson, H., & Wright, A. (1998). An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. Journal of manipulative and physiological therapeutics, 21(7), 448-453.
  105. Vicenzino, B., Collins, D., & Wright, A. (1996). The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain, 68(1), 69-74.
  106. Abbott, J. H. (2001). Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. Manual Therapy, 6(3), 170-177.
    • Trigger Point Sensitivity
  107. Ruiz-Sáez, M., Fernández-de-las-Peñas, C., Blanco, C. R., Martínez-Segura, R., & García-León, R. (2007). Changes in pressure pain sensitivity in latent myofascial trigger points in the upper trapezius muscle after a cervical spine manipulation in pain-free subjects. Journal of manipulative and physiological therapeutics, 30(8), 578-583.
  108. Srbely, J. Z., Vernon, H., Lee, D., & Polgar, M. (2013). Immediate effects of spinal manipulative therapy on regional antinociceptive effects in myofascial tissues in healthy young adults. Journal of manipulative and physiological therapeutics, 36(6), 333-341.
  109. Coronado, R. A., Bialosky, J. E., Bishop, M. D., Riley 3rd, J. L., Robinson, M. E., Michener, L. A., & George, S. Z. (2015). The comparative effects of spinal and peripheral thrust manipulation and exercise on pain sensitivity and the relation to clinical outcome: a mechanistic trial using a shoulder pain model. journal of orthopaedic & sports physical therapy, 45(4), 252-264.
    • A-Fibers versus C-Fibers
  110. Bialosky, J. E., Bishop, M. D., Robinson, M. E., Zeppieri Jr, G., & George, S. Z. (2009). Spinal manipulative therapy has an immediate effect on thermal pain sensitivity in people with low back pain: a randomized controlled trial. Physical therapy, 89(12), 1292-1303.
    • Inconsistencies
  111. Penza, C. W., Horn, M. E., George, S. Z., & Bishop, M. D. (2017). Comparison of 2 lumbar manual therapies on temporal summation of pain in healthy volunteers. The Journal of Pain, 18(11), 1397-1408.
  112. Thomson, O., Haig, L., & Mansfield, H. (2009). The effects of high-velocity low-amplitude thrust manipulation and mobilisation techniques on pressure pain threshold in the lumbar spine. International Journal of Osteopathic Medicine, 12(2), 56-62.
  113. Aspinall, S. L., Jacques, A., Leboeuf-Yde, C., Etherington, S. J., & Walker, B. F. (2019). No difference in pressure pain threshold and temporal summation after lumbar spinal manipulation compared to sham: A randomised controlled trial in adults with low back pain. Musculoskeletal Science and Practice.
  114. Orakifar, N., Kamali, F., Pirouzi, S., & Jamshidi, F. (2012). Sacroiliac joint manipulation attenuates alpha-motoneuron activity in healthy women: a quasi-experimental study. Archives of physical medicine and rehabilitation, 93(1), 56-61.
  115. Jordon, M. K., Beattie, P. F., D’Urso, S., & Scriven, S. (2017). Spinal manipulation does not affect pressure pain thresholds in the absence of neuromodulators: a randomized controlled trial. Journal of Manual & Manipulative Therapy, 25(4), 172-181.
  116. O’Neill, S., Ødegaard-Olsen, Ø., & Søvde, B. (2015). The effect of spinal manipulation on deep experimental muscle pain in healthy volunteers. Chiropractic & manual therapies, 23(1), 25.
    • H-reflex Attenuation
  117. Dishman, J. D., & Bulbulian, R. (2000). Spinal reflex attenuation associated with spinal manipulation. Spine, 25(19), 2519-2525.
  118. Dishman, J. D., Burke, J. R., & Dougherty, P. (2018). Motor Neuron Excitability Attenuation as a Sequel to Lumbosacral Manipulation in Subacute Low Back Pain Patients and Asymptomatic Adults: A Cross-Sectional H-Reflex Study. Journal of manipulative and physiological therapeutics, 41(5), 363-371.
  119. Suter, E., McMorland, G., & Herzog, W. (2005). Short-term effects of spinal manipulation on H-reflex amplitude in healthy and symptomatic subjects. Journal of manipulative and physiological therapeutics, 28(9), 667-672.
  120. Murphy, B. A., Dawson, N. J., & Slack, J. R. (1995). Sacroiliac joint manipulation decreases the H-reflex. Electromyography and clinical neurophysiology, 35(2), 87.
  121. Dishman, J. D., Cunningham, B. M., & Burke, J. (2002). Comparison of tibial nerve H-reflex excitability after cervical and lumbar spine manipulation. Journal of manipulative and physiological therapeutics, 25(5), 318-325.
  122. Dishman, J. D., & Burke, J. (2003). Spinal reflex excitability changes after cervical and lumbar spinal manipulation: a comparative study. The spine journal, 3(3), 204-212.
  123. Dishman, J. D., Dougherty, P. E., & Burke, J. R. (2005). Evaluation of the effect of postural perturbation on motoneuronal activity following various methods of lumbar spinal manipulation. The Spine Journal, 5(6), 650-659.
  124. Floman, Y., Liram, N., & Gilai, A. N. (1997). Spinal manipulation results in immediate H-reflex changes in patients with unilateral disc herniation. European Spine Journal, 6(6), 398-401.
  125. Bulbulian, R., Burke, J., & Dishman, J. D. (2002). Spinal reflex excitability changes after lumbar spine passive flexion mobilization. Journal of Manipulative & Physiological Therapeutics, 25(8), 526-532.
    • V-wave and M-wave
  126. Grindstaff, T. L., Beazell, J. R., Sauer, L. D., Magrum, E. M., Ingersoll, C. D., & Hertel, J. (2011). Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle instability. Journal of Electromyography and Kinesiology, 21(4), 652-658.
  127. Azadvari, M., Razavi, S. Z. E., Rezaiee-Moghaddam, F., Reza-Soltani, Z., Azizi, S., & Rakhshan, A. (2018). H-Reflex Attenuation after Lumbosacral Manipulation in Patients With Low Back Pain. Acta Medica Iranica, 56(10), 671-671.
  128. Niazi, I. K., Türker, K. S., Flavel, S., Kinget, M., Duehr, J., & Haavik, H. (2015). Changes in H-reflex and V-waves following spinal manipulation. Experimental brain research, 233(4), 1165-1173.
  129. Christiansen, Thomas Lykke, Imran Khan Niazi, Kelly Holt, Rasmus Wiberg Nedergaard, Jens Duehr, Kathryn Allen, Paul Marshall, Kemal S. Türker, Jan Hartvigsen, and Heidi Haavik. "The effects of a single session of spinal manipulation on strength and cortical drive in athletes." European journal of applied physiology 118, no. 4 (2018): 737-749.
  130. Colloca, C. J., Keller, T. S., & Gunzburg, R. (2004). Biomechanical and neurophysiological responses to spinal manipulation in patients with lumbar radiculopathy. Journal of manipulative and physiological therapeutics, 27(1), 1-15.
  131. Cao, D. Y., Reed, W. R., Long, C. R., Kawchuk, G. N., & Pickar, J. G. (2013). Effects of thrust amplitude and duration of high-velocity, low-amplitude spinal manipulation on lumbar muscle spindle responses to vertebral position and movement. Journal of manipulative and physiological therapeutics, 36(2), 68-77.
  132. Sung, P. S., Kang, Y. M., & Pickar, J. G. (2005). Effect of spinal manipulation duration on low threshold mechanoreceptors in lumbar paraspinal muscles: a preliminary report. Spine, 30(1), 115-122.
  133. Pickar, J. G., & Kang, Y. M. (2006). Paraspinal muscle spindle responses to the duration of a spinal manipulation under force control. Journal of manipulative and physiological therapeutics, 29(1), 22-31.
    • Central Nervous System (CNS) Mediated Changes
  134. Haavik-Taylor, H., & Murphy, B. (2007). Transient modulation of intracortical inhibition following spinal manipulation. Chiropractic Journal of Australia, 37(3), 106.
  135. Lelic, D., Niazi, I. K., Holt, K., Jochumsen, M., Dremstrup, K., Yielder, P., … & Haavik, H. (2016). Manipulation of dysfunctional spinal joints affects sensorimotor integration in the prefrontal cortex: A brain source localization study. Neural plasticity, 2016.
  136. Daligadu, J., Haavik, H., Yielder, P. C., Baarbe, J., & Murphy, B. (2013). Alterations in cortical and cerebellar motor processing in subclinical neck pain patients following spinal manipulation. Journal of manipulative and physiological therapeutics, 36(8), 527-537.
  137. Sparks, C., Cleland, J. A., Elliott, J. M., Zagardo, M., & Liu, W. C. (2013). Using functional magnetic resonance imaging to determine if cerebral hemodynamic responses to pain change following thoracic spine thrust manipulation in healthy individuals. journal of orthopaedic & sports physical therapy, 43(5), 340-348.
  138. Haavik, H., Niazi, I., Jochumsen, M., Sherwin, D., Flavel, S., & Türker, K. (2017). Impact of spinal manipulation on cortical drive to upper and lower limb muscles. Brain sciences, 7(1), 2.
  139. Dishman, J. D., Ball, K. A., & Burke, J. (2002). First prize central motor excitability changes after spinal manipulation: a transcranial magnetic stimulation study. Journal of manipulative and physiological therapeutics, 25(1), 1-9.
  140. Dishman, J. D., Greco, D. S., & Burke, J. R. (2008). Motor-evoked potentials recorded from lumbar erector spinae muscles: a study of corticospinal excitability changes associated with spinal manipulation. Journal of manipulative and physiological therapeutics, 31(4), 258-270.
  141. Humphries, K. M., Ward, J., Coats, J., Nobert, J., Amonette, W., & Dyess, S. (2013). Immediate effects of lower cervical spine manipulation on handgrip strength and free-throw accuracy of asymptomatic basketball players: a pilot study. Journal of chiropractic medicine, 12(3), 153-159.
  142. Harkey, M., McLeod, M., Van Scoit, A., Terada, M., Tevald, M., Gribble, P., & Pietrosimone, B. (2014). The immediate effects of an anterior-to-posterior talar mobilization on neural excitability, dorsiflexion range of motion, and dynamic balance in patients with chronic ankle instability. Journal of sport rehabilitation, 23(4), 351-359.
  143. Fisher, B. E., Piraino, A., Lee, Y. Y., Smith, J. A., Johnson, S., Davenport, T. E., & Kulig, K. (2016). The effect of velocity of joint mobilization on corticospinal excitability in individuals with a history of ankle sprain. journal of orthopaedic & sports physical therapy, 46(7), 562-570.
  144. Fryer, G., & Pearce, A. J. (2012). The effect of lumbosacral manipulation on corticospinal and spinal reflex excitability on asymptomatic participants. Journal of manipulative and Physiological Therapeutics, 35(2), 86-93.
    • Hormones and Neurotransmitter
  145. Molins-Cubero, S., Rodríguez-Blanco, C., Oliva-Pascual-Vaca, Á., Heredia-Rizo, A. M., Boscá-Gandía, J. J., & Ricard, F. (2014). Changes in pain perception after pelvis manipulation in women with primary dysmenorrhea: a randomized controlled trial. Pain Medicine, 15(9), 1455-1463.
  146. (236) Sanders, G. E., Reinert, O., Tepe, R., & Maloney, P. (1990). Chiropractic adjustive manipulation on subjects with acute low back pain: visual analog pain scores and plasma beta-endorphin levels. Journal of Manipulative and Physiological Therapeutics, 13(7), 391-395
  147. (105) Puhl, A. A., & Injeyan, H. S. (2012). Short-term effects of manipulation to the upper thoracic spine of asymptomatic subjects on plasma concentrations of epinephrine and norepinephrine—a randomized and controlled observational study. Journal of manipulative and physiological therapeutics, 35(3), 209-215.
  148. Kokjohn, K., Schmid, D. M., Triano, J. J., & Brennan, P. C. (1992). The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. Journal of Manipulative and Physiological Therapeutics, 15(5), 279-285.
  149. Brennan, P. C., Kokjohn, K., Kaltinger, C. J., Lohr, G. E., Glendening, C., Hondras, M. A., … & Triano, J. J. (1991). Enhanced phagocytic cell respiratory burst induced by spinal manipulation: potential role of substance P. Journal of manipulative and physiological therapeutics, 14(7), 399-408.
  150. Brennan, P. C., Triano, J. J., McGregor, M., Kokjohn, K., Hondras, M. A., & Brennan, D. C. (1992). Enhanced neutrophil respiratory burst as a biological marker for manipulation forces: duration of the effect and association with substance P and tumor necrosis factor. Journal of manipulative and physiological therapeutics, 15(2), 83-89.
  151. Mackawan, Surussawadi, et al. "Effects of traditional Thai massage versus joint mobilization on substance P and pain perception in patients with non-specific low back pain." Journal of Bodywork and Movement Therapies 11.1 (2007): 9-16.
  152. Sampath, K. K., Botnmark, E., Mani, R., Cotter, J. D., Katare, R., Munasinghe, P. E., & Tumilty, S. (2017). Neuroendocrine response following a thoracic spinal manipulation in healthy men. journal of orthopaedic & sports physical therapy, 47(9), 617-627
  153. Valera-Calero, A., Gallego-Izquierdo, T., Malfliet, A., & Pecos-Martín, D. (2019). Endocrine response after cervical manipulation and mobilization in people with chronic mechanical neck pain: a randomized controlled trial. European journal of physical and rehabilitation medicine, 55(6), 792-805.
  154. Didehdar, D., Kamali, F., Yoosefinejad, A. K., & Lotfi, M. (2019). The effect of spinal manipulation on brain neurometabolites in chronic nonspecific low back pain patients: a randomized clinical trial. Irish Journal of Medical Science (1971-), 1-8.
  155. Paungmali, A., O’Leary, S., Souvlis, T., & Vicenzino, B. (2004). Naloxone fails to antagonize initial hypoalgesic effect of a manual therapy treatment for lateral epicondylalgia. Journal of manipulative and physiological therapeutics, 27(3), 180-185.
  156. Paungmali, A., Vicenzino, B., & Smith, M. (2003). Hypoalgesia induced by elbow manipulation in lateral epicondylalgia does not exhibit tolerance. The Journal of Pain, 4(8), 448-454.
    • Skin Changes:
  157. La Touche, R., París-Alemany, A., Mannheimer, J. S., Angulo-Díaz-Parreño, S., Bishop, M. D., Lopéz-Valverde-Centeno, A., … & Fernández-Carnero, J. (2013). Does mobilization of the upper cervical spine affect pain sensitivity and autonomic nervous system function in patients with cervico-craniofacial pain?: A randomized-controlled trial. The Clinical journal of pain, 29(3), 205-215.
  158. Sterling, M., Jull, G., & Wright, A. (2001). Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Manual therapy, 6(2), 72-81.
  159. Moulson, A., & Watson, T. (2006). A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population. Manual therapy, 11(3), 214-224.
  160. Jowsey, P., & Perry, J. (2010). Sympathetic nervous system effects in the hands following a grade III postero-anterior rotatory mobilisation technique applied to T4: a randomised, placebo-controlled trial. Manual therapy, 15(3), 248-253.
  161. Packer, A. C., Dibai-Filho, A. V., Costa, A. C. D. S., Macedo, A. B., Bortolazzo, G. L., & Rodrigues-Bigaton, D. (2015). Immediate effects of upper thoracic manipulation on the skin surface temperature of the vertebral region in healthy women. Fisioterapia e Pesquisa, 22(1), 54-60.
  162. Tsirakis, V., & Perry, J. (2015). The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on sympathetic outflow to the lower limbs. Manual therapy, 20(1), 103-108.
  163. Moutzouri, M., Perry, J., & Billis, E. (2012). Investigation of the Effects of a Centrally Applied Lumbar Sustained Natural Apophyseal Glide Mobilization on Lower Limb Sympathetic Nervous System Activity in Asymptomatic Subjects. Journal of Manipulative & Physiological Therapeutics, 35(4), 286-294.
  164. Yu, I. Y., Jung, I. G., Kang, M. H., Lee, D. K., & Oh, J. S. (2015). Immediate effects of an end-range mobilization technique on shoulder range of motion and skin temperature in individuals with posterior shoulder tightness. Journal of physical therapy science, 27(6), 1723-1725.
  165. Simon, R., Vicenzino, B., & Wright, A. (1997). The influence of an anteroposterior accessory glide of the glenohumeral joint on measures of peripheral sympathetic nervous system function in the upper limb. Manual Therapy, 2(1), 18-23.
    • Skin Changes: Differences
  166. Perry, J., Green, A., Singh, S., & Watson, P. (2015). A randomised, independent groups study investigating the sympathetic nervous system responses to two manual therapy treatments in patients with LBP. Manual therapy, 20(6), 861-867.
  167. Perry, J., Green, A., Singh, S., & Watson, P. (2011). A preliminary investigation into the magnitude of effect of lumbar extension exercises and a segmental rotatory manipulation on sympathetic nervous system activity. Manual therapy, 16(2), 190-195.
  168. Jiang, C. B., Wang, J., Zheng, Z. X., Hou, J. S., Ma, L., & Sun, T. (2012). Efficacy of cervical fixed-point traction manipulation for cervical spondylotic radiculopathy: a randomized controlled trial. Zhong xi yi jie he xue bao= Journal of Chinese integrative medicine, 10(1), 54-58.
  169. Chiu, T. W., & Wright, A. (1996). To compare the effects of different rates of application of a cervical mobilisation technique on sympathetic outflow to the upper limb in normal subjects. Manual Therapy, 1(4), 198-203.
  170. Harris, W., & Wagnon, R. J. (1987). The effects of chiropractic adjustments on distal skin temperature. Journal of manipulative and physiological therapeutics, 10(2), 57-60.
    • Cardiovascular Changes
  171. Yung, E. Y., Oh, C., Wong, M. S., Grimes, J. K., Barton, E. M., Ali, M. I., & Cameron, D. (2017). The immediate cardiovascular response to joint mobilization of the neck-a randomized, placebo-controlled trial in pain-free adults. Musculoskeletal Science and Practice, 28, 71-78.
  172. Yung, E., Oh, C., Wong, M., Grimes, J. K., Barton, E. M., Ali, M. I., & Breakey, A. (2019). Non-thrust cervical manipulations reduce short-term pain and decrease systolic blood pressure during intervention in mechanical neck pain: a randomized clinical trial. Journal of Manual & Manipulative Therapy, 1-12.
  173. Vicenzino, B., Cartwright, T., Collins, D., & Wright, A. (1998). Cardiovascular and respiratory changes produced by lateral glide mobilization of the cervical spine. Manual Therapy, 3(2), 67-71.
  174. McGuiness, J., Vicenzino, B., & Wright, A. (1997). Influence of a cervical mobilization technique on respiratory and cardiovascular function. Manual Therapy, 2(4), 216-220.
  175. Minarini, G., Ford, M., & Esteves, J. (2018). Immediate effect of T2, T5, T11 thoracic spine manipulation of asymptomatic patient on autonomic nervous system response: Single-blind, parallel-arm controlled-group experiment. International Journal of Osteopathic Medicine, 30, 12-17.
  176. Budgell, B., & Polus, B. (2006). The effects of thoracic manipulation on heart rate variability: a controlled crossover trial. Journal of manipulative and physiological therapeutics, 29(8), 603-610.
  177. Ghaffar, T., Sajjad, A., & Rasul, A. (2016). Effects of thoracic spine mobilization on vitals and blood oxygen level in healthy individuals. Journal of Islamic International Medical College, 11, 163-166.
  178. Ward, J., Coats, J., Tyer, K., Weigand, S., & Williams, G. (2013). Immediate effects of anterior upper thoracic spine manipulation on cardiovascular response. Journal of manipulative and physiological therapeutics, 36(2), 101-110.
  179. Ward, J., Tyer, K., Coats, J., Williams, G., & Kulcak, K. (2015). Immediate effects of upper thoracic spine manipulation on hypertensive individuals. Journal of Manual & Manipulative Therapy, 23(1), 43-50.
  180. de Araujo, F. X., Schell, M. S., Ferreira, G. E., Pessoa, M. D. V., de Oliveira, L. R., Borges, B. G., … & Silva, M. F. (2018). Autonomic function and pressure pain threshold following thoracic mobilization in asymptomatic subjects: A randomized controlled trial. Journal of bodywork and movement therapies, 22(2), 313-320.
  181. Araujo, F. X., Schell, M. S., Ferreira, G. E., Pessoa, M. D., Pinho, A. S., Plentz, R. D., & Silva, M. F. (2019). Short-Term Effects of Different Rates of Thoracic Mobilization on Pressure Pain Thresholds in Asymptomatic Individuals: A Randomized Crossover Trial. Journal of Chiropractic Medicine, 18(1), 33-41.
  182. da Silva, A. C., de Godoy Marques, C. M., & Marques, J. L. B. (2018). Influence of Spinal Manipulation on Autonomic Modulation and Heart Rate in Patients With Rotator Cuff Tendinopathy. Journal of chiropractic medicine, 17(2), 82-89.
  183. Welch, A., & Boone, R. (2008). Sympathetic and parasympathetic responses to specific diversified adjustments to chiropractic vertebral subluxations of the cervical and thoracic spine. Journal of chiropractic medicine, 7(3), 86-93.
  184. Win, N. N., Jorgensen, A. M. S., Chen, Y. S., & Haneline, M. T. (2015). Effects of upper and lower cervical spinal manipulative therapy on blood pressure and heart rate variability in volunteers and patients with neck pain: a randomized controlled, cross-over, preliminary study. Journal of chiropractic medicine, 14(1), 1-9.
  185. Roy, R. A., Boucher, J. P., & Comtois, A. S. (2009). Heart rate variability modulation after manipulation in pain-free patients vs patients in pain. Journal of manipulative and physiological therapeutics, 32(4), 277-286.
  186. Alonso-Perez, J. L., Lopez-Lopez, A., La Touche, R., Lerma-Lara, S., Suarez, E., Rojas, J., … & Fernández-Carnero, J. (2017). Hypoalgesic effects of three different manual therapy techniques on cervical spine and psychological interaction: A randomized clinical trial. Journal of bodywork and movement therapies, 21(4), 798-803.
  187. Vicenzino, B., Cartwright, T., Collins, D., & Wright, A. (1999). An investigation of stress and pain perception during manual therapy in asymptomatic subjects. European Journal of Pain, 3(1), 13-18.
  188. Plaugher, G., Long, C. R., Alcantara, J., Silveus, A. D., Wood, H., Lotun, K., … & Rowe, S. H. (2002). Practice-based randomized controlled-comparison clinical trial of chiropractic adjustments and brief massage treatment at sites of subluxation in subjects with essential hypertension: pilot study. Journal of manipulative and physiological therapeutics, 25(4), 221-239.
  189. Goertz, C. M., Salsbury, S. A., Vining, R. D., Long, C. R., Pohlman, K. A., Weeks, W. B., & Lamas, G. A. (2016). Effect of spinal manipulation of upper cervical vertebrae on blood pressure: results of a pilot sham-controlled trial. Journal of manipulative and physiological therapeutics, 39(5), 369-380.
    • Cervical
  190. Packer, A. C., Pires, P. F., Dibai-Filho, A. V., & Rodrigues-Bigaton, D. (2015). Effect of upper thoracic manipulation on mouth opening and electromyographic activity of masticatory muscles in women with temporomandibular disorder: a randomized clinical trial. Journal of manipulative and physiological therapeutics, 38(4), 253-261
  191. Pires, P. F., Packer, A. C., Dibai-Filho, A. V., & Rodrigues-Bigaton, D. (2015). Immediate and short-term effects of upper thoracic manipulation on myoelectric activity of sternocleidomastoid muscles in young women with chronic neck pain: A Randomized Blind Clinical Trial. Journal of manipulative and physiological therapeutics, 38(8), 555-563.
    • Lower Trapezius
  192. Cleland, J., Selleck, B., Stowell, T., Browne, L., Alberini, S., St. Cyr, H., & Caron, T. (2004). Short-term effects of thoracic manipulation on lower trapezius muscle strength. Journal of Manual & Manipulative Therapy, 12(2), 82-90.
  193. Liebler, E. J., Tufano-Coors, L., Douris, P., Makofsky, H. W., McKenna, R., Michels, C., & Rattray, S. (2001). The effect of thoracic spine mobilization on lower trapezius strength testing. Journal of Manual & Manipulative Therapy, 9(4), 207-212
    • Extensor Muscles
  194. Mehyar, F., Santos, M., Wilson, S. E., Staggs, V. S., & Sharma, N. K. (2017). Immediate Effect of Lumbar Mobilization on Activity of Erector Spinae and Lumbar Multifidus Muscles. Journal of chiropractic medicine, 16(4), 271-278.
  195. Pecos-Martín, D., de Melo Aroeira, A. E., Silva, R. V., de Tejada Pozo, G. M., Solano, L. R., Plaza-Manzano, G., … & Falla, D. (2017). Immediate effects of thoracic spinal mobilisation on erector spinae muscle activity and pain in patients with thoracic spine pain: a preliminary randomised controlled trial. Physiotherapy, 103(1), 90-97.
  196. Chesterton, P., & Payton, S. (2017). Effects of spinal mobilisations on lumbar and hamstring ROM and sEMG: A randomised control trial. Physiotherapy Practice and Research, 38(1), 17-25.
  197. Chesterton, P., Payton, S., & McLaren, S. (2018). Acute effects of centrally-and unilaterally-applied posterior–Anterior mobilizations of the lumbar spine on lumbar range of motion, hamstring extensibility and muscle activation. Journal of back and musculoskeletal rehabilitation, (Preprint), 1-11.
  198. (DeVocht, J. W., Pickar, J. G., & Wilder, D. G. (2005). Spinal manipulation alters electromyographic activity of paraspinal muscles: a descriptive study. Journal of manipulative and physiological therapeutics, 28(7), 465-471.
  199. Bicalho, E., Setti, J. A. P., Macagnan, J., Cano, J. L. R., & Manffra, E. F. (2010). Immediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic low-back pain subjects. Manual therapy, 15(5), 469-475.
  200. Koppenhaver, S. L., Fritz, J. M., Hebert, J. J., Kawchuk, G. N., Childs, J. D., Parent, E. C., … & Teyhen, D. S. (2011). Association between changes in abdominal and lumbar multifidus muscle thickness and clinical improvement after spinal manipulation. journal of orthopaedic & sports physical therapy, 41(6), 389-399.
  201. Koppenhaver, S. L., Fritz, J. M., Hebert, J. J., Kawchuk, G. N., Parent, E. C., Gill, N. W., … & Teyhen, D. S. (2012). Association between history and physical examination factors and change in lumbar multifidus muscle thickness after spinal manipulation in patients with low back pain. Journal of Electromyography and Kinesiology, 22(5), 724-731.
    • Intrinsic Core Muscles
  202. Barbosa, A. W. C., Silva, A. M., Silva, A. F., Martins, F. L. M., & Barbosa, M. C. S. A. (2014). Immediate improvements in activation amplitude levels of the deep abdominal muscle following a sacroiliac joint manipulation during rapid upper limb movement. Journal of bodywork and movement therapies, 18(4), 626-632.
  203. (101) Puentedura, E. J., Landers, M. R., Hurt, K., Meissner, M., Mills, J., & Young, D. (2011). Immediate effects of lumbar spine manipulation on the resting and contraction thickness of transversus abdominis in asymptomatic individuals. journal of orthopaedic & sports physical therapy, 41(1), 13-21.
  204. Konitzer, L. N., Gill, N. W., & Koppenhaver, S. L. (2011). Investigation of abdominal muscle thickness changes after spinal manipulation in patients who meet a clinical prediction rule for lumbar stabilization. journal of orthopaedic & sports physical therapy, 41(9), 666-674.
  205. Ferreira, M. L., Ferreira, P. H., & Hodges, P. W. (2007). Changes in postural activity of the trunk muscles following spinal manipulative therapy. Manual Therapy, 12(3), 240-248.
    • Hip Flexors
  206. Chi-ngai, L., Thomas, C. T. W., & Chi-Kong, C. (2016). The effect of passive lumbar mobilization on hip flexor strength-a pilot study. Indian Journal of Physiotherapy & Occupational Therapy, 10(2).
  207. Yuen, T. S., Lam, P. Y., Lau, M. Y., Siu, W. L., Yu, K. M., Lo, C. N., & Ng, J. (2017). Changes in lower limb strength and function following lumbar spinal mobilization. Journal of manipulative and physiological therapeutics, 40(8), 587-596.
    • Pelvic Floor:
  208. de Almeida, B. S. N., Sabatino, J. H., & Giraldo, P. C. (2010). Effects of high-velocity, low-amplitude spinal manipulation on strength and the basal tonus of female pelvic floor muscles. Journal of manipulative and physiological therapeutics, 33(2), 109-116.
  209. Haavik, H., Murphy, B. A., & Kruger, J. (2016). Effect of spinal manipulation on pelvic floor functional changes in pregnant and nonpregnant women: A preliminary study. Journal of manipulative and physiological therapeutics, 39(5), 339-347.
    • Hamstrings
  210. (89) Tamer, S., Öz, M., & Ülger, Ö. (2014). Effects of Sacroiliac Joint Mobilization on Hamstring Muscle Flexibility and Quadriceps Muscle Strength. Orthopaedic journal of sports medicine, 2(11_suppl3), 2325967114S00174.
    • Quadriceps
  211. (88) Gong, W. T., Ma, S. Y., & Kim, B. G. (2007). The Influence of Sacroiliac Joint Mobilization on Lower Extremity Muscle Strength. Journal of the Korean Society of Physical Medicine, 2(2), 101-112.
  212. (61) Kim, B. K., An, H. J., Heo, S. Y., Kim, B. J., & Choi, W. S. (2018). Effects of Lumbar Central Posteroanterior Mobilization on Isometric Knee Extension and Patellar Tendon Reflex Amplitude: A Pilot Study. Journal of International Academy of Physical Therapy Research, 9(1), 1435-1441.
  213. (106) Grindstaff, T. L., Hertel, J., Beazell, J. R., Magrum, E. M., & Ingersoll, C. D. (2009). Effects of lumbopelvic joint manipulation on quadriceps activation and strength in healthy individuals. Manual therapy, 14(4), 415-420.
  214. Sanders, G. D., Nitz, A. J., Abel, M. G., Symons, T. B., Shapiro, R., Black, W. S., & Yates, J. W. (2015). Effects of lumbosacral manipulation on isokinetic strength of the knee extensors and flexors in healthy subjects: a randomized, controlled, single-blind crossover trial. Journal of chiropractic medicine, 14(4), 240-248.
  215. (108) Grindstaff, T. L., Hertel, J., Beazell, J. R., Magrum, E. M., Kerrigan, D. C., Fan, X., & Ingersoll, C. D. (2012). Lumbopelvic joint manipulation and quadriceps activation of people with patellofemoral pain syndrome. Journal of athletic training, 47(1), 24-31.
  216. (109) Passmore, S. R., Johnson, M. G., Aloraini, S. M., Cooper, S., Aziz, M., & Glazebrook, C. M. (2019). Impact of Spinal Manipulation on Lower Extremity Motor Control in Lumbar Spinal Stenosis Patients: A Small-Scale Assessor-Blind Randomized Clinical Trial. Journal of Manipulative and Physiological Therapeutics, 42(1), 23-33.
  217. Suter, E., McMorland, G., Herzog, W., & Bray, R. (1999). Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain. Journal of Manipulative and Physiological Therapeutics, 22(3), 149-153.
  218. Suter, E., McMorland, G., Herzog, W., & Bray, R. (2000). Conservative lower back treatment reduces inhibition in knee-extensor muscles: a randomized controlled trial. Journal of manipulative and physiological therapeutics, 23(2), 76-80.
    • Gluteus Maximus and Medius
  219. Yerys, S., Makofsky, H., Byrd, C., Pennachio, J., & Cinkay, J. (2002). Effect of mobilization of the anterior hip capsule on gluteus maximus strength. Journal of Manual & Manipulative Therapy, 10(4), 218-224.
  220. Makofsky, H., Panicker, S., Abbruzzese, J., Aridas, C., Camp, M., Drakes, J., … & Sileo, R. (2007). Immediate effect of grade IV inferior hip joint mobilization on hip abductor torque: a pilot study. Journal of Manual & Manipulative Therapy, 15(2), 103-110.
    • Shoulder Muscles
  221. Swanson, B. T., Holst, B., Infante, J., Poenitzsch, J., & Ortiz, A. (2016). EMG activity of selected rotator cuff musculature during grade III distraction and posterior glide glenohumeral mobilization: results of a pilot trial comparing painful and non-painful shoulders. Journal of Manual & Manipulative Therapy, 24(1), 7-13.
  222. Ribeiro, D. C., Sole, G., Venkat, R., & Shemmell, J. (2017). Differences between clinician-and self-administered shoulder sustained mobilization on scapular and shoulder muscle activity during shoulder abduction: A repeated-measures study on asymptomatic individuals. Musculoskeletal Science and Practice, 30, 25-33.
  223. Ribeiro, D. C., Day, A., & Dickerson, C. R. (2017). Grade-IV inferior glenohumeral mobilization does not immediately alter shoulder and scapular muscle activity: a repeated-measures study in asymptomatic individuals. Journal of Manual & Manipulative Therapy, 25(5), 260-269.
    • Knee Muscles
  224. Kaya Mutlu, E., Ercin, E., Razak Ozdıncler, A., & Ones, N. (2018). A comparison of two manual physical therapy approaches and electrotherapy modalities for patients with knee osteoarthritis: A randomized three arm clinical trial. Physiotherapy theory and practice, 34(8), 600-612.
  225. Ghanbari, A., & Kamalgharibi, S. (2013). Effect of knee joint mobilization on quadriceps muscle strength. International Journal of Health and Rehabilitation Sciences (IJHRS), 2(4), 186-91.
    • Ankle
  226. Ersoy, U., Kocak, U. Z., Unuvar, E., & Unver, B. (2019). The Acute Effect of Talocrural Joint Mobilization on Dorsiflexor Muscle Strength in Healthy Individuals: A Randomized Controlled Single-Blind Study. Journal of sport rehabilitation, 28(6), 601-605.
    • Distal Muscles
  227. de Camargo, V. M., Alburquerque-Sendín, F., Bérzin, F., Stefanelli, V. C., de Souza, D. P. R., & Fernández-de-las-Peñas, C. (2011). Immediate effects on electromyographic activity and pressure pain thresholds after a cervical manipulation in mechanical neck pain: a randomized controlled trial. Journal of manipulative and physiological therapeutics, 34(4), 211-220.
  228. Dunning, J., & Rushton, A. (2009). The effects of cervical high-velocity low-amplitude thrust manipulation on resting electromyographic activity of the biceps brachii muscle. Manual therapy, 14(5), 508-513.
  229. Sueki, D., Almaria, S., Bender, M., & McConnell, B. (2018). The immediate and 1-week effects of mid-thoracic thrust manipulation on lower extremity passive range of motion. Physiotherapy theory and practice, 1-11.
  230. Pollard, H., & Ward, G. (1998). The effect of upper cervical or sacroiliac manipulation on hip flexion range of motion. Journal of manipulative and physiological therapeutics, 21(9), 611-616.
  231. Pollard, H., & Ward, G. (1997). The effect of sacroiliac manipulation on hip flexion range of motion. Australasian Chiropractic & Osteopathy, 6(3), 80.
    • Reflexive Activity
  232. Nougarou, F., Pagé, I., Loranger, M., Dugas, C., & Descarreaux, M. (2016). Neuromechanical response to spinal manipulation therapy: effects of a constant rate of force application. BMC complementary and alternative medicine, 16(1), 161.
  233. Herzog, W., Conway, P. J., Zhang, Y. T., Gal, J., & Guimaraes, A. C. (1995). Reflex responses associated with manipulative treatments on the thoracic spine: a pilot study. Journal of manipulative and physiological therapeutics, 18(4), 233-236.
  234. Herzog, W., Scheele, D., & Conway, P. J. (1999). Electromyographic responses of back and limb muscles associated with spinal manipulative therapy. Spine, 24(2), 146-152.
  235. Currie, S. J., Myers, C. A., Durso, C., Enebo, B. A., & Davidson, B. S. (2016). The neuromuscular response to spinal manipulation in the presence of pain. Journal of manipulative and physiological therapeutics, 39(4), 288-293.
    • Symptomatic versus Asymptomatic
  236. Colloca, C. J., & Keller, T. S. (2001). Stiffness and neuromuscular reflex response of the human spine to posteroanterior manipulative thrusts in patients with low back pain. Journal of manipulative and physiological therapeutics, 24(8), 489-500.
    • Muscle Activity and Outcomes
  237. Kamel, D. M., Raoof, N. A. A., & Tantawy, S. A. (2016). Efficacy of lumbar mobilization on postpartum low back pain in Egyptian females: A randomized control trial. Journal of back and musculoskeletal rehabilitation, 29(1), 55-63.
  238. Hanrahan, S., Van Lunen, B. L., Tamburello, M., & Walker, M. L. (2005). The short-term effects of joint mobilizations on acute mechanical low back dysfunction in collegiate athletes. Journal of athletic training, 40(2), 88.
  239. Abe, K. Y., Tozim, B. M., & Navega, M. T. (2015). Acute effects of Maitland’s central posteroanterior mobilization on youth with low back pain. Manual Therapy, Posturology & Rehabilitation Journal, 1-5.
  240. Marshall, P., & Murphy, B. (2006). The effect of sacroiliac joint manipulation on feed-forward activation times of the deep abdominal musculature. Journal of manipulative and physiological therapeutics, 29(3), 196-202.
  241. Cibulka, M. T., Rose, S. J., Delitto, A., & Sinacore, D. R. (1986). Hamstring muscle strain treated by mobilizing the sacroiliac joint. Physical therapy, 66(8), 1220-1223.
  242. Shih, Y. F., Yu, H. T., Chen, W. Y., Liao, K. K., Lin, H. C., & Yang, Y. R. (2018). The effect of additional joint mobilization on neuromuscular performance in individuals with functional ankle instability. Physical Therapy in Sport, 30, 22-28.
  243. Ko, T., Lee, S., & Lee, D. (2009). Manual therapy and exercise for OA knee: effects on muscle strength, proprioception, and functional performance. Journal of Physical Therapy Science, 21(4), 293-299.
    • Joint Position Sense
  244. Gong, W. (2014). The influence of lumbar joint mobilization on joint position sense in normal adults. Journal of physical therapy science, 26(12), 1985-1987.
  245. Yang J, Lee B, Kim C. Changes in proprioception and pain in patients with neck pain after upper thoracic manipulation. J Phys Ther Sci. 2015;27(3):795-8.
  246. Learman, K. E., Myers, J. B., Lephart, S. M., Sell, T. C., Kerns, G. J., & Cook, C. E. (2009). Effects of spinal manipulation on trunk proprioception in subjects with chronic low back pain during symptom remission. Journal of manipulative and physiological therapeutics, 32(2), 118-126.
    • Balance
  247. Farazdaghi, M. R., Motealleh, A., Abtahi, F., Panjan, A., Šarabon, N., & Ghaffarinejad, F. (2018). Effect of sacroiliac manipulation on postural sway in quiet standing: a randomized controlled trial. Brazilian journal of physical therapy, 22(2), 120-126.
  248. Son, J. H., Park, G. D., & Park, H. S. (2014). The effect of sacroiliac joint mobilization on pelvic deformation and the static balance ability of female university students with SI joint dysfunction. Journal of physical therapy science, 26(6), 845-848.
  249. Kim, B. K., An, H. J., Heo, S. Y., Kim, B. J., & Choi, W. S. (2018). Effects of Lumbar Central Posteroanterior Mobilization on Isometric Knee Extension and Patellar Tendon Reflex Amplitude: A Pilot Study. Journal of International Academy of Physical Therapy Research, 9(1), 1435-1441.
  250. Heo, S. Y., Kim, B. K., Moon, O. K., & Choi, W. S. (2018). Immediate Effects of Lumbar Rotational Mobilization on the One-Legged Standing Ability in Healthy Individuals: A Randomized Controlled Trial. Journal of International Academy of Physical Therapy Research, 9(3), 1521-1527.
  251. Gong, W. T., & Han, J. M. (2005). The effects of Sacroiliac joint mobilization on the Equilibrium Ability. The Journal of Korean Academy of Orthopedic Manual Physical Therapy, 11(1), 29-36.
  252. Gong, W. T., Jung, Y. W., & Bae, S. S. (2005). The effects of sacroiliac joint mobilization and lumbopelvic stabilizing exercises on the equilibrium ability. The Journal of Korean Physical Therapy, 17(3), 285-295.
    • Pulmonary function
  253. Shin, D. C., & Lee, Y. W. (2016). The immediate effects of spinal thoracic manipulation on respiratory functions. Journal of physical therapy science, 28(9), 2547-2549.
  254. da Silva, P. H. L., de Ré, D., Behne, G. R., Vazatta, M. P., & de Carvalho, A. R. (2013). Maximum respiratory pressure alterations after spinal manipulation. The European Journal of Physiotherapy, 15(2), 64-69.
  255. Jung, J. H., & Moon, D. C. (2015). The effect of thoracic region self-mobilization on chest expansion and pulmonary function. Journal of physical therapy science, 27(9), 2779-2781.
  256. Joo, S., Lee, Y., & Song, C. H. (2018). Immediate Effects of Thoracic Spinal Manipulation on Pulmonary Function in Stroke Patients: A Preliminary Study. Journal of manipulative and physiological therapeutics, 41(7), 602-608.
    • Additional Research
  257. Riley, S. P., Cote, M. P., Leger, R. R., Swanson, B. T., Tafuto, V., Sizer, P. S., & Brismée, J. M. (2015). Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: a randomized clinical trial. Journal of Manual & Manipulative Therapy, 23(1), 3-11.
  258. Niemistö, L., Lahtinen-Suopanki, T., Rissanen, P., Lindgren, K. A., Sarna, S., & Hurri, H. (2003). A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain. Spine, 28(19), 2185-2191.
  259. Niemistö, L., Rissanen, P., Sarna, S., Lahtinen-Suopanki, T., Lindgren, K. A., & Hurri, H. (2005). Cost-effectiveness of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain: a prospective randomized trial with 2-year follow-up. Spine, 30(10), 1109-1115.
  260. Lluch, E., Duenas, L., Falla, D., Baert, I., Meeus, M., Sanchez-Frutos, J., & Nijs, J. (2018). Preoperative pain neuroscience education combined with knee joint mobilization for knee osteoarthritis. The Clinical journal of pain, 34(1), 44-52.

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