Spinal Manipulative Therapy and Sports
Performance Enhancement:
A Systematic ReviewThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Manipulative Physiol Ther. 2017 (Sep); 40 (7): 535–543 ~ FULL TEXT
Marcelo B. Botelho, DC, MD, MSc, Bruno A.P. Alvarenga, PT, DC, Nícolly Molina, PT, Marcos Ribas, PT, Abrahão F. Baptista, PT, MSc, PhD
Graduate Program in Medicine and Health,
Faculty of Medicine, Federal University of Bahia,
Salvador, Bahia, Brazil.
OBJECTIVE: The purpose of this study was to review the literature regarding the relationship between spinal manipulative therapy (SMT) and sports performance.
METHODS: PubMed and Embase databases were searched for original studies published up to July 2016. Inclusion criteria were if SMT has been applied to athletes and if any sports performance-related outcome was measured.
RESULTS: Of the 581 potential studies, 7 clinical trials were selected. Most studies had adequate quality (?6/11) when assessed by the PEDro scale. None of those studies assessed performance at an event or competition. Four studies revealed improvement in a sports performance test after SMT. Meta-analysis could not be performed because of the wide differences in methodologies, design, and outcomes measured. Spinal manipulative therapy influences a wide range of neurophysiological parameters that could be associated with sports performance. Of the 3 studies where SMT did not improve test performance, 2 used SMT not for therapeutic correction of a dysfunctional vertebral joint but to an arbitrary previously set joint.
There is more like this at our
CHIROPRACTIC AND SPORTS PageCONCLUSIONS: Although 4 of 7 studies showed that SMT improved sports performance tests, the evidence is still weak to support its use. Spinal manipulative therapy may be a promising approach for performance enhancement that should be investigated with more consistent methodologic designs.
KEYWORDS: Athletes; Athletic Performance; Musculoskeletal Manipulations; Spine; Sports
From the FULL TEXT Article:
Introduction
The competitive nature of professional sports creates a constant demand for therapeutic options that could influence sports performance. [1, 2] Most of the spinal manipulative therapy (SMT) studies in athletes are mainly focused on frequency of use, and the results are merely descriptive. [1, 3–6] It is also easy to find anecdotal statements in which professionals or athletes claim that SMT increased performance. However, the majority of such reports are based on the opinion or background experience of these individuals and not on the result of specific scientific research designed for this purpose. [7–10]
Spinal manipulative therapy consists of a high-velocity, low-amplitude movement, applied at the paraphysiological space, just beyond the passive joint range of motion. [9] Several studies have evaluated its safety [11, 12] and efficacy for the treatment of musculoskeletal disorders, [11] in short-term [12–17] as well as long-term results. [18, 19] These and other studies indicate that SMT is considered a safe and effective approach for the treatment of biomechanical musculoskeletal disorders. [12, 20–26] Different disciplines, such as chiropractic, [9, 27–29] physiotherapy, [30] osteopathy, [31] and orthopedics, [32] use SMT as a therapeutic option in their practices.
Sports performance is defined as a combination of specific physical routines or procedures performed by someone who is trained or skilled in a physical activity and influenced by physiological, psychological, and sociocultural factors. [33] Interestingly, it is rare to find studies that evaluate treatment effects on athletes’ real performance during a competitive event. Usually, researchers use laboratory or field tests that they believe to be directly associated with the event performance in spite of knowing that this relationship between test and event performance has not been adequately established thus far. [34]
Spinal manipulative therapy has been increasingly utilized in sports and has been shown to be a useful therapeutic strategy for biomechanical joint dysfunction, especially that involving the spine. [5, 6, 9, 27] Several neurophysiological effects have been described, [35, 36] but a unifying physiological mechanism is still not clear. Electromyographic activity is usually decreased in resting muscles after SMT [37–39] and increased at isometric contraction. [40] Corticospinal [41, 42] excitability is usually increased, with some exceptions. [39] Increased muscle strength, [43, 44] decreased muscle inhibition, [45] and muscle fatigue prevention were observed, [46] as were lower levels of proinflammatory cytokines [47] and pain sensation in humans [11, 13–19, 48–51] and animals. [52, 53]
All these changes could interfere with sports performance, but there is still limited evidence to support SMT’s ability to enhance sports performance. The aim of this study was to systematically review the scientific literature for clinical trials addressing this question.
Discussion
There is disagreement between sports professionals and athletes regarding SMT and its effect on sports performance. [7–10] An increasing number of studies on this theme have been performed, and the current review reveals a number of clinical trials assessing SMT effects in performance tests. [44, 60, 61, 63, 65, 66, 69]
Of the 7 included studies, 4 revealed improvements after SMT. Sandell et al [60] observed an increase in hip extension but no changes in running velocity after SMT. Costa et al [61] observed an increased full-swing range in golfers, Botelho and Andrade [44] observed increased grip strength in Judokas, and Deutschmann et al [69] observed increased kicking speed after SMT in soccer players.
Shrier et al, [66] Humphries et al, [65] and Olson et al [63] found no differences in their measured outcomes. Humphries et al [65] and Olson et al [63] chose to not apply SMT as a therapy procedure to correct dysfunctional joint segments. Their protocol used previously determined joints regardless of clinical evaluation findings (left column of C5–6 used by Humphries et al, and L3 bilateral mammillary process used by Olson et al). Humphries et al [65] and Botelho and Andrade [44] assessed grip strength, and their contrasting results could be indicating that SMT produces different neurophysiological responses when applied for biomechanical joint dysfunction corrections [44] or when applied to a previously determined site. [65]
All selected studies evaluated individual performance on specific tests. However, sports performance itself, at an event, was not assessed by any of the studies. [44, 60, 61, 63, 65, 66, 69] Suitable study designs to investigate “real” sports performance, during a sporting event, has been shown to be very challenging and difficult to perform. Some common flaws are frequently found and contribute to the low quality of evidence in this area. One of the main limitations frequently observed is the inherent difficulty to have an appropriate sample size, especially when dealing with high performance athletes. [34]
Most of the researchers use performance tests to assess treatment efficacy, even if there is a lack of studies showing correlation between these tests and actual performance.34 They usually choose routine tests performed by team staff to evaluate the athletes’ physical performance, which is used to determine training routines and game team selection. These tests prioritize physical capacities, such as running velocity, jump height, strength, and others. [70]
Potential Mechanisms of SMT in Sports Performance
Afferent processing, modulation, and correspondent efferent response are part of the complex system responsible for motor control and physical performance. All included studies’ outcomes should be influenced, to some extent, by those mechanisms; therefore, it is important to analyze current SMT neurophysiological evidence linked to them.
Several of the described neurophysiological effects of SMT [35–39, 41–43, 45, 47–51, 71] were observed in non-athletes, and there is still a lack of evidence to assume that these effects would also occur in athletes. However, Botelho and Andrade [44] found similar results as those observed in the non-athletic population, when assessing grip strength in judokas.
Proprioceptive afferents include Golgi tendon organs, muscle spindles, and other mechanoreceptors, such as Pacinian corpuscles and Ruffini endings. These specialized receptors are highly concentrated in axial and deep cervical muscles. [72, 73] Vertebral joint dysfunctions are believed to generate central proprioceptive deficit input from those receptors, as there is impaired motion of the vertebrae. [74, 75] Spinal manipulative therapy has an influence on such dysfunctions and has been shown to improve proprioceptive processing and motor control, [74–76] which could potentially influence sports performance.
Some experimental evidence further reinforces this idea. Haavik and Murphy [77] demonstrated that biomechanical dysfunction of cervical joints generates impaired perception of elbow joint position. [77] They also demonstrated that when cervical dysfunction is corrected by SMT, there is a subsequent improvement in the perception of elbow position. Such vertebral dysfunctions are believed to lead to a progressive state of maladaptive neuroplasticity, which could be responsible for impairment of joint proprioception. [35, 77] The same authors also described other changes after the biomechanical dysfunctions of the spine were corrected by SMT. An increased ability of the central nervous system (CNS) to adequately integrate and suppress the response of 2 simultaneous peripheral nervous stimulations has been observed. [78] When SMT is applied after a motor training task, it changes the way the CNS responds to subsequent motor training tasks. [76]
Other neurophysiological findings showed decreased activity after SMT in resting paraspinal muscles on surface electromyography [37] and in H-reflex analysis. [38, 39, 71, 79] This decreased muscle tonic activity can be one of the plausible causes associated to the increased hip extension observed by Sandell et al, [60] once the hip flexors muscles have been identified as the main limiting structures for hip extension. However, the effects of SMT on tonic muscle activity are still controversial [37–39, 46, 79, 80] because data acquisition and analysis are quite different among studies. [81, 82]
Additionally, after SMT, cortical motoneuron excitability changes were observed in studies with transcranial magnetic stimulation. Dishman et al [41, 42] identified a transient increase in motor evoked potential (MEP) amplitude, which lasted up to 60 seconds after SMT. [41, 42] This implies increased excitability of the corticomotor pathway after SMT and may justify the results of increased grip strength observed in judokas after SMT. [44] Fryer and Pearce [39] found a reduction in MEP. However, in their research protocol MEPs were evaluated only 10 minutes after lumbar SMT was applied. [39] These contrasting results suggest that the SMT effect is transient, and this needs to be further demonstrated.
CNS modulation through sensorimotor integration, combined with cortical motoneuron and spinal reflex excitability changes after SMT, should be the central mechanism associated with the increased full-swing in golfers, [61] the increased kicking speed in soccer players, [69] and the increased hip extension in runners. [60] These mechanisms should be related to the improved muscle strength observed in judokas [44] and in non-athletes. [43, 45]
Limitations
One of the most important limitations of the present study was that a meta-analysis of the selected studies could not be performed. Those studies presented a wide range of methodologic designs and measured outcomes. Therefore, it was not plausible to perform a quantitative analysis (meta-analysis). The reviewers were not previously trained to use the PEDro scale.
Recommendations for Future Studies
Methodologic design quality is especially important when developing a clinical trial on SMT because of the inherent difficulty in patient blinding and in the creation of an effective placebo group. [28, 83, 84] Different guidelines, such as the guideline for nonpharmacologic treatment of the Equator group, are available to help improve study uniformity. [85] None of the selected studies reported using any guideline.
With regard to methodology design recommendations, we encourage a series of interventions in which outcomes are measured before and after each intervention. That would not only address the duration of the SMT effects but also show whether there is any cumulative effect from repeated SMT interventions.
Improvement of an isolated physical aspect, such as strength, does not necessarily mean enhancement of sports performance. Sports performance needs to be measured during a real sport event, when possible. The best way to assess it is in sports that objectively measure performance, such as swimming or track and field events. In those sports, time measured at a competition can accurately demonstrate if an athlete’s performance is better or worse at that moment. However, team sports, such as soccer, basketball, and football, have multiple physical and mental variables that may influence team performance and, thus, the result of a match.
Individual sports with subjective performance definitions, such as dancing and gymnastics, and sports that are dependent on equipment, such as car racing, cycling, or shooting, or even sports that are dependent on animals, such as horse riding, are not ideal sports to properly assess the effects of SMT.
Developing adequate placebo models for hands-on therapies, such as SMT, is a challenging task. Similar models (sham manipulation) have had contrasting results in achieving [84] or not achieving [28] blinding in studies. Populations that are naive to treatment should have a higher potential of successful placebo models, such as the one proposed by Botelho and Andrade [44] (treating table drop mechanism). Other riskier and more costly options include short-duration anesthesia (propofol and remifentanil). [83] Therefore, the ideal study design model would be a randomized clinical trial with a placebo/sham group, administered in modalities, such as track and field competitions or swimming, with more than one intervention. Measurements should be taken before and after interventions, and long-term follow-up is necessary. These models would properly address the duration and the accumulation of SMT effects and help discover an ideal number of interventions prior to a competitive event.
Additionally, cohort-type studies that evaluate treatment impact on lesion prevention, as performed by Brumm et al,86 who analyzed the effects of osteopathic manipulative foot treatment on the incidence of stress fractures in cross-country athletes, are also encouraged. Lesion prevention is very important for the maintenance and improvement of athletes’ performance.
Conclusions
Although most of the included studies (4 of 7) showed that SMT led to improved sports performance test results, the evidence is still weak to support its use with this aim. Therefore, despite the common contention of some athletes and sports-related professionals that SMT enhances sports performance, this review revealed that such a claim is not supported by current evidence. Spinal manipulative therapy may be a promising approach for performance enhancement, but it needs to be better and more deeply investigated.
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