Clinical Compass

Behind every paper we translate are researchers doing the work to move the evidence forward.

As we close out this month's Research Translation series, we'd like to recognize and thank the authors of our featured systematic review:

Alec L. Schielke, DC
Robert J. Trager, DC
Joel M. Stevans, DC, PhD
Morgan R. Price, DC
Ronald D. Wilcox, DC
Sheryl A. Walters, MLS
Clinton J. Daniels, DC, MS

Their work gave us the opportunity to explore important questions about spinal manipulative therapy for older adults—from comparative effectiveness and clinical significance to evidence certainty, patient selection, and the limitations of the current research.

Research like this doesn't give us a simple answer to every clinical question.

It gives us something equally valuable: better evidence to inform better questions, better conversations, and better clinical decisions.

Thank you to the authors for advancing the evidence around conservative spine care for older adults—and for giving our profession more to learn from, critically evaluate, and build upon.

What should patients know?

Getting older doesn't automatically mean hands-on care is off the table.

This month's featured systematic review suggests that spinal manipulative therapy may be one reasonable conservative treatment option for appropriately selected older adults with certain chronic spinal conditions.

But perhaps the bigger takeaway is this:

There may be more than one evidence-informed way to manage chronic spine pain.

SMT, exercise, physical therapy, education, home exercise, and other conservative approaches don't necessarily need to compete for a single “best” treatment.

Instead, treatment decisions can consider what matters to the individual patient—their clinical presentation, overall health, goals, preferences, potential risks, and response to care.

For patients, that means asking questions, understanding the available options, and participating in decisions about your care.

For clinicians, it means making space for those conversations.

As we wrap up this month's Research Translation series, we'd love to hear from you:

How can clinicians better involve older adults in choosing between evidence-informed conservative treatment options?

Because patient-centered care isn't simply about choosing an evidence-informed treatment.

It's about choosing it with the patient.

Before we overstate the results…

There are reasons to be encouraged by this systematic review.

There are also important reasons to be cautious.

The review included:

7 randomized controlled trials
1,226 participants
Evidence certainty ranging from very low to moderate

When interpreting the findings, we also need to consider:

• The relatively small number of available trials
• Small sample sizes for some comparisons
• Imprecision in the estimates
• Risk of bias
• Clinical heterogeneity across populations, conditions, interventions, and outcomes

These limitations don't mean the findings should be dismissed.

But they do affect how confidently we can apply them.

That's an important part of responsible research translation—especially when the findings appear favorable.

It's easy to critically appraise research when we disagree with the results. Evidence-informed practice requires us to apply that same scrutiny when the findings support what we already believe.

So, is the evidence promising?

Yes.

Is it definitive?

Not yet.

More high-quality research in older adults is needed to better understand which patients are most likely to benefit, which approaches are most appropriate, and how those outcomes compare with other conservative treatment options.

What should clinicians care about?

This systematic review doesn't tell us that spinal manipulative therapy is the best treatment for older adults with chronic spinal conditions.

And it doesn't need to.

Across the included trials, SMT generally produced outcomes that were comparable to—and in some instances modestly better than—other conservative approaches.

That supports a more practical clinical takeaway:

SMT can be considered one conservative treatment option for appropriately selected older adults, in the absence of contraindications.

Not because it consistently outperformed exercise, physical therapy, education, or other conservative interventions.

But because evidence-informed care doesn't require every reasonable treatment to prove itself superior to every alternative.

Instead, clinicians can consider:

• The patient's clinical presentation
• Goals and preferences
• Comorbidities and potential risks
• Precautions and contraindications
• Available evidence
• Response to care

From there, the question becomes less:

“Is SMT better than everything else?”

And more:

“Is SMT a reasonable evidence-informed option for this patient?”

That's an important distinction.

SMT doesn't need to outperform every other conservative treatment to have a place among the available options.

Does one conservative treatment have to “win”?

Not necessarily.

One of the most useful takeaways from this systematic review is that spinal manipulative therapy can sit alongside other conservative approaches as a reasonable treatment option for some older adults.

Across the included studies, SMT was often compared with other active interventions—including exercise, physical therapy, education, and home exercise—and frequently produced comparable outcomes.

That shifts the clinical conversation.

Instead of asking:

“Which treatment is best?”

We can ask:

“Which evidence-informed option best fits this patient?”

The answer may depend on the patient's clinical presentation, goals, preferences, comorbidities, potential risks, access to care, and response to treatment.

And in many cases, care doesn't have to be either/or. Conservative approaches can be combined or adapted as a patient's needs change.

Evidence-informed care isn't a competition between treatments or professions.

It's about understanding the reasonable options available and using clinical expertise and shared decision-making to determine the best path forward for the individual patient.

The goal isn't for a treatment to win. The goal is for the patient to benefit.

Statistically significant. But clinically meaningful?

Those aren't always the same thing.

In one trial included in this systematic review, older adults with lumbar spinal stenosis who received manual therapy + individualized exercise showed greater improvement in some functional outcomes compared with medical care or group exercise.

The difference was statistically significant.

But there was an important caveat:

The between-group difference did not reach the reported threshold for a minimal clinically important difference (MCID).

Why does that matter?

Statistical significance helps us determine whether an observed difference is unlikely to be explained by chance alone.

Clinical significance asks a different question:

Was the difference large enough to actually matter to the patient?

A result can be statistically significant without producing a change that patients would perceive as meaningful in their everyday lives.

That doesn't make the finding irrelevant. It changes how we interpret it.

When evaluating research, don't stop at the p-value.

Ask:

How large was the effect? And was it meaningful enough to matter to the patient?

Because evidence-informed care isn't just about identifying differences.

It's about understanding whether those differences are likely to make a meaningful difference in someone's life.

“Not superior” doesn't mean “not effective.”

It's an important distinction—and one that can easily get lost when interpreting research.

Many of the studies in this systematic review weren't comparing spinal manipulative therapy with no treatment.

They were comparing SMT with other active conservative interventions, including exercise, rehabilitation, and physical therapy approaches.

So when two treatments produce similar outcomes, that doesn't necessarily mean neither treatment worked.

It may mean both are reasonable treatment options.

This is the difference between asking:

“Did SMT outperform the comparator?”

and

“Did SMT perform comparably to another established conservative approach?”

Those are very different research questions.

Comparative effectiveness research helps us understand how available treatment options perform relative to one another. When outcomes are similar, clinical decisions may then incorporate other important factors—such as the patient's presentation, preferences, goals, potential risks, access to care, and response to treatment.

Evidence-informed practice isn't always about finding a single “winner.”

Sometimes the evidence tells us we have more than one reasonable path forward.

Can this review tell us that spinal manipulative therapy is safe for older adults?

Not definitively.

And understanding why is an important part of reading research critically.

This systematic review was designed to evaluate the efficacy of spinal manipulative therapy in older adults. It was not designed to establish safety or quantify the risk of rare, serious adverse events.

The authors discuss adverse events and clinical precautions, but the randomized controlled trials included in the review were not adequately powered to evaluate rare serious events.

That distinction matters.

Evidence that a treatment is effective is not automatically evidence that a treatment is safe.

Safety questions often require different study designs, much larger populations, and specific adverse-event monitoring to reliably identify uncommon risks.

So while these findings can help us understand whether SMT may provide benefit for certain older adults, we shouldn't use this review alone to make definitive claims about safety.

This is evidence literacy in practice:

Ask not only what a study found—but what the study was actually designed to answer.

Where did spinal manipulative therapy actually show an advantage?

One area that stood out was chronic neck pain.

In one of the trials included in this systematic review, SMT combined with home exercise and advice resulted in greater pain reduction compared with:

• Supervised rehabilitative exercise + home exercise/advice
• Home exercise/advice alone

That's an encouraging finding—but there's an important detail:

Not every outcome favored SMT.

While pain reduction demonstrated a between-group advantage, disability and other functional outcomes did not necessarily show the same benefit.

And that's exactly why the outcome being measured matters.

When we say a treatment "worked," what do we mean?

Less pain?
Better function?
Reduced disability?
Improved quality of life?

A treatment can demonstrate an advantage for one outcome without being superior across every measure that matters to a patient.

The takeaway: SMT may be a valuable option for older adults with chronic neck pain, particularly for pain reduction—but the evidence doesn't support a blanket conclusion that it's superior for every outcome.

Good research translation requires looking beyond "Did it work?" and asking "What improved—and by how much?"

Does age alone rule out spinal manipulation?

No.

A patient's age is one piece of the clinical picture—but it shouldn't be the only factor determining whether spinal manipulative therapy is appropriate.

This systematic review supports SMT as a potential treatment option for older adults with certain spinal conditions in the absence of contraindications.

The key is appropriate patient selection.

Before deciding how—or whether—to incorporate SMT, clinicians should consider factors such as:

• Bone health and fracture risk
• Comorbidities
• Medications
• Current clinical presentation
• Patient goals and preferences
• Precautions and contraindications

Age-related changes in bone density and quality, for example, may influence clinical decision-making and warrant precautions, technique modifications, or an alternative approach.

The takeaway isn't that SMT is appropriate for every older adult.

It's that chronological age alone doesn't determine clinical appropriateness.

Evidence-informed care requires us to evaluate the individual patient, assess risk, and select an approach that reflects both the evidence and the person in front of us.