The research has been interesting because obviously the debate hasn't been resolved, but it's becoming refined enough now that I think there are some key bits of information that we can get move on in future studies that will help improve clinical practice and help us understand what type of benefit you get from and who is going to benefit most from receiving spinal manipulative therapies.
There's little doubt that spinal manipulation is modulating nociception. But it is really important to differentiate between nociception and pain because when you measure clinical outcomes, there are plenty of trials where there are no differences between spinal manipulative therapy and comparison treatments. So, it's an interesting paradox and something I think we can tease out because ideally, the modulation of nociception would have a bigger benefit clinically but that hasn't been the case. Looking to future research, one of the things we need to consider is the type of endpoints that we're using. Especially with back pain, there is usually pain while patients are moving, and if that endpoint isn't teased out from the more spontaneous or resting pain, which is more commonly measured, that could be an issue. Another very foundational issue is that the adequate dosage has not been established. And some people just seem to respond better, and so we need to get better at identifying who the responders are. All of these things will help us to better understand who can benefit the most from this treatment approach.