The Field Just Published a Reality Check on Spinal Manipulation for Radiculopathy.

The Source Paper

In late 2025, Giovannico and colleagues published a systematic review with meta-analysis in the Journal of Orthopaedic and Sports Physical Therapy on the efficacy of high-velocity low-amplitude thrust (HVLAT) manipulation for radiculopathy. The team searched five electronic databases through May 2024 and identified eleven randomized controlled trials with 991 total participants. The eligible trials covered cervical, thoracic, and lumbar radiculopathy and reported outcomes for pain, disability, range of motion, or quality of life. Risk of bias was assessed with the revised Cochrane RoB 2 tool. Certainty of evidence was rated using GRADE.

The headline finding: HVLAT reduced pain compared to sham manipulation, with a mean difference of 1.20 points on standard pain rating scales (95% confidence interval -1.90 to -0.50). Compared to nonrecommended interventions, the mean difference was 1.16 points. Compared to conventional physical therapy alone, manipulation produced an additional 1.26 points of pain reduction at short and medium follow-up. At long-term follow-up, the differences disappeared. Overall risk of bias was rated high. Certainty of evidence ranged from very low to moderate across outcomes.

The authors concluded that HVLAT could reduce pain and disability in cervical and lumbar radiculopathy in the short and medium term, with the qualifier that the comparison against spinal mobilization with leg movement showed no clear advantage. The paper landed in the literature as one of the cleaner attempts to summarize what manipulation does and does not do for nerve-root pain.

The Letter

In May 2026, JOSPT published a letter from Domenico Marotta with the running title "Time for a Reality Check." The letter reexamines the evidence and clinical relevance of HVLAT for radiculopathy and pushes back on the framing of the Giovannico conclusions. Letters of this kind are a structural feature of the scholarly literature: a way for clinicians and methodologists to challenge the interpretation of published findings inside the same journal where the original work appeared, on the record, with the original authors invited to respond.

The substance of the critique follows a pattern familiar from any meta-analysis with low certainty of evidence. When the underlying trials carry high risk of bias, when the effect size is small relative to what patients actually notice, and when the long-term follow-up shows no advantage over comparison treatments, the gap between "statistically significant" and "clinically meaningful" widens. A 1.20-point reduction on an eleven-point pain scale (zero to ten) is real. Whether that one-point difference, on average, constitutes a treatment that patients should choose over alternatives is a separate question, and that question is what the letter reopens.

The Giovannico authors responded in the same issue. The response defends the analytic choices, accepts the certainty-of-evidence limitations as transparently reported, and reframes the original conclusions as support for manipulation inside a multimodal plan rather than as endorsement of manipulation as standalone care. That last reframing matters. It moves the clinical question from "does manipulation work" to "what does manipulation contribute to a broader treatment approach," which is the question most patients and clinicians are actually asking.

What the Numbers Mean Clinically

The minimum clinically important difference (MCID) for the numeric pain rating scale (NPRS) is commonly placed at 1.5 to 2.0 points in spine pain populations, depending on the patient subgroup and the anchor used to define what counts as a meaningful improvement. The Giovannico effect sizes for manipulation versus sham, versus nonrecommended care, and versus physical therapy alone all sit just below that threshold on average. The confidence intervals around those estimates do extend into clinically meaningful territory at the upper bound, which is not the same as saying the average patient experiences a meaningful change. It is saying that some patients do.

For an individual patient considering chiropractic care for radiculopathy, the honest framing is: on average, the additional pain reduction from manipulation over sham or over physical therapy alone is real but modest. A subset of patients will experience a meaningful reduction. Another subset will not. The current evidence cannot reliably predict which group an individual patient falls into before the trial of care begins.

Why the Long-Term Equivalence Matters

The most underdiscussed finding in the Giovannico paper is the absence of any long-term advantage. At follow-up beyond the short and medium term, manipulation produced no greater pain reduction than the comparison treatments. This is not a critique of manipulation. It is a consistent finding across most musculoskeletal interventions: the early relief differs by modality, the long-term outcome converges. Patients who choose manipulation, mobilization, exercise, or supervised physical therapy for chronic spine and nerve-root pain end up in similar places six to twelve months later, on average.

What the long-term equivalence implies clinically is that the value of manipulation is concentrated in the early phase of care. It can shorten the curve to relief. It can change the texture of the first weeks of recovery. It rarely changes the final destination by itself. That is consistent with what most experienced clinicians observe in practice, with what the American College of Physicians 2017 guideline on noninvasive treatments for low back pain recommends (nonpharmacologic care first, with manipulation as one of several reasonable options inside that broader recommendation), and with the same long-term-convergence pattern documented in the de Zoete et al. 2026 Cochrane review of spinal manipulation for chronic low back pain.

What This Looks Like in Practice for Sciatica Patients

Sciatica is the patient-facing label most people use for what the literature calls lumbar radiculopathy. The mechanism is a nerve-root irritation, most often at L5 or S1, that produces a pain pattern down the posterior or lateral leg. The cause varies. A herniated disc, a stenotic foramen (a presentation whose long-term natural history was recently mapped in the Mc Auliffe five-year cohort), a piriformis-related entrapment, or a combination of the three account for most presentations a chiropractor sees.

What the Giovannico evidence supports for the sciatica patient: a course of manipulation may produce additional short-term pain reduction over no care, sham care, or conventional physical therapy alone. The effect size is modest. Pairing manipulation with movement-based care, postural correction, and graded loading is more defensible than relying on manipulation as the only intervention. Long-term outcomes depend more on what the patient does between visits than on what is delivered during visits.

What the evidence does not support for the sciatica patient: manipulation as a guaranteed fix, manipulation as a treatment that works equally well for every cause of nerve-root pain, or manipulation as a substitute for the diagnostic workup that distinguishes a mechanical problem from one requiring imaging and surgical consultation.

For the patient profile that most often walks into a Brookside chiropractic office, the framing I use is this: manipulation can help with the early phase. It is one tool in a multimodal plan. It is not the whole plan. The questions that matter are whether the pain pattern is mechanical, whether red flags are absent, and whether there is a movement and loading protocol the patient can sustain between visits.

Why the Letter Itself Is Worth Reading

Most public arguments about chiropractic care happen on social media, in podcast clips, and in blog posts that cite no original sources. The Marotta letter and the Giovannico response are the opposite of that. They are signed, published, citable, and embedded in the same journal volume as the original work. Anyone with access to JOSPT can read the full exchange and form their own interpretation. That structural feature, a published letter inviting a published response, is one of the slow-moving parts of the literature that holds the field accountable to its own evidence.

The chiropractic profession benefits from this kind of internal critique. Overstatement of effect sizes hurts the profession by setting patient expectations the evidence cannot meet. Dismissal of legitimate critique hurts the profession by signaling that practitioners are not honest brokers of the literature. The Marotta letter falls into a longer pattern of physical therapy and rehabilitation researchers asking pointed methodological questions about manual therapy interventions. Those questions deserve straightforward answers, and the Giovannico response provides one.

For a chiropractic clinician reading the exchange, the takeaway is not that manipulation does not work. It is that the case for manipulation needs to be made with appropriately calibrated language. "Pain reduction in the short term, modest effect size, low to moderate certainty, no long-term advantage over alternatives, best used inside a multimodal plan" is the version of the claim the current evidence will support. Anything stronger requires evidence that does not yet exist.

Where the Field Should Go Next

The remaining open questions on manipulation for radiculopathy are specific. Which radiculopathy phenotype responds best to thrust manipulation versus mobilization versus traction-based care? What is the minimum effective dose, and at what point does additional treatment stop adding value? What predicts non-response, so that patients who will not benefit can be redirected earlier? How does manipulation interact with concurrent active care (graded exercise, neural mobilization, postural rehabilitation) in terms of additive or synergistic effect?

Trials designed to answer those questions would be more informative than the next pooled analysis of trials that ask the same questions the current eleven trials already addressed. This echoes the same theme the Elliott et al. trial sequential analysis raised in the prior issue of this commentary about chronic low back pain trials more broadly: the field has reached the limits of what generic comparison studies can tell it. The next decade of useful research is about precision, not replication.