Spinal manipulative therapy for nonspecific low back pain: does targeting a specific vertebral level make a difference? A systematic review with meta-analysis

Review written by Dr Sandy Hilton info

Key Points

  1. Spinal Manipulative Therapy (SMT) is used globally for the treatment of nonspecific low back pain.
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Spinal manipulative therapy (SMT) is used globally by musculoskeletal specialists including physiotherapists, osteopaths, and chiropractors (1). Clinical practice guidelines recommend SMT for the treatment of nonspecific low back pain as recently as the 2021 paper by George et al. on interventions for acute and chronic low back pain (2). The aim of SMT is to relieve pain, improve function, and improve quality of life. Both joint manipulative techniques that involve cavitation of the joint and joint mobilization are underpinned by a theory of improving segmental mobility to relieve pain.

The clinical application of SMT is to identify a dysfunctional segment (or segments) and apply targeted manipulation/mobilization in order to restore normal segmental mobility. This clinical practice is not supported by the evidence regarding the need to target a specific spinal level to achieve the goal of increased mobility and decreased pain. A 2021 systematic review by Nim et al. found that SMT effectiveness was not dependent on which segment was mobilized/manipulated (3). The Nim study had limitations with heterogeneity, no meta-analysis, and including only manipulation techniques.

The authors of this paper aimed to update the evidence with a quantitative analysis of the differences between targeted and non-targeted SMT for patients with nonspecific low back pain.

Clinical practice guidelines recommend spinal manipulative therapy for the treatment of nonspecific low back pain as recently as a 2021 paper for acute and chronic low back pain.
It is important for the clinician to work with the patient in front of them and decide together what feels best or results in the most functional benefit for that individual.


  • A systematic review registered with PROSPERO and reported in accordance to PRISMA.
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