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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.
  2. Textbooks and courses teach about specificity with SMT.
  3. There is no added benefit of targeted SMT over non-targeted SMT.

BACKGROUND & OBJECTIVE

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.
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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.

METHODS

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

  • Included studies were with subjects 18 years and older, nonspecific low back pain with or without radiculopathy, and comparing targeted with non-targeted SMT, and describing the method of candidate site choice in the protocol.

  • Studies comparing different grades of manipulation (grade IV at a specific site vs grade V at a non-specific site) were not included.

  • The primary outcome was patient-reported pain intensity. The secondary outcome was self-reported disability.

  • Outcomes and adverse events were assessed post-intervention and at the follow-up closest to 12 months.

  • The authors detail the statistical analysis and data generation from the included studies. Not all included studies reported the same type of data and the authors generated results from the available information. For example: “For studies not reporting standard deviations for the final scores, baseline standard deviations were extracted and used as standard deviations in the final scores.”

RESULTS

  • 37 out of 4627 studies were included for full-text screening.

  • 10 of the 37 studies were included in the meta-analysis which included 931 participants with nonspecific low back pain.

  • Treating therapists in the 10 studies: 6 physiotherapists, 2 chiropractors, 2 osteopaths.

  • 2 of the studies examined mobilizations and 8 manipulations.

  • In 9 studies the therapists identified the candidate site through manual examination, 1 through pressure algometry.

  • Pain Intensity: There was no difference in pain intensity on a 0 -10 scale at post-intervention or at follow-up between treating targeted and non-targeted segments.

  • Disability: There was no difference in disability on a 0 -10 scale at post-intervention or at follow-up between treating targeted and non-targeted segments.

  • Adverse Events: There were no serious adverse events in any paper, four studies reported muscle soreness, stiffness of short duration, or aggravation of pain. These were equally distributed between targeted and non-targeted groups.

LIMITATIONS

10 studies were included with a total of 29 different therapists/clinicians providing the treatment. The authors point out that this is an exceedingly small representation of the large global number of therapists providing SMT.

CLINICAL IMPLICATIONS

There are large organizations and numerous clinicians dedicated to teaching specificity of spinal segmental mobilization and manipulation. Some professional testing for licensure or specialization includes questions on specificity of SMT. Revising these practices to reflect the equal benefit of NOT being specific with SMT has yet to take hold.

This meta-analysis adds to the body of literature supporting being less concerned about particular techniques that require precise hand placement or precise application of manual therapy to a particular segment or tissue type. This is good news for therapists looking to improve their ability to help people with nonspecific low back pain.

This does not mean “nothing works”, it is just the opposite and a hopeful bit of encouragement that you, the clinician, can work with the patient in front of you and decide together what feels best or results in the most functional benefit. If this study gets reproduced with a larger sample and has the same results, I wonder if organizations will change to reflect the evidence as the authors recommend?

+STUDY REFERENCE

Sørensen P, Glissmann C, Poulsen E, Juhl C (2023) Spinal manipulative therapy for nonspecific low back pain: Does targeting a specific vertebral level make a difference?: A systematic review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 9, 1–11.

SUPPORTING REFERENCE

  1. Hurwitz, E.L. (2012b) ‘Epidemiology: Spinal manipulation utilization’, Journal of Electromyography and Kinesiology, 22(5), pp. 648–654.
  2. George, S.Z. et al. (2021) ‘Interventions for the management of acute and chronic low back pain: Revision 2021’, Journal of Orthopaedic & Sports Physical Therapy, 51(11).
  3. Nim, C.G. et al. (2021) ‘The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: Myth or reality? A systematic review’, Scientific Reports, 11(1).
Spinal manipulative therapy for… By Dr Sandy Hilton