Author Names
Sørensen, P. W., Nim, C. G., Poulsen, E., & Juhl, C. B.
Reviewer Name
Catherine Gardner, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Abstract OBJECTIVE: We aimed to examine whether targeting spinal manipulative therapy (SMT), by applying the intervention to a specific vertebral level, produces superior clinical outcomes than a nontargeted approach in patients with nonspecific low back pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, Scopus, PEDro, and Index to Chiropractic Literature were searched up to May 31, 2023. STUDY SELECTION CRITERIA: Randomized controlled trials comparing targeted SMT (mobilization or manipulation) to a nontargeted approach in patients with nonspecific low back pain, and measuring the effects on pain intensity and patient-reported disability. DATA SYNTHESIS: Data extraction, risk of bias, and evaluation of the overall certainty of evidence using the GRADE approach were performed by 2 authors independently. Meta-analyses were performed using the restricted maximum likelihood method. RESULTS: Ten randomized controlled trials (n = 931 patients) were included. There was moderate-certainty evidence of no difference between targeted SMT and a nontargeted approach for pain intensity at postintervention (weighted mean difference = −0.20 [95% CI: −0.51, 0.10]) and at follow-up (weighted mean difference = 0.05 [95% CI: −0.26, 0.36]). For patient-reported disability, there was moderate-certainty evidence of no difference at postintervention (standardized mean difference = −0.04 [95% CI: −0.36, 0.29]) and at follow-up (standardized mean difference = −0.05 [95% CI: −0.24, 0.13]). Adverse events were reported in 4 trials, and were minor and evenly distributed between groups. CONCLUSION: Targeting a specific vertebral level when administering SMT for patients with nonspecific low back pain did not result in improved outcomes on pain intensity and patient-reported disability compared to a nontargeted approach.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Yes
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- Yes
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Yes
Key Finding #1
There is no difference between targeting and not targeting a specific vertebral level for spinal manipulative therapy (SMT).
Key Finding #2
There was no difference in the change in pain intensity, disability, or adverse events post-intervention between non-targeted and targeted spinal manipulative therapy.
Key Finding #3
New high-quality studies have the possibility to change these results.
Please provide your summary of the paper
The primary goal of this review was the investigate if there is a difference between targeting or not targeting specific vertebral levels for spinal manipulative therapy. This review looked at 10 studies between 1998 to 2020 specifically looking at adults with non-specific low back pain with or without leg pain. They did not look at the differences between grades of spinal manipulative therapy. The two primary outcome measures being studied were patient-reported pain intensity and self-reported disability, which were both assessed post-intervention and again around a 12-month follow-up. Adverse events were also assessed, which included muscle soreness, aggregation of pain, or stiffness lasting less than 48 hours. The review with meta-analysis showed with moderate certainty evidence that there is no difference in changes in pain intensity, disability, or adverse events between groups of patients with low back pain who received either targeted or nontargeted spinal manipulative therapy.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This recent study (Sep. 2023) will impact clinical practice specifically because it contradicts previously written textbooks and educational material. Historically, students have been taught to palpate a patient’s specific vertebral level to target the intervention and how important it was to find the most appropriate vertebrae. With the results of this review and the included studies, it is clear that this is an outdated concept. As a result, educational materials such as textbooks, lecture materials, and continuing education courses should be updated to reflect the most recent and supported knowledge.
