Targeting a Specific Vertebral Level with SMT for Back Pain…does it matter?

Spinal manipulative therapy (SMT) is a cost effective and safe treatment, and as a result it is included in almost all clinical practice guidelines and practice recommendations for low back pain. The two most common types of SMT are joint mobilization and manipulation, with the main difference between the two being the force required to obtain “cavitation of the joint” resulting in an audible crack. For the clinician, the aims of pain relief and improvements in function and quality of life are similar.

To normalize segmental dysfunction, clinicians typically attempt to perform targeted treatment at the dysfunctional vertebral level. It is believed by some that targeting a specific spinal level is necessary in order to achieve a positive clinical effect. Despite this, the published literature appears to suggest the contrary. However, limitations exist within the current literature such as including trials that only examined manipulation and not mobilization, no meta-analysis completed, and large heterogeneity within the data sets. As a result, the authors of this systematic review aimed to update the knowledge base and quantitatively estimate the differences between targeted SMT and non-targeted SMT for patients with non-specific low back pain. 

Comment from study author Dr. Casper Glissman Nim (DC, PhD):

“In this review, we aimed to expand on our previous review published in Scientific Reports, which was also reviewed on Dr. Thistle’s site (“Targeting SMT Application – Importance of Segmental Pain vs. Stiffness” – posted in 2022). In this review, we have limited the heterogeneity by only including participants with low back pain, while extending our inclusion criteria to allow for the inclusion of more studies. This allowed us to conduct a meta-analysis and statistically quantify the difference between a targeted and non-targeted approach, or a lack of difference. This step is critical when implementing evidence into clinical practice and educational settings.

The reader who only skims the title and abstract may find it hard to understand why we investigate whether a specific approach is relevant for a non-specific pain. However, there are two critical things to consider here. Clinicians may assume that they know the nociceptive source of the pain, but the evidence suggests that subgrouping low back pain based on available tests is nearly impossible. Instead, clinicians attempt to localize the mechanical source of the pain and sometimes aim SMT towards that. This second approach is exactly the approach that was used in the majority of studies, and it is what happens in real life.

Therefore, we find our results important for all aspects of clinical practice and, perhaps even more importantly, undergraduate education. It is also important to note that these findings do not negate the biomechanics of SMT, as factors such as speed and force are still important, at least for patient satisfaction. We all know that when we receive treatment from a novice “adjuster,” force profiles and speed are critical. However, we are currently experiencing a paradigm shift in the way we understand how SMT works and its clinical effects. This paper adds a bit more certainty to the otherwise uncertain field of low back pain interventions.”

Dr. Casper Nim is a chiropractor (2016) and received his PhD in 2021 from the University of Southern Denmark. He is currently employed at the Spine Centre of Southern Denmark as a senior researcher and the University of Southern Denmark as an assistant professor, investigating 1) spinal manipulation and specificity, 2) pain trajectories for patients with low back pain, and 3) is currently running a feasibility trial geared towards a large RCT investigating multidisciplinary long-term care for persistent secondary-care patients with low back pain.

RESEARCH REVIEW: Importance of Targeting a Specific Vertebral Level with SMT for Back Pain (featuring guest commentary from study [2nd] author Dr. Casper Nim)!

This paper was published in JOSPT (2023). 

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