Research Review Service

So I would like to take a minute to promote a company which I have been working with for a while now, Research Review Service.  RRS, was started by Dr. Shawn Thistle, a practicing chiropractor from Toronto, CA.   His company, made up of various types of clinicians/researchers, has critiqued and disseminated over 550 research articles, to help the clinician incorporate literature into practice.  The site is subscription based, but I can’t stress how much quality information is located there (especially if you don’t have journal access).   Below is an example of a recent review I added to the site.  Cheers!
(Note: The review provided below was formatted for .  Reviews on RRS appear as the screenshot seen below the review)

Immediate Effects of Region-Specific vs. Non-Region-Specific SMT for Chronic LBP +MP3
Research Review By Dr. Joseph Brence©
specific_nonspecific_clbp Download
Date Posted:
June 2013
Study Title:
Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: A randomized controlled trial
Oliveira RF, Liebano RE, Costa LCM et al.
Author’s Affiliations:
Universidade Cidade de Sao Paulo, Brazil.
Publication Information:
Physical Therapy 2013; 93: 748–756.
Background Information:
Spinal manipulative therapy (SMT) is a common intervention used by Chiropractors, Physical Therapists and Osteopathatic Physicians for the treatment of various conditions, including low back pain (LBP). While these techniques are routinely used, the mechanisms behind how they work are not completely understood. In 2011, Fritz et al. attempted to investigate the effects of SMT in individuals with LBP. These researchers found that the effects of SMT are multifactorial and can result in a reduction of spinal stiffness and improved lumbar multifidus recruitment (1). Another paper by this same group of researchers found evidence that clinical improvements following SMT are associated with increased thickening of the multifidus during a submaximal task (2).In addition to our incomplete understanding of the mechanisms of SMT, determining which segment to manipulate is subject to questionable reliability (3). Further, a recent systematic review found that there were changes in pain sensitivity in both local and remote sites following SMT (4). This indicates that SMT may have central, as well as peripheral effects on the nervous system.The goal of this randomized clinical trial was to assess the immediate effects of a single, regional versus non-regional spinal manipulation in patients with chronic low back pain.
Pertinent Results:
  • 148 participants (74 per group, average age 46) with a history of chronic non-specific low back pain (i.e. symptoms > 12 weeks) were included in the analysis (with none lost prior follow-up).
  • The researchers collected demographical data, pain intensity (numerical pain rating scale), pain pressure thresholds and disability (on a Roland Morris Disability Questionnaire).
  • Both groups in this study had improved pain intensity; 1.91 points in the region specific manipulation group and 1.41 points in the non-region specific group. No between-group statistically significant differences were detected.
  • Patients allocated the region specific SMT group did not increase their pressure pain threshold. Patients allocated to the non-region specific group increased their pressure pain threshold locally (i.e. at lumbar levels), but not remotely (i.e. tibialis anterior level).
Clinical Application & Conclusions:
This study was quite novel in that it aimed to assess the effects of SMT at a region specific level versus a non-region specific level. This type of study gives us better insight into the potential mechanisms involved in SMT and allows us to better understand if the effects are related to biomechanical changes, where mechanical forces lead to alterations to specific vertebral areas, or non-biomechanical changes, such as neurophysiological and non-specific effects. This current study supports the latter option, and the authors were able to demonstrate changes in pain following SMT, despite the applied location. In my professional opinion, I suspect this further calls into question our need for “specificity” or “segmental isolation” with our manipulative techniques.
Study Methods:
This study was a two-armed randomized-controlled trial, comparing regional versus non-regional SMT in individuals with chronic LBP.Inclusion criteria: Individuals with chronic low back between the ages of 18-80 with a minimum pain intensity score of 3 on the 11-point Numeric Pain Rating Scale.Exclusion criteria: Individuals with a contraindication to the treatment (spinal canal stenosis, spinal fracture, acute rheumatic diseases, hemorrhagic diseases, active tuberculosis, and recent deep vein thrombosis), pregnancy, nerve root compromise and previous spinal surgery.After obtaining informed consent, a therapist collected demographical data, disability (measured on the Roland Morris Disability Questionnaire) and assessed pain intensity and pressure pain thresholds (at L3 and L5 levels bilaterally and at the middle of the tibialis anterior bilaterally). Following this initial assessment, the participants were taken into a treatment room and a therapist performed a clinical examination to determine which vertebral level was to be manipulated. The therapist asked the patient to identify the painful vertebral level and then confirmed this upon inspection and palpation. He then observed trunk movements in all planes and palpated tissues around the lumbar spine. The therapist then opened a randomization envelope informing whether the vertebral level should be manipulated “according to the examination” or “at an upper thoracic vertebrae”.If the participant was allocated to receive a region specific manipulation, the therapist manipulated between L2-5 based upon clinical examination. If the participant was allocated to receive a non-region specific manipulation, a global HVLAT was performed between T1 and T5.Following the intervention, reassessment of pain intensity, pressure pain thresholds and adverse events were taken.
Study Strengths/Weaknesses:
Study Strengths:
  • The study aimed to further investigate and understand the mechanisms behind spinal manipulation.
  • The study was adequately powered.
  • The study did not only take subjective pain measures, but also assessed pressure pain thresholds both locally and globally to investigate for a central effect.
Study Weaknesses:
  • This study only assessed the immediate effects of SMT – no short or long-term follow-up was conducted.
  • Clinically, SMT is used in conjunction with a comprehensive treatment plan and this study investigated it’s effects in isolation.
  • The results of this study can only be generalized to individuals with chronic low back pain.
Additional References:
  1. Fritz JM, Koppenhaver SL, Kawchuk GN et al. Preliminary investigation of the mechanisms underlying the effects of manipulation: exploration of a multi-variate model including spinal stiffness, multifidus retruitment, and clinic findings. Spine 2011; 36(21): 1772-1781.
  2. Koppenhaver SL, Fritz JM, Herbert JL et al. Associated between changes in abdominal and lumbar multifidus muscle thickness and clinical improvement after spinal manipulation. J Ortho Sport Phys Ther 2011; 41(6): 389-399.
  3. Haneline MT & Young M. A review of intraexaminer and interexaminer reliability of static spinal palpation: a literature synthesis. J Manip and Phys Ther 2009; 32(5): 379-386.
  4. Coronado RA, Gay CW, Bialosky JE et al. Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis. J Electromyogr Kinesiol 2012; 22(5): 752-767.
  Please refer to the Lumbar Spine – Manipulation/Mobilization section of the RRS database for further reviews.RRSexample
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