QUESTION: In people with chronic low back pain, what is the average effect of directing manipulation at the most painful lumbar level compared with generic manipulation of the spine? DESIGN: Randomised controlled trial with concealed allocation, a blinded assessor and intention-to-treat analysis. PARTICIPANTS: 148 people with non-specific chronic low back pain with a minimum level of pain intensity of 3 points (measured from 0 to 10 on the pain numerical rating scale). INTERVENTIONS: All participants received 10 spinal manipulation sessions over a 4-week period. The experimental group received treatment to the most painful segment of the lower back. The control group received treatment to the thoracic spine. OUTCOME MEASURES: The primary outcome was pain intensity, measured at the end of the intervention (week 4). Secondary outcomes were: pain intensity at weeks 12 and 26; pressure pain threshold at week 4; and global perceived change since onset and disability, both measured at weeks 4, 12 and 26. RESULTS: Each group was randomly allocated 74 participants. Data were collected at all time points for 71 participants (96%) in the experimental group and 72 (97%) in the control group. There were no clinically important between-group differences for pain intensity, disability or global perceived effect at any time point. The estimate of the effect of directing manipulation at the most painful lumbar level, as compared with generic manipulation, on pain intensity was too small to be considered clinically important: MD 0 (95% CI -0.9 to 0.9) at week 4 and -0.1 (95% CI -1.0 to 0.8) at week 26. CONCLUSION: No clinically important differences were observed between directed manipulation and generic manipulation in people with chronic low back pain. TRIAL REGISTRATION: NCT02883634.

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