Spinal Manipulation in Low Back Pain: Evidence and Clinical Predictions

1. Joint Manipulations

2. The Evidence up to 2004 • Assendelft et al. Cochrane Database Syst Rev. 2004 • Systematic Review of RCT’s that evaluated spinal manipulative therapy for patients with low back pain were researched to update effectiveness of spinal manipulation in comparison to other therapies

3. Comparison Treatments • Classified in seven treatment categories: • Sham • Conventional general practitioner care • Analgesics • Physical Therapy • Exercises • Backschool • Therapies judged to be ineffective or even harmful (traction, corset, bedrest, homecare, topical gel, no treatment and diathermy)

4. Outcomes Manipulation had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises or back school For patients with acute low back pain, manipulation was superior only to sham therapy, or therapies judged to be ineffective or even harmful

5. Clinical Prediction Rule for Spinal Manipulation • In 2004 Childs et al developed a clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation ). • Purpose: determine the likelihood of patients responding with a 50% or greater reduction in disability following a program of spinal manipulation and exercise. Childs, J. et. al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Annals of internal medicine Vol. 141, No. 12, 2004

6. Five criteria were identified • Duration of current episode less than 16 days • No symptoms distal to the knee • Lumbar spine hypomobility at any level • FABQ work subscale score <19 points • Hip internal rotation with 1 or both hips having at least 35 degrees of internal rotation

7. Outcome • When at least 4 of the five criteria were met: +LR = 13.2. • When only 1 or 2 of the criteria were met: - LR = .10

8. Which patients do not benefit from spine manipulation? • Longer symptom duration • Presence of symptoms distal to the back • Absence of hypomobility in the lumbar spine • Negative SI provocation tests • Reduced hip rotation ROM

9. Better outcomes with manipulation • A case control study by Fritz showed that patients receiving thrust manipulation had: • Fewer treatment sessions, • Shorter length of stay • Lower cost in physical therapy than patients receiving non-thrust manipulation. Fritz JM, Brennan GP, Leaman H. Does the evidence for spinal manipulation translate into better outcomes in routine clinical care for patients with occupational low back pain? A case control study. Spine Journal 2006

10. So why the reluctance to manipulate in the face of overwhelming evidence? Two main reasons: • Not educated well enough • Fear of harm

11. Complications Serious complications due to L spine manipulations are extremely rare. It is estimated at 1 per 100 million lumbar manipulations results in a cauda equina lesion In comparison, each year 7600 people die in the US alone as a result of taking NSAIDs Another 76000 people require hospitalization as a result of taking NSAIDs

12. Safety and effectiveness • Not dependent on: • Type of practioner • Technique used • Years of experience

13. Cervical Spine CPR • Symptom duration < 38 days • Expectation that manipulation will help • Difference in C rotation side to side >10 degrees • Pain with PA spring testing mid C spine • If 3 out of 4 attributes present, the probability of experiencing a positive outcome improved to 90% • Positive LR 13.5 • Puentedura E et al. Development of a clinical prediction rule to identify paitients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. JOSPT 2012 Vol 42 No 7

14. CPR for treatment of a subgroup of patients with neck pain with T spine manipulation, exercise and educationCleland et al. Physical Therapy 2007 • Six predictors were developed • Symptom duration < 30 days • No symptoms distal to the shoulder • Looking up does not aggravate the symptoms • FABQPA <12 • Decreased upper thoracic kyphosis • Cervical extension <30 days • If 3 of 6 present: 86% success rate with manipulation

15. The audible pop is the sound resulting from the release of nitrogen gas in the joint cavity when a sufficiently large negative pressure is created The audible pop

16. Flynn (2006) concluded that a perceived audible pop may not relate to improved outcomes for patients with non radicular low back pain, either immediate or at long term follow up The audible pop

17. Beffa (2004) found that manipulation was not associated with the targeted joint frequently enough to make a statistical difference Does spinal manipulation cavitate the targeted joint?

18. KimRoss (2004) found that manipulations are accurate about half the timeIn the L spine the average error was at least one vertebra away from the targeted level.(5.29 cm)In the T spine the average error was 3.5 cmMost procedures were associated with multiple cavitations, including the targeted level Accuracy

19. MechanicalPsychologicalNeurological Effects of Manipulation

20. Mechanical Effect of Manipulation • Restore positional faults • Breaking up intra articular adhesions • Release of meniscoid inclusions

21. Positional Fault Talus

22. Stress reaction Talus

23. Mechanical force used during manipulation has a direct effect on the central nervous system, creating positive neurophysiological responses resulting in a reduced overall central sensitization Neurological Effect of Manipulation

24. The effects of manipulation are beyond biomechanical changes only; however, in the current literature, there is no clear explanation for some of the effects of manipulationSillevis et al. Immediate effects of thoracic spine thrust manipulation JMMT 2010 Neurological Effect of Manipulation

25. Effect on autonomous nervous system Thoracic spine manipulation showed favorable outcomes in the treatment of a patient with UE complex regional pain syndrome T spine manipulation resulted in a decrease in dystrophic and allodynic symptoms Menck et al. Thoracic spine dysfunction in upper extremity complex regional pain syndrome type I. JOSPT 2000;30(7)

26. Cervical Spine Manipulation for Pediatric Population

27. Anatomical Considerations

28. Biomechanical considerations

29. Biomechanical considerations

31. Informed Consent You have to obtain informed consent Verbal consent is recommended and document as such in your notes Informed consent differs from state to state, which makes it difficult to specify how this needs to be worded

32. Our recommendation “I would like to perform a “quick stretch” to your neck to improve the movement of a particular joint. You may sense a “popping” of the joint and may experience some local soreness due to the stretching procedure. Is it OK to perform this quick stretch?”

33. Component technique • In component technique we aim to create the barrier • Use basic principles of focusing, multiple components, and for “locking” contra rotation • Use secondary components to minimize amplitude of primary component or lever • Use compression • Identify the barrier, then back of a little • Hold the secondary components to maintain the barrier and amplify only the primary lever direction • Use good posture for security and effectiveness • When ready, focus forces, and engage the barrier

34. Posture and Manipulation • Conscious considered use of operator posture helps control: • Depth of forces • Direction of technique • Amplitude of levers • Power of the procedure • Sensitivity of hold • It improves the ability to focus the forces to a specific target site • It helps improve safety, security, effectiveness and reduces fatigue

35. Posture and Manipulation • General rules • Use a wide base • Use your body to perform technique, keep your hands “fixed” • Use rhythm • Demonstrate control

36. Posture and manipulation • Keep your head up. Literally • Keep your knees slightly bent • Move with your hips, and have your hands follow • Keep your centre of gravity low • Visualize the procedure • Keep the objective in mind • Play with the tissues • Mini thrusts

37. Keep your head up • Keeps the spine straight • The straighter the spine, the more force directed into the patient, not the therapist • Avoids too close proximity • Brings elbows close to side for improved control

38. Keep knees slightly bent • Sharper impact possible • Less flexion in your spine • Subtle changes in direction can be accommodated • Less bending in the PT spine

39. Move your hips, with hands following • Easier acceleration • Hands are less uncomfortable for the patient when held steady • Proprioceptive palpation with operator body • Hands follow, allowing for maintenance of local control

40. Keep center of gravity low • Better balance • Easier changes in direction • Better transmission of force • Less therapist muscle stress

41. Visualize the procedure • How is your posture? • Are you using max efficiency? • Do you understand the principle of the procedure? • What would your posture look like in the mirror?

42. Keep the objective in mind • Is another way better? • Are you struggling with the wrong aspects? • Is control of the structures a problem? • Is another way possibly better?

43. Play with the tissues • Constructive fiddling is often useful to find the optimal direction/path of manipulation • Keep it moving. If you hold it still you only have about a 2 second window to perform the technique • Tissue reaction is the best guide, keep testing and assessing the responses • Less mistakes if you ask the tissues

44. Mini thrusts • Prepare the tissues for final thrust • If you use only one thrust, you have a 25% chance of a good technique. Using mini thrusts significantly increases your chances of a good technique • Tissue anger will warn you off with mini thrusts • Barriers often ease without a more major method • Easier to get to the motion barrier with mini thrusts

45. In thrust techniques • Usually one leg forward, one back • The thrusting hand is on the side of the rear leg • The rear heel is slightly raised • Keep your back straight • Brief isometric contraction of the abdomen

46. Focusing (isolate) to the segment • Focus to the joint using one or more vectors of compression, creating local tissue tension • Build the barrier • Once you have identified the barrier, back off a little • Use posture for security and effectiveness • When ready, focus your forces, and engage the barrier • Hold the secondary components to maintain the barrier and amplify only the primary lever direction

47. How can we focus without locking? • Use several components • Control the part being worked accurately • Direct forces according to anatomical principles • Be highly aware of palpatory cues • Learn how tissues respond to varied forces • Keep an open mind to the varied possibilities

48. Basic routine to build barrier using multiple components • Focus to the segment • Test the primary lever amplitude at the segment • Add some of the 1st chosen secondary lever • Retest the primary lever: • If the endfeel is not good, add some of the 2nd chosen secondary lever • Retest the primary lever • If the endfeel is still not good: • Add some of the 3rd chosen secondary lever • Retest the primary lever amplitude • At optimum barrier point, thrust in primary lever - without losing the other components