Is spinal manipulation working in the suspected area?

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Is spinal manipulation working in the suspected area? - March 4, 2005 8:44:00 PM

january

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Hi all,

Sorry, if the subject is a bit provocative but is there evidence/papers proving that spinal manipulation acts really where the PT/chiro thought it?
Is there some scientific study showing that the intended forces of mobilization are directed and absorbed by the spinal joint they wanted?

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Re: Is spinal manipulation working in the suspected area? - March 5, 2005 2:17:00 AM

SJBird55

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How about if you jump into the Orthopaedics section (the next section down) and check out the discussion regarding manipulation and the clinical prediction rule? There was a huge, long discussion there.

(in reply to january)

Post #: 2

Re: Is spinal manipulation working in the suspected area? - March 5, 2005 2:17:00 AM

PTupdate.com

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I think that many of the more general manipulations that are performed end up "popping" the most mobile segment, while the hypomobile or malaligned segement is the one causing the problem in the first place. The reflex arc from the rapid joint expansion gives some nice temporary relief, but does not address their real need. Thus, they keep getting cracked over and over and over and over and over.

John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]

_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to january)

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Re: Is spinal manipulation working in the suspected area? - March 5, 2005 3:10:00 AM

Alex Brenner PT MPT OCS

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John,
I disagree. I have been performing manipulations since I was a student and I have never had a patient that I had to repeatedly manipulate over and over. If I found this to be the case I would try another intervention. I think those of us that perform manipulation do not do this as our sole intervention. There is always some type of impairment based exercise program or treatment regiment that goes along with the manipulation. Who would just manipulate over and over and over? I dont think you would find many manipulators that do this.

_____________________________

Alex Brenner, PT, MPT, OCS

(in reply to january)

Post #: 4

Re: Is spinal manipulation working in the suspected area? - March 5, 2005 3:13:00 AM

Alex Brenner PT MPT OCS

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Jan,
I don't think we really know right now what exactly happens when we perform a manipulation. It is also very difficult to target a specific joint when manipulating. I think that is why some of the names for the manipulation techniques are "Lumbosacral region manipulation" or the "Lumbopelvic manipulation". We are not sure exactly what is cavitating either the pelvis, sacroiliac or lumbar facet joints. I am not sure and I really don't think it matters too much.

We do know however that it works (please read the thread that SJ mentioned above). This is apparent when we see large drops in Oswestry scores following this type of intervention.

_____________________________

Alex Brenner, PT, MPT, OCS

(in reply to january)

Post #: 5

Re: Is spinal manipulation working in the suspected area? - March 5, 2005 3:50:00 AM

Diane

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[QUOTE]Who would just manipulate over and over and over? I dont think you would find many manipulators that do this.[/QUOTE]Ahem...Army, I agree that probably not many self-identified manipulators would, however the catagory of manipulator that self-identify as 'adjustors' would and do.
[QUOTE]I don't think we really know right now what exactly happens when we perform a manipulation. It is also very difficult to target a specific joint when manipulating.[/QUOTE]How disarmingly honest of you to admit. Thank you for that. :)

(in reply to january)

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Re: Is spinal manipulation working in the suspected area? - March 5, 2005 4:00:00 AM

jma

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The spine is a tricky place to do manipulations from all the of reasons stated above. Unlike the upper or lower extremities, where one can stabilize one area and manipulate the other, it is very hard to stabilize, or hold for that matter, one spinal segment and manipulate the other exclusively.

JMA

(in reply to january)

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Re: Is spinal manipulation working in the suspected area? - March 5, 2005 5:38:00 AM

Diane

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JMA, agreed. Especially since from the outside you have to "get through" a bunch of tough, slippery, rubberish defensive layers, like the thoraco lumbar fascia (all three layers of it) and latissmus/trapezius. It's a lot easier to have a perceptual fantasy of isolating a segment than it is to actually "know" that's what you are doing.

(in reply to january)

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Re: Is spinal manipulation working in the suspected area? - March 5, 2005 6:08:00 AM

PTupdate.com

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Army,

I do not think I conveyed into writing what was running through my head.

I was indicating more those cases where a person has been going to a chiro for years, and the manipulation performed is just a standard trunk rotation with thrust....nothing done to isolate a specific level. Pretty much the same thing when we lean back in a chair and pop our own backs.

I would say that most PT's performing specific level manipulations (and there really are not that many) would not make this type of mistake.

Duffy

_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to january)

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Re: Is spinal manipulation working in the suspected area? - March 5, 2005 1:20:00 PM

wjPT

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From: San Diego, CA
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January,

This article in Spine may have some answers you are looking for:
Ross JK, Bereznick DE, McGill SM. Determining cavitation location during lumbar and thoracic spinal manipulation. Spine. 2004;29(13):1452-1457.

Basically this article states that thoracic manipulations had a trend for greater accuracy than lumbar manipulations, with neither location yielding highly specific manipulations.

Also try searching further on medline for similar research articles.

warren

(in reply to january)

Post #: 10

Re: Is spinal manipulation working in the suspected area? - March 5, 2005 4:10:00 PM

chiroortho

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[QUOTE]I don't think we really know right now what exactly happens when we perform a manipulation.[/QUOTE]I agree 100%. This is probably the single most important area that I would like to know more about. [QUOTE]It is also very difficult to target a specific joint when manipulating. I think that is why some of the names for the manipulation techniques are "Lumbosacral region manipulation" or the "Lumbopelvic manipulation".[/QUOTE]Again, total agreement. In chiro school we were trained to manipulate 'L5', but there is simply no way to simply manipulate 'L5' if for no other reason than L5 articulates via a tripod joint with L4 above and sacrum below. Further, even when I attempt to isolate segments as best I can, I frequently obtain 2 or 3 cavitations, and I am a gentle manipulator. When I have attempted a manipulation to an area and was not satisfied that I induced as much motion as I wanted to, and the patient says 'It's okay, I can take it, push harder' I tell the patient that 'I can move a rhinoceros spine if I wanted to but that is not my goal. We'll try again next time.' I just don't buy the 'segmental' isolation. We try to isolate as much as possible, but as others have aptly noted, there are musculoligamentous connections that preclude pure segmental manipulation. [QUOTE]We are not sure exactly what is cavitating either the pelvis, sacroiliac or lumbar facet joints. I am not sure and I really don't think it matters too much.[/QUOTE]This is true. There are theories that I have read over the years, some better than others, but the bottom line for me is that manipulation properly rendered is safe, provides patients with relief, and can have long-lasting results, whatever the reason. The Flynn data show that 90+% of folks can get lasting relief from LB manipulation, and having viewed the technique over and over again, I don't think anyone would argue that his particular manipulative technique is 'specific'.

Manipulation has been around for a LONG time, and has a proven track record for safety and efficacy for pain relief. Anybody can screw up, sure, but we can burn people with hot packs too.

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Greg Priest, DC, DABCO

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Re: Is spinal manipulation working in the suspected area? - March 5, 2005 10:10:00 PM

Alex Brenner PT MPT OCS

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Another piece of the puzzle to throw in are the findings of Flynn and collegues in 2003. The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain. Arch Phys Med Rehabil. 2003 Jul;84(7):1057-60. Flynn TW, Fritz JM, Wainner RS, Whitman JM.

They conclude that the audible pop is not even needed in order to have a positive outcome with the lumbosacral region manipulation performed on patients.

When I manipulate a spine not only am I not worried about precisely aiming the manipulation I don't even really care too much if it cavitates or not. What is more important to me is if the patient is moving better and with less pain/disability.

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Alex Brenner, PT, MPT, OCS

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Re: Is spinal manipulation working in the suspected area? - March 6, 2005 1:01:00 AM

Diane

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[QUOTE]When I manipulate a spine not only am I not worried about precisely aiming the manipulation I don't even really care too much if it cavitates or not. What is more important to me is if the patient is moving better and with less pain/disability. [/QUOTE]This is weird, but I agree. There's not even any need to do anything highvelocity back there, probably. 'Pain in the back responds to passive movement' is the takeaway message I'm getting here. Probably no need to be anal retentive about what segments one is trying to be on, or overly violent. Just move the back for the patient somehow, to wake up something that went into a snooze and interfered with normal function. That sort of approach I can live with.

(in reply to january)

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Re: Is spinal manipulation working in the suspected area? - March 6, 2005 1:40:00 AM

chiroortho

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Army, your point about cavitation or the lack thereof is a very good point, and I think a lot of folks that utilize manip interpret a lack of cavitation with a lack of movement. Many, many times I have provided manip without cavitation and the patient has in fact responded well. This is one of the reasons that I think manipulation affects mechanisms other than the joint proper.

Conversely, there have been patients that responded satisfactorily only after cavitation. And many times I have perceived a slight but palpable 'clunk' of the joints under my hands although no audible cavitation occurred, and the patients responded with an immediate 'Ahhhh'. So I agree that the noise itself is of questionable significance.

The key is movement.

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Greg Priest, DC, DABCO

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Re: Is spinal manipulation working in the suspected area? - March 6, 2005 7:32:00 PM

january

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Hi All,

I was absent for the weekend and did not thought that many of you were so interested by the subject. Thanks to all.

-SJBird55
I checked out the discussion regarding manipulation but it doesn't reply to my question.

-PTupdate.com
[QUOTE]that are performed end up "popping" the most mobile segment, while the hypomobile or malaligned segement is the one causing the problem in the first place.[/QUOTE]That's all my questioning since manipulation is intended to mobilize a stiff segment surrounded by soft ones. The forces may be lost in the soft components before any action in the stiff one?

-ArmyPT
[QUOTE]I think those of us that perform manipulation do not do this as our sole intervention. There is always some type of impairment based exercise program or treatment regiment that goes along with the manipulation.[/QUOTE]But thus how are we sure that it was manipulation that worked?

[QUOTE]I don't think we really know right now what exactly happens when we perform a manipulation. It is also very difficult to target a specific joint when manipulating. I think that is why some of the names for the manipulation techniques are "Lumbosacral region manipulation" or the "Lumbopelvic manipulation". We are not sure exactly what is cavitating either the pelvis, sacroiliac or lumbar facet joints. I am not sure and I really don't think it matters too much.[/QUOTE]Saying to a patient that I'm mobilising his L4 but thinking that I do not know where it happens let me perplex!

-Diane
[QUOTE]There's not even any need to do anything high velocity back there, probably.[/QUOTE]I agree totally. If a joint went slowly in a bad position without popping, perhaps it is possible to make a reverse slow movement to take it back in place?

Thanks for references, I will read them carefully and give some thoughts.

(in reply to january)

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Re: Is spinal manipulation working in the suspected area? - March 6, 2005 11:31:00 PM

Alex Brenner PT MPT OCS

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Jan,
There are several good quality studies that show that manipulation is efficacious for lower back pain. I personally am not worried too much about why or how it works, the evidence shows us that it does indeed work. We know it works because there was a good quality research study that looked at manipulation and exercise versus just exercise and found that the manipulation and exercise group did much better. The success of this group could only be contributed to the manipulation.

Have you read the Flynn et al Clinical Prediction Rule study and the follow on validation study by Childs et al that were referenced in the other thread that you read? What do you think about those?

[QUOTE]Saying to a patient that I'm mobilising his L4 but thinking that I do not know where it happens let me perplex![/QUOTE]Why not just say to your patient, "There is a physical therapy technique that has been shown in recent research to provide relief to low back pain. In fact, you have a 80% (if the person has 4 out of the 5 clinical predictors) of getting significantly better if I perform this technique on you."

Why are you even saying "mobilising L4" etc.? Do you think your patient even knows what that means or even knows where that is on his or her low back?

_____________________________

Alex Brenner, PT, MPT, OCS

(in reply to january)

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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 12:03:00 AM

Barrett

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Jan,

I agree with Army, you don't want to make it very complicated.

Perhaps you could just say, "What I want to do in your case is have you lie on your side so that I can rotate your trunk very fast while you let me. I don't know how far you'll turn in response to my force and there's no way of measuring the amount of force I'm actually going to use. In fact, I don't even know or care which structures within your body this force will effect or how. It wouldn't be right to say they were spinal structures since so many others may be involved. Let's just call them your "trunkal structures," okay? In case you're worried I have a couple of studies here that say you've got a pretty good chance of feeling better later if I do this."

That should do it.

_____________________________

Barrett L. Dorko P.T.
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 12:40:00 AM

Alex Brenner PT MPT OCS

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Nice. I think you should go back and relearn the technique. It sounds like you performed this very forcefully. This is not the case.

Also, the lumbosacral region manipulation is performed supine. I could show you sometime if you would like.

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Alex Brenner, PT, MPT, OCS

(in reply to january)

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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 1:05:00 AM

Barrett

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Army,

I didn't say anything about how much force is used. I said no one knew, and that's true. I assume the "slack" is taken from the system beforehand and that the attempted thrust is at end range of whatever structures you imagine you've recruited. If I were you, I wouldn't assume I don't know about the nuances of manipulative technique and the spectrum of its practice. As for your "supine" comment-What about the part where the upper trunk ends up all but sidelying?

It comes down to this: "I don't know what I'm doing exactly or why the result is so positive in such a case, and, in fact, I don't much care. But I have a study driving my choice of treatment, and that's how I practice."

I am merely restating what I've heard here repeatedly.

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Barrett L. Dorko P.T.
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 1:21:00 AM

JLS_PT_OCS

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I also try not to tell patients too much in the way of detailed explanation.
I usually say something like "no one knows what really causes back pain. In this case we can see from your limited range of movement that your back is not moving freely, and I want to try a technique to help it move better and with less pain, so we can speed up the rehabilitation process."

Real general leadup there. In fact, since like Army I'm not even sure exactly what's going on, I think it would be disingenous of me to try to explain it in anatomical terms also. The primary problem is that people have been given too many "diagnoses" anyway. Especially of this condition.

I would respectfully suggest that those who think this technique requires a lot of force have not learned it properly. Probably 50% of patients I use this technique with have a cavitation with just the positioning, before any thrust is given. I work harder to move their leg passively when performing the SLR exam than I push on their ASIS to do the (probably poorly-named) "thrust".

So ideas of manipulators passively cranking their patients hither and yon like rag dolls are simply inaccurate.
Cranking real hard is a great way to scare somebody into thinking you're a quack and not wanting to come back...

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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**

(in reply to january)

Post #: 20