Manipulation in the presence of disc lesions (Full Version)

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kiwi PT -> Manipulation in the presence of disc lesions (March 17, 2008 12:02:51 AM)

Does anybody perform manipulation in the presence of disc herniations or other radicular symptoms (not including thoracic manip for cervical)? Doesn't seem like a really strong rational for it, but also doesn't seem like a lot of evidence specifically demonstrating it as dangerous in these scenarios. Some recommend it for in the absence of progressive neurological deficit, and there is some osteopathic and chiropractic research on SMT in these scenarios.


Kyle



rwillcott -> RE: Manipulation in the presence of disc lesions (March 17, 2008 9:05:21 AM)

I follow the 5 CPR's for lumbar spine manipulation.  Are you familiar with these?   



kiwi PT -> RE: Manipulation in the presence of disc lesions (March 17, 2008 11:37:11 AM)

Yes I am very aware of the CPR it identifies those most likely to have a rapid improvement with manipulation. It does not provide evidence that manipulation is worse or better than specific alternatives in cases where the rule is not positive.  Also if someone is positive on 4/5 but not for no pain below the knee I take it you are still manipulating rwillcott? I'm not specifically advocating it but have heard from others that the fear that many PTs, including me, have of manipulation in these cases is not firmly rooted in eveidence. Just curious as to others thoughts.

Kyle PT



steve -> RE: Manipulation in the presence of disc lesions (March 17, 2008 12:16:53 PM)

Hi Kiwi,

Good question. The specifics of the CPR that there was no neurological abnormalities on the exam before the use of the 5 factors. I would definately use manipulation with someone positive on 4/5 with pain below the knee - They did this on patients in the CPR and had great outcomes.

You are right about the fear of manipulation with patients presenting with disk herniations - the risk is likely over estimated. I have a good friend who is a chiro and in his own words says that he "Hits the disk hard" when there is a herniation and there is a whole theory on how this reabsorbs the herniation. This stated, I would suggest that if you are maniping and anything goes wrong irrespective of if it is a direct result of treatment you will likely be blamed. I feel much more comfortable with less aggresive techniques such as directional preference/positioning exercises and traction.

Steve



TexasOrtho -> RE: Manipulation in the presence of disc lesions (March 17, 2008 1:10:48 PM)

I think the CPR allows us to identify who benefits but is far from telling us what is truly happening.  Even Flynn would likely agree that we aren't 100% sure what's going on.  I think there is some pretty big neurophysiologic event at play personally, but that's just me. 

I look at it as manipulating a series of findings vs a disc as I don't think we are so sure of ourselves to say it is a "disc" that is being manipulated.  We seem to be getting closer to making the connection, but aren't there yet.

There are so few adverse events associated with manipulation in the absense of horrendous risk factors (fx, RA, equina etc..), that I don't see a a reason not to perform them if you determine they are indicated.  The C-spine is another issue for me altogether so I assume we are talking lumbar.



steve -> RE: Manipulation in the presence of disc lesions (March 17, 2008 2:18:34 PM)

Rereading your question kiwi, I would agree with Rod - if its an MRI finding but doesnt match with symptoms I dont worry as lots of asymptomatic individuals have herniations. If there neuro exam shows diminished reflex, fatiguable myotome, SLR below 45 degrees I likely wouldnt manip.

Could you clarify what you mean by herniation?

Steve



Kaden -> RE: Manipulation in the presence of disc lesions (March 17, 2008 2:43:04 PM)

I would agree with Steve that since current neurological symptoms excluded those from participating when the CPR was developed, that even if meet 4/5 criteria manip should not be the first line of defense.

Now, if this paitent has failed more conservative approaches and is headed down the path of surgical intervention then it might be worth attempting manipulation prior to surgical intervention as long as no significant red flags.



rwillcott -> RE: Manipulation in the presence of disc lesions (March 17, 2008 3:15:37 PM)

When is someone too old to be manipulated?

I have a 70 year old patient that meets 4/5 CPR's for manipulation of the lumbar spine.  I have seen him for 3 sessions and he has had no relief.  I've been fairly conservative since he has a total hip and due to his age. Treatment has consisted of gentle manual therapy of his left lumbar spine, IFC, heat and an exercise program.

Something tells me he would get some relief from a manip however I don't feel comfortable performing it.  I'm sure there are some chiro's out there that wouldn't think twice.

What do others think?

Rob



kiwi PT -> RE: Manipulation in the presence of disc lesions (March 17, 2008 6:09:08 PM)

quote:

ORIGINAL: steve

Could you clarify what you mean by herniation?




I did not have one specific clinical senario in mind, but was thinking of instances where there were some clinical correlations with or without imaging.

"If there neuro exam shows diminished reflex, fatiguable myotome, SLR below 45 degrees I likely wouldnt manip"

This is what my feelings are; however there are those who do, and use progressive neurological deficit as the criterea not to. I am not aware of any evidence to say clearly they are wrong. So as long someone isn't getting worse some would use it.  No way am I going to manip the person with 20 deg SLR who says "well I'm better than I was last week". 

As to age, the pop in the CPR was 18 to 60 so I don't think it could be used to predict outcomes in other populations. At 70 there HUGE variation in peoples general health level of activity and bone integrity, some I think it would be appropriate for and some it wouldn't, I was in an olympic distance triathlon a couple years ago and there was a 74 year old that was only about 30 minutes behind me. I would definately use caution (pain free set up, ensure a low amplitude and use minimum force neccesary) in such a case.

How about the reverse of rwillcot's question how young do you manipulate? The idea of thrusting asymptomatic babies as some do horrifies me, but teenagers who have been radiographically cleared of spondy's or other pathology certianly sounds plausible.

Thanks for your thoughts guys,
Kyle PT



proud -> RE: Manipulation in the presence of disc lesions (March 18, 2008 11:51:50 AM)

quote:

ORIGINAL: rwillcott

When is someone too old to be manipulated?

I have a 70 year old patient that meets 4/5 CPR's for manipulation of the lumbar spine.  I have seen him for 3 sessions and he has had no relief.  I've been fairly conservative since he has a total hip and due to his age. Treatment has consisted of gentle manual therapy of his left lumbar spine, IFC, heat and an exercise program.

Something tells me he would get some relief from a manip however I don't feel comfortable performing it.  I'm sure there are some chiro's out there that wouldn't think twice.

What do others think?

Rob


Age is not a contraindication per se right. But you would want to know the medical history quite well. Osteoporosis, severe OA are examples of the pitfalls with the elderly. Has this patient had a recent X-ray? I would might err on the side of caution if no recent X-ray is available.

In the past, I have manipulated the lumbar spine of patients into there 60's, 70's and one in his 80's. I would suggest the side lying manipulation as it is really quite a gentle manip anyway. Do a pre-manipulative hold and if no pain....I'd say manipulate.



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