In Flynns' always cited 2002 study where he developed a CPR to treat lumbar pain, they use the supine thrust (i think called "chicago roll" manip- pt side bend away, rotate to, and thrust from ASIS) - they state that the Therapist is standing on the opposite side to be manipulated, then thrust through the ASIS on the side to be manipulated. The side that was chosen was based on standing flexion test, and secondly side of pain.
I may have my mechanics wrong but when, in this position, you thrust say the R ASIS, this would seem to max close the R L5/S1 and through the sacrum cavitate the L side lumbar spine.... is that correct?? if so i would think they would ASIS thrust the side opposite to pain...
I dont use this technique but would like to know what its intentions are...
Joined: March 21, 2006
Forget the technique for a moment. Think about this important and correct concept. You can't be specific when you manipulate the lumbar spine. This is not an 'SI' joint manipulation. It is simply a manipulation that provides a neurophysiological effect. You cannot specifically manipulate one level of the spine into a specific direction.
I don't have the study at my finger tips, but there is a study that compared students to experienced PT's when performing manipualtion fo the spine. The experienced PTs were allowed to assess and then perform a manipualtion at the 'specific' level that they felt was affected. The students performed manipulations as well to the spine. Guess how their level to be manipualted was determined? It was drawn from a hat. Guess who had better outcomes? The students.
Joined: March 21, 2006
This article should open your eyes:
Does the Manual Therapy Technique Matter?
Joshua A. Cleland, DPT, OCS Assistant Professor, Physical Therapy Program, Franklin Pierce College, Concord, NH and Physical Therapist, Rehabilitation Services of Concord Hospital, Concord, NH
John D. Childs, PT, PhD, MBA, OCS, FAAOMPT Assistant Professor and Director of Research, US Army-Baylor University Doctoral Program in Physical Therapy
Decision-making related to manual therapy interventions has traditionally been based on biomechanical theoretical constructs.1 Most approaches generally advocate that the practitioner should accurately identify a segmental dysfunction based on the assessment of intersegmental motion or alignment, towards which a specific manual therapy intervention is then directed to ameliorate the underlying dysfunction. Presumably, these dysfunctions are associated with the patient’s experience of pain and disability, hence a failure to adequately address them are thought to interfere with recovery.
While the evidence for the effectiveness of manual therapy techniques continues to expand, mounting evidence has emerged challenging the usefulness of the biomechanical model. First, the physical examinations procedures commonly used to identify biomechanical dysfunctions presumably amenable to manual therapy interventions have almost universally been shown in multiple studies to be unreliable2-6 and lack validity for their use.7,8 Even presuming biomechanical dysfunctions can be identified, recent evidence has emerged suggesting that manual therapy practitioners are unable to accurately localize manipulative techniques to a specific segment.9-12 The purpose of this brief commentary is to review recent evidence related to the specificity of manual therapy interventions.
Recent in vivo dynamic MRIs studies have investigated spinal kinematics during posteroanterior (PA) mobilization in both the lumbar9 and cervical10 spine. Kulig et al9 demonstrated that when a PA Grade IV13 force was directed at any segment in the lumbar spine rotation in the sagittal plane occurs at all lumbar vertebrae, suggesting that the technique is not specific to any one segment. Lee and colleagues10 investigated the effects of a Grade III13 mobilization directed at the C5 spinous process, the maximum intervertebral rotation occurred in the direction of extension at the C2/C3 segment (approximately 3.8 degrees) while the C7/T1 segment actually rotated into flexion (approximately 2 degrees). This suggests that not only is a PA mobilization directed at C5 not specific but also that the 2-3 segments above and below the target vertebrae experienced the greatest amount of rotation in the sagittal plane.
Recent studies11,12 have investigated the accuracy and precision of spinal manipulation techniques as determined by the location of cavitations. Beffa and Mathews11 investigated the location of cavitations performed with a technique directed at L5 and another technique directed an the sacroiliac joint. There was no correlation between the technique used and the joint that cavitated. In fact each of the techniques resulted in cavitations throughout the lumbosacral region (Figure 1). Furthermore, Ross et al12 investigated the accuracy of manipulation directed at the thoracic and lumbar spine. The results demonstrated that thoracic spine manipulation was accurate 53% of the time while lumbar spine manipulation was only accurate 46% of the time. In addition, the majority of the manipulations resulted in multiple cavitations from which the authors concluded that manipulation is not segment specific.
While the aforementioned studies suggest that manual therapy interventions are not specific to an individual segment, the logical question becomes, “does it matter”? A number of studies14-16 have investigated the effects of different manual therapy techniques on patient-centered outcomes in patients with neck and low back pain. Chiradejnant et al14 investigated the effects of a therapist selected mobilization technique versus a randomly selected technique (central PA, unilateral PA, transverse PA) on outcomes. The results demonstrated that a significant reduction in pain occurred in both groups; however, no difference was observed between the groups, lending credibility to the idea that perhaps the particular technique utilized may not be overly important.
Haas and colleagues15 investigated the effectiveness of manipulating a cervical segment identified as being impaired based on endplay assessment versus a randomly selected segment on pain and stiffness in a group of patients with neck pain. Immediate and evening follow-up demonstrated that both the groups exhibited statistically significant reductions in pain and stiffness, but there were no differences between the groups. Another study demonstrated no difference in outcome among 30 patients with neck pain who were randomly assigned to receive either a cervical rotatory or a cervical lateral break manipulation for 10 treatments,16 The collective conclusions from these studies question whether the choice of technique is necessary to optimize the clinical outcome and provide evidence that the effects of manual therapy interventions may not be as precise as previously thought.15 Future randomized clinical trials should be performed to investigate the long-term effects of different manipulation techniques on patient-centered outcomes.
Recently a clinical prediction rule was developed17 and validated18 that used a manipulation technique purported to target the sacroiliac joint as the treatment of choice for identifying patients with low back pain likely to benefit rapidly and dramatically (based on patient reported levels of disability) from spinal manipulation. Interestingly, the presence of sacroiliac provocation tests, motion tests and symmetry tests were not identified as predictor variables for patients who would respond positively to this particular manipulation technique. In fact the results of these two studies suggest that the manipulation technique used (Figure 2) will result in significant reductions in disability, despite the absence of a well understood rationale as to the mechanism responsible for the favorable effects on clinical outcomes.
Recent evidence refuting the specificity of mobilization and manipulation techniques, combined with data suggesting that one particular technique might not be superior to another, questions the necessity to practice based on a strict biomechanical model when treating patients with low back and neck pain. Future work should continue to examine whether there are preferential effects for different manual therapy techniques, and whether efforts to be specific are worthwhile. Future research should also continue to elucidate the mechanisms underlying the favorable effects of manual therapy on clinical outcomes in patients with low back and neck pain.
1. Jull G, Moore A. Are manipulative therapy approaches the same? Man Ther. 2002;7:63. 2. Love R, Brodeur R. Inter- and intra-examiner reliability of motion palpation for the thoracolumbar spine. J Manipulative Physiol Ther. 1987;10:261-6. 3. Mootz R, Keating J, Kontz H, Milus T, Jacobs G. Intra- and interobserver reliability of passive motion palpation of the lumbar spine. J Manipulative and Physiol Ther. 1989;12:440-5. 4. Keating J, Bergmann T, Jacobs G, Finer B, Larson K. Interexaminer reliability of eight evaluative dimensions of lumbar segmental abnormality. J Manipulative Physiol Ther. 1990;13:463-70. 5. O'Haire C, Gibbons P. Inter-examiner and intra-examiner agreement for assessing sacroiliac anatomical landmarks using palpation and observation: pilot study. Man Ther. 2000;5:13-20. 6. Meijne W, van Neerbos K, Aufdemkampe G, van der WP. Intraexaminer and interexaminer reliability of the Gillet test. J Manipulative Physiol Ther. 1999;22:4-9. 7. Abbot JH, Mercer SR. Lumbar segmental hypomobility: Criterion-related validity of clinical examination items (a pilot study). N Z J Physiother. 2003;31:3-9. 8. Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996;21:2594-602. 9. Kulig K, Landel R, Powers CM. Assessment of lumbar spine kinematics using dynamic MRI: a proposed mechanism of sagittal plane motion induced by manual posterior-to-anterior mobilization. J Orthop Sports Phys Ther. 2004;34:57-64. 10. Lee RY, McGregor AH, Bull AM, Wragg P. Dynamic response of the cervical spine to posteroanterior mobilisation. Clin Biomech (Bristol , Avon ). 2005;20:228-31. 11. Beffa R, Mathews R. Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds. J Manipulative Physiol Ther. 2004;27:e2. 12. Ross JK, Bereznick DE, McGill SM. Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine. 2004;29:1452-7. 13. Maitland G, Hengeveld E, Banks K, English K. Maitland's verterbal manipulation. 6th ed. Oxford: Butterworth- Heinemann; 2000. 14. Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of "therapist-selected" versus "randomly selected" mobilisation techniques for the treatment of low back pain: a randomised controlled trial. Aust J Physiother. 2003;49:233-41. 15. Haas M, Groupp E, Panzer D, Partna L, Lumsden S, Aickin M. Efficacy of cervical endplay assessment as an indicator for spinal manipulation. Spine. 2003;28:1091-6. 16. van Schalkwyk R, Parkin-Smith GF. A clinical trial investigating the possible effect of the supine cervical rotatory manipulation and the supine lateral break manipulation in the treatment of mechanical neck pain: a pilot study. J Manipulative Physiol Ther. 2000;23:324-31. 17. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Butler B, Rendeiro D, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835-43. 18. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients likely to benefit from spinal manipulation: A validation study. Ann Intern Med. 2004;141:920-8.
rwillcott- thanks for your post! I had heard about that article a while back, i guess if you blow up the spine, you blow up the spine... i was still thinking that the side might matter (but i think in some of the manip research they would just go to the opposite side and thrust if they didnt get a cavitation...) i guess if i "thought" i felt a hypomobility with the magic hands, and i chose to thrust, i would want to do so in a way that mechanically made sense to open that side... but then research shows it not to really matter...frustrating
Joined: March 21, 2006
Don't feel bad. Feel enlightened. In my opinion you are one of the few PT's that takes the time to question the techniques we use. I was in your shoes not long ago and my treatment was very manual therapy driven. As I learned more and questioned techniques I came to the conclusion that what we think we are doing is not correct. This site as well as SS helped to open mind to concepts of neurophysiology and pain. These fields give a better explanation of the effect of the 'Chicago Roll' technique you were inquirng about.
Next time you're on a manual therapy course mention the Chiradejnant et al 2003 study to the instructor. Most won't be familiar with the study. Others will wish you didn't bring it up. None will accept the results.
thanks (is it Rob?)- what is this SS site? If i soon attend a manip course i will wave that article in the air from the back of the class (thinking about SMTcert, ive taken the MTC classes though have yet to go through with the cert, same with the mulligan classes)- was going to start a thread on this site about opinions on texts and cont edu classes that you all have found clinically useful, maybe you will have some insight...
A good site devoted to the pursuit of understanding how the central and peripheral nervous are the major players in pain, particularly pain of a persistent nature. You'll enjoy it, but be prepared to discard 99% of what you have been told in your MTC course work.
In regards to the Chicago technique, it was originally thought to be an SIJ gaping technique, but as with other lumbar manipulative techniques, has been found to be unspecific. This does not mean ineffective. I use it, and have found success similar to what was found in Childs validation study of the lumbar manip CPR. however, my patient population does not have nearly as many patients that are positive on the rule as Childs did in his study. I manipulate the painful side first. Can't see much sense in using a standing flexion test given the inter and intra rater reliability being as poor as it is.
Jess Brown, PT Board Certified in Orthopaedic Physical Therapy