Manipulative Intervention Research Articles

Manipulative therapy of secondary lymphedema in the presence of locoregional tumors

Complete decongestive therapy (CDT), including manual lymphatic drainage (MLD) is a manipulative intervention of documented benefit to patients with lymphedema (LE). Although the role of CDT for LE is well described, to the authors' knowledge there are no data regarding its efficacy for patients with LE due to tumor masses in the draining anatomic bed. Traditionally, LE therapists are wary of providing therapy to such patients with 'malignant' LE for fear of exacerbating the underlying cancer, and that the obstruction will render therapy less effective. In the current study, the authors' experience providing CDT for such patients is discussed. Cancer survivors with LE were referred to therapists at 2 Atlanta-area clinics. CDT consists of treatment (Phase 1) and maintenance phases (Phase 2). During Phase 1, the patient undergoes manipulative therapy and bandaging daily until the LE reduction plateaus; at that point, Phase 2 (self-care) begins. At the beginning and end of Phase 1, LE is quantified and differences in girth volume calculated. The results for patients completing Phase 1 therapy for LE in the presence of locoregional masses were compared with results for patients with LE in the absence of such disease. Both volume reduction of the affected limb and number of treatments to plateau were analyzed. Between January 2004, and March 2007, LE of 82 limbs in 72 patients was treated with CDT and Phase 1 was completed. The median number of treatments to plateau was 12 (range, 4-23 treatments); the median limb volume reduction was 22% (range, -23 to 164%). Nineteen limbs (16 patients) with associated chest wall/axillary or pelvic/inguinal tumors had nonsignificant difference in LE reduction (P = .75) in the presence of significantly more sessions to attain plateau (P = .0016) compared with 63 limbs in 56 patients without such masses. Patients with LE may obtain relief with CDT regardless of whether they have locoregional disease contributing to their symptoms. However, it will likely take longer to achieve that effect. Manipulative therapy of LE should not be withheld because of persistent or recurrent disease in the draining anatomic bed.

Immediate Effects on Pressure Pain Threshold Following a Single Cervical Spine Manipulation in Healthy Subjects

A placebo, control, repeated-measures, single-blinded randomized study. To compare the immediate effects on pressure pain threshold (PPT) tested over the lateral elbow region following a single cervical high-velocity low-amplitude (HVLA) thrust manipulation, a sham-manual application (placebo), or a control condition; and to analyze if a different effect was evident on the side ipsilateral to, compared to the side contralateral to, the intervention. Previous studies investigating the effects of spinal manual therapy used passive mobilization procedures. There is a lack of studies exploring the effect of cervical manipulative interventions. Fifteen asymptomatic volunteers (7 male, 8 female; aged 19-25 years) participated in this study. Each subject attended 3 experimental sessions on 3 separate days, at least 48 hours apart. At each session, subjects received either the manipulation, placebo, or control intervention provided by an experienced therapist. The manipulative intervention was directed at the posterior joint of the C5-6 vertebral level. PPT over the lateral epicondyle of both elbows was assessed preintervention and 5 minutes postintervention by an examiner blinded to the treatment allocation of the subject. A 3-way analysis of covariance (ANCOVA) with intervention, side, and time as factors, and gender as covariate, was used to evaluate changes in PPT. The analysis of variance detected a significant effect for intervention (F = 31.46, P < .001) and for time (F = 33.81, P < .001), but not for side (F = 0.303, P > .5). A significant interaction between intervention and time (F = 15.74, P < .001) was also found. Gender did not influence the comparative analysis (F = 0.252, P > .6). Post hoc analysis revealed that the application of a HVLA thrust manipulation produced a greater increase of PPT in both elbows, as compared to placebo or control interventions (P < .001). No significant changes in PPT levels were found after the placebo and control interventions (P > .6). Within-group effect sizes were large for PPT levels in both elbows after the manipulative procedure (d > 1.0), but small after placebo or control intervention (d < 0.1). The application of a manipulative intervention directed at the posterior joint of the C5-6 vertebral level produced an immediate increase in PPT over the lateral epicondyle of both elbows in healthy subjects. Effect sizes for the HVLA thrust manipulation were large, suggesting a strong effect of unknown clinical importance at this stage, whereas effect sizes for both placebo and control procedures were small, suggesting no significant effect.

Palpation of the sacroiliac joint: An anatomical and sensory challenge

Background The sacroiliac joint (SIJ) is identified as one of many possible sources of non-specific low back pain and may be a target for diagnostic palpation. Putative diagnostic palpation of joint motion, tissue texture changes and pain form a routine aspect of practice in manual healthcare. However, the tactile tradition of diagnostic palpation is beset with anatomical and sensory confounding that may establish an upper ceiling for sensitivity and specificity. For illustrative purposes, this is highlighted by a review of the anatomy of the sacroiliac joint (SIJ). Increasing critical awareness of the inherent limitations in the tactile tradition of diagnostic palpation may lead to the development of a standardised and technologically based approach. Aims and objectives To highlight anatomical and sensory difficulties that may be associated with the use of diagnostic palpation. To promote wider critical consideration for the continuing role of diagnostic palpation as a tactile tradition in manual healthcare and to speculate that a technological answer may provide a more reliable and valid alternative. Discussion Reviewing the anatomy of the sacroiliac region demonstrates why diagnostic palpation of the SIJ may be more difficult than may be commonly perceived. Furthermore, the somatosensory basis of diagnostic palpation is a confounding variable that may not be possible to circumvent. In an era in which evidence for clinical practice is sought, it is timely that specific elements of this distinctive diagnostic tradition in manual healthcare be critically examined. It is speculated that the development of a technological solution may provide an alternative. Conclusion Review of the relevant anatomy helps enhance critical thinking about the use of palpation in manual healthcare practice. The diagnostic examination of the SIJ by palpation appears to be an accepted investigative approach of manual healthcare but is confounded by anatomical and sensory variables. Illustrative of systematic and possibly insurmountable anatomical and sensory confounding, the continued use of non-standardised, manual diagnostic palpation as a basis for manipulative intervention is questionable. There is a need to develop a sophisticated, technologically based alternative that offers a reliable multimodal input, standardization of findings and comparative indexing of such findings to a reference data-base. Therein lies an opportunity for a pan-disciplinary lingua-franca in diagnostic palpation.

Gross range of motion in the cervical spine: the effects of osteopathic muscle energy technique in asymptomatic subjects.

Muscle energy technique is an established osteopathic manipulative intervention often used to treat somatic dysfunctions of the spine. There are little objective data to demonstrate its efficacy, however. To determine the efficacy of this osteopathic manipulative technique, the authors compared active cervical range of motion among asymptomatic young and middle-aged adults (n=18) before and after this treatment protocol, comparing those results against matched control subjects (n=14) who received sham manipulative treatment. Range of motion was measured in three planes (flexion/extension, lateral bending, rotation) on all subjects (N=32) using a motion-analysis system. Multiplanar gross cervical motion restrictions were diagnosed in this asymptomatic population. In the treatment group, cervical long restrictor muscles were treated with the muscle energy technique in the sagittal, frontal, and horizontal planes. The control group had relative restrictions addressed by means of a sham manipulative treatment protocol in which the barriers to motion were not challenged therapeutically. The muscle energy technique produced a significant increase in overall regional cervical range of motion in the treatment group (approximately 4 degrees) when compared with control subjects (P<.001). Significant differences were also observed in the magnitude of change in the three planes of movement (rotation, P<.002; lateral bending, P<.01), with flexion/extension being the least affected (P=.2). These data demonstrate that the application of the muscle energy technique can produce acute increases in the active cervical range of motion in asymptomatic subjects.

The Audible Pop From High-Velocity Thrust Manipulation and Outcome in Individuals With Low Back Pain

Objective To determine the relationship between an audible pop with spinal manipulation and improvement in pain and function in patients with low back pain. Methods In this pragmatic study, 70 patients from a multicenter clinical trial were randomly assigned to receive high-velocity thrust manipulation and included in this secondary analysis. Patients were managed in physical therapy twice the first week, then once a week for the next 3 weeks, for a total of 5 sessions. A single high-velocity thrust manipulative intervention purported to affect the lumbopelvic region was used during the first two sessions. Therapists recorded whether an audible pop was heard by the patient or therapist. Outcome was assessed with an 11-point pain rating scale, the Oswestry Disability Questionnaire, and measurement of lumbopelvic flexion range of motion. Repeated measures analyses of variance were used to examine whether achievement of a pop resulted in improved outcome. Results An audible pop was perceived in 59 (84%) of the patients. No differences were detected at baseline or at any follow-up period in the level of pain, the Oswestry score, or lumbopelvic range of motion based on whether a pop was achieved ( P > .05). The odds ratios and 95% confidence intervals for achieving a successful outcome at each of the follow-up periods all approximated a value of 1, suggesting no improvement in the odds of successful outcome among patients in which an audible pop occurred. Conclusions The results of this pragmatic study suggest that a perceived audible pop may not relate to improved outcomes from high-velocity thrust manipulation for patients with nonradicular low back pain at either an immediate or longer-term follow-up.

Transplantation of a polyembryonic wasp embryo: a technique for transferring endoparasitic embryo into the host egg

Concealed development of many animal embryos prevents examination of development and limits the application of embryo manipulation techniques aimed at understanding developmental processes. In embryos developing in utero, such as in mammals, it is necessary to dissect embryos from the mother and, upon manipulative intervention, to implant them back into the recipient. Parasitic wasps present a promising system for understanding the evolution of early developmental processes. In basal ectoparasitic species that lay eggs on the surface of the host, it is possible to adapt embryo manipulation techniques developed in Drosophila. However, their derived endoparasitic relatives, which exhibit various modifications of developmental programs, undergo concealed development within the host body. For example, the parasitic polyembryonic wasp Copidosoma floridanum oviposits an egg into the egg of the host moth Trichoplusia ni. The host larva emerges and the parasite undergoes development within the host body, preventing embryo manipulation as a means of examining developmental regulation. Here we present a protocol for embryo transfer that allows the transplantation of C. floridanum egg into the host egg. This approach opens a new avenue in the application of various embryo manipulation techniques aimed at understanding the evolution of embryogenesis in endoparasitic Hymenoptera. In addition, this approach has potential for the development of other tools in C. floridanum, such as transgenesis and reverse genetics, which can also be extended to other endoparasitic species.

Increased lymphatic flow in the thoracic duct during manipulative intervention.

The thoracic pump and the abdominal pump are osteopathic manipulative (OM) lymphatic pump techniques frequently used by osteopathic physicians to treat patients with infections (eg, pneumonia, otitis media). Although there is a widely accepted belief among the osteopathic medical profession that increasing lymphatic flow is beneficial, no measurements of lymph flow during osteopathic manipulative treatment have been reported. The authors surgically instrumented five mongrel dogs to record lymphatic flow in the thoracic duct (TDF) and cardiac variables during three intervention protocols. After recovery from surgery, canine subjects were placed in a standing-support sling, and TDF, cardiac output, mean aortic blood pressure, and heart rate were recorded during two randomized 30-second sessions of manipulative intervention using the osteopathic thoracic pump and abdominal pump techniques on two successive days. Lymph flow in the thoracic duct increased from 1.57+/-0.20 mL x min(-1) to a peak TDF of 4.80+/-1.73 mL x min(-1) during abdominal pump, and from 1.20+/-0.41 mL x min(-1) to 3.45+/-1.61 mL x min(-1) during thoracic pump. Lymph flow in the thoracic duct and cardiac variables were also recorded for canine subjects during physical activity (ie, treadmill exercise at 3 miles per hour at 0% incline). During physical activity, TDF increased from 1.47+/-0.33 mL x min(-1) to 5.81+/-1.30 mL x min(-1). Although cardiac variables did not change significantly during manipulative intervention with lymphatic pump techniques, cardiac output and heart rate did increase during physical activity. The authors conclude that physical activity and manipulative intervention using thoracic pump and abdominal pump techniques produced net increases in TDF (P<.05).

Management of a Chronic Lumbar Disk Herniation with Chiropractic Biophysics Methods After Failed Chiropractic Manipulative Intervention

To discuss the use of chiropractic biophysics methods in the treatment and rehabilitation of a patient with a chronic disk herniation at the L5-S1 disk, retrolisthesis of L5, and a reduced lumbar lordosis. A 23-year-old woman suffered from chronic unremitting symptoms of lower back pain and left-leg pain. She was treated five years prior, without relief. Diagnosis at that time was low-back pain and lumbar subluxation. Approximately 3 years later, she was evaluated by an orthopedic surgeon. Magnetic resonance imaging showed a moderate posterior disk protrusion at L5-S1 with degeneration. Chiropractic treatment of this patient consisted of mirror-image chiropractic adjustments, 3-point bending lumbar extension traction, and postural exercises. The patient responded well with a complete resolution of her symptoms and a restoration of her lumbar lordosis. This article suggests that successful management of chronic low-back pain symptoms may require a close analysis of a patient's postural deviations and sagittal plane curves. This study suggests that it is possible to restore lumbar lordosis in some cases and this may have an unforeseen benefit to the patient. Further study is warranted into the treatment of chronic low-back pain with chiropractic biophysics methods.

Breech presentation: increasing maternal choice.

Pregnant women with a third trimester breech presentation are almost invariably offered Caesarean section as the mode of delivery of first choice, especially when external version has failed to turn the fetus to cephalic. However, increasingly women are resorting to alternatives, to avoid either operative delivery or manipulative intervention in late pregnancy. This paper reviews some of the options for women with breech presentation, focusing especially on integrating these options into conventional maternity care.

Immediate Improvements in Side-to-Side Weight Bearing and Iliac Crest Symmetry After Manipulation in Patients with Low Back Pain

Background Although there is good evidence that spinal manipulation is an effective treatment to improve pain and function for patients with low back pain (LBP), there is little evidence to support the mechanism by which manipulation works. Objectives To determine if iliac crest (IC) and weight-bearing (WB) symmetry improve after spinal manipulation and to determine if improvements in IC and WB symmetry are associated with improvements in pain and function in patients with low back pain. Design Single group, within-subjects, repeated measures design. Method Thirty consecutive patients (mean age = 40±13) who came to a spine specialty center for treatment of acute or chronic LBP and who would be receiving spinal manipulation participated in the study (14 male patients). Patients completed a series of self-report measures of pain and function and received a standardized physical examination, including the assessment of IC and WB symmetry. Patients received a standardized manipulative intervention, and immediate and 3- to 4-day follow-up examinations were performed by a blinded examiner. Paired t tests were performed to determine within-group changes, and Pearson product moment correlation coefficients were calculated to determine the relationship between improvements in IC and WB symmetry and improvements in pain and function. To control for the potential that an association between changes in IC and/or WB symmetry and changes in pain and function could be confounded by the baseline outcome measure, simultaneous linear regression was performed on any significant correlation. Partial F tests were used to determine if the additional explained variability was significant. Results Patients with LBP demonstrated significant improvements in IC and WB symmetry after manipulation ( P<.001). Improvements in WB symmetry were associated with improvements in the patients' self-reported levels of pain 3 to 4 days after manipulation ( r=.5, P=.007). Based on the significant association between improvements in WB symmetry and improvements in pain, the final pain score was regressed on the change in WB symmetry, after controlling for the baseline level of pain. The addition of the change in WB symmetry explained a 10% additional increase in variability in the patient's level of pain at the 3- to 4-day follow-up ( P = .01). No relationship was found between improvements in IC and WB symmetry and improvements in function as determined by the Oswestry Disability Questionnaire 3 to 4 days after manipulation. Conclusion IC and WB symmetry improved immediately after spinal manipulation. Improvements in WB symmetry were related to improvements in the patients' self-reported levels of pain, even after controlling for the baseline level of pain. Improvements in IC and WB symmetry were not related to changes in function. The results of this study provide initial data to elucidate how manipulation may work to improve pain and function in patients with LBP.

False-negative extension/rotation pre-manipulative screening test on a patient with an atretic and hypoplastic vertebral artery

The use of vertebral manipulation in the medical and paramedical community is a common treatment approach. Various practitioners use the modality of low-amplitude, high-velocity impulse (thrust) techniques on the cervical spine to improve vertebral range of motion and function, whilst reducing cervicogenic headaches and pain (Hurwitz et al. 1996). Delivery of a high-velocity, low-amplitude rotatory thrust to the cervical spine has been reported in the literature as a possible mechanism for vertebral artery dissection and sequelae (Hufnagel et al. 1999). Although this hypothesized mechanism of arterial injury is documented as rare in occurrence (Haldeman et al. 2002), there is a clinical tenet to implement valid premanipulative screening techniques to reduce this potential risk. Since being reported in the literature by DeKleyn and Nieuwenhuyse (1927), the combined extended/rotated position of the cervical spine has been employed as a clinical pre-manipulative screening maneuver. The validity and positive predictive value of this screening test has been challenged (Cote et al. 1996). The combined physiological extended and rotated cervical spine position has been postulated to affect vertebral artery (VA) blood flow based on mechanically occlusive haemodynamic constructs. This test is classically described as placing the patient’s cervical spine in an extreme (end-range) physiological combined extended and rotated position. Occlusion of the vertebral artery in this position is thought to occur when compressive forces exceed the blood flow pressure force through the vessel. The vertebral artery is divided into four zones; Zone I is most caudal extending from the subclavian artery to C6; Zone II is regarded as the length extending cranially from the C6 foramen tranversaria to C2; Zone III extends from the C2 foramen transversaria to the point where the artery punctures the tectorial membrane, and finally Zone IV is regarded as the length that is intracranial and ultimately communicates with the basilar artery. There is a general impression that the contralateral vertebral artery is stretched and the ipsilateral compressed in the extended/rotated position. Altered blood flow may be due to either of these morphological changes in Zone III of the vertebral artery (Symons & Westaway 2001). Theoretically, with a mechanically induced blood flow alteration, there is decreased perfusion to the brainstem manifesting vertebrobasilar signs and symptoms. This positive response cues the practitioner into making an informed decision on the utility and application of a manipulative intervention. This case report documents a false-negative extended/rotated screening outcome of a patient with an atretic (lacking in normal lumen patency) right vertebral artery and a radiologically confirmed atlantoaxial instability. This case highlights issues with respect to a pre-manipulative screening test and its clinical construct and utility. Manual Therapy (2003) 8(2), 120–127 r 2003 Elsevier Science Ltd. All rights reserved. 1356-689X/03/$ see front matter doi:10.1016/S1356-689X(02)00111-X

Complications Arising from Spinal Manipulative Therapy in New Zealand

Summary Complications arising from spinal manipulative therapy applied by physiotherapists have received scant attention in the literature. Published investigations and case studies have predominantly reported adverse outcomes of chiropractic and medical manipulative intervention. The present study aimed to explore the extent and range of serious spinal manipulative complications in New Zealand caused by physiotherapists and other health professionals. A further aim was to determine whether a prospective study of this problem was warranted. A questionnaire was posted to all neurologists, neurosurgeons, orthopaedic, and vascular surgeons throughout the country (n = 230) asking them to describe any complications arising from spinal manipulative therapy witnessed in the previous five years. The response rate was 63% (n = 146) with 42 incidents reported. Cervical spine complications accounted for 62% of the total, including 14 cerebrovascular accidents of which at least two involved the carotid artery system. Physiotherapists were responsible for one-third (14) and chiropractors for more than half (23) of all complications. These findings indicate that serious complications arising from manipulative physiotherapy may constitute a hitherto unrecognised substantial proportion of all spinal manipulative complications. Further research seems justified using a prospective study design to ascertain the incidence rate of particular complications and identify hazardous techniques.