Spinal Manual Therapy Research Articles

Effect on healthcare utilization and costs of spinal manual therapy for acute low back pain in routine care: A propensity score matched cohort study.

Spinal manual therapy (SMT) is a popular treatment option for low back pain (LBP). The aim of our analysis was to evaluate the effects of manual therapy delivered by general practitioners and ambulatory orthopedic surgeons in routine care on follow up consultations, sick leave, health service utilization and costs for acute LBP compared to matched patients not receiving manual therapy. This is a propensity score matched cohort study based on health claims data. We identified a total of 113.652 adult patients with acute LBP and no coded red flags of whom 21.021 (18%) received SMT by physicians. In the final analysis 17.965 patients in each group could be matched. Balance on patients’ coded characteristics, comorbidity and prior health service utilization was achieved. The provision of SMT for acute LBP had no relevant impact on follow up visits and days of sick leave for LBP in the index billing period and the following year. SMT was associated with a higher proportion of imaging studies for LBP (30.6% vs. 23%, SMD: 0.164 [95% CI 0.143–0.185]). SMT did not lead to meaningful savings by replacing other health services for LBP. SMT for acute non-specific LBP in routine care was not clinically meaningful effective to reduce sick leave and reconsultation rates compared to no SMT and did not lead to meaningful savings by replacing other health services from the perspective of health insurance. This does not imply that SMT is ineffective but might reflect a problem with selection of suitable patients and the quality and quantity of SMT in routine care. National Manual Medicine societies should state clearly that imaging is not routinely needed prior to SMT in patients with low suspicion of presence of red flags and monitor the quality of provided services.

Acute electromyographic responses of deep thoracic paraspinal muscles to spinal manual therapy interventions. An experimental, randomized cross-over study

This single group, randomized, cross-over study explored whether manual therapy alters motor tone of deep thoracic back muscles by examining resting electromyographic activity (EMG) after 2 types of manual therapy and a sham control intervention. Twenty-two participants with thoracic spinal pain (15 females, 7 males, mean age 28.1 ± 6.4 years) had dual fine-wire, intramuscular electrodes inserted into deep transversospinalis muscles at a thoracic level where tissues appeared abnormal to palpation (AbP) and at 2 sites above and below normal and non-tender to palpation (NT). A surface electrode was on the contralateral paraspinal mass at the level of AbP. EMG signals were recorded for resting prone, two 3-s free neck extension efforts, two 3-s resisted maximal voluntary isometric contractions (MVIC), and resting prone before the intervention. Randomized spinal manipulation, counterstrain, or sham manipulation was delivered and EMG re-measured. Participants returned 1 and 2 weeks later for the remaining 2 treatments. Reductions in resting EMG followed counterstrain in AbP (median decrease 3.3%, P = 0.01) and NT sites (median decrease 1.0%, P = 0.05) and for the surface electrode site (median decrease 2.0%, P = 0.009). Reduction in EMG following counterstrain during free neck extension was found for the surface electrode site (median decrease 2.7%, P < 0.01). Spinal manipulation produced no change in EMG, whereas counterstrain technique produced small significant reductions in paraspinal muscle activity during prone resting and free neck extension conditions. The clinical relevance of these changes is unclear.

To Compare the Effect of MWM v/s MWM along with Neural Tissue Mobilization in Case of Cervical Radiculopathy

Cervical radiculopathy is a pathological condition of the cervical nerve root that may lead to chronic pain and disability. The symptoms of cervical radiculopathy typically include severe neck pain with radiation of the pain to the back of shoulder, shoulders, arm, or hand. Numbness or tingling in the arm can also be present. Mulligan's other spinal manual therapy treatment techniques involve the concurrent application of both therapist applied accessory apophyseal joint gliding and end range active physiological movement on the part of the patient. Neural tissue mobilization uses specific positions and movement of neck and arm to reduces nerve mechanosensitivity, restore function and resolve symptoms. Many of the evidences are existed which says that mulligan alone and ULTT(upper limb tension test) alone have the effective in cervical radiculopthy. So in this study want the effect of mulligan mobilization along with ULTT on pain and functional scale is being checked.

Motor Control Exercises Reduces Pain and Disability in Chronic and Recurrent Low Back Pain

Meta-analysis of randomized, controlled trials. To determine the short-term, intermediate, and long-term effectiveness of MCE, with regard to pain and disability, in patients with chronic and recurrent low-back pain. Previous meta-analyses have shown no difference between the effects of MCE and general exercise in the treatment of low back pain. Several high quality studies on this topic have been published lately, warranting a new meta-analysis. We searched electronic databases up to October 2011 for randomized controlled trials clearly distinguishing MCE from other treatments. We extracted pain and disability outcomes and converted them to a 0 to 100 scale. We used the RevMan5 (Nordic Cochrane Centre, Copenhagen, Denmark) software to perform pooled analyses to determine the weighted mean differences (WMDs) between MCE and 5 different control interventions. Sixteen studies were included. The pooled results favored MCE compared with general exercise with regard to disability during all time periods (improvement in WMDs ranged from -4.65 to -4.86), and with regard to pain in the short and intermediate term (WMDs were -7.80 and -6.06, respectively). Compared with spinal manual therapy, MCE was superior with regard to disability during all time periods (the WMDs ranged between -5.27 and -6.12), but not with regard to pain. Furthermore, MCE was superior to minimal intervention during all time periods with regard to both pain (the WMDs ranged between -10.18 and -13.32) and disability (the WMDs ranged between -5.62 and -9.00). In patients with chronic and recurrent low back pain, MCE seem to be superior to several other treatments. More studies are, however, needed to investigate what subgroups of patients experiencing LBP respond best to MCE.

Spinal manual therapy produces rapid onset analgesia in a rodent model

A rapid hypoalgesic effect following spinal manual therapy (SMT) has been demonstrated in humans. Although the characteristics of the pain relief are well described, the mechanisms have remained speculative. The purpose of this suite of studies was to investigate the effects of SMT on pain measures using animal models. This study employed a randomized, controlled design. Study 1: Rats without inflammation were allocated to either a treatment group (n = 6) that received three applications of joint mobilization centrally over L5 or a sham-treated group (n = 6) who received non-specific handling. Pressure pain threshold (PPT) and thermal pain threshold (TPT) were measured before and immediately after each intervention. Results demonstrated significantly increased mechanical nociceptive thresholds in the SMT group (p = 0.01) compared to that of the sham-treated group but no difference for thermal nociceptive thresholds. Study 2: The time course effect of an inflammatory and mechanical response following i.pl injection of inflammatory mediators was investigated to determine the appropriate time period for a treatment intervention. Study 3: The effects of SMT on mechanical nociception were investigated following interplanar injection of inflammatory mediators into the right hind paw of rats as a pain model (n = 6 for both SMT and sham-treated groups). Injection of endogenous metabolites produced significant swelling and flaring as well as increased PPT values following SMT (p < 0.02) compared with controls. These results demonstrate a rapid analgesic response following application of SMT, which has similar characteristics as that seen in both symptomatic and asymptomatic human populations.

The neurophysiological effects of a single session of spinal joint mobilization: does the effect last?

Studies detailing the neurophysiological effects of spinal manual therapy have fueled a paradigm shift away from a strict biomechanical model. However, a recent systematic review of the temporal nature of a single session of spinal thrust manipulation found that the neurophysiological effects were only temporary. The objective of this review was to examine the temporal nature of neurophysiological effects after one session of spinal mobilization. Studies eligible for this review had to report on the temporal component of the neurophysiological effects of a single session of joint mobilization of the spine in human subjects. In order to be sure that the temporal nature of these effects was captured, the studies had to monitor neurophysiological effects for a time beyond the immediate post-treatment period. This systematic review followed the methodology for preferred reporting items for systematic reviews and meta-analyses. In order to assess the quality, strength, and importance of the included studies, the grading of recommendations assessment, development and evaluation system was used. Results of this review showed that the neurophysiological effects of a single session of spinal mobilization are mostly 5 minutes or less. An exception to these findings is hypoalgesia which may last up to 24 hours, based on one study. Continued research on small samples of healthy subjects with irrelevant immediate outcomes like salivary rate, skin conductance, and skin temperature should give way to randomized controlled trials on subjects with pain and decreased function.

Rehabilitation Following Lumbosacral Percutaneous Nucleoplasty: A Case Report

Case report. Lumbar spine nucleoplasty is a new surgical option for patients with disc pathology. There are no reports in the literature describing the role of physical therapy in postoperative lumbar nucleoplasty management. The purpose of this case is to describe the postoperative physical therapy management of a patient who underwent this procedure. A 50-year-old male, 7 weeks following a L5/S1 lumbar nucleus replacement, completed 6 weeks of rehabilitation. The focus of the treatment was controlled reloading of the spine through a spinal stabilization progression in weight-bearing and non-weight-bearing activities. In addition, education, spinal manual therapy techniques, and a home exercise program were also incorporated. The patient's Oswestry Disability Index decreased from 56% to 4% over 6 weeks of treatment. When contacted at 6, 12, 18, and 24 months posttherapy, his Oswestry Disability Index was 2%, 2%, 0%, and 0%, respectively, and he had returned to all previous activities without recurrence of symptoms. This case report outlines the clinical decision-making process during the postoperative management of an individual who had undergone a single-level lumbar nucleoplasty. A postoperative regimen of education, segmental spinal stabilization, and a home exercise program might have contributed to the observed improvement in pain and disability levels in this patient. The role of these postoperative interventions warrants further research. Therapy, level 4.

Immediate and Carryover Changes of C5-6 Joint Mobilization on Shoulder External Rotator Muscle Strength

Objective Clinical evidence has shown that extremity dysfunction, such as muscle weakness or inhibition, is associated with spinal disorders. Spinal manual therapy is a common therapeutic approach used to address extremity muscle weakness. The purpose of the study was to assess changes in the maximal muscle strength of the shoulder external rotators immediately and at 10, 20, and 30 minutes after cervical joint mobilization at the C5-6 segment. Methods Eighteen participants with existing or a history of neck pain were screened by 2 investigators independently for muscle weakness of shoulder external rotators. Fifteen qualified participants underwent shoulder external rotator strength testing with a handheld dynamometer. Each participant was tested 6 times, twice before, immediately after, and at 10, 20, and 30 minutes after a C5-6 joint mobilization on the involved side. The 2 strength data collected before the mobilization were used to determine intratester reliability. Results The intratester reliability of the shoulder external rotator strength was excellent (intraclass correlation coefficient 3,2 = 0.985). One-way analysis of variance with repeated measures showed a statistical significance in strength data ( P = .002). Post hoc tests revealed a significant increase between prejoint mobilization and immediately postjoint mobilization ( P = .003) and between pre joint mobilization and 10-minute post joint mobilization ( P < .001). Conclusions The results of the study suggest that C5-6 joint mobilization increases muscle strength of the shoulder external rotators immediately and its effect carries over for 10 minutes but not after 20 minutes.

Sympathetic nervous system effects in the hands following a grade III postero-anterior rotatory mobilisation technique applied to T4: A randomised, placebo-controlled trial

Joint mobilisation to the T4 vertebra has been advocated as a treatment for T4 syndrome. To date no controlled studies have investigated the effects of thoracic spinal manual therapy (SMT) applied to T4 on sympathetic activity in the hands. This study investigated whether a grade III postero-anterior rotatory joint mobilisation technique applied to the T4 vertebra at a frequency of 0.5 Hz had demonstrably greater effects than a validated placebo intervention on skin conductance (SC) in the hands of healthy subjects.A power analysis calculation was performed and using a double blind, placebo-controlled, independent groups design, 36 healthy subjects (18–35 years) were randomly assigned to two groups (placebo intervention or treatment intervention). A BioPac unit recorded continuous SC measures before, during and after each experimental intervention. An exit questionnaire was used to validate the expectancy effects of the placebo intervention. Results demonstrated a significant difference between groups in SC in the right hand during the post-treatment rest period (F = 4.888, p = 0.034); with the treatment intervention being sympathoexcitatory in nature. A trend towards a significant difference between groups was also demonstrated in the left hand during the rest period (F = 4.072, p = 0.052).This study provides preliminary evidence that joint mobilisation applied to the T4 vertebra at a frequency of 0.5 Hz can produce sympathoexcitatory effects in the hand. Further research is recommended in a patient population.

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.

Variables Associated with Abandoning the Manual Therapy Approach Learned in Physical Therapy School

Numerous manual therapy backgrounds are taught during formal education and continuing education courses within the United States. Many of these approaches employ disparate philosophies for examination and treatment. The purpose of this study was to determine what variables are associated with abandoning the manual therapy approach learned in school. This study surveyed 439 Board-Certified Orthopaedic Specialists (OCS), members of the American Physical Therapy Association. Data were collected through an Internet survey and analyzed using SPSS version 12.0. Logistic regression analysis determined that increased years of experience was associated with the likelihood of abandoning one's spinal manual therapy approach learned in school. There were no variables associated with the likelihood of abandonment of a peripheral approach. Moreover, clinicians were less likely to report abandonment of an approach if their PT school emphasized the Maitland, eclectic, Osteopathic, McKenzie, Cyriax, Kaltenborn, or Paris approach to the spine. The variables that made a clinician less likely to abandon his or her peripheral manual therapy approach were that a clinician' feels that the approach is effective' with the additions of the backgrounds of Maitland, Kaltenborn, Cyriax, eclectic, Paris, or Osteopathic approach or "none." All variables with the exception of years of experience were associated with the likelihood of retaining versus abandoning one's manual therapy approach learned during formal education.

Effectiveness of manual therapy in the treatment of non-specific neck pain: a review

The aim of the current review was to assess the evidence for the effectiveness of cervical spine manipulation and mobilisation in the treatment of non-specific neck pain. A review of the literature was performed in a systematic format, based upon a structured search of six computerised bibliographic databases, together with manual searching of selected journals and reference lists to identify randomised clinical trials (RCTs) researching the effectiveness of manual therapy in the treatment of non-specific neck pain. The methodological quality of the studies was assessed using a set of pre-defined criteria adapted from Koes et al. (Koes BW, Assendelft WJJ, van der Heijden GJMG, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ 1991; 303 :1298–303) and updated in the light of recent literature.A total of 12 RCTs met the selection criteria. The scores achieved for methodological quality of the studies ranged from 25 points to 67 points out of a possible 100 points. Only four RCTs scored above 50 points: two of these reached a positive conclusion about the effectiveness of spinal manual therapy in the treatment of non-specific neck pain, and two a negative conclusion. Eight RCTs scored below 50 points; six of these reached a positive conclusion and two a negative conclusion.RCTs researching the effectiveness of manual therapy for non-specific neck pain demonstrate methodological shortcomings in both design and reporting. The effectiveness of spinal manual therapy on non-specific neck pain remains inconclusive. The available evidence favoured spinal manual therapy when it was used in conjunction with exercise, particularly in the treatment of patients with chronic non-specific neck pain. Further, well-designed RCTs are needed to draw valid conclusions about the effectiveness of spinal manual therapy on nonspecific neck pain. In such future RCTs, placebo treatments should be designed to be indistinguishable (as far as possible) from manual therapy, and without the specific effects of active therapy. Furthermore, psychosocial factors should be considered prior to randomisation of patients by using appropriate measures.

Naloxone Fails to Antagonize Initial Hypoalgesic Effect of a Manual Therapy Treatment for Lateral Epicondylalgia

Background Recent research has shown that Mulligan’s Mobilization With Movement treatment technique for the elbow (MWM), a peripheral joint mobilization technique, produces a substantial and immediate pain relief in chronic lateral epicondylalgia (48% increase in pain-free grip strength). [1] This hypoalgesic effect is far greater than that previously reported with spinal manual therapy treatments, prompting speculation that peripheral manual therapy treatments may differ in mechanism of action to spinal manual therapy techniques. Naloxone antagonism and tolerance studies, which employ widely accepted tests for the identification of endogenous opioid-mediated pain control mechanisms, have shown that spinal manual therapy-induced hypoalgesia does not involve an opioid mechanism. Objective The aim of this study was to evaluate the effect of naloxone administration on the hypoalgesic effect of MWM. Methods A randomized, controlled trial evaluated the effect of administering naloxone, saline, or no-substance control injection on the MWM-induced hypoalgesia in 18 participants with lateral epicondylalgia. Pain-free grip strength, pressure pain threshold, thermal pain threshold, and upper limb neural tissue provocation test 2b were the outcome measures. Results The results demonstrated that the initial hypoalgesic effect of the MWM was not antagonized by naloxone, suggesting a nonopioid mechanism of action. Conclusions The studied peripheral mobilization treatment technique appears to have a similar effect profile to previously studied spinal manual therapy techniques, suggesting a nonopioid-mediated hypoalgesia following manual therapy.

Position-Assisted Combination Technique (PACT) in the Management of Type-II Impairment in the Thoracic and Lumbar Spine

In the osteopathic literature, manipulative techniques are classified as either direct or indirect. Direct technique passively mobilizes articular and myofascial tissues against an opposing restrictive barrier, whereas indirect manipulation moves these same tissues away from the motion barrier into tissue "ease." Direct technique is suited for low reactive tissues characterized as stiff and tight, whereas indirect technique is indicated when there is reflex muscle splinting associated with somatic and/or neurologic pain. In this article, direct and indirect forms of manipulation are combined into one technique and referred to as Position-Assisted Combination Technique (PACT). The theory and clinical application of PACT is described and illustrated for common Type-II impairments (FRS, ERS) with major motion loss present in the thoracic and lumbar spine. The integration of other forms of spinal manual therapy into PACT, including muscle energy technique, non-thrust mobilization/manipulation, and high-velocity/low-amplitude thrust is described in detail.

Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity

Recent findings that spinal manual therapy (SMT) produces concurrent hypoalgesic and sympathoexcitatory effects have led to the proposal that SMT may exert its initial effects by activating descending inhibitory pathways from the dorsal periaqueductal gray area of the midbrain (dPAG). In addition to hypoalgesic and sympathoexcitatory effects, stimulation of the dPAG in animals has been shown to have a facilitatory effect on motor activity. This study sought to further investigate the proposal regarding SMT and the PAG by including a test of motor function in addition to the variables previously investigated. Using a condition randomised, placebo-controlled, double blind, repeated measures design, 30 subjects with mid to lower cervical spine pain of insidious onset participated in the study. The results indicated that the cervical mobilisation technique produced a hypoalgesic effect as revealed by increased pressure pain thresholds on the side of treatment (P=0.0001) and decreased resting visual analogue scale scores (P=0.049). The treatment technique also produced a sympathoexcitatory effect with an increase in skin conductance (P<0.002) and a decrease in skin temperature (P=<0.02). There was a decrease in superficial neck flexor muscle activity (P<0.0002) at the lower levels of a staged cranio-cervical flexion test. This could imply facilitation of the deep neck flexor muscles with a decreased need for co-activation of the superficial neck flexors. The combination of all findings would support the proposal that SMT may, at least initially, exert part of its influence via activation of the PAG.