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Manual Therapy Techniques

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SUMMARY:
Manual therapy interventions for the lumbar spine have been associated with improvements in pain, function and disability in individuals with non-specific low back pain (LBP), lumbar spinal stenosis (LSS) and lumbosacral radicular syndrome (LRS).

NON-SPECIFIC LOW BACK PAIN (LBP):

"Defined by the American College of Physicians and American Pain Society as "pain that cannot be reliably attributed to a specific disease or spinal abnormality" and accounts for over 85% of patients with low back pain that present to primary care. This is due to the inability to validate specific anatomical sources as the cause of symptoms and the conflict in classification schemes based on specific anatomical abnormality currently present in the medical literature."  Chou, 2007, Ann Internal Med

There is conflicting evidence regarding the efficacy of manual/manipulative therapy for individuals with low back pain. Several systematic reviews have reported no benefit of spinal manipulative therapy over general practitioner care, analgesics, exercises, physical therapy management or back school. However, many authors have proposed that the paucity of supportive evidence for LBP interventions is the result of the failure of researchers to identify subgroups of patients that are likely to respond to specific interventions. The ability to sub-group or classify patients according to their history and physical exam findings could improve research methodology by allowing more homogenous groups of patients in studies. This would help to avoid the inclusion of patients in outcome studies for whom no benefit would be expected, which may obscure the intervention’s true benefit.

For chronic low back pain, the latest Cochrane Review (2011) with meta-analysis included 26 RCT's (of which only 9 were considered to have a low risk of bias) and concluded that there is "high quality evidence" to suggest that there is statistically significant difference, but no clinically relevant difference between spinal manipulation and other interventions for reducing pain and improving function in patients with chronic low back pain.

Flynn and colleagues developed a clinical prediction rule (CPR) to identify patients with LBP who were likely to respond favorably to a specific lumbosacral spinal manipulation technique. Five variables were identified as predictors and together formed the CPR. The variables were:

    1) Duration of symptoms less than 16 days
    2) At least one hip with greater than 35 degrees of internal rotation,
    3) Hypomobility with lumbar spring testing in one or more segments
    4) A score of less than 19 on a sub-scale of the Fear-Avoidance Beliefs Questionnaire (FABQ) and,
    5) No symptoms distal to the knee.

The CPR demonstrated a positive likelihood ratio of 24, indicating that individuals who were positive for at least four of the five variables increased their likelihood of a successful outcome with manipulation from 45% (pre-test probability) to 95% (post-test probability). Successful outcome was defined as a 50% or greater reduction in Oswestry Disability Index (ODI) scores. The ODI is a valid measure of disability for individuals with LBP. This CPR was later validated in two subsequent randomized controlled trials

Childs and colleagues conducted a validation study to test this CPR in a variety of clinical settings and among clinicians with varying levels of experience. Successive patients referred to physical therapy with a primary complaint of low back pain were randomized to receive either a lumbosacral spinal manipulation technique or a core stabilization exercise program. Patients who met the criteria for the CPR (positive for four or more variables) and were treated with spinal manipulation demonstrated significantly better outcomes than those who received spinal manipulation but did not meet the CPR or those who met the CPR and were treated with core stabilization. These results were maintained at the 6-month follow-up evaluation.

Cleland and colleagues explored the generalizability of the lumbosacral manipulation CPR (described above) to other manipulative techniques. In this randomized controlled trial, patients with lower back pain who met the CPR were randomized to receive either a supine lumbosacral thrust manipulation, a sidelying lumbar thrust manipulation, or a prone non-thrust lumbar manipulation. No differences in pain or disability were found between the supine and sidelying thrust manipulation techniques at short or long-term follow up. However, when compared to the two groups receiving thrust manipulation, subjects in the prone non-thrust manipulation group demonstrated higher disability (ODI) scores at the one-week , four-week and six-month follow up examinations. These results indicate that this CPR is generalizable to at least one additional thrust manipulation technique (lumbar sidelying thrust manipulation) but not to a non-thrust technique (prone lumbar non-thrust manipulation).

Koppenhaver and colleagues explored the relationship between lumbar multifidus (LM) muscle and clinical improvement after spinal manipulation.  They demonstrated that clinical improvement measured by the oswestry disability index correlated with increasing thickness of the lumbar mutifidus muscle.  In other words increases in LM muscle thickness were able to predict improved disability out at 1 week.  Immediate changes in contraction of this muscle was seen post spinal manipulation.

Flynn, 2002, Spine
Childs, 2004, Ann Intern Med
Assendelft, 2008, Cochrane Database Syst Rev
Cleland, 2009, Spine
Koppenhaver, 2010, J Orthop Sports Phys Ther
Rubinstein, 2011, Cochrane Database Syst Rev

LUMBAR SPINAL STENOSIS (LSS):
There are currently no studies that have investigated the effect of manual therapy alone on clinical outcomes in individuals with LSS. There is one study that included lumbar spine manual therapy interventions in a comprehensive conservative treatment protocol for individuals with LSS. In this randomized controlled trial, subjects with LSS were randomized to receive one of two treatment programs. The experimental group received manual therapy interventions to the spine and lower extremities (as needed), exercise and body-weight supported treadmill walking. At 6 weeks, a higher percentage of the patients in the manual therapy/exercise/body weight support treadmill group demonstrated clinically meaningful recovery compared to patients in the flexion/ultrasound/walking group. Although between -group differences in clinical outcomes were no longer significant at one year, disability, treadmill walking times and satisfaction all favored the manual therapy/treadmill walking/exercise group.
Whitman, 2006, Spine

LUMBOSACRAL RADICULAR SYNDROME (LRS):

A systematic review by Leininger et. al. stated that "there is moderate quality evidence that spinal manipulation is effective for the treatment of acute lumbar radiculopathy. The quality of evidence for chronic lumbar spine-related extremity symptoms ......of any duration is low or very low."

A good point to note however, is that when studied in isolation, manual/manipulative therapy has not been shown to be superior to other conservative interventions for individuals with LRS. However, manual therapy has been included in a treatment approach that was found beneficial for individuals with lower back and lower extremity pain. Browder et al. studied the effectiveness of an extension oriented treatment approach (EOTA) vs. abdominal strengthening in patients with lower back pain with symptoms extending distal to one or both buttocks. Inclusion criteria also included subjects demonstrating symptom centralization with lumbar extension movements. Included in the EOTA protocol were regular applications of lumbar posterior to anterior vertebral mobilization techniques. Subjects in the EOTA group demonstrated greater improvement in disability at short (1 & 6-week) and long term (6-month) follow up. Because individuals in the EOTA group received a combination of exercise and manual therapy interventions, it is currently unknown what effect, if any, the mobilizations had on subjects disability levels.

Pim, 2007, Eur Spine J
Browder, 2007, Phys Ther
Leininger, 2011, Phys Med Rehabil Clin N Am

ANKYLOSING SPONDYLITIS (AS):

There is very little evidence to suppor the use of manual therapy in the management of of patients with AS. An RCT with only 32 subjects with AS were randomized to receive clinician imparted mobilizations and self-mobilizations 1 hour twice a week in addition to an impairment-based home exercise program for a total of 8 weeks compared to a control group receiving no treatment.  At eight week follow-up, there were significantly better improvements in chest expansion, posture, and spine mobility in the manual therapy group.

Rose, 2003, J Manipulative Physiol Ther


OTHER CLINICAL EVIDENCE:


Non-Specific Low Back Pain

Cleland, 2006, J Orthop Sports Phys Ther
Stuber, 2009, J Chiropr Med
Clinical Guideline Subcomittee on LBP: AOA, 2010, J Am Osteopath Assoc
Senna, 2011, Spine


Lumbar Spinal Stenosis

Creighton, 2006, JMMT
Backstrom, 2011, Manual Therapy


Ankylosing Spondylitis

Widberg, 2009, Clin Rehabil
Passalent, 2011, Curr Opin Rheumatol


OTHER RELEVANT EVIDENCE:

Powers, 2003, Clin Biomech
Kulig, 2004, J Orthop Sports Phys Ther
Raney, 2007, J Orthop Sports Phys Ther
Landel, 2008, Phys Ther
Grindstaff, 2009, Man Ther
Fritz, 2011, Spine


  

 

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