Lumbar Manipulation

Question 1

Chiropractic Philosophy

Answer 1

• Alterations in the vert. column lead to abnormal neural function—causing disease
• Lesion: “subluxation”
• Tx: removal of subluxations via “adjustments (chiro)” aka “spinal manipulation (PT)”
• Chiro’s acct for majority of claims submitted for reimbursement for manipulation

Question 2

Maitland Mobilization Grading

YOU KNOW THIS!!**

Grades I-V

Answer 2

see pics

Grades I,II== pain

Grades III-V== mobility

Question 3

Manual Therapy

Define:

Answer 3

Intervention in which the hands of the provider apply forces to the pts soft tissues or joints

Question 4

Joint Mobilization

Defined:

Answer 4

Manual Therapy involving mvmt or accessory motions of joint sometimes interpreted to include Grade V (thrust) techniques

Question 5

Manipulation

Defined:

Answer 5

often to describe Grade V Thrust Techniques

sometimes used to describe any type grade of joint or STM

Question 6

The Law

regarding Manipulation/Thrust Techniques

Answer 6

• NJ PT Practice Act: PTs can both perform and use the word manipulation (thrust tech’s)
• PA PT Practice Act: PTs can perform “manual therapy” or “jt mob” of any grade, including Grade V (thrust), but may NOT refer to it as a “manipulation”

Other 48– Practice Acts vary

Question 7

MSK Purposes of Spinal Manipulation

4:

Answer 7

1. Relief of pain
2. Restoration of ROM
3. Restoration of function
4. Correction of positional/alignment faults—more DC’s

Question 8

Proposed Mech’s of Pain Relief from Spinal Manipulation

Twomey & Taylor

Answer 8

• Correction of malposition (subluxation)
• Reduction of disc herniation
• Eliminating adhesions around disc or facet
• Repositioning of internal derangements, entrapped synovial folds, or plica w/in facet jts
• Inhibitory stretch reflex from facet caps or afferent input from spinal tissues**** ASK!!!

Question 9

Who Should Perform Manipulations

Answer 9

• skilled practitioners
• sparingly, appropriately
• In PT–incorporate into comprehensive programs that includes pts ed, self-tx, ex, functional restoration, fitness, ergo’s, body mechs, posture*****

NOTE: Train pts in tissue altered state if you want to change the tissue***

Question 10

SE’s of Spinal Manipulation

Answer 10

• Common: Transient local discomfort/soreness
• Less Common: HA, fatigue, dizzy/nausea, radiating discomfort
• Rare Comps: fx, sublux, dislocation, vert aa injury, CE injury
  
  • <1 injury per 100,000,000 manips

*NOTE: Risks escalate if CONTRAINDICATIONS EXIST—-SCREEN ACCORDINGLY!!!

Question 11

2 Tech’s for Spinal Manipulation

Answer 11

1. Long Lever
2. Short Lever

Question 12

Long Lever Spinal Manipulation

Answer 12

**DOES NOT matter what segment you’re manipulating

• Forces are applied @ some distance distal and/or proximal to the motion segment
• Nonspecific UNLESS positioning is used so that force is directed at a specific motion segment
• WE LEARNED 2 LONG LEVER TECH’S

Question 13

Short Lever Manipulation Tech.

Answer 13

• A specific motion segment is localized
• Forces are applied directly to this motion segment
• Ex. P-A glide over L5

Question 14

Spinal Manipulation

Whats the “Pop”?

Answer 14

• Cavitation
• “Reduction”—Chiro
• Unsworth et al.
  
  • sudden separation of jt surfs;
  • collapse of gas bubble inside joint

Question 15

IS THE POP NECESSARY???

Answer 15

NO!!!

Question 16

**IMPORTANT SLIDE**

CONTRAINDICATIONS FOR LS THRUST MANIPULATION

KNOW IT!!!

Answer 16

• Spondylolisthesis
• Osteoporosis
• Metabolic bone dis’s
  
  • osteoporosis, Paget’s, etc.
• Primary jt disease
  
  • RA, septic arthritis, etc.
• Acute inflamm dis
• Primary or metastatic malignant bone disease
• Fx
• Joint ankylosis (fusing)
• Certain genetic disorders
  
  • ex. Down’s Syndrome
• HypERmobility of the involved segment—rel. contraindication
• B/L, Multisegmental, or progressive or severe neuro deficit
• Sacroperineal (Saddle) numbness or parasthesias–CE syndrome
• B&B signs–CE
• Painful mvmts in all directions
• Paralysis in a nonperipheral nerve distribution
• HypERreflexia or presence of patho reflexes
• Psychiatric disorders (if not under control)
• Long hx of anticoagulant meds or steroids
• Vert AA Disease–for CS manips
• CN signs or sx’s or dizziness –for CS manips

Question 17

Evidence of Spinal Manips

Answer 17

CONFLICTING!!!

Some studies found more effective

Some studies not more effective

Conflicting—indicates need to look for a specific subgroup of pts w/ LBP that would benefit from manip

Question 18

What are we doing now w/ Spinal Manipulations and determining whether or not it is effective and for WHO?

Answer 18

More recent models focused more on development of a CPR

CPR– assists in class. process and improves decision making

Recent researc focused on baseline exam factors w/out assumptions based on theory or tradition

GOAL: ID pts likely to respond to manipulation, w/ rapid and sustained improvement defined as 50% or greater reduction in self-reported disability

Question 19

CPR for Manipulations

*REMEMBER MUST BE NO CONTRAINDICATIONS PRESENT!

5 Factors:

Answer 19

1. Current sx duration < 16d (more acute)
2. Work subscale of FABQ < 19
3. HypOmobility of the LS assessed w/ P-A pressure– Spring Test
4. IR of @ least one hip > 35degs –R/O OA
5. Sx’s NOT extending distal to knee

Question 20

LS Manipulation CPR

With 4/5 CPR factors present……

Answer 20

Pts were HIGHLY LIKELY to improve

+LR= 24

Chance of improvement= 92%

*NOTE: W/ 2 or Fewer factors present…

• -LR= .09
• Chance of improvement= 9%

Question 21

Childs et al. Validation Study of CPR

Answer 21

see pics

Question 22

Important Components of the Manipulation CPR

**MOST IMPORTANT CRITERIA FOR MANIP CLASS.

What is it?

Answer 22

• Short duration of symptoms < 16d
• NO LEG PAIN distal to knee

**KNOW THESE!!!

Question 23

Important Components of the Manipulation CPR:

Answer 23

• Short duration of Sx’s <16d*
• No leg pain distal to knee*
• Pts w/ 2 or fewer CPR factors very UNLIKELY to improve w/ manip
• Pts >60yo NOT INCLUDED in dev. the CPR
• Pts w/ signs of nerve root compression NOT INCLUDED ***

Question 24

Manipulation Techniques

Answer 24

• importance of specific tech challenged
• Thrust tech more effective vs. non-thrust
• No current evidence one manipulation tech superior
• Poor correlation b/w spinal lvls producting cavitation and actual targeted lvls
• Selecting tech vs. predetermined tech== no better results

Question 25

**Critical Factor to _Optimal Outcomes_ w/ manipulation appears to NOT BE \_\_\_\_\_\_\_\_\_\_\_\_\_, but \_\_\_\_\_\_\_\_\_\_\_**

Answer 25

NOT be _which tech is used_, but _accurate ID of pts likely to respond_

Question 26

**To manipulate of not to manipulate, that is the question...** **YES If...**

Answer 26

* **NO CONTRAINDICATIONS PRESENT\*\*\*** * Exam findings support **clinical decision making rule of Flynn et. al** * **​\*\***Recommended @ least 3/5 factors * Skills are adequate * Procedure is **goal directed** and **part of a comprehensive program\*\*\***

Question 27

**To manipulate of not to manipulate, that is the question...** **NO If...**

Answer 27

* CONTRAINDICATIONS ARE PRESENT\*\*\* * must be NONE!!! * Exam findings are **inconclusive** that the pt is a **good candidate** * Skills are inadequate * Pt does not wish to be manipulated\*\*\*

Question 28

Exam Components to **help you determine if pt is a candidate for manipulation:**

Answer 28

* Medical Hx * **any contraindications???** * Hx Pain * **Below knee? How many days current episode?** * Segmental P-A motion testing * **Spring test LS** * Hip IR testing * FABQ * **Work subset**

Question 29

**Manipulation Lab** * **Standard Manipulation Technique aka Classic SI Manipulation**

Answer 29

See pics

Question 30

**Manipulation Lab** * **Alternate S/L Manipulation Technique aka Neutral Gapping Tech.** * **\*\*_Symptomatic side UP!!_**

Answer 30

SEE PICS

Question 31

Basic ROM Ex's **AFTER MANIPULATION:**

Answer 31

* Prone press-up * Lower trunk rotation * **from hooklying→ lower knees side to side** * Alt. KTC * B/L KTC * **mindful of _directional preferences!!!_**