Lumbar Manipulation Flashcards
Chiropractic Philosophy
- 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
Maitland Mobilization Grading
YOU KNOW THIS!!**
Grades I-V
see pics
Grades I,II== pain
Grades III-V== mobility
Manual Therapy
Define:
Intervention in which the hands of the provider apply forces to the pts soft tissues or joints
Joint Mobilization
Defined:
Manual Therapy involving mvmt or accessory motions of joint sometimes interpreted to include Grade V (thrust) techniques
Manipulation
Defined:
often to describe Grade V Thrust Techniques
sometimes used to describe any type grade of joint or STM
The Law
regarding Manipulation/Thrust Techniques
- 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
MSK Purposes of Spinal Manipulation
4:
- Relief of pain
- Restoration of ROM
- Restoration of function
- Correction of positional/alignment faults—more DC’s
Proposed Mech’s of Pain Relief from Spinal Manipulation
Twomey & Taylor
- 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!!!
Who Should Perform Manipulations
- 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***
SE’s of Spinal Manipulation
- 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!!!
2 Tech’s for Spinal Manipulation
- Long Lever
- Short Lever
Long Lever Spinal Manipulation
**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
Short Lever Manipulation Tech.
- A specific motion segment is localized
- Forces are applied directly to this motion segment
- Ex. P-A glide over L5
Spinal Manipulation
Whats the “Pop”?
- Cavitation
- “Reduction”—Chiro
- Unsworth et al.
- sudden separation of jt surfs;
- collapse of gas bubble inside joint
IS THE POP NECESSARY???
NO!!!
**IMPORTANT SLIDE**
CONTRAINDICATIONS FOR LS THRUST MANIPULATION
KNOW IT!!!
- 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
Evidence of Spinal Manips
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
What are we doing now w/ Spinal Manipulations and determining whether or not it is effective and for WHO?
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
CPR for Manipulations
*REMEMBER MUST BE NO CONTRAINDICATIONS PRESENT!
5 Factors:
- Current sx duration < 16d (more acute)
- Work subscale of FABQ < 19
- HypOmobility of the LS assessed w/ P-A pressure– Spring Test
- IR of @ least one hip > 35degs –R/O OA
- Sx’s NOT extending distal to knee
LS Manipulation CPR
With 4/5 CPR factors present……
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%
Childs et al. Validation Study of CPR
see pics
Important Components of the Manipulation CPR
**MOST IMPORTANT CRITERIA FOR MANIP CLASS.
What is it?
- Short duration of symptoms < 16d
- NO LEG PAIN distal to knee
**KNOW THESE!!!
Important Components of the Manipulation CPR:
- 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 ***
Manipulation Techniques
- 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
Critical Factor to Optimal Outcomes w/ manipulation appears to NOT BE _____________, but ___________
NOT be which tech is used, but accurate ID of pts likely to respond
To manipulate of not to manipulate, that is the question…
YES If…
- 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***
To manipulate of not to manipulate, that is the question…
NO If…
- 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***
Exam Components to help you determine if pt is a candidate for manipulation:
- 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
Manipulation Lab
- Standard Manipulation Technique aka Classic SI Manipulation
See pics
Manipulation Lab
- Alternate S/L Manipulation Technique aka Neutral Gapping Tech.
- **Symptomatic side UP!!
SEE PICS
Basic ROM Ex’s AFTER MANIPULATION:
- Prone press-up
- Lower trunk rotation
- from hooklying→ lower knees side to side
- Alt. KTC
- B/L KTC
- mindful of directional preferences!!!
