Spinal Manipulation Flashcards
Describe Grade I-V joint mobilizations.
Grade I: small amplitude, in early range of movement
Grade II: large amplitude, in midrange of movement
Grade III: large amplitude to point of limitation in movement range
Grade IV: small amplitude at endrange of movement
Grade V: small amplitude, quick thrust at endrange of movement
R1 is the [first/maximal] point of resistance felt.
first
R2 is the [first/maximal] resistance felt.
maximal
A thrust manipulation is a [low/high] velocity and [low/high] amplitude therapeutic movement within or at end ROM.
high velocity
low amplitude
What are manipulations intended to restore? (3)
(1) optimal motion
(2) optimal function
(3) reduce pain
T/F: A mobilization can include manual therapy techniques that are small amplitude, high velocity (i.e. manipulations)
True
What is the main difference between a mobilization and manipulation?
speed
mobilization = varying speeds and amplitudes (can include a manipulation)
manipulation = high velocity, low amplitude
What is the purpose of a “chiropractic” adjustment?
to correct subluxations of the spine and give freedom of action to impinged nerves that may cause pain or deranged function
What two states prohibit manipulation by PTs?
Arkansas and Washington
Which state prohibits manipulation but has an endorsement that would allow a PT to do so in their individual practice?
Washington
What is the main argument to support the practice of manipulation by PTs?
They are provided professional education that prepares them to do so!
What are the indications for spinal manipulation? (5)
improve motion, decrease pain, restore ease of movement/improved function, treatment based/patient selection criteria classification approach, and patients who are pain adaptive
What would NOT be an indication for spinal manipulation? (2)
(1) to put the back in alignment
(2) to adjust a subluxed joint
What are the criteria from the Treatment Based Classification System? (5)
(1) no symptoms distal to knee
(2) recent onset of symptoms (<16 days)
(3) low FABQ (<19)
(4) hypomobility of lumbar spine
(5) hip internal rotation >35
What characteristics make a patient “pain adaptive”? (4)
- Clear aggravating and easing factors.
- Have the endogenous (within their own body) ability to modulate pain without medical interventions
- Tend to react quickly to pain, but also modulate pain endogenously, often within the same treatment session
- Nociceptive pain drivers.
What characteristics would make a patient a “non-pain adaptor”? (5)
- Persistent pain patterns.
- Limited endogenous (within their own body) ability to modulate pain
- Tend to react slower to pain stimulus, but also pain persists
- Not responsive within the same treatment session
- Nociplastic (central sensitization) pain drivers.
What are the contraindications for spinal manipulation? (GO!)
anti-coagulant therapy, downs syndrome/RA, vertebral artery compromise, osteoporosis, infectious disease, malignancy, relevant recent trauma or fracture, fusion, gross spondylolisthesis, severe unremitting nighttime pain, multi-level nerve root pathology, worsening neurologic function, upper motor neuron lesions
What are the precautions to spinal manipulations? (9)
inflammatory disease, cancer history, long-term steroid use, osteopenia, hypermobility syndromes, connective tissue disease, cervical anomalies, recent manipulation by another health professional, and patient equipoise
The risk of cauda equina following spinal manipulation is ______.
<1/100 million
What are the common side effects of manipulation? ()
local discomfort, fatigue, headache, radiating discomfort, stiffness, dizziness, or muscle spasm (resolve in <24 hours)
What are biomechanical explanations for how spinal manipulation works?
- Short term mechanical change in vertebral position
- Short term mechanical increase in range of motion
- Improvement in impairment associated with movement
- Changes in the diffusion of water within the lumbar intervertebral discs at the L1-2, L2-3, and L5-S1 levels after treatment of spinal manipulative therapy
- Improved activation of lumbar multifidus following lumbar manipulation
T/F: Spinal manipulation techniques are specific to a segment.
False, they aren’t specific to a segment or necessarily an area of the spine (i.e. cervical, thoracic, or lumbar)
What are neurophysiological explanations for how spinal manipulations works?
- Spinal Cord Hypoalgesia (↓sensitivity to pain)
- Sympathoexcitatory (blood flow, heart rate, skin conductivity, temperature changes)
- Decrease of Temporal Summation (lowered pain perception)
- Peripheral inflammatory mediators (change blood levels of inflammatory mediators)
- Central Mediated (changes in pain “experience” in CNS)
- Endocrine Response (Opioid responses, B-endorphins)
- Muscle Reflexogenic (↓ muscle hypertonicity)
- Descending inhibition
How long to neurophysiological effects of manipulation last?
15-20 minutes (short lasting)
It is a [single mechanism/cascade of effects] that impact nociception through pain modulation.
cascade of effects
What are the temporal effects of spinal manipulation?
30 minutes to 5 hours (immediate and short term)
What would help carry-over the effects of spinal manipulation from short term to long term?
adding in an exercise program
What are the psychological reasons why spinal manipulation works?
- Placebo
- Non-Specific Treatment Effects
- Improvements in depression, mental component scores
- Therapeutic Alliance
- Expectation – patients want to be touched!
What are some other reasons why spinal manipulation works? (4)
- Regression to the Mean
- Confirmation bias
- Misattributed natural recovery
- Pain Adaptive
Most mobilization forces are between ___ and ___ N.
30-120 N
Most manipulation forces are ___ N.
<300 N
When is it recommended you use thoracic spine manipulations?
- Acute neck pain with mobility deficits
- Chronic neck pain with mobility deficits
- Chronic neck pain with radiating pain
When is it recommended you use cervical spine manipulations?
- Chronic neck pain with mobility deficits
- Chronic neck pain with headaches
- Subacute neck pain with headaches
What are the factors that indicate someone with shoulder pain is likely to demonstrate short-term improvements following cervical and thoracic spine manipulations? (5)
(1) pain free shoulder ROM <127 degrees
(2) shoulder IR <53 degrees
(3) negative Neer test
(4) not taking medications for shoulder pain
(5) duration of symptoms <90 days
What occurs with a “pop” in a manipulation?
Generation and collapse of gas and liquid as the facet joint surfaces are separated within the joint capsule
Does a “pop” or cavitation of synovial joint indicate a successful manipulation?
No, there isn’t a relationship between cavitation and outcome of manipulation
What is regional interdependence?
Seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint
What are the principles of spinal manipulation?
- Establish fulcrum
- Localize to motion restriction
- Small amplitude of thrust force is applied at a fast rate, small range (high velocity low amplitude HVLA)
- Balanced position of therapist and patient
- Avoid peripheralization of symptoms
- Patient relaxation
- Pre-manipulative hold to assess patient response
What should you do to determine the correct patient for manual therapy?
- Perform a thorough assessment
- Determine contraindications/precautions/systemic conditions
- Assess any worrisome symptoms (arterial dissection in progress, myelopathy, etc.)
- Previous reaction to manipulation
- Match patient expectation
- Determine where segmental instabilities are
- Patient preparation: verbal consent, explain what you are doing, use a slow deliberate set-up and a premanipulative hold 10 seconds
If the patient doesn’t fit the clinical prediction rule for manual therapy, what should you do?
(1) rule out contraindications to manual therapy
(2) use patient response to movement as your guide
(3) assess pain and stiffness
(4) begin with limited dose
(5) utilize and check with patient during pre-manipulative positioning
What should you consider with augmented exercises with spinal manipulations?
(1) direction of manipulation (i.e. opening vs. closing)
(2) activation (i.e. arthrokinematics, stretch, movement pattern support, and general activation)
(3) prioritizing 3-4 exercises
What should you include in your documentation of manipulative interventions? (6)
(1) rate of force application
(2) location in range of available movement (i.e. beginning, middle, or at the end point of the available ROM)
(3) direction of force
(4) target force (i.e. specific level or general region)
(5) relative structural movement (i.e. describe which structural region was intended to remain stable and which structure or region was intended to move
(6) patient position (i.e. supine, prone, recumbent, and rotation/side bending)
