Spinal Manipulation

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Description 

Spinal Manipulation is a intervention Physical Therapists have been employing since the beginning of physical therapy practice. However, physical therapists providing spinal manipulations has come under the scrutiny of other professions even though manipulation is not exclusive to any one domain or profession. The challenge has been brought forth to many state legislators because some chiropractors have argued that manipulations are not within the scope of physical therapy practice. The APTA has created a page that delineates the difference between physical therapy manipulation and chiropractic manipulation. They have also published a manipulation education manual.

Indication

The underlying pathological cause of low back pain (LBP) is only determined in about 15% of all cases. Because of this, there has been much confusion and debate about the best way to treat patients with LBP. There have been numerous studies done to determine the effectiveness of different treatment interventions for these patients. Evidence has been conflicting regarding the effectiveness of spinal manipulation as an intervention in this patient population. However, Flynn et. al determined that patients that meet certain criteria were more likely to experience short-term improvements with spinal manipulation. A clinical prediction rule was developed in order to identify these patients with LBP who will most likely benefit from spinal manipulation. Spinal manipulation is a sub-group of the Treatment-Based Classification Approach for low back pain.

The use of spinal manipulation as part of treatment for low back pain is recommended by several clinical practice guidelines, including the New Zealand Guidelines for Acute Low Back Pain, and the recently published NICE guidelines.

Clinical Prediction Rule for Manipulation 

The following five factors are the criteria included in the five factor predictor rule for manipulation:

• Pain lasting less than 16 days
• No symptoms distal to the knee
• FABQ score less than 19
• Internal Rotation of greater than 35 degrees for at least one hip
• Hypomobility of a least one level of the lumbar spine

The patients that received the most benefit from spinal manipulation for LBP are those that met at least four out of the five criteria for spinal manipulation.The positive likelihood ratio for those exhibiting four out of five of the factors is 24.3  

However, the two most important identifiers for manipulation are:

• Pain lasting less than 16 days
• No symptoms distal to the knee 

Key Evidence

Fritz, Cleland, and Childs published an article in 2007 entitled "Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy" which lays out the Treatment Based Classification Approach and explains the classification critia for the different intervention subgroups.

In 2002 Flynn et al . which was published in 2004. This study found that the treatment effects were the greatest in patients who met at least 4 of the 5 factors.  

References

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