Article Review

Comparison of the Effectiveness of Three Manual Physical Therapy Techniques in a

Subgroup of Patients With Low Back Pain Who Satisfy a Clinical Prediction Rule
Summer Demeuse, SPT

The purpose of this article by Cleland et al. was to compare 2 different thrust and 1 non-

thrust manual therapy techniques in patients who met the requirements for the spinal

manipulation clinical predictive rule (CPR) to determine which technique will have the most

benefit. The patients were separated into 3 groups and recievedreceived different manipulation

techniques to the lumbar spine to determine the effects on the Oswestry Disability Questionnaire

(ODQ) and the Numerical Pain Rating Scale (NPRS) scores. There were 5 total treatment

sessions over 4 weeks where the manual techniques were only used during the first 2 sessions

within a 1-week period in combination with the same ROM exercise for each group. For the

following 3 sessions which were 1x/week, each group performed the same exercises. The ODQ

and NPRS were taken at baseline, 1-week, 4-weeks, and 6 months.

The supine thrust manipulation group received a high velocity low amplitude (HVLA)

thrust in a posterior/inferior direction applied to the anterior superior iliac spine (ASIS) which

was the technique that way used to create the CPR and part of the eligibility criteria to be in this

study. The side-lying thrust manipulation group received an HVLA in side-lying to the pelvis in

an anterior direction. For the two trust techniques, the more symptomatic side was manipulated if

indicated by the patient, otherwise chosen by the therapist. The technique was repeated once on

the same side followed by twice on the opposite side if a cavitation was not noted on the first

attempt. The non-thrust manipulation group received a low velocity, high large amplitude

oscillatory mobilization at the L4-L5 segment in the poster-anterior direction. Two sets of
oscillatory mobilizations were applied to L4 followed by L5 for 60 seconds with a 30 second rest

period between.

The study concluded that there was no significant difference between the supine vs side-

lying thrust manipulations at any measurement period during the study. Meanwhile at every

measurement period there were significant differences between the supine thrust manipulation

and non-thrust manipulation and side-lying thrust and non-thrust manipulations. The non-trust

manipulation group had a more gradual decrease in ODQ scores whereas the thrust groups had

rapid acute effects followed by a gradual decrease. The two thrust techniques had similar curves

for ODQ scores with the supine thrust technique having about 2-4 points lower except for the 4-

week to 6-month period where the score increased by 1-2 points.

The threshold for a minimal clinically important difference (MCID) for the ODQ is

improvement by 30%, but the researchers defined success by a 50% reduction. All groups had

significant improvements at each follow up period with supine thrust having the highest

percentage of patients followed by side-lying thrust, and lastly non-thrust. One thing to note is

that the two thrust groups only improved from about 50% of patients to about 90% from 1-week

to 6 months whereas the non-thrust improved from <10% of patients to almost 70%.

There were significant differences in NPRS scores between the supine thrust and non-

thrust techniques and the side lying thrust and non-thrust techniques at 1-week and 4-weeks, but

they did not maintain long term differences at 6 months as they all were within half of a point of

each other. There was no significant difference between thrust techniques at any measurement.

The two thrust techniques had almost identical curves but differed due to the supine technique

having .5-.25 points lower on the NPRS at each measurement.

 There were multiple factors in this study that I noticed that can attribute to its quality.

The prevalence of LBP in different locations within the United States could be affected by

different factors depending on the geographical location (occupation, socioeconomic status, etc).

The population sample used was from various locations (That’s because it was a multi-center

study, probably to reach sufficient numbers for statistical significance.) and settings in the United

States which is an important to include for generalizability.

Using the same exercises for all three groups was crucial to reduce confounding variables

that could have been attributed to finding a difference between the techniques. The exercises

given were identical to the exercises used in the study where CPR was validated. The purpose of

this article, generalizing a technique to the specific patient population who satisfied the CPR,

was consistent as with the results as the researchers used the same exercises to make a valid

conclusion built off of the purpose.

The researchers indicated their attempt to localize treatment, but I also find importance

that they put forth the idea that it is not likely to localize the technique to a particular single

spinal level. The side lying thrust technique and non-trust technique indicated that they

performed it on a specific segment whereas the supine thrust technique was not specified. The

L4-L5 segment that was specified for both techniques were chosen based on 2 previous research

showing greater effectiveness compared to the upper lumbar spine. Using a segment that has

been proven in prior research for its success contributes to the high quality of this article.

The diverse outcome measures used strengthened the overall quality of the evidence by

giving a comprehensive view on LBP. LBP Low back pain (Don’t start sentences with

acronyms.) is an extremely complicated, multi-factorial symptom to classify and investigate, so

utilizing these different outcome measures allowed the researchers to explore the participants

perception of pain, psychological effects, and their functional abilities in everyday life.

Lastly, looking at the long-term effects of the techniques for > 6 months could have

unfolded further results. As stated above, the ODQ and NPRS curves for the thrust techniques

had rapid acute affects, but either plateaued or increased at the 6-month mark whereas the non-

thrust technique had a gradual decreasing slope. To say that the thrust techniques are more

effective than the non-thrust may not be the entire truth if the study observed the effects longer

than 6 months.

While I was out on my clinical education experience, we saw patient’s with LBP

frequently. The presentations of the patients were all over the board which made it difficult to

feel confident in a plan for treatment. Learning the skills to perform these techniques, having

many “tools in my toolbox”, and examining the research behind their effectiveness excites me to

treat patients with a wide variety of LBP presentations.

Older manipulation theories focused on alignment and stiffness where the therapist was

focused on moving a specific segment in a particular direction. These theories did not focus on

the key factors, velocity and amplitude, that define the difference between a thrust and non-thrust

technique. Finding an article comparing the two techniques interested me after learning more

about the history of manual therapy and different theories on the physiology of their clinical

effectiveness. Since I will encounter patients that will fear manipulation techniques, I wanted to

compare the theories to determine how much of a difference in the outcomes can be attributed to

the differences (velocity and amplitude) between the two techniques and their

neurophysiological effects that influence outcomes.

 Moving forward in my future practice, I will utilize these techniques as another “tool in

the toolbox” to help patients decrease LBP and increase their daily functioning. Some patients

may opt out of any thrust techniques, have excessive guarding, or have any other individual

qualities or contraindications where I would not utilize a HVLA technique, so having both thrust

and non-thrust options is essential. Having a variety of manual techniques to use is important due

to the individual and diverse presentations of LBP in addition to adaptability of the therapist and

willingness to try all other options to yield the best result for my future patients.

Performing a technique using multiple attempts, repositioning the patient and/or therapist,

in addition to other adjustments as needed for success is crucial for a novice clinician as I am

learning and improving my manipulation skills. To be successful with a manipulation, we

learned you do not always need an audible cavitation and we are not always positive which side

is “popping”. The researchers used the modifications stated above if needed, but I dislike that

they based their success of the manipulation on if they heard or the patient felt a “pop”. (Which

may have confounded the results because of the endorphin release from the patient when they

‘got what they paid for’ in this study.) In future practice, I will consider the individual nature of

the patient on each visit, their feedback on the last session, and balance evidence-based

knowledge with clinical reasoning to obtain optimal results.

The order in which the manipulations were performed and changing the technique if

needed is also important to consider. To ensure validity for research purposes it was important to

keep the order of treatments the same between groups with the first two sessions including the

manipulation technique and ROM exercises followed by only exercises on the remaining visits.

The order and/or utilization of different interventions may affect individual outcomes, so it is

important to use clinical reasoning to plan each session. Using evidence-based practice is very
important but needs to be weighed appropriately with clinical reasoning skills. These thoughts

while reading the article will carry over into future clinical practice.

References
1. Cleland, J. A., Fritz, J. M., Childs, J. D., & Kulig, K. (2006). Comparison of the effectiveness

of three manual physical therapy techniques in a subgroup of patients with low back pain who

satisfy a clinical prediction rule: Study protocol of a randomized clinical trial

[NCT00257998]. BMC Musculoskeletal Disorders, 7(1). doi: 10.1186/1471-2474-7-11

PTH 662 – Manual Therapy II Literature Review Paper 2020

Student: Summer Demeuse Faculty Initials: JTZ

Scoring Criteria
1. Clearly describes the clinical question or purpose 1/1
2. Identifies/references the source of the answer 1/1
3. Provides brief description of methods/analysis 1/1
4. Provides synopsis of conclusions/discussion 1/1
5. Assessed the quality of the evidence provided 1/1
6. Identifies why reference(s) is/are appealing/interesting 1/1
7. Clinical implications (relevance to practice?) 2/2
8. Grammar/spelling/punctuation 1/1
9. Clarity, organization, conciseness 1/1

Total Score 10 /10

Percent Score 100%
Additional Feedback: Summer, the authors (who also did the CPR’s study) wanted
to discern if it was actually the manipulative technique that led to successful
outcomes or if other techniques could be just as successful. I think that they
found their answer, which most manual therapists know; a single technique
doesn’t work for all patients and, as you state, you have to balance the CPR
knowledge with sound clinical reasoning when determining the best course of
action with patients suffering from LBP. Good job with the review! Dr. Zipple