OD) To Manipulate Or Not To Manipulate Researched by Aaron Ebejer Distributed with permission by ONT TrainingThe information for this ebook was excellently researched and written by the author Aaron Ebejer who has kindly allowed OMT Training to use the information to distribute to the wider manual therapy community.Topics: Definitions of Spinal Manipulation Why May Therapists Perform Spinal Manipulation? Contraindications — Red Flags & Spinal Masquerades Cervical Arterial Dissection (CAD) with Cervical Pens Manipulation Pre-Manipulative Testing: Identifying VBI, CAI & Cervical Instability ‘Over-Manipulation Syndrome’ a “The Crack” - Tribonucleation: Is it important? eNO Proposed Mechanisms to Spinal Manipulation 9. The Effect of Spinal Manipulation on Immunity 10. The Truth About ‘Specificity’ of Spinal Manipulation 11. Conclusion of Part One 12. Quick Explanation of Acute & Chronic Pain 13. Spinal Manipulation for Acute & Chronic Low Back Pain 14. Spinal Manipulation for Acute & Chronic Neck Pain 15. Spinal Manipulation for Radiculopathy 16. Spinal Manipulation: A Tool in the Toolbox — Importance of a multimodal Approach to Treatment 1 SeYou're going to hear a little pawp Welcome, what's the crack? Okay... That's my pun for the article! Within this article we will be looking into the evidence of spinal manipulation, whilst exploring some “hot topics” along the way. In December 2019, | attended OMT's Spinal Manipulation Course by Giles Gyer and Jimmy Michael. Firstly, amazing course with great content, very interactive, very practical and the guys made the day enjoyable with decent banter. | would highly recommend attending if you are considering attending a manipulation course as part of your development; no paid advertising | swear! Many of the topics covered in this article and some of the research referenced was originally by introduced by Giles Gyer and Jimmy Michael, so cheers guys the course inspired me to write this article, Furthermore, much of the inspiration and passion for 2You're going to hear a little pawp Welcome, what's the crack? Okay... That's my pun for the article! Within this article we will be looking into the evidence of spinal manipulation, whilst exploring some “hot topics” along the way. In December 2019, | attended OMT's Spinal Manipulation Course by Giles Gyer and Jimmy Michael. Firstly, amazing course with great content, very interactive, very practical and the guys made the day enjoyable with decent banter. | would highly recommend attending if you are considering attending a manipulation course as part of your development; no paid advertising | swear! Many of the topics covered in this article and some of the research referenced was originally by introduced by Giles Gyer and Jimmy Michael, so cheers guys the course inspired me to write this article, Furthermore, much of the inspiration and passion for 2manual therapy was sparked by my university musculoskeletal lecturer Raymond Lam, his teaching and clinical approach broached many of these topics and research papers, so cheers Ray! Please note, this article will be composed of two parts! Part one will explore many of the “hot topics’ for spinel manipulation es displayed below, part two will explore the effectiveness of spinal manipulation as a therapeutic intervention. Grade Ccrado V at Grado | Grado tt sito ar ge} Grade V PL ep aL (Coit tation (Begin (Anatomia pont range ‘rn ‘tmoton) Many clinicians often define spinal manipulation as a high velocity (high speed), low amplitude (small movement) ‘thrust’ collectively known as a HVLA’ (Hengeveld and Banks, 2013) which engages the soft tissue barrier or ‘limit’ and promotes a small quantity of movement past the pathological or restricted range of movement (ROM), but ot past or up to the anatomical limit where permanent damage could ensue. 6..,.9 ‘map? o.9 ~s However, other definitions and abbreviations of spinal manipulation are circulating, some of which can be displayed above. Vernon & Mrozek (2005) documented that at the time 3of publication no universally aD OI accepted definition of spinal Bren aaa ans manipulation currently exists; this statement still stands true i NOT at present. D | CORRECTIVE [tecconectceocacs the public or ‘patients’ and practitioners of manipulation to familiarise themselves with different terminology for the sake of comprehension. Potential patients or clients \q receiving ‘manual _ therapy" especially should make themselves aware of the difference between manipulation and “mobilisations” b i Why May Therapists Perform Spinal Manipulation? Physiotherapists, sports therapists, osteopaths and chiropractors typically use spinal manipulation for three reasons: pain reduction, improving the quality (normalise) & quantity (ROM) of a patient's movement TEMPORARILY to encourage engagement with or participation in a rehabilitation programme which might otherwise be limited by the factors above. There are two key points that are often overlooked. The first is that manipulation produces TEMPORARY effects on the body, which when we start evaluating the evidence will become abundantly clear. The second is the need for a follow up in the form of a REHABILITATION PROGRAMME, thus producing @ multimodal approach to treatment with the premise of maintaining these effects. Research from Vincent et al. (2013) also suggests the positive effects of manipulation are enhanced when exercise programme is introduced, rather than practitioners solely implementing manipulation in isolation. Research on multimodal approaches including spinal manipulation for shoulder, neck, lower back pain from the likes of Brantingham et al, (2011), Akindele-Agbeja et al (2017), Bussiéres et al, (2018), Coulter et al, (2019) and Groisman et al. (2018) has established multimodal approaches produce greater reductions in pain, increased ROM, improved functional ability anc overall clinical effectiveness (including patient reported outcome measures). The level of evidence and thus clinical effectiveness is conditional and often multifactorial, for example: what part of the spine is studied, presenting condition, commodities, the patients’ socioeconomic background, patient demographics, ete.Exercise 12.2 Consider agroup exercise programme (biomechanical, aerobic, mind-body or acombinatlon of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica. Take people's specific needs, preferences and capabilities into account when choosing the type of exercise. Orthotics 123 Denotoffer belts or corsets for managing low back pain wth or without sciatica, 124 — Donotoffer footorthoties for managing low back pain with or without sciatica, 125 Donototter rocker sole shoes for managing low back pain with or without sciatica, Manual therapies 12.6 Donotoffer traction for managing low back pain with or without sciatica. Neral eps 127 ee ee pain wit It is reassuring that The National Institute for Health and Care Excellence (NICE), which provides numerous clinical guidelines for many different conditions by evaluating the current evidence base, currently recommends spinal manipulation as a non-invasive treatment modality in the management of low back pain and sciatica when combined with multimodal approach (NICE, 2016). Contraindications - Red Flags, Spinal Masquerades & Red Herrings @In medicine, @ contraindication is a condition or factor that serves as a reason to withhold a certain medical treatment due to the harm that it would cause the patient ‘Taber's Medical Dictionary, 2018). There are two types of contraindications: A relative contraindication means caution should be used when two drugs or procedures are used together, and it is only acceptable to do so if the benefits outweigh the risk (Taber's Medical Dictionary, 2019). A absolute contraindication is an event or substance could cause a life-threatening situation. A procedure or medicine that falls under this category must be avoided Taber's Medical Dictionary, 2019) WHO (2005) has recommended that therapists using spinal manipulation within their practice must screen for contraindications before manipulation is performed. Relative contraindications/precautions for spinal manipulation are: * Articular hypermobility and instability - localised (WHO, 2005), spondylolysis - with no stability (WHO, 2005), post-surgical joint or segments with no evidence of instability (Canadian Chiropractic Association, undated), previous adverse reactions to manual therapy (Greenhalgh and Sslfe_ 2005), spondylitis (WHO. 2005), spondylolisthesis - without slippage/instabiliy (WHO, 2005), osteoporosis - localised (WHO. 2005), benign bone tumours (\\/HO, 2005), severe or painful disc pathology, such as discitis or disc herniation (VWHO, 2005), anticoagulant therapy (WHO. 2005), aneurysm - distal manipulation (VVHO. 2005), psychogenic - malingerers, hysterics, hypochondriacs and those with dependent personalities (\WVHO. 2005), subacute and chronic ankylosing spondylitis and other chronic arthropathies (WHO. 2005), pregnancy (Stuber et al,, 2012), growing children (Puentedura & O'Grady, 2015). Absolute contraindications for spinal manipulation are: + Inflammatory joint conditions - localised (\WHO. 2005), fractures and dislocations WHO, 2005), spondylolisthesis - progressive (WHO, 2005), atlantoaxial instability (WHO, 2005), avascular necrosis (WHO. 2005), malignancies (WHO, 2005), localised infection (\VHO, 2005), vertebrobasilar insufficiency syndrome (WVHO. 2005), aneurysm - localised (WHO, 2005), acute myelopathy (WHO. 2005), increased ICP (\WHO, 2005), meningitis (WHO, 2005), cauda equina syndrome WHO, 2005), anomalies such as dens hypoplasia, unstable os odontoideum, haematomas (WHO. 2005), whether spinal cord or intracanalicular (\VHO. 2005), discogenic pathology with worsening neurological status (WHO. 2005), congenital dysplasialinstability (WHO. 2005), pregnancy if complications are present (Stuber et al., 2012) and uncontrolled hypertension (Smith, 2018). You will note that some of these conditions are located in both the relative and absolute contraindications, this is due to the contraindication being circumstantial. Therefore, clinical judgement and/or further medical consult may be needed to clarify particular cases.Red Flags Ramanayake and Basnayake (2018) state red flags are described es clinical findings (signs and symptoms) which raise the clinician's index of suspicion to a high level suggesting a Serious underlying pathology and not simply a musculoskeletal condition. It is essential for clinicians to clear red flags during their assessment to identify the contraindications to manual therapy as demonstrated above and clinical presentations Which may indicate serious underlying pathology. Red flags are often regional specific, for example the cervical spine red flags differ slightly in their questioning and presentation compared to the thoracic spine and lumbar spine and thus the clinician has to adapt their questioning approaches to the clinical presentation and area of complaint. ‘Common Cervical, Thoracic & Lumbar Spine Red Flags <20 and >55 years old (Greenhalgh and Selfe, 2006) Hx of cancer, ?anticoagulation ?long term use of steroids and smoking (Greenhalgh and Selfe, 2006) Potential Pregnancy — ?ectopic pregnancy (Chong et al., 2017) // Lumbar specific Bilateral pins + needles, numbness and weakness (Greenhalgh and Selfe, 2006) 5D, 3N and 1T: Dizziness, Diplopia, Drop attacks (loss of power or consciousness), Dysphagia (problems swallowing), Dysarthria (problems speaking), Nystagmus, Nausea (vomiting), Neurological Symptoms and Tinnitus (Maitland, 2013) // Cervical specific Cervical Instability: occipital numbness or paraesthesia, headaches, vertigo and visual disturbances (Hauser et al., 2014) // Cervical specific Disturbance of gait and coordination Burton & Ruane (2012) Saddle anaesthesia (Greenhalgh and Selfe, 2006) // Lumbar specific Bowel/bladder dysfunction - urinary retention, or faecal incontinence Greenhalgh and Selfe, 2006) // Lumbar specific Sexual dysfunction (Angus and Horner, 2019) // Lumbar specific Pain — constant, increase night pain, thoracic pain, abdominal pain or during coughing or sneezing ?rib dysfunction or ?discogenic (Greenhalgh and Selfe, 2006) Recent trauma or surgery (Greenhalgh and Selfe, 2006) Increased pain in supine position (NSW Therapeutic Advisory Group, 2015) Systemically unwell/B Symptoms - Weight loss, night sweats & fevers (Greenhalgh and Selfe, 2006)ver and all bladder Appendix The most common red fiags of the cervical, thoracic and lumber spine can been seen in the table and have been collected and summarised from Greenhalgh & Selfe (2008), Hauser et al., 2014), Angus and Homer (2018), Burton & Ruane (2012), Chong et al 2017) and NSW Therapeutic Advisory Group (2015). For the points that are generally region specific, | have made this clear within the comments. Jull et al. (2004) also states persistent severe restriction of lumbar flexion and non-mechanical pain and should also be added to this list. Another thing worth noting is many clinicians support the use of the mnemonics to remember reg flags such as SNOOP (headaches), TUNA FISH (back pain) and NIFTI (back pain). Ultimately, as long as the clinician clears all the red flags, the method you implement is of little consequence. sg al Masquerades & Red Herrings According to Walcott et al (2011) spinal masqueraders are conditions which present themselves as LBP but are actually caused by referred pain from a visceral structure and will often be non-mechanical in nature. A red herring in medicine is a sign or symptom which is misleading or distracting resulting in an incorrect diagnosis. Rosenblum et al. (2015) states this situation forms false certainty and the search for the actual problem ends. For example, in chronic pain cases, imaging findings are often red herrings as it could be an incidental finding; the real source of pain and distress usually lies elsewhere, being generated by soft tissue or by the brain itself or a combination (Rosenblum et al.. 2015). 8Figure 1 Clinical examination ofthe shoulder showed an Figure 2 Radiographic study showed 3 large bony lesion evident winging ofthe left weapula ’pepartment of Epidemiology and Biostatistics, EMGO Istituto Health nd Cae Research, VU Univerty Medical Center, Amsterdam, etheands Department ot General Practice, Erasmus Medical Centr Rater, Netherlands. Deparment of Public Health and Primary Care, een Univesity Medical Center, eben, Netherands. Department of Primary and Commun Cae, Radboud University Medical Center, imegen Netherlands. SDepariment of Health cence, Faulty of Earth and fe Sclences, U Univesity Amsterdam, Neterande Contac adress: Sidney M Rtinstein, apartment of Epidemiology and Bostic, EMGO Institute for Health and Care Research, WU ‘Unters Medical Center, PO Box 7057, Rom OSL, amsterdam, 1007 MB, Nethefands. sn /ubnstonvumes tiorial group Cochrane Back and Neck Group Publication status and date Ete no change to conclusions), published nse 1, 2013, tation: Ruben St, van Middthoop M, asendet WL), de Boer MR, van Tuer MU. Spinal manipulative therapy for chronic owe backpoin.CocroneDotobose of Sstemotic Reviews 201, sue 2 Art No. €D0081 12. OOF 10 102/14651858.CDON812 pubs Copyright© 2013 The Cochrane Collaboration Publsed by John Wiley & Sons, 87Firstly, we have a Cochrane Systematic Review by Rubinstein et al. (2011) who reviewed the research for Spinal manipulative therapy for chronic LBP. The authors of this study concluded that spinal manipulation was equally as good as other therapeutic interventions for chronic LBP. "SMT [Manipulation] appears to be no better or worse than other exis patients with chronic low-back pain.” ing theray Therefore, one could speculate from this review that spinal manipulation can be used in the management of chronic LBP. Meta*Analysis | > Spine J, 2018 May;18(5}866-879. doi: 10.1016/;spinee.2018.01.013. Epub 2018 Jan 31. Manipulation and Mobilization for Treating Chronic Low Back Pain: A Systematic Review and Meta- Analysis lan D Coulter ", Cindy Crawford 2, Eric L Hurwitz 3, Howard Vernon 4, Raheleh Khorsan 5, Marika Suttorp Booth 2, Patricia M Herman 2 Affiliations + expand PMID: 29371112 PMCID: PMC6020029 DOI: 10.1016/jspinee.2018.01.013 Free PMC article Abstract Background context: Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain, However, questions remain about their efficacy, dosing, safety, and how these approaches compare with other therapies. Purpose: The present study aims to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain. Coulter et al. (2018) published a systematic review and meta-analysis to determine the efficacy, effectiveness and safety of various mobilisation and manipulation therapies for treatment of chronic LBP. They found both mot patients with chronic LBP. It should be noted that manipulation appeared to produce a larger effect than mobilisation but both therapies appeared safe. 58 ation & manipulation therapies moderately effective