How do I perform & know when

to use manipulation for LBP?

1
 (Alrwaily et al., 2016, p.1059)
From: Treatment-Based Classification System for Low Back Pain: Revision and Update
Phys Ther. 2016;96(7):1057-1066. doi:10.2522/ptj.20150345 Phys Ther | © 2016 American Physical Therapy Association
 Why Use It & How Does It Work?

• Increase motion and decrease pain

• What did we discuss with the Australian approach?
– decrease in pain perception
– increased mechanical pain thresholds
– No effect on thermal pain thresholds
– Unlikely due to release of β-endorphins.
• A decrease and increases in local motoneuron activity has been noted,
but the effect is short lived and there are inconsistencies when
comparing the cervical and lumbar regions. “… the effect of SMT on
the motor system is inconclusive.” (Souvlis, Vincenzino, & Wright, 2004, p.373)
• The exact mechanism is still being examined but this is what has
currently been proposed:
– Changes in autonomic nervous system
• sympathetic mediation of muscular and vascular tone
– And a neuroendocrine system response.
• Changes in cortisol release which is mediated through the hypothalamic-pituitary axis
3
(Kovanur-Sampath, Mani, Cotter, Gisselman, & Tumilty, 2017; Sampath et al., 2017)
Various Authors have Various indications for HVLA thrust

• Hypomobility 
• Motion restriction 
• Joint fixation 
• Acute joint locking 
• Motion loss with somatic dysfunction 
• Somatic dysfunction 
• Restore bony alignment 
• Meniscoid entrapment
• Adhesions 
• Displaced disc fragment 
• Pain modulation 
• Reflex relaxation of muscles 
• Reprogramming of the Central Nervous System
• Release of endorphins
• Clinical prediction rule (Gibbons & Tehan, 2010 or 2016, p.57 ) 4
 Contraindications
Absolute
• Bone: any pathology that has led to significant bone weakening:
– Tumour, e.g. metastatic deposits
– Infection, e.g. tuberculosis
– Metabolic, e.g. osteomalacia
– Congenital, e.g. dysplasias
– Iatrogenic, e.g. long-term corticosteroid medication
– Inflammatory, e.g. severe rheumatoid arthritis
– Traumatic, e.g. fracture.
• Neurological
– Cervical myelopathy
– Cord compression
– Cauda equina compression
– Nerve root compression with increasing neurological deficit.
• Vascular
– Diagnosed cervical artery dissection
– Aortic aneurysm
– Bleeding diatheses, e.g. severe haemophilia.
• Lack of a diagnosis
• Lack of patient consent
• Patient positioning cannot be achieved because of pain or resistance. 5
(Gibbons & Tehan, 2016, p.46 )
 Relative not relatives
Special consideration should be given before the use of HVLA thrust technique in the
following circumstances:
• Adverse reactions to previous manual therapy
• Disc herniation or prolapse
• Inflammatory arthritides
• Pregnancy
• Spondylolysis
• Spondylolisthesis
• Osteoporosis
• Anticoagulant or long-term corticosteroid use
• Advanced degenerative joint disease and spondylosis
• Vertigo
• Psychological dependence upon HVLA thrust technique
• Ligamentous laxity/hypermobility
• Arterial calcification.
The above list is not intended to cover all possible clinical situations. Patients who have
pathology may also have coincidental spinal pain and discomfort arising from
mechanical dysfunction that may benefit from manipulative treatment. 6
(Gibbons & Tehan, 2016, p.46 )
 When to use manipulation
• Hypomobility
– Facet restriction
– Soft tissue restriction
– Pain
• MDT - dysfunction
• Clinical Prediction rule

7
 Regional SI Manipulation
(lumbar manipulation?)
• Inclusion Criteria
– ages of 18 and 60 years,
– diagnosis related to the lumbosacral spine,
– chief complaint of pain and/or numbness in the
lumbar spine, buttock, and/or lower extremity.
– The baseline Oswestry disability score had to be at
least 30%.

(Flynn, et al., 2002)

8
 Regional SI Manipulation
• Exclusion criteria
– current pregnancy,
– signs consistent with nerve root compression
(positive straight-leg raise at 45°, or diminished
lower extremity strength, sensation, or reflexes),
– prior lumbar spine surgery,
– or a history of osteoporosis or spinal fracture.

(Flynn, et al., 2002)

9
 Regional SI Manipulation
• Clinical prediction rule – 5 variables
– Symptoms <16 days duration
– One hip with >35 degrees of internal rotation
– Lumbar hypomobility
– No symptoms distal to the knee
– FABQ work score <19 (out of 42 points)
• 6, 7, 9, 10, 11, 12, 15
• Higher scores represent greater fear

(Flynn, et al., 2002)

10
 FEAR AVOIDANCE BELIEFS QUESTIONNAIRE (FABQ)

Measurement Characteristics: The FABQ has been demonstrated to be valid

and reliable in a chronic LBP population and appears to be a useful screening tool
for identifying acute LBP patients who will not return to work by 4wks.

11
12
 Regional SI Manipulation
• Probability of success (50% improvement of Oswestry
in 5 days)

– 5 variables present = 99%

– 4 variables present = 95%
– 3 variables present = 68%
– 2 variables present = 49%
– 1 variable present = 46%
– If 4 of the 5 variables were met the Positive Likelihood Ratio of
success is 24.5
• This prediction rule has been validated in another
study and was published in the Annals of Internal
Medicine (Childs, et al., 2004)
• When these criteria and intervention were compared
to the McKenzie Mechanical Diagnosis Therapy the
systems yielded similar results. Although this study
was likely underpowered, it is important because it
suggests that the CPR for spinal manipulation may be
important for its prognostic nature versus intervention.
(Schenk, Dionne, Simon, & Johnson, 2012)
• Non-Thrust and Thrust were compared using these
criteria and suggested those who meet the criteria
were likely to benefit equally from both. (Learman, et
al., 2014) (Flynn, et al., 2002)
13
 Determining the Side
• The side to be manipulated was determined with the
following algorithm:
– first, the side of the positive standing flexion test;
– if this test was negative, the side of tenderness during
sacral sulcus palpation was manipulated.
– If neither side was tender, the side reported by the patient
to be more symptomatic was manipulated.
– If the patient was unable to identify a more symptomatic
side, the therapist flipped a coin to determine the side.

(Flynn, et al., 2002)

14
Sacro-Iliac Region Manipulation
This is really a lower lumbar
(Classic) HVLA manipulation

• Translate pelvis toward you and

maximally side-bend the patient’s
lower extremities and trunk to the
right
• Thread your right forearm through
the patient’s arms. Rest your
fingertips on the patient’s sternum
or the table. Stand upright and
rotate the trunk to the left
(maintain the right side-bending)
• Contact the patient’s right ASIS
with your left hand when it rises
from the table. Perform a smooth
thrust in an anterior to posterior
direction

Modification
Click Here (Wainner, et al., 2001)15
 16
(Apeldoorn et al., 2012, p.1349)
 The art of manipulation is very individual requiring HVLA thrust
techniques to be adapted to the needs of both practitioner and
patient. While there will be differences between practitioners, the
underlying principles for the safe and effective application of HVLA
thrust techniques can be summarized as follows:
• Exclude contraindications • Understand the risk-benefit
(Review Gibbons & Tehan, 2010, p.37, analysis, related that information
38, & 61; Gibbons & Tehan, 2016,
p.44-46).
to the client, and Obtain
informed consent.
• Recognize the influence of
• Ensure patient comfort.
any cautionary conditions
(Review Gibbons & Tehan, 2010, p.61).
• Ensure operator comfort and
optimum posture.
• Identify a treatable somatic
lesion • Use appropriate spinal locking.
– Symptom reproduction • Identify appropriate pre-thrust
– Tissue tenderness tissue tension.
– Asymmetry • Apply high velocity low amplitude
– Range of motion thrust with minimal force.
– Tissue texture changes 17
(Gibbons & Tehan, 2000 & 2010)
 Safety Considerations
• Strong evidence supports that Differential Diagnosis
is essential and referral to an appropriate medical
practitioner should occur when:
(1) the patient’s clinical findings are suggestive of serious
medical or psychological pathology,
(2) the reported activity limitations or impairments of body
function and structure are inconsistent with the
diagnosis/classification scheme, or
(3) the patient’s symptoms are not resolving with
interventions aimed at normalization of the patient’s
impairments of body function.
(Delitto, et al., 2012)
18
 Harm
• “Serious complications associated with HVLA thrust techniques applied to the
lumbar spine and pelvis are extremely uncommon, and adverse
consequences such as worsening lumbar disc herniation or cauda equina
syndrome were found to be extremely rare in five systematic reviews of
spinal manipulation.” (Gibbons & Tehan, 2016, p.42)
– Transient effects (local or radicular stiffness, pain, or discomfort) can
occur within 24 hours, but resolve within 72 hours.
• “Comparative Harm: It is helpful to consider the safety and complications
associated with what is perhaps the most frequently prescribed treatment for
acute LBP---non-steroidal anti-inflammatory drugs (NSAIDs)---
– in order to put the safety of manipulation in context.
– Major side effects involve the GI tract, and 1% to 3% of users are thought
to develop GI bleeding due to NSAID use.
– Each year, 7,600 deaths and 76,000 hospitalizations in the U.S. may be
attributable to NSAIDs.
• “At least 16,500 NSAID-related deaths occur each year in the United States
among patients with osteo- and rheumatoid arthritis…” (Durrance, 2003).
• Gibbons & Tehan (2016) cite a systematic review for spinal manipulation in
the treatment of disc herniation estimated the risk for symptoms worsening
(including cauda equina) to be less than 1 in 3.7 million (p.42).
19
(Wainner, et al., 2001)
 Lumbar Complications
Substantive reversible
• Minor vertebral
compression fx
• Disc herniation-prolapse
• Nerve root compression
• Adjoining or Regional strain
Substantive & Serious
NON-reversible
• Significant vertebral
compression fx or
disruption of spinal canal
• Disc herniation-prolapse-
extrusion
• Persistent radiculopathy
• Cauda equina
20
(Gibbons & Tehan, 2016, Table 5-4, p.46)21
 Case Report
History & Treatment Treatment
• 77 y/o male • Chiropractor
• 1 month hx LBP – Manipulation with no
• PMH: improvement over 7 sessions
– R inguinal hernia repair, 2 months prior
– Asthma
– Chronic atrial fibrillation
– Long hx of multiple episodes of LBP
• Meds: bronchodilator & warfarin
(anticoagulation for afib)
• Radiographs: slight decalcification,
old compression fractions of corpus
L2 & L3, DJD

(Solheim, et al., 2007) 22

 Lumbar Epidural Hematoma After FIGURE 1. Preoperative sagittal, T1-weighted, contrast-enhanced MRI
scan showing an epidural hematoma at the L3–L4 level on the dorsal side
Chiropractic of the dural tube. There is an older compression fracture of the L3 corpus
Manipulation For Lower-back Pain: Case
Report

• Last Rx felt immediate increase in sx,

(Solheim, et al., 2007, p. E170)

radicular pain, numbness in R inguinal
area, decreased sensation to genitalia,
R gluteal region, and lateral thigh.
• Sx progressed over 3-4 days including R
LE weakness, incomplete bladder
emptying
• Day 10 after manipulation admitted to
hospital
• Laminectomy and evacuation of
hematoma
• 3 months later
– Gait normalized
– No residual weakness
– Still decreased sensation in genital region,
but improved
– Still had incontinence issues, incomplete
voiding, and nocturia
23
(Solheim, et al., 2007)
 Skill development and clinical reasoning

Prior to the HVLA thrust:

• the patient should be relaxed and the positioning
should not cause pain
– possibly just a light stretch
• palpation should reveal no muscle guarding or spasm
• the patient should be positioned such that it require
very little movement to produce the desired effect.
Some describe a “crisp” endfeel prior to application
of the thrust.

24
Dave Johnson, PT, PhD, FAAOMPT
 Skill development and clinical reasoning
If you do not get an audible pop upon doing a thrust
technique, and you choose to try again:
– reposition precisely and add only quickness to your next attempt
– do not add amplitude or force

Opinion:
– the main reason to do a thrust is to “jostle the joint” to relieve a
slight, remaining restriction
– the real work of restoring mobility and function is usually done
via non-thrust
– a cavitation (or “audible pop”) is mainly a sign that the joint can
move
25
Dave Johnson, PT, PhD, FAAOMPT
 Skill development and clinical reasoning

Flynn TW, Fritz JM, Wainner RS, Whitman JM. The audible pop is not
necessary for successful spinal high-velocity thrust manipulation in
individuals with low back pain. 2003. Arch Phys Med & Rehab 84:1057069.

– using SI region thrust: an audible pop occurred for 50 of 71 subjects.

– in 14 of 19 dramatic responders, an audible pop occurred.
– odds ratio was 1.2 (0.38 to 4.04) and suggested a pop would not
improve odds of achieving a dramatic reduction

26
 Lumbar HVLA
• Use a wide a base of support
– Have, where possible, one leg in front of the other with the rear heel raised

• Do not rely solely upon arm strength and speed

– practice speed by tearing one sheet of toilet tissue without causing the roll to
unwind
• Think about a piece of paper dropping and the speed necessary to catch it

• Use your body with fixed forearms and hands where possible

• Do not stoop or bend over the patient – Your hip heights should be equal

• Keep your own spine erect as possible

27
Dave Johnson, PT, PhD, FAAOMPT
 Typical Lumbar (10.3, Gibbons & Tehan, 2010, 229-232; 2016, p.251-254 )
Neutral and neutral/extension positioning

Neutral/extension position
Type 1 movement

Sidebending and rotation to

opposite sides.

Locking
Sidebending and rotation to the
same side.

Please note; when I say “I will start the

video”, YOU will need to do that
manually, by clicking on the picture.

(Gibbons & Tehan, 2000)

28
 Typical Lumbar (10.4, Gibbons & Tehan, 2010, 233-236; 2016, p.255-258 )
Flexion positioning

Flexion positioning
Type 2 movement

Sidebending and rotation to

the same side.

Locking
Rotation and sidebending to
opposite sides i.e. Sidebending
and reverse rotation.

Please note; when I say “I will

start the video”, YOU will need
to do that manually, by clicking
on the picture.
29
(Gibbons & Tehan, 2000)
 Sacro-Iliac Region Manipulation
This is really a lower lumbar
(Modification) HVLA manipulation

• Translate the pelvis towards you

and maximally side-bend the
patient’s lower extremities and
trunk to the right
• Without losing the right sidebending
lift & rotate the trunk so the patient
rests on their left shoulder
• Contact the patient’s right ASIS
with your left hand
• Grasp the top shoulder and scapula
with your right hand and rotate the
trunk to the left while maintaining
the right side-bending
• Once the right ASIS starts to
elevate, perform a smooth thrust in
an anterior to posterior direction

(11.3 Sacroiliac L Ant Innominate, Gibbons & Tehan, 2010, 263-266)

(Wainner, et al., 2001)30
 Thoracic Spine T4-9 9.1
Extension Gliding

Positioning for thrust: Lean forwards with the thrusting part of your chest
against the spinous process of T6. Introduce a backwards (compressive) and upwards force to the
patient's folded arms. Maintaining all holds and pressures, bring the patient backwards until your
body weight is evenly distributed between both feet
Adjustments to achieve appropriate pre-thrust tension
Immediately pre-thrust: Relax and adjust your balance
Delivering the thrust: The direction of thrust with your arms is towards you
and slightly upwards. Simultaneously, apply a thrust directly forwards against
the spinous process of T6 with your sternum 31
(Gibbons & Tehan, 2010, p.181-184; 2016, p.203-206 )
 32
(Apeldoorn et al., 2012, p.1349)
 References
• Adams, M., Bogduk, N., Burton, K., & Dolan, P. (2002). The biomechanics of back pain. New
York: Churchill Livingstone.
• Alrwaily, M., Timko, M., Schneider, M., Stevans, J., Bise, C., Hariharan, K., & Delitto, A. (2016).
Treatment-Based Classification System for Low Back Pain: Revision and Update. Physical
Therapy, 96, 1057-1066. doi:10.2522/ptj.20150345
• Apeldoorn, A. T., Ostelo, R. W., van Helvoirt, H., Fritz, J. M., Knol, D. L., van Tulder, M. W., & de
Vet, H. C. (2012). A randomized controlled trial on the effectiveness of a classification-based
system for subacute and chronic low back pain. Spine, 37(16), 1347-1356. doi:
10.1097/BRS.0b013e31824d9f2b
• Childs, J.D., Fritz, J.M., Flynn, T.W., Irrgang, J.J., Johnson, K.K., Majkowski, G.R., & Delitto, A.
(2004). A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit
from Spinal Manipulation: A Validation Study. Annals of Internal Medicine, 141, 920-928.
• Delitto, A., George, S. Z., Van Dillen, L. R., Whitman, J. M., Sowa, G., Shekelle, P., . . . Godges, J. J.
(2012). Low back pain. The Journal of Orthopaedic and Sports Physical Therapy, 42(4), A1-57.
doi: 10.2519/jospt.2012.0301
• Durrance, S.A. (2003). Older adults and NSAIDs: avoiding adverse reactions. Geriatric Nursing,
24, 348-352.
• Edwards, B.C. (1994). Clinical assessment: The use of combined movements in assessment and
treatment. In L.T. Twomey, & J.R. Taylor (Eds.), Physical therapy of the low back (2nd ed., pp.
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 References
• Fritz, J. M., & George, S. (2000). The use of a classification approach to identify subgroups of
patients with acute low back pain. Interrater reliability and short-term treatment outcomes.
Spine, 25(1), 106-114.
• Fritz J.M., Delitto, A., & Erhard, R.E. (2003). Comparison of classification based physical therapy
with therapy based on clinical practice guidelines for patients with acute low back pain: a
randomized clinical trial. Spine, 28(13), 1363-71.
• Fritz, J. M., Cleland, J. A., & Childs, J. D. (2007). Subgrouping patients with low back pain:
Evolution of a classification approach to physical therapy. The Journal of Orthopaedic and
Sports Physical Therapy, 37(6), 290-302. http://dx.doi.org/10.2519/jospt.2007.2498
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prediction rule for classifying patients with low back pain who demonstrate short-term
improvement with spinal manipulation. Spine, 27(24), 2835-2843.
• Henry, S.M., Fritz, J.M., Trombley, A.R., & Bunn, J.Y. (2012). Reliability of a treatment-
based classification system for subgrouping people with low back pain. Journal of Orthopaedic
& Sports Physical Therapy, 42(9), 797-805.
• Gellhorn, A. C., Chan, L., Martin, B., & Friedly, J. (2012). Management patterns in acute low
back pain: the role of physical therapy. Spine, 37(9), 775-782. doi:
10.1097/BRS.0b013e3181d79a09
34
 References
• Gibbons, P., & Tehan, P. (2000). Manipulation of the spine, thorax and pelvis (2nd ed.). New York: Churchill
Livingstone.
• Gibbons, P., & Tehan, P. (2010). Manipulation of the spine, thorax and pelvis (3rd ed.). New York: Churchill
Livingstone.
• Gibbons, P., & Tehan, P. (2016). Manipulation of the spine, thorax and pelvis (4th ed.). New York: Churchill
Livingstone.
• Learman K, Showalter, C., O’Halloran, B., Donaldson, M., & Cook, C. (2014). No differences in outcomes in people
with low back pain who met the clinical prediction rule for lumbar spine manipulation when a pragmatic non-
thrust manipulation was used as the comparator. Physiotherapy Canada, 66(4), 359-366. doi:10.3138/ptc.2013-49.
• Kovanur-Sampath, K., Mani, R., Cotter, J., Gisselman, A. S., & Tumilty, S. (2017). Changes in biochemical markers
following spinal manipulation-a systematic review and meta-analysis. Musculoskeletal Science & Practice, 29, 120-
131.
• Sampath, K. K., Botnmark, E., Mani, R., Cotter, J. D., Katare, R., Munasinghe, P. E., & Tumilty, S. (2017).
Neuroendocrine Response Following a Thoracic Spinal Manipulation in Healthy Men. Journal of Orthopaedic &
Sports Physical Therapy, 47(9), 617-627.
• Schenk R, Dionne, C., Simon, C., & Johnson, R. (2013). Effectiveness of mechanical diagnosis and therapy in
patients with back pain who meet a clinical prediction rule for spinal manipulation. The Journal of manual &
manipulative therapy, 20(1): 43-49. doi:10.1179/2042618611Y.0000000017.
• Solheim, O., Jorgensen, J. V., & Nygaard, O. P. (2007). Lumbar epidural hematoma after chiropractic manipulation
for lower-back pain: case report. Neurosurgery, 61(1), E170-171.
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therapists. [Computer software]. Manipulations, Inc. ISBN #: ISBN 0-9714792-1-6. Available through the American
Physical Therapy Association www.apta.org 35