Teaching Spinal Manipulation | Modern Manual Therapy Blog

Teaching Spinal Manipulation

Just finished teaching Spinal Manipulation to a great class of D'Youville College DPT students.

Many of them were 2nd years and a few were 3rd years (DPT phase). All in all it was a great class. It's refreshing that in my 13 year of teaching, I am still changing the curriculum almost every year, and sometimes more as I teach it twice a year. There was a lot of good research on spinal manipulation in the past year, so I made sure to touch upon many of the studies. I also incorporated some of the recent approaches I have been exposed to like the SFMA concepts. Here are some recent additions/changes to my course this time around.

  • In the long term, both MDT and SMT have good outcomes for lower back pain, but MDT outcomes were superior
  • Those who met the CPR for lumbar thrust manipulation also fit into the derangement category
    • this makes sense and goes along with Dr. Brence's points about CPRs being prognostic rather than predictive
    • the aforementioned CPR definitely identifies a healthier population that would respond rapidly to either approach
    • it is possible, many of these falling into this category would respond to any active treatment, and possibly even rest/time would get a majority better
    • our role is choosing the best approach for the particular patient depending on their presentation and evaluation, plus the education would prevent the recurrence of lower back pain
    • recurrence ranges from 24% when controlled for acute lower back pain to 87% when looking 1 year after recovery, but not controlling for acute episodes and recovery
  • those who met the cervical CPR (thoracic thrust), responded equally well to thoracic thrust and cervical thrust, but slightly faster with cervical thrust in the first few visits
  • a similar study, also by Dunning, who apparently favors cervical thrust (and thus definitely affecting not only the design but outcomes of the study) also showed that there was a great difference in the first 48 hours for cervical and upper thoracic thrust for cervical pain vs mobilization only
    • while this was criticized for the short term, this is important to me as a private practice owner, and keeping patients and referral sources happy
    • some patients who are in severe, but acute pain, would be much happier to have not only a faster treatment (a few thrusts, vs minutes of mobilization) that increased ROM and decreased pain better within the first 48 hours
    • MDT would definitely work for those compliant enough to get to end range to activate similar mechanisms like inhibition and "bombarding" the CNS, but getting to end range is faster, and has a similar effect with thrust to either or both the upper thoracic and cervical spines
  • I reviewed cervical and thoracic PIVM, not lumbar, and I have not used it regularly in years
  • despite the research stating specificity is not needed, I still feel it is more likely safer to use good component technique in the cervical spine to create a mid range barrier
  • thoracic spine specificity is most likely not needed, but I will still spring for patient response and end feel
    • this is more out of habit because I do not think it is warranted to manipulate the entire thoracic spine motion segment by motion segment
  • those who have pain with full ROM, will most likely respond faster to treatment than those with limited ROM without pain, who will respond faster than those with limited ROM and pain (simple enough, and intuitive, but pointed out very nicely by Gray Cook, in Movement)
All in all, I had a blast, as many of the students did. Even though I do not use nearly as much thrust in my clinic as I did after first graduating from St. Augustine's DPT program, it is still a great tool to have in my box. Nothing keeps a class awake like practicing manipulation!

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