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!

5 comments:

  1. Erson,
    Thank you for your post and a great website. However, I wanted to comment on your above post. You make the comments "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." This conclusion is simply not true. The Validation study by Childs determined that patients who did not recieve manipulation that did not fit the CPR did not have the samepositive course as those who did. In fact, patients who did not recieve the manipulation had a relative risk of nearly 10 for worsening in disability in the short term follow-up.

    Tom

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  2. I bet it's nice as a student having a clinician be so open as it appears you are E. i would have loved reading my teachers 'thoughts' through blogging wheni learned under them at school. Seems to make an awesome learning environment.

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  3. Thanks Harrison, it's been a great trip and I was refreshed to see how much my content has changed as I went over my old lectures.

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  4. Thanks for the correction Tom. It's been a while since I read Childs' follow up validation study. Are you saying the patients who did not meet the CPR and did not receive the manipulation had a higher risk of disability? What if they did meet the CPR but received exercise only and the conservative care guidelines? Was that looked at?

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  5. If you are looking at the four horses in the raise you had 1) folks who fit the CPR and recieved manipulation and exercise, 2) those who fit the CPR and recieved exercise only, 3) those who did not fit the CPR and recieved manipulation and exercise, and 4) those who did not fit the rule and recieved only exercise the results were overhemingly in favor of group 1, with grups 2 and 3 essentially tied, and group 4 pulling up the rear at 6 months. As this shows it is the persons who fir the CPR and recieved manipulation who did the best, by far, and the grup who fit the CPR but did not recieve the manipulation did comparable to folks who did not fit the rule and recieved manipulation, discrediting the idea that the CPR is prognostic for all persons with low back pain as oppossed to a subgroup most likely to experiance rapid changes if they recieve the correct treatment.

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