Top 5 Fridays! 5 Changes to My Recent Spinal Manip Course | Modern Manual Therapy Blog

Top 5 Fridays! 5 Changes to My Recent Spinal Manip Course

It's refreshing to teach a course twice a year to upcoming grads and local PTs - although no local PTs were enrolled this class - boo! Here are 5 changes I made between March 2012, and August 2012.

1) Taking away PIVM completely!

In March I de-emphasized it, and mentioned the need for movement, and not specificity, this time, I only practiced cervical downglide, mainly because that is the thrust I am most likely to perform. It's better than flipping someone over to prone, springing them a few times, then flipping them back over to do a downglide thrust.

I also told them to document upper, mid, lower cervical downglide/upglide thrust - which most likely makes it more reliable for the intra or inter PT treatments the following visits.

2) Changing my slide from "Joint Dysfunction" to "Movement Dysfunction"

I rarely do joint work anyway, but in using systems like MDT and the SFMA, I am looking at how movement either affects or does not affect symptoms and the quality of movement. Does it hurt or not? True or false. Does it make the pain change in intensity or location? By de-emphasizing structure, but still using whatever manual treatment you find effective (joint mobs will do, I just rarely use them), it's really quite liberating to simply test and retest movements and/or movement patterns/function.

I still emphasized you need to know these things for the licensure exam, as their ortho prof was not too excited about points 1 and 2.

3) We didn't practice the vertebral artery test

I teach premanipulative holds, which should tell you enough information in regard to potential adverse events. While research shows us there is no way to predict an adverse event, you are still better safe than sorry, and my premanipulative hold is the same position I am going to thrust in, far from end range due the the myriad of components used to create a barrier at mid range.

4) Neurophysiologic effects were emphasized way over mechanical effects

I still teach some mechanical effects, like choosing the right technique and or direction, but overall each course I find myself taking out more and more slides like "breaking adhesions" and "altering positional faults." I am not sure I ever caused the first one with a thrust, but am sure I have palpated a positional fault, correlated it a loss of motion/function, manipulated it, felt it was restore to neutral, and they had improvement in function and pain. Maybe this still happens, but I'm not palpating for it, so I don't see/feel it.

5) This is more of 4) part II - Emphasis on Patient Expectation

I enjoyed the recent Development of a CPR for Cervical Manipulation in the May 2012 JOSPT because 4 criteria were identified.

  • Sx duration < 38 days
  • pain with mid cervical spine springing (not specific as it most likely moves up to 2 levels above and below)
  • patient expectation of improvement
  • a side to side difference of rotation at least 10 degrees
I have taught for years based on experience that patients who want a manipulation will likely improve from a manipulation. Just as I teach a contraindication is the patient says "I hate cervical manipulation, please don't do it!" An indication for me to do a cervical (or any thrust) would be the patient says - it just feels like it needs to go, or needs to crack, etc... 

If they have no red flags, or contraindications, and have some sort of movement dysfunction, I will absolutely consider thrust manipulation as an option. Most likely, I would try IASTM, FR, or some sort of mobilization first, unless they would run off to their chiro for a quick fix (but not get preventative exercise).

Some pics...

Learning the lumbar thrust from the CPR

is this normal? - DN

Still DN!

This was actually better after some thoracic, lumbar thrusts, most likely has some hip dysfunction s/p labral repair. I think some of it may also be motor control issues but we didn't check too much

Thoracic P/A rotatory thrust - how many segments does this move?

thoracic supine component technique, grab those shoulders patient!

Here's a vid of me being a guinea pig.


  1. What is your main reasoning for de-emphasizing and then completely removing PIVM?

  2. The lack of reliability inter-rater, studies showing experienced manual PTs cannot even agree on the level when told just to palpate L5, etc... and also other studies showing P/A glides at one level also moved 1-2 levels above and below. Also, with the emphasis on manual therapy being neurophysiolgic, specificity is not needed. I now only test and re-test movement quality, quantity, and function. Then treat, then re-test. It's liberating. Try it.

  3. E,
    Changes look good. I dolike # 5 in particular. I have been meaning to write on is for awhile but just haven't. Expectation is alongside challenge as first few words on my whiteboard wi my new students. It is huge in patient care. Does expectation necessarily mean improved outcomes? Not sure but doesn't hurt. It goes back to true pt preferences and not just the other 2 parts of the Sackett model. We seem to forget this...

    I do agree too on joint dysfunction part but I think as OMpT, is still needs to be included. I wouldnt leave it out completely. Even tho research may show otherwise, we can pick these up and are a 'reason' to perform MT, other than just going in blind and saying only getting neurophysiological results. You have the skills...don't let aberrant movement patterns take that away from you...


  4. I here ya HV, it's just that I work on "joints" so little these days, very rarely doing glides or distractions. I will still perform thrust manip maybe less than once a week unless I have an acute lumbar. Mostly doing soft tissue work, MDT and corrective exercise. I still do some PIVM prior to manipulating the thoracic or cervical, just to get a feel for resistance and don't go in "blind."

    Does having expectation of improvement lead to better outcomes? Not always, but it sure doesn't hurt to have the patient on your side initially.


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