JOINT MANIPULATIONS

© The Manual Therapy Institute PLLC 2018.

Policy on the Practice of ManipulationPreamble

Students at MTI are initially taught mobilization techniques, which are then progressively developed into manipulative techniques. Manipulative techniques involve the application of a high speed, small amplitude thrust beyond the physiological passive range of a joint. They are often referred to as high velocity thrusts (HVT) and are frequently associated with a ‘popping sound’ (otherwise known as a ‘cavitation’). The graduated increase in the forces applied to the spine is seen as an important safety aspect of this process.

However, there are potential dangers associated with the use of manual therapy techniques and recognized contraindications to their use, in particular with respect to HVT techniques.

For the safety of students and patients, the following policy will be followed with respect to the application of mobilization and manipulative techniques taught at the Manual Therapy Institute

Policy

Students must screen for the presence of contraindications to manipulation Students must read and understand ‘Contraindications to

Manipulation’ and “Pre Manipulative Screening” & its associated references.

Students will assess for potential vertebro‐basilar insufficiency (VBI) and/or upper cervical ligament stability by following the ‘VBI and upper cervical stability protocol” on each and every occasion before practicing any cervical techniques.

Students have the right to withdraw from practicing manual therapy if they feel unsafe or have conditions that may preclude them from practicing safely, without prejudice or bias.

Students must sign a copy of the Manual Therapy Institute consent formattached acknowledging that they have read, understood and will comply with this policy.

In rare circumstances students may have an adverse reaction to a manual test or procedure. In such an event, the following policy must be followed:

The student who has the adverse reaction and/or other student’s involved will report to the lecturer the nature and extent of the problem, either at the time of the incident or as soon as is possible in the event of a delayed reaction.

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Spinal Manipulation Screening Form

Pre Manipulative Screening Record

Date:Patient Name:Student Name:

SUBJECTIVE OBJECTIVE

Y N √ box if no symptoms of VBI √

History of Trauma?Sustained End Range CervicalRotation

Previous VBI Symptoms orHistory? Pre-‐Manipulative Position in Supine

Differential diagnosis?Vestibular System

(Quick Movement of theHead)

Y N Y NDysphagia NauseaDysarthria NystagmusDrop Attacks Numbnes

s &/or Tingling of lips or

DizzinessDiplopia

SUBJECTIVE OBJECTIVEPositive Negative Positive Negative

DiscussedRisks/Benefits of manipulation Yes NoPatient questions Yes No

Informed Consent Given by Patient Yes No

Instability TestingAlar Ligaments Positive/NegativeTransverse Ligament Positive/Negative

General HealthAny musculoskeletal or general medical problem(s) or condition(s)? Yes/NoIf yes, please detail:

Student DeclarationI have undergone the above screening procedures today and agree with the findings as detailed above. I consent to the application of manipulative techniques to my spine. I have also signed the Spinal Manipulation Consent Form

Signed: ___________________________________________________________

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Spinal Manipulation Consent Form

I voluntarily consent to participate in the practice of spinal manipulative techniques during the manual therapy program taught by the Manual Therapy Institute.

I have read and understand the ‘Policy on the Practice of Manipulative Techniques’ the ‘Contraindications to Manipulation’ and the “VBI and Upper Cervical Instability Screening Protocol"

I understand that I have the right to refuse to have manipulative procedures applied to me at anytime.

Name ______________________________________________________

Signature ______________________________________________________

Date ______________________________________________________

Witness ______________________________________________________

Signature ______________________________________________________

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Joint Manipulation

The evidence

Lumbar spine

There is overwhelming evidence for the safety and efficacy of manipulation to provide short-term relief of acute low back pain. Manipulation should be utilized frequently in the management of patients with acute LBP. Unfortunately, many physical therapists appear to be reluctant to use manipulation in the treatment of patients with acute LBP despite evidence for its effectiveness.

Serious complications due to manipulation are extremely rare. Minor complications are frequent, resolve rapidly, and in the majority of the cases these complications are no different than sensory or affective phenomenon often experienced during normal daily activities. The estimated rate of occurrence of cauda equina syndrome as a complication of lumbar spinal manipulation is estimated to be on the order of less than 1 case per 100 million manipulations. To compare, it is helpful to consider the safety and complications associated with what is perhaps the most frequently prescribed treatment for acute LBP: NSAIDS.

Major side effects involve the GI tract, and 1-3% of users are thought to develop GI bleeding due to NSAID use.

Each year, 7600 deaths and 76000 hospitalizations in the US may be attributable to NSAIDS

Standard NSAID procedures produce side effects in just less than 30 % of exposed individuals, especially if used for more than 4 weeks. COX-2 inhibitors have not established a clinically meaningful safety advantage over NSAIDS.

A detailed review of the evidence also suggests that the safety and effectiveness of manipulation is not dependent on the type of practitioner, technique used, or years of experience.

Some evidence supports the use of spinal manipulation rather than mobilization. In two studies spinal manipulation was compared with spinal mobilization for patients with LBP. Superior results with the use of manipulation were found in both studies. A case control study by Fritz13 showed that patients receiving thrust manipulation had fewer treatment sessions, a shorter length of stay and lower cost in physical therapy than patients receiving non-thrust manipulation.

Since not every low back patient is a manipulation candidate, the challenge for therapists is to identify the patients with low back pain who are good candidates for spinal manipulation. In 2004 Childs et al4 developed a clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation). Its purpose was to determine the likelihood of patients responding with a 50% or greater reduction in disability following a program of spinal manipulation and exercise.

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The following five criteria were identified: Duration of current episode less than 16 days No symptoms distal to the knee Lumbar spine hypomobility at any level FABQ work subscale score <19 points Hip internal rotation with 1 or both hips having at least 35 degrees of internal

rotationWhen at least 4 of the five criteria were met: +LR = 13.2. When only 1 or 2 of the criteria were met: - LR = .10

On the flip side, there are patients for whom manipulations will be of little benefit. A longer symptom duration, presence of symptoms distal to the back, absence of hypomobility in the lumbar spine, negative SI provocation tests and reduced hip rotation ROM were more common in subjects who did not improve with manipulation. If a patient exhibits several of these signs upon evaluation, the likelihood of improvement with manipulation may be minimal. In a retrospective review of patients with occupational low back pain, the evidence supported superior clinical outcomes with the use of manipulation for a subgroup of patients12.

Cervical spine

Upper cervical manipulations should be used with caution. Use of this technique should be based upon sound clinical reasoning: a thorough physical therapy examination, an evidence-based interpretation of the clinical state and circumstances, patient preferences and actions, and the research literature. Stay away from endrange techniques, especially extension and rotation. Incorporate T spine manipulation in the treatment of C spine disorders.Patients may present for treatment of acute-onset headache or neck pain arising from a dissection in progress. Individuals with CAD may have transient ischemic signs and symptoms as warning signs in the preceding few weeks. General cardio- vascular risk factors do not appear to be associated with dissection, with the exception of diagnosed migraine. Clinicians should carefully question patients presenting with recent onset, moderate to severe, or unusual neck pain or headache about minor trauma and any signs of visual disturbance, dizziness and balance deficits, arm paresthesia, or speech deficits. Events and presentations of cervical artery dysfunction are rare, but are an important consideration as part of your assessment. Arterial dissection and other vascular presentations are fairly recognizable if the appropriate questions are asked during the patient history, if interpretation of elicited data enables recognition of this potential, and if the physical exam can be adapted to explore any vasculogenic hypothesis further.

Based on the current evidence, there is no strong foundation for the claim that there is a causal relationship between cervical manipulation and vertebral artery dissection or stroke. There is no strong empirical evidence to support the notion that upper cervical

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manipulation carries any greater risk of injury than middle or lower cervical manipulation, or that non thrust mobilization to any region of the cervical spine carries any less risk than manipulation to the same region.

The exact mechanism and risk factors for vertebral artery dissection must be considered no more than speculation at this time. The occurrence of stroke following manipulation appears to be a rare and unpredictable event. It is very difficult to definitely determine exactly which patients are at serious risk. Do not further examine or treat a patient with signs and symptoms of cervical artery disease. You cannot ignore the presence of cardinal signs and symptoms. A patient with cardinal signs and symptoms warrants a referral to a medical specialist for appropriate management.

Develop a high index of suspicion for cervical vascular pathology, particularly in cases of cervical trauma. Be aware of the limitations of current objective tests. Reliance on objective testing alone represents incomplete clinical reasoning. In cases of acute onset headache “unlike any other”, conservative treatment techniques are recommended in the early stages26.

Alternative approach to direct cervical treatment:Clinical trials have reported that thoracic spine manipulation results in improvements in perceived levels of cervical pain, ranges of motion, and disability in patients with mechanical neck pain, although the mechanism by which this occurs is not known7.

Cleland et al (2007) developed 6 predictors: Symptom duration <30 days No symptoms distal to the shoulder Looking up does not aggravate the symptoms FABQPA<12 Decreased upper thoracic kyphosis Cervical extension <30 degrees

If 3 of 6 present: 86% success rate with manipulation.

Given the concern regarding the risks associated with cervical spine manipulation, thoracic spine manipulation provides an alternative, or supplement to, cervical manipulation and mobilization to maximize the patient’s outcome with an extremely low level of risk. The current evidence suggests that during the initial treatment sessions there is a large likelihood of improved patient outcomes when thoracic manipulation is coupled with cervical active range of movement exercises. Subsequent sessions can then introduce more direct manual cervical treatments if warranted. This approach allows the therapist to observe the patient’s response to treatment over a longer time period and theoretically minimizes the risks associated with cervical manipulation in the presence of an emerging cervical vascular disorder, such as arterial dissection.

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Thoracic spineAlthough pain in this area is frequently reported, the etiology is too often enigmatic. There is only one low quality RCT study identified pertaining to the efficacy of manipulative therapy for mechanical thoracic pain. Outcomes for both pain and ROM in the manipulation group were significantly improved at the end of the initial treatment (2-3 weeks) and at the 1 month follow up. High quality RCT’s are needed to establish the efficacy of manipulation in thoracic pain. No RCT’s examining the use of ribcage manipulation in the management of thoracic spine or chest wall pain were found. The estimated rate of complication of thoracic pain or ribcage manipulation in particular is not known but is thought to be extremely low. Two studies looked at the influence of T spine manipulation on the autonomous nervous system, and its effect on UE Complex Regional Pain Syndromes. It was concluded that inclusion of T spine manipulation was beneficial in the treatment of UE CRPS30,23

Extremities

High quality evidence supports the use of manual therapy (including thrust mobilization/manipulation) and exercise as a primary intervention for the treatment of hip osteoarthritis, regardless of the severity of the arthritic changes.A randomized clinical trial by Hoeksma et al.14 compared manual therapy and exercise therapy in osteoarthritis of the hip. The manual therapy protocol consisted of joint manipulation and specific muscle stretching. It showed that the manual therapy group had significantly better outcomes in pain, stiffness, hip function, and range of motion, with effects persisting 6 months following treatment .Manual physical therapy provided better

outcomes then exercise alone for hip OA No difference was observed in the effect of manual therapy on the basis of baseline levels of hip function, pain, and ROM. Those patients with severe radiological grading of OA had significantly worse outcome on ROM. However, manual therapy in this group of patients outperformed exercise therapy in terms of pain and hip function.Manual therapy should be the treatment of first choice for all patients compared to exercise therapy. While studies of mobilization and manipulation for patients with extremity complaints are few, RCT’s have been reported for patients with complaints in all extremity regions that indicate its use may be beneficial. No complications due to manipulation and mobilization of the extremities were reported. On a last note, there is supportive evidence that impairment in 1 region may be associated with a patient’s primary complaint and impairments in a distant region. Therefore, a thorough upper or lower quadrant screening exam is indicated for patients with extremity complaints. However, a method of determining the contribution of impairments identified in distant regions to a patient’s primary complaint is unknown at this time. Therefore, clinical reasoning and judgment must guide clinical decision-making.

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The audible pop

The pop is the sound resulting from the release of nitrogen gas in the joint cavity when a sufficiently large negative pressure is created. The nitrogen is normally dissolved in the synovial fluid, but explodes out of the solution when the pressure is sufficiently reduced.When 2 joint surfaces are separated the capsule will be drawn into the joint in an attempt to maintain intracapsular volume. Should the separation increase beyond the capacity of the capsule to compensate, either fluid must enter the joint, or gas must form to accommodate the increasing volume. When we manipulate a joint, the separation of the surfaces is too rapid for fluid to diffuse into the joint. The resultant reaction is the formation of nitrogen gas bubble. It takes a few minutes up to a few hours before the gas is re-dissolved back into the synovial fluid. Until that time a second pop is not possible. In a study by Flynn10 in 2006 it was suggested that a perceived audible pop may not relate to improved outcomes from high velocity thrust manipulation for patients with non radicular low back pain at either immediate or long term follow up. It should be noted however, that the manipulation used in this study was a non-specific regional L spine manipulation, which increases the chances that the cavitation originated from a different joint than the one that was targeted.

Does spinal manipulation cavitate the targeted joint?

A study by Beffa2 in 2004 found that spinal manipulation was not associated with the targeted joint frequently enough to be of statistical difference. A study by KimRoss15 in 2004 found that in the lumbar and thoracic spine, manipulations are accurate about half the time. In the lumbar spine, the average error was at least one vertebra away from the targeted level (5.29 cm). In the thoracic spine, the average error was 3.5 cm, so for this region, manipulation appears to be more accurate. Most procedures were also associated with multiple cavitations. Whenever this happened, in most cases cavitation emanated from the targeted level as well

Mechanisms of joint manipulation

A better understanding of the mechanisms of manipulation is necessary for several reasons. First, recent evidence suggests successful outcomes with joint manipulations are dependent on identifying individuals likely to respond rather than identification of a specific lesion. Subsequently, clinical prediction rules based on clusters of signs and symptoms have been proposed to identify responders. While helpful in directing clinical practice, an explanation is lacking as to why such patterns of signs and symptoms predicts successful clinical outcomes. An understanding of the mechanisms behind joint manipulation could assist in the identification of individuals likely to respond to joint manipulation.

A second benefit of the identification of joint manipulation mechanisms is the potential for increased acceptance of these techniques by health care providers. Despite the literature supporting the effectiveness of joint manipulation in specific musculoskeletal conditions, health care practitioners at times provide or refer for joint manipulation at a

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lower than expected rate. The lack of an identifiable mechanism of action for joint manipulation may limit the acceptability of these techniques as they may be viewed as less scientific. Knowledge of mechanisms may promote more appropriate use of joint manipulation by healthcare providers.

Joint manipulation likely works through biomechanical and/or neurophysiological mechanisms. A limitation of the current literature is the failure to acknowledge the potential for a combined effect of these mechanisms. Collectively, the literature suggests a biomechanical effect of joint manipulation; however, lasting structural changes have not been identified, clinicians are unable to reliably identify areas requiring joint manipulation, choice of technique does not seem to affect outcomes, and sign and symptom responses occur in areas separate from the region of application. The effectiveness of joint manipulation, despite the inconsistencies associated with a purported biomechanical mechanism, suggests that additional mechanisms may be at work. It is suggested that a mechanical force from joint manipulation initiates a cascade of neurophysiological responses from the peripheral and central nervous system, which are then responsible for the clinical outcomes.

Spinal manipulation has been shown to have an immediate effect on muscle activation by way of an increase in strength of muscles under study. Specifically, spinal manipulation has been shown to have an immediate effect of increased strength of the quadriceps muscle, lumbar paraspinal muscles, cervical flexor muscles and the cervical extensor muscles. Spinal manipulation has also been shown to have an immediate effect on the inhibition of tight muscles, resulting in increased muscle flexibility. Increased flexibility, following lumbar spine manipulation, has been shown with the hamstring muscle and the knee extensor muscles. Last, spinal manipulation has been shown to have the immediate effect of activation of muscles that function to stabilize the lumbar spine.

Spinal manipulation also has an effect on the levels of inflammatory chemokines in acute and chronic back pain. Chemokines are inducers of inflammation, play a rolein communication between inflammatory cells and neurons, and contribute to pain transmission. The production of inflammatory mediators has been shown to be upregulated in patients with cervical spine pain. Compared with asymptomatic controls baseline production of all chemokines was significantly elevated in acute, and chronic LBP patients. Following spine manipulation, patient reported outcomes showed significant improvements in visual analog scale and Oswestry Disability Index scores. This was accompanied by a significant decline in chemokine production in both groups of patients. Thus, decrease of their production following spinal manipulation may alter expression and/or sensitivity of chemokine receptors in the treated patients33.

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Mechanical: stretching or rupturing of intra articular adhesions, release of meniscoid inclusions, restore positional faults.

Neurological1. Activation of type III mechanoreceptors, resulting in reflex relaxation of

hypertone muscles2. Increasing activity in proprioceptors3. Adjustment of nociceptor receptor pattern4. Reduced overall central sensitization 5. Effects on autonomous nervous system

Psychological. The pop and the laying on of hands can be an effective psychological event. The psychological effects are not the reason why we use manipulation, but it must be considered.

Contra indicationsThere are a number of contraindications to the use of manipulative techniques. Some are absolute contraindications; others can be considered cautions. With respect to cautions the physical therapist, after careful consideration of a specific patient’s situation, may decide that a mobilization or manipulative thrust is an appropriate and safe technique to use on that patient, on that day. Such a decision is influenced by a number of factors including the treating physical therapist’s knowledge, skill and experience, the choice of technique (and grade) and general health of the patient.

Contra indications Fracture Ligament rupture No working hypothesis Multi level nerve root pathology Worsening neurological function Unremitting, severe non mechanical pain Unremitting night pain (preventing patient from falling asleep) Empty endfeel and severe multidirectional spasm, which can be the result of

various serious pathologic findings Upper motor neuron lesions

Cautions Disc herniation Anything that can weaken bone: local infection, osteoporosis, neoplasm Pharmacology: steroidal drugs, anti coagulants, drugs you don’t know Pregnancy. Risk of ligamentous damage due to relaxin effect and risk of

coinciding with miscarriage Inflammatory disease Systemically unwell Patient unable to relax Physique Undiagnosed pain

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Lack of patient consent When you sense that the joint will not ‘give’ Adverse reactions to previous manual therapy Disc herniation/prolapse Pain with psychological overlay When spinal movements and /or palpation reproduces distal symptoms Chronic pain and Fibromyalgia- type syndromes. Inadequate signs to explain the

patient’s widespread symptoms, long-term dependency without much hope of benefit.

Emotionally dependent patients. Desire manipulation, long term dependency without much hope of benefit

Pediatric population

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Cervical spine joint manipulation for the pediatric populationThe question: at what age is it safe to manipulate a cervical spine? Guidelines for now are based on pathoanatomic- and developmental features.

Anatomical considerationsUntil the ossification centers in the upper cervical spine have completely fused, it would not be wise to manipulate. The odontoid apex does not completely fuse until 12 years of age. This means that stability provided by transverse and alar ligaments is not optimal until that time.

Biomechanical considerations

Upper cervical spineOcciput-C1 is vulnerable to injury in young children for the following reasons:

The occipital condyles are smaller The O-A articulation is shallower in the sagittal plane and horizontal in the

coronal plane (planar articulation vs. more cup like) Stabilizing ligaments and muscles are more elastic and less developed Large head and short neck place fulcrum of flexion at Occiput-C2 complex Odontoid synchondrosis is susceptible to translational forces

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Mid/low cervical spineThe mid/low cervical spine tends to be more hypermobile in the pediatric population for the following reasons:

Facet joints are biased towards the axial plane (horizontal) and are shallower Immature vertebral bodies are shorter anterior (wedge shape) The disc is expansible along the longitudinal axis, allowing more distraction Absence of uncinate processes when < 10 yrs of age Joint capsules and ligaments more elastic Disproportionate large head

SummaryConsidering all the anatomical and biomechanical factors in the pediatric population, the following guidelines are appropriate when it comes to the clinical decision making:

1. No cervical manipulations until all the ossification centers in the cervical spine are fused.

2. Consider the change in facet joint inclination when mobilizing/manipulating the pediatric cervical spine

3. Use the minimal force necessary if you decide to manipulate, as the disc, ligaments and joint capsule are significantly more flexible in the pediatric population.

As further research evolves, more will be added, especially in the area of determining if the diagnostic process has been adequately performed prior to this patient walking into your clinic. All of which will be related to age, diagnostics performed, MOI, and established clearance protocols29.

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References

1. Rubinstein S, Terwee C, Assendelft W, deBoer M and van Tulder M. Spinal Manipulative Therapy for Acute Low Back Pain. An update of the Cochrane Review. Spine. 2013;(38) 3:158-177

2. Beffa R and Mathews R. Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds. J of Man and Phys Ther. 2004;27(2)

3. Bourdillon JF, Day EA, Bookhout MR. Spinal manipulation 5th edition, 1992 Butterworth-Heinemann, Oxford

4. Childs, J. et. al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Int Med.2004;141(12)

5. Childs, J. et al. Clinical decision making in the identification of patients likely to benefit from spinal manipulation: a traditional versus an evidence based approach. JOSPT. 2003;33(5)

6. Cleland, J and Childs J. (2005) Does the manual therapy technique matter? Clinical commentary. Evidence in Motion

7. Cleland, J. et al. Short term response of thoracic spine thrust versus non thrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. 2007. Phys Ther; 4

8. Dunning J et al. Upper cervical and upper thoracic thrust manipulation versus non thrust mobilization in patients with mechanical neck pain: a randomized clinical trial (2012) JOSPT (42)1: 5-18

9. Orthopaedic Physical Therapy Clinics of North America. ManipulationRichard E. Erhardt, DC, PT Guest Editor. Saunders, 1998

10. Flynn, T. et al. The audible pop from high velocity thrust manipulation and outcome in individuals with low back pain. J of Man and Phys Ther. 2006;29 (1):40-45

11. Fransen M, McConnell S, Bell M. Therapeutic exercise for people with osteoarthritis of the hip or knee. 2003; Cochrane Database Syst Rev.

12. Fritz J, et al. Factors related to the inability of individuals with low back pain to improve with a spinal manipulation. Phys Ther. 2004; 84 (2)

13. Fritz JM, Brennan GP, Leaman H. Does the evidence for spinal manipulation translate into better outcomes in routine clinical care for patients with occupational low back pain? A case control study. Spine 2006

14. Hoeksma HL, Dekker J, Ronday HK et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004;51(5):722-729

15. Kim Ross J. Bereznick D, McGill S. (2004). Determining the cavitation location during lumbar and thoracic spine manipulation. Spine 2004;29(13):1452-1457

16. Thiel, H. and Rix, G. Is it time to stop functional pre-manipulation testing of the cervical spine? Manual Therapy 2005

17. Meade TW, Dyer S, Browne W (1990) Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ. 300:1431–1437

18. Bialosky J et al.The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man. Ther. 2009;14(5): 532-538

19. Dunning, J et al. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. JOSPT 2012;42 (1)

20. Lalanne K, Lafond D, Descarreaux M. Modulation of the flexion-relaxation response by spinal manipulative therapy: a control group study. J of Man and Phys Ther. 2009;3(32):203-9.

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21. Keller TS, Colloca CJ. Mechanical force spinal manipulation increases trunk muscle strength assessed by electromyography: a comparative clinical trial. J of Man and Phys Ther. 2000;23(9):585-95

22. Jull GA, O’Leary SP, Falla D. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. J of Man and Phys Ther. 2008;31(7):525-33.

23. Sillevis R, Cleland J, Hellman M, Beekhuizen K. Immediate effects of a thoracic spine thrust manipulation on the autonomic nervous system: a randomized clinical trial. JMMT 2010; 18 (4):181-190

24. Sterling M, Jull G, Wright A. Cervical mobilization: concurrent effects on pain, motor function and sympathic nervous system activity. Man Ther.2001;6:72-81.

25. Suter E. McMorland G. Herzog W, Bray R. Conservative lower back treatment reduces inhibition in knee-extensor muscles: a randomized controlled trial. J of Man and Phys Ther. 2000;23(2):76-80.

26. Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, and Kerry R. (2012) International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention. IFOMPT consensus document

27. Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic non specific low back pain: a systematic review of randomized controlled trials. Spine. 1997; 22; 2128-2156

28. Puentedura E et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. JOSPT .2012;42 (7)

29. Jurica P and Boucher B. Manual therapy for the cervical spine in the pediatric population: what do we need to know? AAOMPT conference 2013, Cincinnati. Breakout session. Unpublished.

30. Menck J, Requejo S and Kulig K. Thoracic Spine Dysfunction in Upper Extremity Complex Regional Pain Syndrome Type I. JOSPT.2000;30(7):401-409

31. Thomas L, Rivett D, Attia H and Levi C. Risk factors and clinical presence of cervical arterial dissection: preliminary results of a prospective case control study. JOSPT.2015;45(7)

32. Teodorczyk-Ineyan J, McGregor M, Triano J and Injeyan S. Elevated production of nociceptive CC chemokines and sE Selectin in patients with low back pain and the effects of spinal manipulation. Clin J Pain. 2018 ;34 (1)

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General rules for manipulation Source: Laurie Hartman

Your posture while doing a manipulation will make or break the technique. Proper posture helps to control:

Depth of force Direction of the technique Amplitude of the levers Power of the procedure Ability to focus forces to specific target site

This will produce a more efficient technique and will result in less fatigue on your body

Keep your knees slightly flexedThis will sharpen the impact. There will be less flexion in your spine. Subtle changes in direction can be easily accommodated

Keep your head upThis keeps the spine straight. More force can be directed to the patient. It avoids too close proximity. It brings the elbows close to your sides for improved control.

Move your hips with your hands followingHands follow, which allows you to maintain local control. Easier acceleration. Hands are less uncomfortable for the patient when you hold them steady. Proprioceptive palpation with operator body

Keep your center of gravity lowBetter balance. Easier to accommodate changes in direction. Better transmission of force

Try and visualize the procedureHow is your posture. Are you using max efficiency. Do you understand the principle of the procedure. What would your posture look like in the mirror.

Keep the objective in mindAre you struggling with the wrong aspects?Is control of the structures a problem?Is another way better?

Play with the tissuesConstructive fiddling with the tissues is often helpful to find the optimal direction/path for the manipulation. Keep it moving. If you hold the patient still, you only have a 2 second window to perform the technique.

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Mini thrustsPrepare the tissues for the final thrust. If you don’t use the mini thrusts, you only have about 25% chance of a successful technique. Tissue anger warns you off. Barriers often ease without a more major method. The motion barrier often amplifies with mini thrusts.

In the thrust techniqueUsually one leg forward, one backThrusting hand on the side of the rear legExtension of the therapist’s spineBrief isometric contraction of abdomen

Technique breakdown Component technique: use of secondary components to minimize the amplitude of the primary component

Focusing (isolate) to the segmentFocus to the joint using one or more vectors of compression, creating local tissue tensionBuild the barrier. Once you have identified the barrier, back off a littleUse posture for security and effectivenessWhen ready, focus your forces, and engage the barrierHold the secondary components to maintain the barrier and amplify only the primary lever direction

How can we focus without locking?Use several componentsControl the part being worked accuratelyDirect forces according to anatomical principlesBe highly aware of palpatory cuesLearn how tissues respond to varied forcesKeep an open mind to the varied possibilities

Basic routine to build barrier using multiple componentsFocus to the segmentTest the primary lever amplitude at the segmentAdd some of the 1st chosen secondary leverRetest the primary lever:If the endfeel is not good, add some of the 2nd chosen secondary leverRetest the primary leverIf the endfeel is still not good:Add some of the 3rd chosen secondary leverRetest the primary lever amplitudeAt optimum barrier point, thrust in primary lever - without losing the other components

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Mid thoracic manipulation, bilateralPatient supine. Use flat hand. Components: flex up to the level, rotate away, sidebend towards, compress with your bodyweight, compress with caudal arm towards your body. With your flat hand on the T spine, you counteract every motion you make on the top side. Pick up the slack 3 times in posterior/cranial direction. Apply thrust in posterior/cranial direction.

Mid thoracic manipulationProne, rotatory, on same vertebraPatient prone. Stand on side of prominent TP. Manipulator dip of caudal hand on prominent TP. Manipulator dip of cranial hand on opposite TP (same level!). Screw home to where the fingers of the cranial hand point caudally and the fingers of the caudal hand point cranially. Thrust with caudal hand in cranial/ anterior direction and with the other hand in caudal direction.

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Mid thoracic manipulationProne, cranial/ anterior thrust

Patient prone. Stand on side of prominent TP. Stabilize lower level with manipulator dip of cranial hand. Manipulator dip of caudal hand is on prominent TP, fingers pointing cranially. Thrust in cranial/anterior direction.

Mid thoracic manipulationTraction, sitting

Involved segment is stabilized with wedge or towel roll. Therapist around patient’s folded arms. Thrust cranially by extending the knees.

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Upper thoracic (T1 - T3) manipulationTherapist makes collapsible fist with hand. Localize to segment. Primary lever of this technique is posterior. Components: pull hand on upper back in caudal direction, while the forearm on patient’s elbows simultaneously moves in cranial direction; compress down; rotate away; sidebend towards; compress the right elbow towards yourself. Thrust in posterior and cranial direction.

CT manipulationDistraction, seated

Patient sitting. Interlace fingers behind neck. Lean patient backwards against chest. Flex head down to level. Therapist squeezes arms against ribcage. Thrust in cranial direction. Make sure not to flex the neck when thrusting.

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CT manipulationSitting, down and backPatient leans back against therapist. Sidebend head towards, rotate away, just enough for the occiput to stick out. Base of left hand is placed under occiput. Thumb of right hand is placed lateral of spinous process of involved segment. Main thrust comes from right hand, down and back, towards opposite hip. Minor thrust with left hand cranially.

Manipulation 1st rib

Patient sitting. Cradle the head. Sidebend head to involved side. Put webspace between thumb and index finger on 1st rib. Thrust in caudal direction upon exhalation.

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Manipulation 3rd rib

Patient prone. Therapist at head of table. Manipulator dip on rib angle 3rd rib. Other hand stabilizes TP on opposite side. Thrust in caudal/anterior direction.

Rib manipulation, ribs 4 - 9Supine, “gun” position

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Patient supine. Use “gun” grip. The indexfinger is placed parallel to the involved rib with the tip of the finger in the interspinous space. The rib angle of the involved rib is placed between index and middle finger. Flex up to the level, then in one smooth movement, roll patient over the involved rib, thrust A-P.

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Manipulation ribs 4-9, prone

Pt prone. Caudal hand stabilizes vertebra. Pisiform of cranial hand is placed on the rib angle of the involved rib. The thrust is with the cranial hand on the rib, in a anterior, somewhat caudal direction.

References1. Hartman L. (1997) Handbook of osteopathic technique, 3rd edition. Cengage

Learning, Hampshire UK.2. Hartman L (1997) DVD Series of Handbook of Osteopathic Technique3. Herbert, D. (2015) Joint Manipulations DVD Series

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