Should We Try to Be Specific With Spinal Manipulation?

Many studies have shown the benefits of manipulation in improving muscle performance, mobility, and, of course, pain. What can be more difficult is determining the appropriate time or place for manipulation. Most manual therapy schools of thought teach their students they can manipulate specific segments and that it makes a difference. When looking at the research, support is lacking on both accounts. Studies have shown that during manipulation, cavitation can occur up to 9.5 cm above or below the "targeted" segment and that non-specific manipulation is just as effective as specific manipulation (Ross et al, 2004) (de Oliveira et al, 2013).

How can it be that a non-specific manipulation is just as effective as a specific? Well the biomechanical theory of manipulation appears unlikely due to the amount of force required for collagen deformation. It seems more likely that the effects of manipulation are neurophysiological in nature. The stimulus to the nervous system may impact the tone of muscles around the various joints allowing improvements in mobility. Could that be possible? It's a theory as to why the non-specific effects can be seen, but I'm uncertain if it's possible to test. Some specific examples could be the improvements in cervical pain from thoracic manipulation (Huisman et al, 2013). While altered mechanics have been suggested, little support has been shown in research. Now, I could comment on the weaknesses of the studies shown as there are always confounding variables that cannot be controlled, but there is little benefit in focusing on that discussion, due to the difficult nature in demonstrating the mechanism of neurological changes.

With all that being said, I do still believe there is benefit in trying to be specific with manipulation. I, personally and clinically, have experienced many scenarios where a general manipulation helped, but was not as helpful as targeting a specific area. There may just be a stiff area of the spine that needs the proper stimulus of increased mobility. Secondly, I believe we become much more effective with our manipulations if we try to increase our specificity. I have sat in on classes where the instructors emphasized the lack of importance in trying to be specific. The instructions were basically to wind up the patient using long levers and thrust. It is far more difficult to perform a manipulation that way, in my opinion. If you try and "target" a segment and lock them out above and below, sensing for movement at the vertebra, you typically allow the patient to relax more, which permits a more effective thrust. Again I'm not saying that we can actually manipulate that one segment, but I think we can narrow our range of force and provide more effective manipulations by allowing the patient to relax properly.

-Chris

References:

Huisman PA1, Speksnijder CM, de Wijer A. (2013). The effect of thoracic spine manipulation on pain and disability in patients with non-specific neck pain: a systematic review. Disabil Rehabil. 2013 Sep;35(20):1677-85.

de Oliveira RF1, Liebano RE, Costa Lda C, Rissato LL, Costa LO. (2013). Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Phys Ther. 2013 Jun;93(6):748-56.

Ross JK1, Bereznick DE, McGill SM. (2004). Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine (Phila Pa 1976). 2004 Jul 1;29(13):1452-7.

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You may have seen some posts earlier on our site about OPTIM Physical Therapy. Several months ago, Chris and Jim joined OPTIM Physical Therapy to create a COMT program based out of Scottsdale, AZ. The mission of the program is to create a residency-like experience for those who are unable to make the financial and location commitment. The program consists of 6 weekend-long courses on-site, in addition to Medbridge courses and online mentoring between classes. Throughout the year, the class as a whole will improve their clinical skills and reasoning while working as a team. Check out www.optimfellowship.com for more information. Only a few spots remain for the year's cohort!

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