Manual Therapy… Why the Apprehension?

According to a survey of 813 british physical therapists conducted by Foster et al, Only 58.9% Physical therapists utilize spinal mobilization (Grade I – IV) and only 2.8% use spinal manipulative therapy (Grade V) when treating patients suffering from low back pain (LBP). Additionally, a survey of 274 canadian physical therapists published by Li et al found that when treating a patient with acute LBP, only 44.4% of therapists utilized spinal mobilization and only 5.0% used spinal manipulation. In the same study, utilization of mobilization and manipulation actually increased when treating a patient in the sub-acute stage at 83.7% and 9.0%, respectively. This finding is especially concerning since one of the variables of the spinal manipulation clinical prediction rule (CPR) is an onset of < 16 days. So, we as a profession are unwilling to perform manual therapy on those individuals that could benefit most. This practice pattern may be because of our apprehension in using such an ‘invasive’ technique on patients that are in such acute distress. However, if the patient is properly screened and is appropriate for manual therapy, the benefits of following through with the treatment will far outweigh the patient’s initial discomfort.

In my experience, this has been the trend that I have seen in the clinic. Honestly, prior to beginning PT school, I had no idea that manual or manipulative therapy was within a physical therapist’s scope of practice. I had the opportunity to work with many talented and experienced therapists throughout my own rehabilitation and during my required ‘observation hours’ and never once did I see anything that resembled manual therapy. So I ask, why are there so many therapists that refuse to utilize such an effective treatment option?

Is it a lack of quality evidence?

When discussing the application of manual therapy to LBP, I find it hard to believe that a lack of evidence is the problem. Erhard et al conducted a small randomized controlled trial (RCT) investigating the effectivness of exercise based on directional preference versus manual therapy. The treatment group was treated with a supine lumbopelvic roll and the hand-heel rock exercise, while the exercise group was treated with an extension-oriented program similar to that proposed by McKenzie. The results showed that 9/12 patients in the manipulation group were discharged at 1 week, while only 2/12 were discharged from the extension-only group. Discharge from PT was determined by obtaining a score of < 11 on the Oswestry Disability Index (ODI). While this study had a small sample size and lacked adequate follow-up data, it did show an increase in positive outcomes when manual therapy was included in a patient’s treatment plan.

In 2002, Flynn et al developed a CPR for the use of spinal manipulation, which was later validated by Childs et al in 2004. The Flynn prospective cohort study showed that when a patient met the CPR and was subsequently treated with manipulative therapy, their likelihood of success increased from 45% to 95%. According to the Childs randomized controlled trial, when a patient met this CPR and was subsequently treated with the supine lumbopelvic roll and lumbar ROM exercises, 44.3% (31/70) achieved success after 1 week versus only 11.5% (7/61) in the exercise-only group. After 4 weeks, 62.9% (44/70) had achieved success, while only 36.1% (22/61) had achieved this same success in the exercise group. Additionally, at the 6 month follow-up, 27.8% of patients in the matched manipulation group were taking pain medication for their back compared to 43.8% in the exercise group. Even patients that did not meet the CPR and were treated with manual therapy used less pain medication as a group (41.2% v. 70.8%). These studies not only showed the benefit of manual therapy, but also gave clinicians an additional tool in identifying patients who would respond favorably. Also, when comparing ODI scores at 6 months post-treatment, the manipulation groups are still superior to the exercise groups. One of the most common arguments against spinal manipulation is that it is a short-term fix with no long-term effects. This study seems to contradict these beliefs.

Cleland et al also investigated the efficacy of manual therapy when applying the Spinal Manipulation CPR. In this case series, 12 patients who satisfied the CPR were treated with the sidelying lumbar roll. After just 2 treatments, 11/12 (91.7%) patients had at least a 50% reduction in the ODI. This study shows continued support for this treatment approach as well as evidence that more than one manual therapy technique can be applied.

Evidence for the efficacy of manual therapy does not stop at the lumbopelvic region. There is also evidence to support its use for neck pain, tension headaches, shoulder impingement, knee osteoarthritis, hip osteoarthritis, and many other diagnoses.

Is it because manual therapy can cause harm to our patients?

According to a systematic review by Assendelft et al, the incidence of serious complications, such as cauda equina syndrome, due to spinal manipulation is < 1/1,000,000. While complications due to cervical manipulation was found to be slightly more prevalent at ~ 1/1,000,000, it was still minuscule when compared to the complication rates of NSAIDs, spinal surgery, or even vigorous exercise.

So, what is it that stops us from using the best evidence to treat our patients? It could be a lack of emphasis on manual therapy and EBP in many PT programs, especially for those therapists who graduated before this material began to emerge in physical therapy curriculums. Even though this material may not have been taught to some of us, it is our responsibility as healthcare professionals to provide the highest quality of care. To achieve this level of care it is necessary to step outside of our clinical practice patterns and implement new treatments when they are applicable. Also, our profession has such a negative perception of the chiropractic profession that I believe this negativity spills into our understanding of their primary intervention. If you ask the general population where they go to be treated for LBP or neck pain almost every individual would respond, “my chiropractor”. This is in part due to their superior marketing and autonomy, but it also has to do with the interventions they use to treat these patients. While I do not agree with how many DCs market themselves or some of the treatment strategies they employ, this is one aspect that I do agree with (even if it is over utilized). Change is a difficult process when you have been treating patients a certain way your entire career, but if it improves your patient outcomes, why not try?

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10 thoughts on “Manual Therapy… Why the Apprehension?

  1. While I agree with you conceptually on the topic of under-utilization of spinal mobilization / manipulation, I think that too much emphasis is being placed on the CPR studies. There are some flaws in the research design which decrease the clinical relevance of these studies as I see them. Flynn et al, describe a series of up to 4 manipulations occurring during a single treatment, until an audible is achieved. As a PT trained in spinal manipulation, I always understood that once the grade V force was applied, then the manip was complete. An audible was not required to achieve a manip, and I can not think of a good reason to do a series of 4 manips on a single patient in one sitting. Manips were also performed both directions of lumbar rotation, which raises some clinical questions as well. Technique selection should raise some eyebrows of experienced manual therapists as well. An SI regional manipulation is one that I would never perform given the options of that vs. a side-lying lumbar rotation manipulation. This CPR also takes no consideration of someone with red-flags for cancer / infection ect. Would you perform a manip on someone with a temp of 103, night sweats, hx. of CA, and acute LBP? The CPR would indicate yes…

    As you can see, there are several questions that can be raised regarding these studies. Overall I do believe that manual therapy is under utilized, but lets not suggest that protocol driven therapy is the way to go either. Clinical reasoning based on evidence and foundations of the scientific method will result in positive experiences for patients.

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  2. Joe,
    Thank you for your comment. The purpose of this blog post was not to promote sole utilization of the CPR, it was to show the efficacy of manual therapy in general to those who are weary. I completely agree that the CPR is not all inclusive, it is simply another tool in the well informed PT’s toolbox. Also, contraindications are always contraindications regardless of the technique, strategy, or philosophy. So, no, I am not inferring that these should be ignored in leu of the CPR. The exclusion criteria for Flynn et al, “Exclusion criteria were current pregnancy, signs consistent with nerve root compression (positive straight-leg raise at <45°, or diminished lower extremity strength, sensation, or reflexes), prior lumbar spine surgery, or a history of osteoporosis or spinal fracture." I would assume that all patients who presented with aforementioned contraindications would be excluded as well and therefore excluded from proper application of the CPR.

    As for the multiple manipulation protocol, it was just that, a protocol. There are always going to be inefficiencies when conducting a RCT or any other large-scale study. I think it can be assumed that this was applied to the study in order to provide consistency in treatment, not because they want everyone to be manipulated until cavitation.

    Thanks again for your comment!

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  3. Jerry,
    I agree there are many different manual interventions that are beneficial for different diagnoses. I definitely implement creep and low load long duration stretching into my treatments as I see fit. Thank you for your comment and I found your website very informative and easy to navigate.

    Thanks!

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  4. Great post. I agree I haven’t seen a ton of PTs use manips, or even mobs. It seems like the ones that do are either recently trained therapists, or PTs who are clearly dedicated to life-long learning/teaching. It’s great that new PTs are being taught mobs/manips, but in my limited experience, I don’t think I practiced enough in PT school. I’m a new PT and I don’t feel extremely comfortable or knowledgeable in applying these techniques. I know their benefit, but my hands don’t feel it yet. I think this will improve with the right con ed classes and focused practice, but not everyone has this drive/vision. Keep posting and educating others, and hopefully our colleagues will start implementing the evidence.

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