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Pain is a big deal, just ask anyone who has it or treats it. There are as many theories about pain, chronicity, and interventions as there are people who have it.
Interestingly enough, I found myself in a platform presentation at CSM on this very topic. I’m sure some of the information presented is old news to those who study pain, but I found it extremely interesting and clinically relevant.
Several researchers from the University of Florida continue to look at possible mechanisms for effectiveness of spinal manipulation performed by Physical Therapists. Steven George (I must mention he is an alum of West Virginia University), Mark Bishop, Joel Bialosky, and others have focused in on a possible dorsal horn mediated mechanism.
Without getting into the neuroanatomy and physiology too deep, this mechanism basically says that manipulation causes an inhibition of some nerve fiber input that carries pain information. This creates a hypoalgesic response that appears to be a local phenomenon.
I’ll be reading more deeply into the proposed neurophysiological mechanisms and will pass along information as I gather it. For now, here are two articles that discuss this topic – take a peek.
George et al. Immediate effects of spinal manipulation on thermal pain sensitivity: an experimental study. BMC Musculoskeletal Disorders. 2006; 7:68
Bialosky et al. The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects. BMC Musculoskeletal Disorders. 2008; 9:19.
In a previous post I mentioned attending CSM in Nashville this past weekend. I forgot to mention the great book I purchased from OPTP.
Orthopedic Physical Examination Tests: An Evidence-Based Approach by Dr. Chad Cook and Dr. Eric Hegedus is a great text book and reference for students, clinicians, and educators. This text (available on Amazon for around $50 – see link above) seeks to describe the usefulness and scientific evidence for many of the special tests we use as Physical Therapists. It offers specificity and sensitivity data for each test and determines a usefulness score based on the quality of the studies that have supported the given test. This will lead to high quality and more efficient exams for sure.
I also have the Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical Therapists book by Dr. Josh Cleland. Like the book by Cook and Hegedus, this book helps clinicans determine the best tests for screening by Physical Therapists.
These two books are must-have’s for all clinicians who want to offer the highest quality care through best practice.
Another article seeking to develop a clinical prediction rule (CPR) has been accepted for publication in the Journal of Orthopaedic and Sports Physical Therapy (JOSPT). Iverson et al found five predictors of success with lumbopelvic manipulation:
1. Difference in hip internal rotation (> 14 degrees)
2. Ankle dorsiflexion with knee flexed (>16 degrees)
3. Navicular drop > 3mm
4. No stiffness with sitting > 20 minutes
5. Squatting is the most painful activity
Pre-test probability of success with manipulation was 45%.
If a hip internal rotation difference of greater than 14 degrees was present, the likelihood of success with manipulation increased to 80%!
If any three of the five factors above were present, likelihood of success improved to 94%.
Keep in mind this is a study performed on 50 subjects with detailed criteria for inclusion. Validation studies will have to be performed, but think of this…
If I told you that from your clinical exam, the likelihood that you would experience a 50% decrease in your knee pain if I performed a lumbopelvic manipulation was 94% – would you want that treatment?
Practice standardization is the future of our profession – get on board.