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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.

As I mentioned in another post, the autonomy of Physical Therapists is under heavy attack from those practitioners who desire to fill their own pockets and disguise it as quality care.  Yes, chiropractors fit in this group.

 For years, chiros have spread mystical theories about vertebral subluxation and how the minor changes in alignment can cause all the world’s problems.  By cracking your neck or back, they can cure all your pain, organ diseases, and my personal favorite – childhood bed wetting.  Patients walk into their offices, are exposed to unnecessary radiation, then told that it will take 85 visits to fix their problems. 

Chiros even offer a little “physical therapy” too!  WAIT – only licensed PT’s can do real Physical Therapy.  Not according to chiros.  They claim they are trained to provide rehabilitation.  That’s a laugher.  Most chiros offer some nutritional supplements, some e-stim, maybe heat and ultrasound.  This is Physical Therapy?  Of course not, see the previous posts here.

 So what’s the difference?  Despite the effectiveness of spinal manipulation in some subgroups of patients, it is not the treatment for EVERY problem.  Electrical stimulation, ultrasound, and a hot pack aren’t either.  Physical Therapists are trained to provide manipulation to patients.  In fact, it’s Physical Therapists who are putting out the research to identify the patients who are likely to benefit from thrust manipulation – funny that chiros aren’t leading the push huh?  We (PT’s) also provide thorough therapeutic exercise to ensure you don’t have to come see us 85 times to get better.

 Let me end with this, chiropractors hang their hat on the bogus theories of vertebral subluxation when the evidence clearly shows otherwise.  They survive on one treatment (spinal manipulation) that they believe NO ONE but chiros should perform.  There are many professionals that have been performing spinal manipulation for a long time and doing it well.  More and more, it looks like Physical Therapists are able to combine quality therapeutic exercise with manual techniques such as manipulation to provide the BEST care for many musculoskeletal problems.  Remember, only licensed PT’s provide Physical Therapy and chiropractors aren’t the only providers skilled and trained to perform spinal manipulation.

In this, the third post of the “Low Back Pain and You” series, we will discuss evidence-based interventions provided by Physical Therapists.  Hopefully, you will see why we should be the first person you see for your back pain and learn what to expect from you Physical Therapist.

Classification and Clinical Prediction Rules (CPR)

As we’ve discussed before, not all back pain is created equal.  So, why do many practitioners continue to treat every case of LBP with the same advice and the same medication?

Fortunately, Physical Therapists have developed a classification system that matches patients with appropriate and effective treatments.  The treatment-based classification system (Delitto et al, 1995) consists of categories based on the response of the patient to active motion.  These groups include active exercise with directional preference, traction, mobilization/manipulation, and stabilization.  In clinical studies, the TBC system has been shown to result in better outcomes than therapy based on clinical practice guidelines. (Fritz et al, 2003) 

More recently, Physical Therapists have developed clinical prediction rules to further identify patients who are most likely to benefit from certain treatments.  There are two clinical prediction rules related to low back pain.  These include the lumbar stabilization CPR (Hicks et al, 2005)and the manipulation CPR (Flynn et al, 2002).  Studies show significant improvements in patients who meet the clinical prediction rules and are treated with matched interventions.

Patients most likely to benefit from spinal stabilization exercises (74-97%  improvement in probability of success if patient fits 3 or more of the following):

  • Younger than 40 years old
  • Straight leg raise > 90 degrees
  • Positive prone instability test
  • Aberrant movement patterns
  • FABQ physical activity subscale < 9

Patients most likely to benefit from spinal manipulation ( presence of 4/5 resulted in an increased likelihood of success to 95%)

  • Duration of symptoms < 16 days
  • FABQ work subscale < 19
  • No symptoms below the knee
  • At least one hip with internal rotation motion > 35 degrees
  • At least one hypomobile lumbar segment

What does all this mean to you as a patient?  If your therapist is treating all back pain the same – find a new therapist.  Modalities such as hot packs, electrical stimulation, and ultrasound have been shown to provide little or no benefit in the treatment of low back pain.  Ask your Physical Therapist if they use classification systems or clinical prediction rules. 

To find a quality Physical Therapist in your area, click HERE

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