Cleland JA, Childs JD. Does the Manual Therapy Technique Matter? Invited Commentary. Orthopaedic Division Review. 2005. September/October;27-28.

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Does the Manual Therapy Technique Matter? Joshua A. Cleland, DPT, OCS Assistant Professor, Physical Therapy Program, Franklin Pierce College, Concord, NH and Physical Therapist, Rehabilitation Services of Concord Hospital, Concord, NH John D. Childs, PT, PhD, MBA, OCS, FAAOMPT Assistant Professor and Director of Research, US Army-Baylor University Doctoral Program in Physical Therapy

Decision-making related to manual therapy interventions has traditionally been

based on biomechanical theoretical constructs.1 Most approaches generally

advocate that the practitioner should accurately identify a segmental dysfunction

based on the assessment of intersegmental motion or alignment, towards which

a specific manual therapy intervention is then directed to ameliorate the

underlying dysfunction. Presumably, these dysfunctions are associated with the

patient’s experience of pain and disability, hence a failure to adequately address

them are thought to interfere with recovery.

While the evidence for the effectiveness of manual therapy techniques continues

to expand, mounting evidence has emerged challenging the usefulness of the

biomechanical model. First, the physical examinations procedures commonly

used to identify biomechanical dysfunctions presumably amenable to manual

therapy interventions have almost universally been shown in multiple studies to

be unreliable2-6 and lack validity for their use.7,8 Even presuming biomechanical

dysfunctions can be identified, recent evidence has emerged suggesting that

manual therapy practitioners are unable to accurately localize manipulative

techniques to a specific segment.9-12 The purpose of this brief commentary is to

review recent evidence related to the specificity of manual therapy interventions.

Recent in vivo dynamic MRIs studies have investigated spinal kinematics during

posteroanterior (PA) mobilization in both the lumbar9 and cervical10 spine. Kulig

et al9 demonstrated that when a PA Grade IV13 force was directed at any

Cleland JA, Childs JD. Does the Manual Therapy Technique Matter? Invited Commentary. Orthopaedic Division Review. 2005. September/October;27-28.

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segment in the lumbar spine rotation in the sagittal plane occurs at all lumbar

vertebrae, suggesting that the technique is not specific to any one segment. Lee

and colleagues10 investigated the effects of a Grade III13 mobilization directed at

the C5 spinous process, the maximum intervertebral rotation occurred in the

direction of extension at the C2/C3 segment (approximately 3.8 degrees) while

the C7/T1 segment actually rotated into flexion (approximately 2 degrees). This

suggests that not only is a PA mobilization directed at C5 not specific but also

that the 2-3 segments above and below the target vertebrae experienced the

greatest amount of rotation in the sagittal plane.

Recent studies11,12 have investigated the accuracy and precision of spinal

manipulation techniques as determined by the location of cavitations. Beffa and

Mathews11 investigated the location of cavitations performed with a technique

directed at L5 and another technique directed an the sacroiliac joint. There was

no correlation between the technique used and the joint that cavitated. In fact

each of the techniques resulted in cavitations throughout the lumbosacral region

(Figure 1). Furthermore, Ross et al12 investigated the accuracy of manipulation

directed at the thoracic and lumbar spine. The results demonstrated that thoracic

spine manipulation was accurate 53% of the time while lumbar spine

manipulation was only accurate 46% of the time. In addition, the majority of the

manipulations resulted in multiple cavitations from which the authors concluded

that manipulation is not segment specific. While the aforementioned studies suggest that manual therapy interventions are

not specific to an individual segment, the logical question becomes, “does it

matter”? A number of studies14-16 have investigated the effects of different

manual therapy techniques on patient-centered outcomes in patients with neck

and low back pain. Chiradejnant et al14 investigated the effects of a therapist

selected mobilization technique versus a randomly selected technique (central

PA, unilateral PA, transverse PA) on outcomes. The results demonstrated that a

significant reduction in pain occurred in both groups; however, no difference was

Cleland JA, Childs JD. Does the Manual Therapy Technique Matter? Invited Commentary. Orthopaedic Division Review. 2005. September/October;27-28.

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observed between the groups, lending credibility to the idea that perhaps the

particular technique utilized may not be overly important.

Haas and colleagues15 investigated the effectiveness of manipulating a cervical

segment identified as being impaired based on endplay assessment versus a

randomly selected segment on pain and stiffness in a group of patients with neck

pain. Immediate and evening follow-up demonstrated that both the groups

exhibited statistically significant reductions in pain and stiffness, but there were

no differences between the groups. Another study demonstrated no difference in

outcome among 30 patients with neck pain who were randomly assigned to

receive either a cervical rotatory or a cervical lateral break manipulation for 10

treatments,16 The collective conclusions from these studies question whether the

choice of technique is necessary to optimize the clinical outcome and provide

evidence that the effects of manual therapy interventions may not be as precise

as previously thought.15 Future randomized clinical trials should be performed to

investigate the long-term effects of different manipulation techniques on patient-

centered outcomes.

Recently a clinical prediction rule was developed17 and validated18 that used a

manipulation technique purported to target the sacroiliac joint as the treatment of

choice for identifying patients with low back pain likely to benefit rapidly and

dramatically (based on patient reported levels of disability) from spinal

manipulation. Interestingly, the presence of sacroiliac provocation tests, motion

tests and symmetry tests were not identified as predictor variables for patients

who would respond positively to this particular manipulation technique. In fact

the results of these two studies suggest that the manipulation technique used

(Figure 2) will result in significant reductions in disability, despite the absence of

a well understood rationale as to the mechanism responsible for the favorable

effects on clinical outcomes.

Cleland JA, Childs JD. Does the Manual Therapy Technique Matter? Invited Commentary. Orthopaedic Division Review. 2005. September/October;27-28.

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Recent evidence refuting the specificity of mobilization and manipulation

techniques, combined with data suggesting that one particular technique might

not be superior to another, questions the necessity to practice based on a strict

biomechanical model when treating patients with low back and neck pain. Future

work should continue to examine whether there are preferential effects for

different manual therapy techniques, and whether efforts to be specific are

worthwhile. Future research should also continue to elucidate the mechanisms

underlying the favorable effects of manual therapy on clinical outcomes in

patients with low back and neck pain.

Reference List 1. Jull G, Moore A. Are manipulative therapy approaches the same? Man

Ther. 2002;7:63.

2. Love R, Brodeur R. Inter- and intra-examiner reliability of motion palpation for the thoracolumbar spine. J Manipulative Physiol Ther. 1987;10:261-6.

3. Mootz R, Keating J, Kontz H, Milus T, Jacobs G. Intra- and interobserver reliability of passive motion palpation of the lumbar spine. J Manipulative and Physiol Ther. 1989;12:440-5.

4. Keating J, Bergmann T, Jacobs G, Finer B, Larson K. Interexaminer reliability of eight evaluative dimensions of lumbar segmental abnormality. J Manipulative Physiol Ther. 1990;13:463-70.

5. O'Haire C, Gibbons P. Inter-examiner and intra-examiner agreement for assessing sacroiliac anatomical landmarks using palpation and observation: pilot study. Man Ther. 2000;5:13-20.

6. Meijne W, van Neerbos K, Aufdemkampe G, van der WP. Intraexaminer and interexaminer reliability of the Gillet test. J Manipulative Physiol Ther. 1999;22:4-9.

7. Abbot JH, Mercer SR. Lumbar segmental hypomobility: Criterion-related validity of clinical examination items (a pilot study). N Z J Physiother. 2003;31:3-9.

8. Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996;21:2594-602.

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9. Kulig K, Landel R, Powers CM. Assessment of lumbar spine kinematics using dynamic MRI: a proposed mechanism of sagittal plane motion induced by manual posterior-to-anterior mobilization. J Orthop Sports Phys Ther. 2004;34:57-64.

10. Lee RY, McGregor AH, Bull AM, Wragg P. Dynamic response of the cervical spine to posteroanterior mobilisation. Clin Biomech (Bristol , Avon ). 2005;20:228-31.

11. Beffa R, Mathews R. Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds. J Manipulative Physiol Ther. 2004;27:e2.

12. Ross JK, Bereznick DE, McGill SM. Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine. 2004;29:1452-7.

13. Maitland G, Hengeveld E, Banks K, English K. Maitland's verterbal manipulation. 6th ed. Oxford: Butterworth- Heinemann; 2000.

14. Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of "therapist-selected" versus "randomly selected" mobilisation techniques for the treatment of low back pain: a randomised controlled trial. Aust J Physiother. 2003;49:233-41.

15. Haas M, Groupp E, Panzer D, Partna L, Lumsden S, Aickin M. Efficacy of cervical endplay assessment as an indicator for spinal manipulation. Spine. 2003;28:1091-6.

16. van Schalkwyk R, Parkin-Smith GF. A clinical trial investigating the possible effect of the supine cervical rotatory manipulation and the supine lateral break manipulation in the treatment of mechanical neck pain: a pilot study. J Manipulative Physiol Ther. 2000;23:324-31.

17. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Butler B, Rendeiro D, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835-43.

18. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients likely to benefit from spinal manipulation: A validation study. Ann Intern Med. 2004;141:920-8.

Cleland JA, Childs JD. Does the Manual Therapy Technique Matter? Invited Commentary. Orthopaedic Division Review. 2005. September/October;27-28.

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Figures Figure 1. Location of cavitations associated with manipulation techniques directed at L5 and the sacroiliac joint11

Figure 2. Manipulation technique used in the Flynn et al17 and Childs et al18 studies.

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Cleland JA, Childs JD. Does the Manual Therapy Technique Matter? Invited Commentary. Orthopaedic Division Review. 2005. September/October;27-28.

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Figure 2. Manipulation technique used in the Flynn et al17 and Childs et al18 studies.