Clinical Assessment of mobilization and manipulation of the lumbar spine.pdf

Clinical Assessment of Manipulation and Mobilization

of the Lumbar Spine

A Critical Review of the Literature

RICHARD P. Dl FABIO

The widespread use of manual therapy techniques suggests some degree of

success in their application. In this article, I review the applied clinical research

on the effectiveness of using manipulation or mobilization of the lumbar spine.

The literature reviewed indicates highly equivocal results when the goal of therapy

was to decrease pain and increase motion. Because of a high incidence of

spontaneous recovery from low back syndromes, performance measures may

appear to improve significantly when proper controls are not used. Evaluation of

the therapeutic effects of manual therapy is complicated by potentially confound-

ing variables when used with other physical therapy procedures. I discuss the

need for further, well-designed studies.

Key Words: Backache; Lumbar region; Manipulation, orthopedic; Physical therapy;

Spine.

Nonsurgical treatment of the low

back is widely used, but its effectiveness

for reducing pain and improving limited

REVIEW OF LITERATURE

istics of the patient sample, the nature

of the treatment, and the method of

assessment were highly variable. Mensor

excluded patients with spinal osteopo-

rosis, degenerative disk disease, spon-

dylolisthesis, and motor weakness but

allowed patients with weak toe extensor

motion is poorly documented. 1- 4 Tra-

ditional physical therapy for low back

syndromes has included the use of mo-

dalities, exercise, patient education, and

Noncontrolled Investigations of

Manipulation and Mobilization

A large percentage of patients with

low back pain are likely to recover spon-

taneously regardless of the type of treat-

posturing. 5, 6 Manual therapy (manipu-

lation or mobilization or both) has been

advocated as a primary treatment for

the patient suffering from back

dysfunction 7-11 ; the common use of

these techniques suggests some degree

of success in their application.

Although certain practical restraints

may limit strict control of the experi-

mental design, the results obtained from

poorly controlled investigations of man-

ual therapy must be questioned. The

clinical efficacy of manipulation and

mobilization has yet to be established

reliably under controlled conditions. A

critical review of manual therapy is nec-

essary to provide a perspective for the

management of low back dysfunction.

Throughout this article, the term "man-

ual therapy" applies broadly to lumbar

manipulation and mobilization tech-

ment received. 2,1 2 Studies without the

proper controls have no mechanism for

ensuring that the observed effects re-

sulted from manual therapy, patient-

therapist interaction, or a natural recov-

ery process. Mensor performed rotary

manipulations on 205 patients who had

backache and reported that nearly half

(96) obtained excellent or good results

muscles to receive manipulation. 1 3 Bur-

ton did not identify specific diagnostic

categories, 1 4 and Price sampled subjects

with "pain of spinal origin." 1 9

Manual therapy procedures differed

across studies and were defined opera-

tionally as traction and rotary manipu-

lation under Sodium Pentothal,®* 1 3

deep soft tissue massage, graded mobi-

lization, high velocity thrust, manual

from the treatment. 1 3 In a retrospective

study of 2,920 patients attending 43 os-

teopathic practices in Great Britain,

over 80% of the patients indicated a

satisfactory result from some manual

and mechanical traction, 1 4 and rotary

manipulation with analgesics. 1 9 These

broad definitions increase the difficulty

in comparing results between studies.

Clinically objective measurements of

lumbar dysfunction and assessment

tools with established reliability are dif-

ficult to find. The various pain rating

scales represent a subjective assessment

tool. A report of pain by the patient

before and after manual therapy was

often used as a primary index of thera-

therapy procedure. 1 4 The majority of

individuals participating in other non-

controlled studies also have shown con-

siderable improvement in signs and

symptoms after manipulation. 15 " 1 8 Price

reported that 59% of a sample of 73

patients indicated that their low back

pain remitted after a single week of ma-

niques, as presented elsewhere, 7-1 1 un-

less otherwise stated.

nipulative treatment. 1 9 The time course

of the reduction in symptoms led Price

to speculate that the incidence of spon-

taneous relief of pain was low. Deter-

mination of whether the improvement

in any measured outcome resulted from

therapy or spontaneous recovery was

impossible because no control or com-

parison group was in place.

Most noncontrolled studies were dif-

ficult to compare because the character-

peutic success or failure. 14-1 9 Range-of-

motion measurements, for example,

rarely were included in the assessment.

Controlled Studies of

Manipulation and Mobilization

Dr. Di Fabio is Director of Physical Therapy,

University of Wisconsin Hospital and Clinics, 600

Highland Ave, Madison, WI 53792 (USA).

This article was submitted January 10,1985; was

with the author for revision two weeks; and was

accepted July 11, 1985.

The interpreted efficacy of lumbar

manual therapy often hinges on experi-

* Abbott Pharmaceuticals, Inc, North Chicago,

IL 60064.

Volume 66 / Number 1, January 1986

TABLE

Summary Characteristics of Patient Samples and Types of Manual Therapy Described in

Selected Controlled Studies of Manipulation and Mobilization for Low Back Dysfunction

(LBD)

bilization have not been widely repro-

duced. Bergquist-Ullman and Larsson

compared spinal mobilization, a back

school program, and a placebo. 5 At 10

days, three weeks, and six weeks after

treatment, a similar decrease in pain was

observed in 182 patients representing all

three groups. When days of sick leave

from work because of recurrence of low

back pain were compared, no significant

differences were found between groups.

In a multicenter study, Doran and New-

ell reported no difference in pain and

spinal motion of 456 patients randomly

assigned to one of four groups—manip-

ulation, modality and exercise, corset,

Fisk 2 0

Evans et al 2 1

Nwuga 2 2

Study

Sample Characteristics

Unilateral LBD

LBD for three weeks (Exclusions: root

compression)

Disk protrusion confirmed by EMG

and myelogram (Additional criteria:

no prior treatment, onset within two

weeks, unilateral reflex and sensory

signs)

LBD (Exclusions: psychological dis-

turbance, pregnancy, scoliosis, root

pain, straight leg raising less than

30 degrees, sensory loss, weak-

ness, atrophy, abnormal reflexes,

hip osteoarthritis, previous manipu-

lation, corset, spondylolisthesis,

bowel or bladder disorder)

LBD (Criteria: noninflammatory origin

and limited spinal motion. Exclu-

sions: age—below 18 years, over

68 years; gross radiologic deform-

ity, restriction of motion in two or

more noncontinuous planes)

LBD (Exclusions: spondylitis, Paget's

disease, bladder or bowel disorder,

previous spinal surgery, pregnancy,

psychological disturbance)

LBD (Exclusions: bilateral pain, abnor-

mal radiological and neurological

signs)

Acute LBD (Criteria: no radiation, du-

ration of pain less than three

months, pain-free one year before

current onset)

Manual Therapy

Rotary thrust

(bilateral)

Rotary oscilla-

tions

Doran and Newell 2 3

"At discretion of

manipulator"

and oral analgesics. 2 3 This study re-

ceived considerable criticism for using

poor patient selection criteria and for

applying manipulative techniques that

were inconsistent. 24,2 5

Other blind controlled studies have

improved on patient selection criteria

and have standardized manual therapy

protocol but still have produced nega-

tive results. Godfrey et al used four

experimental groups in a single, blind

randomized trial of rotational manipu-

Godfrey et al 2 6

Maigne 2 7

Sims-Williams et al 2 8

Jay son et al 1 2

Maitland 7

lation. 2 6 Group 1 received soft tissue

massage and a rotational thrust of the

Glover et al 2 9

Rotary thrust

(lower spine

and sacrum)

Mobilization

type described by Maigne. 2 7 Group 2

received manipulation and electrostim-

ulation of the paraspinal muscles with

the subjects in the prone position. Mas-

sage only (Group 3) and electrostimu-

lation only (Group 4) completed the

array of randomization. Subjective as-

sessments of pain and activities of daily

living were combined with objective as-

sessments of passive and active spinal

motion. No significant differences were

seen in the outcomes among any group.

One difficulty inherent in the design

of many clinical studies was the poten-

tial influence of a placebo on the out-

come measures. This issue was briefly

addressed by Godfrey et al who stated

that, "The credibility and efficacy of

various placebo treatments have never

been investigated, and without an ap-

propriate placebo treatment, bias [from

the patient's perspective with regard to

their treatment] cannot be identified

and minimized." 26(p304 )

Jayson et al 1 2 and Sims-Williams et

Bergquist-Ullman and

Larsson 5

mental design and protocol. The pres-

ence of control groups, random assign-

ments to control and treatment groups,

and blind assessment of the outcome of

intervention are critical factors to be

considered for a valid clinical trial.

Interpretations of the efficacy of spinal

mobilization and manipulation are lim-

ited when the effects of manual therapy

are confounded by other forms of phys-

ical therapy treatment.

Fisk administered rotary manipula-

tion as the sole treatment for 10 care-

fully selected patients who had similar

algesics alone. 2 1 After 42 days, both

groups had received both types of inter-

vention but in a different sequence. An

increase in forward bending during the

trials of manual therapy was contrasted

with a decrease in this motion during

trials with analgesics alone. Pain de-

creased only in the group manipulated

first.

Nwuga used rotary oscillations in

combination with lifting and posture in-

structions. 2 2 The control group received

short wave diathermy, pelvic tilt exer-

cise, and lifting instructions. The man-

ual therapy group showed an increase in

active spinal motion (osteokinematic)

and significant improvement in SLR.

symptoms. 2 0 The resistance to bilateral

passive hamstring stretch during straight

leg raising was measured before and

after manual therapy in the patient sam-

ple and in a sample of 10 healthy vol-

unteers. The patients with back pain

demonstrated an asymmetry in ham-

string tension that was reduced signifi-

cantly after manipulation.

Evans et al used a controlled crossover

trial in which two groups of patients

al 2 8 applied Maitland's 7 technique and

found that pain reduction and spinal

motion improved for both manual ther-

apy and placebo groups. Patients who

began the study as outpatients and who

had a shorter duration of symptoms,

however, reported more of an improve-

As in the Evans et al 2 1 study, all meas-

urements were made by a physician or

therapist who had no knowledge of pa-

tient group assignment.

Controlled studies producing positive

results from joint manipulation and mo-

PHYSICAL THERAPY

with back pain received a course of ro-

tary manipulation with analgesics or an-

PRACTICE

ment from therapy than did the controls

one month after treatment. A one-year

follow-up showed that groups receiving

manual therapy had no better improve-

ment than controls. In fact, the control

groups were significantly better on pain

measures. Jayson et al concluded that,

"In patients likely to improve anyway,

mobilization and manipulation may

hasten improvements, but do not affect

the long term prognosis. " 12(p409 )

The immediate advantage of manip-

ulation and mobilization has been re-

ported by others. Glover et al measured

patients' complaints of pain 15 minutes

controlled studies in the Table to illus-

trate that exclusions from patient sam-

ples and the descriptions of manual ther-

apy vary considerably. The individual

studies should be read to obtain the

specific details in context.

pain have an unknown etiology. 3 7 In

addition, the interplay of variables such

as the skill level of clinicians performing

manual therapy, selection of patients

with different conditions, and the use of

manual therapy with other therapeutic

modalities may all contribute to equiv-

ocal results. Continuation of soundly

designed investigative work is a neces-

sary, yet difficult, task facing practition-

ers.

DISCUSSION

Progress in treating low back pain has

been limited because of a lack of scien-

tifically tested protocols and highly spec-

ulative theories on the mechanism(s) of

therapeutic action. 2-4,3 3 Haldeman eval-

uated the scientific basis for manipula-

tive therapy and proposed that therapy

must be demonstrated to have consist-

ent results under controlled conditions

and to have a specified effect on the

musculoskeletal or neuromuscular sys-

tem. 3 Moritz suggested that the variables

used to quantify the outcome of manual

therapy must be reviewed and specified

in more detail. 4 For instance, measuring

the angle of hip flexion during SLR

provides limited information because of

the potential for false positive tests. A

high interobserver reliability has been

found for measurements of mobility in

CONCLUSIONS

after rotational manipulation. 2 9 The

manipulated group reported signifi-

cantly greater relief compared with a

matched group receiving simulated

short wave diathermy. The groups had

no difference between them three and

seven days postintervention.

Findings that suggest that mobiliza-

tion is no more effective than placebo

deserve further scrutiny. Zybergold and

Piper assigned 28 patients to three

This review has produced more ques-

tions than answers regarding the efficacy

of manual therapy. For example, what

is the mechanism of action of manual

therapy? Is mobilization (vs manipula-

tion) more effective with certain diag-

nostic categories? How should the

knowledge of spontaneous recovery of

many patients with back pain alter an

approach to treatment? When should

treatment be started, how long should it

last, and how long are treatment effects

sustained? The answers to these ques-

tions will provide physical therapists

with the tools needed to use effective

clinical interventions and to scrutinize

the continuing development of manual

therapy techniques.

groups. 3 0 The first group received moist

heat and flexion exercises; the second

group received a home program in back

care; and the third group received heat,

gentle mobilization, and manual trac-

tion. Because the same therapist admin-

istered all treatments, the possibility of

experimenter bias cannot be over-

looked. If, however, the bias was in favor

of any given form of treatment, it did

not surface in the results. No significant

differences were found when pain in-

dexes, motion, and functional ability

were compared across the three groups.

Distinct benefits resulting from man-

ual therapy have been alleged in studies

that did not assign patients randomly to

various experimental groups, made per-

formance evaluations with full knowl-

edge of the intent of treatment, or used

multiple lumbar segments, 3 4 but corre-

lations of segmental mobility with clin-

ical dysfunction are not impressive. 3 5

Additionally, measures of improvement

in functional capacity are difficult to

interpret because emotional and physi-

cal factors contribute to function.

Controlled studies that measured

spinal range of motion focused primar-

ily on active physiological movement

(ie, the extent of forward bend-

ing) 12,21,22,26,28,30 Only one controlled

study reported an attempt to measure

both active and passive physiological

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an evaluation of spinal component mo-

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Pain indexes varied widely in the con-

trolled studies, and reports of reliability

were scant. The pain scales I reviewed

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In brief, when clinical trials of spinal

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PHYSICAL THERAPY

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