How should we teach lumbar manipulation? A consensus study

Provider kinematic strategies during the delivery of spinal manipulation and mobilization: a scoping review of the literature

BACKGROUND

Spinal manipulation (MAN) and mobilization (MOB) are biomechanically different yet both elicit pain reduction and increased range of motion. Previous investigations have focused on quantifying kinetics (e.g., applied forces) or, recipient kinematics (i.e., movements) during MAN and MOB. While these studies provide valuable information, they do not report on the strategies adopted by providers when performing the complex motor tasks of MAN and MOB. This review sought to synthesise the literature reporting on provider kinematics during the delivery of MAN and MOB.

METHODS

This scoping literature review is reported following the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) statement. MEDLINE (Ovid), PsychINFO, Cochrane Library, Web of Science, Embase, Scopus, PEDro, ICL and CINAHL databases were searched from inception to September 2023 for terms relating to provider kinematics during the delivery of MAN and MOB. Data were extracted and reported descriptively, including: general study characteristics, number and characteristics of individuals who delivered/received MAN and/or MOB, region treated, equipment used and kinematic parameters of the individual delivering the procedure.

RESULTS

Of 4,844 records identified, five (0.1%) fulfilled the eligibility criteria and were included in the analysis. Of these, provider kinematics were reported for the delivery of MAN in four (80%) and for the delivery of MOB in one (20%) article. Practitioners applied the procedure in all (100%) and students in one (20%) study. Spinal regions treated were: lumbar (n = 4), thoracic (n = 2) and cervical (n = 1). Data were reported heterogeneously but were most commonly captured using either video or motion capture equipment (n = 4, 80%). The direction of applied force was fully reported in one (20%) and only partially reported (one spinal region) in another study.

CONCLUSIONS

There are a small number of studies reporting heterogeneously on provider kinematics during the delivery of MAN and MOB. Clear reporting of the procedure from a biomechanical perspective and of the measurement equipment used could enable future meta-analysis of provider kinematic data, the use of provider kinematic data in the development of technique skills curricula and could feasibly be used to mitigate risk of injury for providers.

Factors that contribute to the perceived treatment effect of spinal manipulative therapy in a chiropractic teaching clinic: a qualitative study

BACKGROUND

Despite the progress made in better understanding the potential mechanisms of spinal manipulative therapy (SMT) and its treatment effects, a knowledge gap continues to exist when identifying the specific factors that contribute to the perceived treatment effect associated with SMT. The purpose of the study was to explore the perceptions of chiropractic clinicians, interns, and patients regarding what factors during a doctor-patient encounter contribute to the perceived treatment effect associated with SMT.

METHODS

This study used convenience sampling to enroll participants from a chiropractic teaching clinic in the United States. Semi-structured interviews were used as the main form of data collection, which took place from January-April 2024. The data was subsequently analyzed using thematic analysis and organized into themes through an iterative open coding process.

RESULTS

Six rounds of interviews were conducted for a total of 18 interviews. Each round consisted of one patient who received treatment including SMT, one intern who performed the treatment, and one clinician who oversaw the treatment. After analyzing the interview data, the following five themes were identified: Treatment Outcome, Therapeutic Alliance, Adjunctive Therapies, Significance of Cavitation, and Psychomotor Skills. Each theme consisted of multiple subthemes which were mentioned by the participant groups at varying frequencies. Patients frequently mentioned the importance of improvement in symptoms following treatment, as well as good communication skills and the use of adjunctive therapies. Interns valued functional change following treatment, while clinicians focused on confidence levels and psychomotor skills. There were differing views on the significance of cavitation, ranging from indifference to an indication of a successful treatment.

CONCLUSION

This qualitative study identified several themes which describe factors that may contribute to the perceived effect associated with SMT. In addition to the psychomotor skills required to perform SMT, educators and practitioners should consider factors such as the therapeutic alliance between patient and provider, use of adjunctive therapies, and assessment of the outcome associated with the intervention.

Development of a basic evaluation model for manual therapy learning in rehabilitation students based on the Delphi method

OBJECTIVE

Manual therapy is a crucial component in rehabilitation education, yet there is a lack of models for evaluating learning in this area. This study aims to develop a foundational evaluation model for manual therapy learning among rehabilitation students, based on the Delphi method, and to analyze the theoretical basis and practical significance of this model.

METHODS

An initial framework for evaluating the fundamentals of manual therapy learning was constructed through a literature review and theoretical analysis. Using the Delphi method, consultations were conducted with young experts in the field of rehabilitation from January 2024 to March 2024. Fifteen experts completed three rounds of consultation. Each round involved analysis using Dview software, refining and adjusting indicators based on expert opinions, and finally summarizing all retained indicators using Mindmaster.

RESULTS

The effective response rates for the three rounds of questionnaires were 88%, 100%, and 100%, respectively. Expert familiarity scores were 0.91, 0.95, and 0.95; coefficient of judgment were 0.92, 0.93, and 0.93; authority coefficients were 0.92, 0.94, and 0.94, respectively. Based on three rounds of consultation, the model established includes 3 primary indicators, 10 secondary indicators, 17 tertiary indicators, and 9 quaternary indicators. A total of 24 statistical indicators were finalized, with 8 under the Cognitive Abilities category, 10 under the Practical Skills category, and 6 under the Emotional Competence category.

CONCLUSION

This study has developed an evaluation model for manual therapy learning among rehabilitation students, based on the Delphi method. The model includes multi-level evaluation indicators covering the key dimensions of Cognitive Abilities, Practical Skills, and Emotional Competence. These indicators provide a preliminary evaluation framework for manual therapy education and a theoretical basis for future research.

The Effectiveness of Instruction on Lumbar Spine Thrust Joint Manipulation Task Performance

INTRODUCTION

Uncertainty exists regarding the best method for teaching thrust joint manipulation (TJM) to student physical therapists. The purpose of this study was to compare the effectiveness of Peyton's 4-step (P4) approach with the "see one, do one" (S1D1) approach for teaching students to perform a lumbar spine TJM task in an academic setting. Secondary objectives were to compare the effects of each instructional approach on students' attitudes and beliefs toward spinal TJM and on their motivation to learn to perform lumbar spine TJM.

REVIEW OF LITERATURE

The S1D1 approach is used in the health care professions for teaching clinical tasks to students. It is unclear whether the P4 approach may better prepare students to practice TJM.

SUBJECTS

Student physical therapists.

METHODS

Using a factorial quasi-experimental design, an equal number of students were assigned to a P4 or S1D1 instruction group for the TJM task. Students' performance accuracy, time, and outcome performing TJM in an academic setting were measured. Paper surveys were used to collect data about students' attitudes and beliefs toward spinal TJM and their motivation to learn TJM. A generalized estimating equations approach was used for data analysis.

RESULTS

Fifty-eight students (29 per group) completed the study. There was an interaction between the instruction group and time on task performance accuracy favoring the P4 approach (P = .03). There was no interaction between the instruction group and task performance time, task performance outcome, attitudes and beliefs toward spinal TJM, or motivation to learn TJM (all P > .19).

DISCUSSION AND CONCLUSION

The P4 approach more effectively improved student accuracy when performing the TJM task in an academic setting than the S1D1 approach. However, no differences between instruction were found for performance time or outcome. Students reported a favorable perception of learning lumbar spine TJM. These preliminary results suggest that instructors may use the P4 approach to improve students' TJM procedural knowledge before task practice. However, limitations of the study may affect the internal validity and generalizability of results.

Factors Associated With Clinical Responses to Spinal Manipulation in Patients With Non-specific Thoracic Back Pain: A Prospective Cohort Study

Introduction: The management of musculoskeletal disorders is complex and requires a multidisciplinary approach. Manual therapies, such as spinal manipulative therapy (SMT), are often recommended as an adjunct treatment and appear to have demonstrable effects on pain and short-term disability in several spinal conditions. However, no definitive mechanism that can explain these effects has been identified. Identifying relevant prognostic factors is therefore recommended for people with back pain.

Objective: The main purpose of this study was to identify short-term candidate prognostic factors for clinically significant responses in pain, disability and global perceived change (GPC) following a spinal manipulation treatment in patients with non-specific thoracic back pain.

Methods: Patients seeking care for thoracic spine pain were invited to participate in the study. Pain levels were recorded at baseline, post-intervention, and 1 week after a single session of SMT. Disability levels were collected at baseline and at 1-week follow-up. GPC was collected post-intervention and at 1-week follow-up. Biomechanical parameters of SMT, expectations for improvement in pain and disability, kinesiophobia, anxiety levels as well as perceived comfort of spinal manipulative therapy were assessed.

Analysis: Differences in baseline characteristics were compared between patients categorized as responders or non-responders based on their pain level, disability level, and GPC at each measurement time point. Binary logistic regression was calculated if the statistical significance level of group comparisons (responder vs. non-responders) was equal to, or <0.2 for candidate prognostic factors.

Results: 107 patients (62 females and 45 males) were recruited. Mean peak force averaged 450.8 N with a mean thrust duration of 134.9 ms. Post-intervention, comfort was associated with pain responder status (p < 0.05) and GPC responder status (p < 0.05), while expectation of disability improvement was associated with GPC responder status (p < 0.05). At follow-up, comfort and expectation of pain improvement were associated with responder GPC status (p < 0.05). No association was found between responder pain, disability or GPC status and biomechanical parameters of SMT at any time point.

Discussion: No specific dosage of SMT was associated with short-term clinical responses to treatment. However, expectations of improvement and patient comfort during SMT were associated with a positive response to treatment.

Learning Spinal Manipulation: Objective and Subjective Assessment of Performance

OBJECTIVE

The purpose of this study was to investigate associations between objective spinal manipulation therapy (SMT) biomechanical parameters and subjective assessments provided by patients, clinicians, and expert assessors.

METHODS

Chiropractic students (N = 137) and expert instructors (N = 14) were recruited. Students were asked to perform a thoracic SMT alternately on each other on a force-sensing table while being observed by an expert instructor. Students who performed (clinicians) and received (patients) SMT, and expert instructors, independently scored each SMT performance using visual analog scales. Correlations between these subjective scores and SMT biomechanical parameters were calculated. The following parameters were evaluated: peak force, preload force, thrust duration, and drop in preload force. Spinal manipulation therapy comfort was also assessed by patients, clinicians, and expert instructors.

RESULTS

Results of the study indicate that thrust duration assessed by instructors and patients was the only parameters significantly correlated with the table data (r = .37; P < .001 and r = .26; P = .002). Comfort assessed by clinicians was significantly correlated with their own assessments of thrust duration (r = .37; P < .001) and preload force (r = .23; P = .007), whereas comfort assessed by instructors was significantly correlated with their own assessment of thrust duration (r = .27; P = .002) and drop in preload force (r = -.34; P < .001). Objective biomechanical parameters of performance did not predict perceived comfort.

CONCLUSIONS

Overall, the results from the subjective assessments of SMT performance are weakly correlated with objective measures of SMT performance. Only the thrust duration evaluated by expert instructors and patients was associated with scores obtained from the table. Perceived comfort of the procedure seems to be associated mostly with perceived thrust duration and preload characteristics.

Use of thrust joint manipulation by student physical therapists in the United States during clinical education experiences

Introduction: Thrust joint manipulation (TJM) is used in physical therapy practice and taught in entry-level curricula in the United States (US); however, research regarding implementation by student physical therapists (SPT)s is scarce. Objectives: To explore the use of TJM in SPT clinical education and factors influencing implementation. Methods: In a cross-sectional exploratory study, accredited physical therapy (PT) programs in the US (n = 227) were invited to participate in an electronic survey. SPTs were queried about TJM use and their clinical instructor's (CI) credentials during their final musculoskeletal clinical experience. Results: Forty-five programs participated in the study, consisting of 2,147 SPTs. Of those, 414 (19.3%) responses were used for analysis and 69% reported using TJM. SPTs who utilized TJM were more likely to have a CI who used TJM (p < 0.001) and/or had advanced certification/training in manual therapy (p < .001). A majority of students agreed or strongly agreed that their academic preparation provided them with clinical reasoning tools (84%) and psychomotor skills (69%) necessary to perform TJM. SPT use of TJM was facilitated by CI clinical practice, SPT competence in psychomotor skill, confidence in clinical reasoning, and practice setting. A main barrier to student use of TJM was CI lack of TJM use. Conclusions: Clinical practice of the CI appears to be a key factor in determining student use of TJM. Level of evidence: 2b.

Biomechanical characteristics of lumbar manipulation performed by expert, resident, and student physical therapists

BACKGROUND

Lumbar manipulation is a commonly used treatment for low back pain, but little research evidence exists regarding practitioner biomechanics during manipulation. Most existing evidence describes rate of force production through the hands into instrumented manikins and it is unclear how the practitioner moves their body and legs to generate this force.

OBJECTIVES

To identify and characterize important kinetic and kinematic factors in practitioners of varying experience performing lumbar manipulation in order to identify which factors distinguish experts from less experienced practitioners.

STUDY DESIGN

This was a cohort observational laboratory study.

METHODS

43 male physical therapists (PT) and PT students (4 experts, 11 residents, 13 third year, and 15 first year students) performed 4 manipulations each on asymptomatic patient models. Angular and linear kinematics of the pelvis were measured using motion capture, and ground reaction forces were measured with force plates under the practitioner's feet.

RESULTS

Peak pelvic angular velocity was greater and in the opposite direction in experts compared to other groups in the frontal plane (p = 0.020) and transverse plane (p = 0.000). Experts had greater downward pelvic linear velocity than third year students and first year students (p = 0.000). Experts also demonstrated faster rate of vertical ground reaction force unloading during the manipulation (p = 0.002).

CONCLUSIONS

Expert performance of manipulation was characterized by increased speed of linear and angular pelvic motion, and increased modulation of vertical ground reaction force. These results help to inform educators and practitioners that teach and use this complex manual skill.

Spinal manipulation after multiple fusions in an adult with scoliosis: a case report

BACKGROUND

Spinal fusion (SF)is a common surgical intervention for individuals with idiopathic scoliosis. However, individuals may experience continued pain and disability from suspected mechanical dysfunction.

CASE DESCRIPTION

The purpose of this case report was to describe how specific thrust manipulation (TM) was used to treat a patient with scoliosis after multilevel SF. The 25-year-old female patient presented with left-sided pain in the rib, thoracic, and lumbar and sacroiliac joint regions that had been aggravated by trail running. After clearance from her surgeon, physical therapy examination and subsequent diagnosis were consistent with mechanical dysfunction of the ribs, lumbar spine, and sacroiliac joint causing decreased ability to participate in high-level activities, such as running.

OUTCOMES

The patient was treated for eight visits her 4 months with specific TM, movement analysis, and physiotherapeutic scoliosis-specific exercises. Pain and function were assessed with the Trunk Appearance Perception scale (TAPS), Scoliosis Research Society questionnaire (SRS-22), Numeric Pain Rating Scale (NPRS), Oswestry Disability Index (ODI), and spirometry. Pain and function improved during treatment, but outcomes for the ODI and spirometry remained the same.

DISCUSSION

The current case report suggests specific TM to areas outside of the fused spinal segments may be beneficial for decreasing pain and improving functional activities and participation levels. However, more research is needed to verify the efficacy of this treatment in clinical practice.