Effects of spinal mobilization on physical function in patients with stroke: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to identify, critically appraise, and synthesize current evidence regarding the effects of spinal mobilization on physical function in patients with stroke. Three databases, PubMed, Embase, and Scopus, were searched from inception to March 15, 2024. Randomized controlled trials comparing the effects of spinal mobilization to conventional therapy were eligible for inclusion. Methodological quality was assessed using the Physiotherapy Evidence Database scale. Meta-analyses were performed to determine the effects of spinal mobilization. Nine randomized controlled trials were included, with a total of 294 patients with stroke. All included studies were evaluated as good or above for quality assessment. No adverse events related to spinal mobilization were reported. Compared to conventional therapy, spinal mobilization demonstrated significantly improved forward head posture (SMD: 1.00, 95% CI: 0.53 to 1.46, p < 0.001); there were no between-group differences on forced vital capacity (SMD: 0.44, 95% CI: -0.01 to 0.88, p = 0.06), forced expiratory volume (SMD: 0.33, 95% CI: -0.12 to 0.77, p = 0.15), balance (SMD: 0.36, 95% CI: -0.04 to 0.77, p = 0.08), gait speed (SMD: 0.48, 95% CI: -0.44 to 1.40, p = 0.31), and trunk function (SMD: 0.79, 95% CI: -0.17 to 1.75, p = 0.11). Cervical mobilization significantly improved forward head posture; however, no significant differences were found in other outcomes. Clinicians may consider spinal mobilization as an adjunctive intervention in stroke rehabilitation to address posture-related impairments to expand treatment strategy and optimize quality of care.

A modern way to teach and practice manual therapy

BACKGROUND

Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment, patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care.

PURPOSE

The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety, comfort, and efficiency. These practical elements are contextualised by positive communication, a collaborative context, and person-centred care. The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies.

METHODS

A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements.

CONCLUSIONS

Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Physiotherapeutic management of a patient with spinal Schwannoma: A case report

INTRODUCTION

Tumors are generally considered as red flags to manual therapy. The purpose of this report is to describe the clinical course of a patient diagnosed with spinal Schwannoma at L2-L3 level, who was referred to physiotherapy (PT) for the treatment of low back pain radiating to the left lower limb.

CASE DESCRIPTION

A 30-year old man previously diagnosed with L2-L3 Schwannoma was referred for physiotherapy for the treatment of radiating pain. The patient had not responded favorably to symptomatic management. As the patient's history and physical examination were consistent with a mechanical dysfunction, it was decided to manage the patient along similar lines. The patient was treated with McKenzie extension and central postero-anterior mobilization over T4-T6 vertebrae. This intervention was followed up with strengthening and aerobic exercises.

RESULTS

The outcomes were measured by the numerical rating scale (NRS), Oswestry Disability Index (ODI) and the Global rate of Change (GRC) scale. The patient responded well to McKenzie extension exercises and Thoracic mobilization. The NRS (7 at rest; 10 on activity) at the time of referral reduced to (2 on activity) at the time of discharge. The outcomes were maintained after 7 months.

CONCLUSION

This case suggests that there is a need to undertake a detailed musculoskeletal examination and mobilization may be safely performed in patients diagnosed with spinal schwannomas. An individualized tailored approach may be beneficial in these patients.

Mechanism of Action of Spinal Mobilizations: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To review the evidence regarding the mechanism of action of mobilizations.

SUMMARY OF BACKGROUND DATA

Spinal mobilizations-low velocity passive oscillatory movements-reduce spinal pain in some patient subgroups. Identifying patients likely to respond remains a challenge since mobilizations' mechanism(s) of action are unclear.

METHODS

Medline, Web of Science, Cinahl, Embase, and Scopus databases were searched for relevant studies. Reference lists of included studies were hand searched. Studies were included if the intervention was passive spinal mobilizations, participants were symptomatic, and outcomes evaluated possible mechanisms of action. Methodological quality was independently assessed by two assessors using a modified Cochrane Back Review Group tool.

RESULTS

Twenty-four studies were included in the review. Four were classified high risk, 14 moderate risk, and four low risk of bias. Commonest methodological limitations were lack of participant blinding, adequate randomization and allocation concealment, and sample size calculation. Evidence suggests that spinal mobilizations cause neurophysiological effects resulting in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation, and improved muscle function. Mobilizations have no effect on temperature pain threshold. Three of four studies reported reduction in spinal stiffness, heterogeneous in location and timing. There is limited evidence (one study in each case) to suggest that mobilizations produce increased nociceptive flexion reflex threshold, improved posture, decreased concentration of substance P in saliva, and improved sway index measured in cervical extension. Evidence does not support an effect on segmental vertebral movement. Two studies investigated correlations between hypoalgesia and mechanism: one found a correlation with sympathoexcitatory changes, whereas the other found no correlation with change in stiffness.

CONCLUSION

These findings suggest involvement of an endogenous pain inhibition system mediated by the central nervous system, although this is yet to be investigated directly. There is limited evidence regarding other possible mechanisms.

LEVEL OF EVIDENCE

3.