Spinal manipulation techniques

There are many differing philosophies and concepts surrounding the practise of spinal manipulation and its effects on the pathologies which may exist in the spine. To satisfy all these philosophies an equal number of institutions has developed, teaching those wishing to learn. No matter what school presents its case or which philosophy is adhered to, all manipulative specialists claim to have a high success rate. They all use techniques which vary in nature, application and intent; they proclaim that their own methods are superior to those used by others; and yet, somehow they all obtain uniformly good results. Self-limitation of low back pain plays, of course, a significant role in this happy situation. Apart from this there are definite benefits which are obtained quickly by using manipulative techniques.

Throughout the years I have practised many forms of mobilisation and manipulation, including osteopathic and chiropractic techniques and those taught by Cyriax. I have come to believe that it is immaterial which manipulative school or philosophy one upholds for, no matter what particular manipulations are used, the results of technique appear to be the same. The general procedures of Cyriax are just as effective as the finely developed specific procedures of the osteopaths and chiropractors.

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It is now well documented that asymmetries in the facet joints and other developmental anomalies occur as regularly in the lumbar region as in the other areas of the spine, and are present in up to fifty-two percent of the population. Where palpable movement restrictions and departures from the typical exist, it is impossible to state that these are either the cause of the patient’s present symptoms or are likely to cause symptoms in the future. To conclude that palpable anomalies should be mobilised is no longer a tenable suggestion. One may well be dealing with perfectly ‘normal’ and asymptomatic asymmetrical lumbar articulations.

Diagnosis by palpation is relevent only when associated with the increase and decrease of mechanical deformation. Those who claim to ‘feel’ restrictions by palpation and simultaneously fail to reproduce the patient’s symptoms, are only fooling themselves and their patients. Enthusiasts searching for sacro-iliac pathology are frequently misled by this philosophy. The production of pain at a certain level by palpation and passive movement is not enough to justify treatment at that level. The pain produced must be the one that has forced consultation — not a new pain induced by the palpation.

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Various manipulative authorities maintain that mobilisation or manipulation of a hypermobile spinal segment should be avoided at all times. This is excellent advice when it applies to pathological hypermobilities as fractures and spondylolisthesis. However, a hypermobile joint in itself is considered by some to cause mechanical pain more readily than joints with a normal or decreased mobility. I must emphasise that a hypermobile joint becomes painful in the same manner as any other joint. When it is placed on full stretch for a long enough period or when the stretch is severe enough pain will be felt. It so happens that in the hypermobile segment a greater range of movement must be accomplished before full stretch is achieved. Thus, hypermobility is not in itself a painful state.

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The basic misunderstanding that passive movements applied to a hypermobile joint are harmful, has led to the systematic development of techniques of specific manipulation which spare the hypermobile joints and affect only the adjacent hypomobile joints. It has also brought about unjustified condemnation of those who advocate general instead of specific manipulation. Many people have criticised and rejected the techniques of Cyriax which are considered to be unselective, non-specific and rather coarse in their application. However, at this time hundreds of Cyriax-trained doctors and physiotherapists successfully apply his methods in many parts of the world and it appears that no harm is caused by his approach. If general manipulation were damaging indeed, then by now there would be enough evidence to support this contention. I am sure that the antagonists of Cyriax would not have allowed any compromising situation to pass unnoticed.

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Unfortunately, it appears that some manipulative schools attempt to enhance the quality and mystique of their skills by increasing the complexity of their techniques. They create the impression that to master the art and science of manipulation one must acquire very complex skills; these are possessed and taught only by an elite group, and if one wishes to enjoy the highest reputation in manipulation one must join this elite group; the only way to do this is to train at an exclusive establishment. This continuing trend is a threat to the scientific development of mechanical therapy.

The procedures which I have chosen for the treatment of low back pain are totally unsophisticated and non-specific. In general, the techniques affect many segments and localisation is not attempted. However, these procedures have an immediate cause and effect on the patient’s symptoms. The reasons put forth for their effectiveness may prove to be wrong in the future, but the effectiveness itself will not change: if patients are selected as suggested and the techniques are applied as suggested, the procedures will be as effective fifty years from now as they are today.

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It is one of the main theses of this book that patients can be taught to manage, treat and control their own low back pain. In order to achieve this it is necessary to depart from the traditional methods of mechanical treatment, whereby the therapist does something to the patient to bring about change. In that case the patient attributes his recovery, rightly or wrongly, to what was done to him and for all future episodes of low back pain he commits himself to the care of the therapist. By avoiding the use of therapist-technique in the initial stages of treatment and substituting patient-technique, the patient will recognise that his recovery is clearly the result of his own efforts. Only few patients fail to assume responsibility for active participation in their treatment.

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At present a great deal of research and academic discussion is taking place in attempts to establish the scientific validation of manipulation and explain its effects. The most obvious and most important effect of mobilisation and manipulation is the increase of range of movement at any joint to which the techniques are applied. This may be caused by a change in the position of an internal structure, or by such an alteration in an adjacent structure that a more normal function is possible than existed prior to the application of the technique. The increase in range of movement as obtained by manipulation and mobilisation can also be achieved by exercises when performed in a certain way. It is my belief that an exercise becomes a mobilisation when performed with a certain frequency and in such a way that a rhythmical passive stretch is created. And in a similar manner a passive mobilisation can become a manipulation. The suggestion put forth is that mobilisation and manipulation are nothing more than extended exercises, and an exercise can therefore become a mobilisation or manipulation. Therapy based on self-mobilisation and self-manipulation has arrived and it is possible to teach patients to practise mobilisation and manipulation of their own spine.

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Provided there is adequate instruction and careful explanation regarding the aims of treatment, the self-treatment concept can be applied successfully to most low back pain patients — that is, to all the patients with the postural syndrome, nearly all with the dysfunction syndrome, and about seventy-five percent of the patients with the derangement syndrome. Thus, twenty-five to thirty percent of patients with low back pain will not recover on the exercise programme alone, and need additional techniques of either mobilisation or manipulation which must be applied by a specialist therapist. The only equipment required to treat patients is an adjustable treatment table, the height of which can be varied and which has an end section of about two feet that can be inclined up or down.

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THE PROCEDURES AND THEIR EFFECTS

After much investigation to determine the optimum number of movements necessary to effect stretching of shortened tissues and alteration in the position of the fluid nucleus, I have come to conclude that usually any significant change will occur within ten to fifteen repetitions of the procedure and no benefit will be obtained by exceeding this number. Therefore, exercises are performed in series of ten to fifteen excursions each. The number of times in the day that a series of exercises must be done varies according to the syndrome to be treated, the effects to be obtained, and the capabilities of the patient involved.

Unless stated otherwise, exercises will be performed with an almost continuous rhythm. On each contraction the maximum possible range must be maintained for a second or two. Each excursion must be followed by relaxation, and a brief pause of only a fraction of a second is required. Normally patients can complete between ten to fifteen excursions in one minute. Therefore no patient should use the excuse that he has not got enough time to do the exercises as instructed.

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In assessing progress the evaluation of pain changes is vital. A patient can improve in several ways: the intensity of the pain may reduce; the frequency with which the pain occurs may decrease; or the site of the pain may alter. Centralisation of the pain indicates that the patient is improving, although in terms of intensity he may still feel one hundred percent of the pain originally complained of. In this case an explanation of the pain behaviour usually satisfies the patient regarding his progress.

If the site of pain has not changed on the patient’s next visit, I always enquire about the frequency and intensity of the pain in the following manner:

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“If you had one hundred units of pain on your last visit, how many do you have today in terms of (a) frequency; and (b) intensity?”.

The procedures include patient-technique as well as therapist-technique. In order to facilitate quick reference the procedures are summarised below.

TABLE OF PROCEDURES

  • Procedure 1 : lying prone
  • Procedure 2 : lying prone in extension
  • Procedure 3 : extension in lying
  • Procedure 4 : extension in lying with belt fixation
  • Procedure 5 : sustained extension
  • Procedure 6 : extension in standing
  • Procedure 7: extension mobilisation
  • Procedure 8 : extension manipulation
  • Procedure 9 : rotation mobilisation in extension
  • Procedure 10 : rotation manipulation in extension
  • Procedure 11 : sustained rotation/mobilisation in flexion
  • Procedure 12 : rotation manipulation in flexion
  • Procedure 13 : flexion in lying
  • Procedure 14 : flexion in standing
  • Procedure 15 : flexion in step standing
  • Procedure 16 : correction of lateral shift
  • Procedure 17 : self-correction of lateral shift
ASSESSMENT OF PAIN Pain gives the body warning and often is accompanied by anxiety and the need to relieve the pain. Pain is both sensation and emotion. As noted earlier, it can be acute or chronic. Health-care professionals may find the following mnemonic tool useful for assessing a client in pain: P = place (client points with one finger to the location of the pain) A = amount (client rates pain on a scale from 0 to 10 ) I = interactions (client describes what worsens the pain) N = neutralizers (client describes what lessens the pain) The scale of 0 to 10, as described in the mnemonic, is a useful method of assessing pain. Further pain assessment skills include observing the client’s appearance and activity. Monitoring the client’s vital signs may be of value in assessing acute pain but not necessarily chronic pain. To assess the pain of children or those with some cognitive dysfunction or dementia, a “smiley face” model often proves beneficial. The first smiley face shows a happy face...
GATE CONTROL THEORY OF PAIN What occurs at the cellular level when pain is experienced? The gate control theory of pain, by P. D. Wall and Ronald Melzack, offers a useful model of the physiological process of pain. Gate control is recognized as a major pain theory. According to the gate control theory, pain is a balance between information traveling into the spinal cord through large nerve fibers and information traveling into the spinal cord through small nerve fibers. Without any stimulation, both the large and small nerve fibers are quiet, and the substantia gelatinosa (SG) blocks the signal to the transmission cell (T cell) connected to the brain. The “gate is closed,” and there is no pain. With pain stimulation, small nerve fibers are active. They activate the T-cell neurons but block the SG neuron, making it impossible for the SG to block the T-cell transmission to the brain. The result is that the “gate is open”; therefore, there is pain. In other words, pain is experienced whenever the substances that ...
Spine Health. PROCEDURE 9 — ROTATION MOBILISATION IN EXTENSION The position of patient and therapist is the same as for procedure 7. By modifying the technique of extension mobilisation so that the pressure is applied first to the transverse process on the one side and then on the other side of the appropriate segment a rocking effect is obtained. Each time the vertebra is rotated away from the side to which the pressure is applied — for example, pressure on the right transverse process of the fourth lumbar vertebra causes left rotation of the same vertebra. The technique should be repeated about ten times on the involved segment and, if indicated, adjacent segments should be treated as well. Fig. Rotation mobilisation in extension. Effects: Also here the external force applied by the therapist enhances the effects on derangement and dysfunction as described for the previous extension procedures. The reasons for adding therapist-technique are the same as for procedure 7. In general, unilateral techniques are likely to effect unilateral...
Spine Health. PROCEDURE 5 — SUSTAINED EXTENSION To apply a sustained extension stress to the lumbar spine an adjustable couch, one end of which may be raised, is a necessary piece of equipment. The patient lies prone with his head at the adjustable end of the couch which is gradually raised, about one to two inches at the time over a five to ten minute period. Once the maximum possible degree of extension is reached, the position may be held for two to ten minutes, according to the patient’s tolerance. When lowering the patient the adjustable end of the couch should slowly be returned to the horizontal over a period of two to three minutes. This must not be done rapidly, for acute low back pain may result. Fig. Sustained extension. Effects: The procedure is predominantly used in the treatment of derangement. The effect is similar to that of the third procedure, but a time factor is added with the graduated increase and the sustained nature of the extension. In certain circumstances a sustained extension stress is preferable...
Spine Health. PROCEDURE 6 — EXTENSION IN STANDING The patient stands with the feet well apart and places the hands (fingers pointing backwards) in the small of the back across the belt line. He leans backwards as far as possible, using the hands as a fulcrum, and then returns to neutral standing. The exercise is repeated about ten times. As with extension in lying it is necessary to move to the very maximum to obtain the desired result. Fig. Extension in standing. Effects: Extension in standing produces similar effects on derangement and dysfunction as extension in lying, but it is less effective in the earlier treatment stages of both syndromes. Whenever extension in lying is prevented by circumstances, an extension stress can be given by extension in standing. In derangement, extension in standing is designed to reduce accumulation of nuclear material in the posterior compartment of the intervertebral joint, provided this accumulation is not gross. In the latter case extension in lying will have to be performed first. Th...