Joint Assessment and Manipulation

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Joint Assessmentand Manipulation

• PRA 635

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Theoretical Model SMT1
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Neurophysiological Effects of SMT1
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Classification Nerve Receptors1
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Evidence for Neurophysiological Effects of SMT1
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Functional Spinal Lesion A.K.A Subluxation2
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Triano JJ. The functional spinal lesion an
evidence-based model of subluxation. Top Clin
Chiropr 20018(1)16-28.

• Proposed mechanisms for restricted function
  (fixation, blockage, hypomobility)
• Z-joint entrapment of an inclusion or meniscoid
  (innervated by nociceptors)
• Annular fragment entrapment at IVD (innervated by
  nociceptors)
• Adhesions and scar formation ? stiffness and
  ?myofascial
• Hyperactive deep intrinsic spinal musculature in
  unilateral, asymmetric patterns

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Triano JJ. The functional spinal lesion an
evidence-based model of subluxation. Top Clin
Chiropr 20018(1)16-28.

• Proposed mechanisms of action from SMT
• Releasing entrapped synovial or disc tissues
• Reducing pain and restoring mobility
• Breaking adhesions
• Stretching myofascial tissues

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SMT Clinical Prediction Rule (CPR) for LBP

• LBP is complicated by multiple factors, including
  inability to identify a pathological source for
  the majority of patients4
• Evidence suggests that a specific diagnosis based
  upon pathoanatomy can be made in only 10-20 of
  LBP cases seen in PC4

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CPR Background

• Thus, a large group (80-90)of patients are often
  provided a diagnosis such as non-specific or
  mechanical LBP
• Research suggests that sub-groups exist within
  large category of non-specific LBP

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CPR Background

• Evidence reports that not all patients with LBP
  should be expected to respond to SMT4
• Flynn et al5 examined clinical presentation
  factors that predicted a successful response to
  two sessions of SMT

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CPR Background

• Five factors were identified as forming the most
  prudent set of predictors for identifying
  patients who attained at least 50 improvement in
  disability within one week with a maximum of two
  SMT interventions5
• Patients with presence of at least 4 of these 5
  criteria correspond to a 95 likelihood of
  success with SMT among this sub-group5

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CPR Criteria

• Five predictor variables5
• Duration symptoms lt 16 days
• No symptoms distal to knee
• FABQ lt 19 points
• At least one hypomobile segment
• At least one hip gt 35 internal rotation ROM

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Pragmatic Application of CPR

• Evidence supports the validity of these five
  criteria for identifying patients with LBP likely
  to benefit from SMT4
• However, pragmatism of application may be
  compromised by patient completion of FABQ and
  clinician examination of hip ROM and spinal
  mobility

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Methods

• 141 patients with LBP who were participants in
  one of two previous studies6
• Subjects were 18-60 years of age with CC of LBP
  with or without referral into LE, and Oswestry
  disability score of at least 30

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Methods

• All subjects were categorized on two criteria
  from baseline information
• Subjects with both criteria present (no distal
  symptoms and duration lt 16 days) were categorized
  as likely to have a good prognosis after SMT
  subjects with 1 or 0 criteria present were
  categorized as poor prognosis after SMT

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Results
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Conclusions

• The high specificity (0.92) and positive
  likelihood ratio (7.2) indicate that patients
  with both criteria present should be referred for
  a manipulation intervention-based on the high
  likelihood of success.6
• The sensitivity (0.56) and negative likelihood
  ratio (0.48) associated with this two-criteria
  rule were only moderate, indicating a relatively
  high potential for false negative results (i.e.,
  subjects designated as likely non-responders who
  ultimately experienced success with
  manipulation).6

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Conclusions

• Given the safety of manipulation in the lumbar
  spine, this finding suggests that referral of
  patients who do not have both criteria present
  may be appropriate in some cases.6
• The results of this study demonstrate that two
  factors symptom duration of less than 16 days,
  and no symptoms extending distal to the knee,
  were associated with a good outcome with spinal
  manipulation.6

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References

• Pickar JG. Neurophysiological effects of spinal
  manipulation. Spine J 2002, 2(5)357-371.
• Triano JJ. Biomechanics of spinal manipulative
  therapy. Spine J 2001, 1(2)121-130.
• Triano JJ. The functional spinal lesion an
  evidence-based model of subluxation. Top Clin
  Chiropr 2001, 8(1)16-28.
• Childs JD, Fritz JM, Flynn TW, Irrgang JJ,
  Johnson KK, Majkowski GR, Delitto A. A clinical
  prediction rule to identify patients with low
  back pain most likely to benefit from spinal
  manipulation a validation study. Ann Intern Med
  2004, 141(12)920-928.
• Flynn T, Fritz J, Whitman J, Wainner R, Magel J,
  Rendeiro D, Butler B, 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(24)2835-2843.
• Fritz JM, Childs JD, Flynn TW. Pragmatic
  application of a clinical prediction rule in
  primary care to identify patients with low back
  pain with a good prognosis following a brief
  spinal manipulation intervention. BMC Family
  Practice 2005, 629.