Aims: To evaluate the effect of neurodynamics mobilization (NDM) on an artificially induced œdema in the median nerve at the level of the carpal tunnel in unembalmed cadavers and to assess whether NDM tensioning techniques (TT) and NDM sliding techniques (SLT) induce similar effects on intraneural fluid dispersion.
Methods: Seven cadavers. Transverse carpal ligament and forearm fascia incised. Blue dye injected under the median epineurium. Dye spread measured with digital calliper at baseline, after spread stabilized 5 min of tensioner/glider. Sutures opened to measure spread. First one technique, then sutures tightened and then the other technique performed for 5 min (if started with slider, then tensioner and the other way around). Both limbs.
Results: Tensioners and sliders provided significant increase of longitudinal spread (compared to when the spread was stabilized). Not significant difference between sliders and tensioners related to the amount/length of spread. Most spread after first session.
Not any significant difference between limbs.
Limitations: Cadaveric study so limited when generalising to live subjects / The dissection to allow the fluid to be injected alters the carpal tunnel anatomy and carpal tunnel pressure may have reduced / The injection does not precisely replicate physiological oedema / No control group.
In practice: Both ND techniques seem to help spread of œdema intraneural.
Boudier-Revéret, M., Gilbert, K. K., Allégue, D. R., Moussadyk, M., Brismée, J. M., Sizer, P. S., … Sobczak, S. (2017). Effect of neurodynamic mobilization on fluid dispersion in median nerve at the level of the carpal tunnel: A cadaveric study. Musculoskeletal Science and Practice, 31, 45–51. https://doi.org/10.1016/j.msksp.2017.07.004
Aims: To (1) examine patients’ general expectations for treatment by physical therapists and specific expectations for common interventions in patients with neck pain, and (2) to assess the extent to which the patients’ general and specific expectations for treatment, particularly spinal manipulation, affect clinical outcomes.
Methods: Retrospective cohort. 140 patients with neck pain, were asked for expectations. Randomly allocated to 2 groups: stretching / strengthening, vs manip / mob / stretching / strengthening. Analysis of relationship between satisfaction of expectation and outcomes at 1 and 6 months calculated.
Results: 137 at 1 month and 114 patients at 6 months. Better expectations led to better outcomes. At 1 and 6 months patients who received what expected did better than those who did not.
Limitations: Statistical analysis / 6 month = is it still the result of 2 sessions of manip? / dropouts / voluntary basis
In practice: Patients with expectations of relief do better. Patient who’s expectations are met tend to do better than the opposite.
Bishop, M. D., Mintken, P., Bialosky, J. E., & Cleland, J. A. (2013). Patient Expectations of Benefit From Interventions for Neck Pain and Resulting Influence on Outcomes. Journal of Orthopaedic & Sports Physical Therapy, 43(7), 457–465. https://doi.org/10.2519/jospt.2013.4492
Aims: The purpose of this clinical perspective is to highlight the potential role of expectation in the clinical outcomes associated with the rehabilitation of individuals experiencing musculoskeletal pain.
Methods: Perspective = Expert opinion
Results: Expectations are associated with clinical outcomes, satisfaction, and influence of behaviour. 4 levels: Predictive = What he believes will happen, Ideal = what he wants, Normative = what should occur, or unformed = lack of preconceived notion. The current definition of expectation is highly variable. Expectation appears to be influenced by a number of individual factors; however, the influence of these factors may be specific to the situation and individual. Currently, the measurement of expectation is not standardized, and failure to fully clarify expectation may lead to confusion regarding measurement methods and numerous measurement approaches. Variability in the measurement of expectation has implications for the generalization of results among studies and from research to clinical practice, as self- report of expectation differs by the measurement tool used.
Despite these inconsistencies, an association exists between predicted expectations and outcomes related to musculoskeletal pain regardless of the method of measurement.
Studies suggest an association between predicted expectation and outcomes related to MSK pain conditions. Furthermore, they suggest a prognostic value for expectation in the treatment of individuals experiencing MSK pain that may surpass the type of treatment provided. Specifically, the exact intervention may not be as important as the individual expectation for the intervention.
Outcomes, therefore, may not depend wholly upon the type of treatment provided, but also are influenced by individual attitudes or beliefs regarding the treatment. Manipulation of expectation, as is common in the placebo literature, suggests a causative effect of expectation on pain-related outcomes that may translate to the clinical management of MSK pain conditions.
In practice: Considering expectations (Predictive and normative and not ideal) may help to choose among treatments with similar level of evidence to maximize effects.
Bialosky, J. E., Bishop, M. D., & Cleland, J. A. (2010). Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing Musculoskeletal Pain. Physical Therapy, 90(9), 1345–1355. https://doi.org/10.2522/ptj.20090306
Altogether, the complete consensus initiative involved 84 clinicians from 22 European countries. The question–answer sets were related to the four following subjects: the background of degenerative meniscus lesions (A), their imaging (B) and management (C), as well as a diagnostic and therapeutic algorithm (D).
Aims: To determine the efficacy of neural mobilization (NM) for musculoskeletal conditions with a neuropathic component.
Methods: SR with MA. Included if MSK issue with ND component, assessing NM efficacy assessing pain, disability, and function. Studies’ risk of bias assessed, 2 reviewers …
Results: 40 studies with 1759 participants. NM is effective in the management of nerve-related low back pain, nerve-related neck and arm pain, and plantar heel pain and tarsal tunnel syndrome. NM seems not to have a positive effect on outcomes measured in the management of carpal tunnel syndrome. Positive neurophysiological effects were present in groups that received NM.
Bias: Limited evidence, small study samples most of the time + heterogeneity of included studies.
In Practice: NM helpful to improve pain, function & disability in patient with MSK conditions with ND involvement. It also reduces intraneural œdema.
Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 47(9), 593–615. https://doi.org/10.2519/jospt.2017.7117
Aims: Synthetize EMG findings in order to better understand the role of gluteal muscle activity in the aetiology, presentation and management of PFPS
Methods: SR 2 independent assessors, Downs and Black Quality Index25 and the PFPS diagnosis checklist. 10 studies included.
Results: Current research evaluating the association of gluteal muscle activity with PFPS is limited by an absence of prospective research. Moderate-to-strong evidence indicates that GMed muscle activity is delayed and of shorter duration during stair ascent and descent in individuals with PFPS. Additionally, limited evidence indicates that GMed muscle activity is delayed and of shorter duration during running, and GMax muscle activity is increased during stair descent.
Limitations: Quality too used, no blinding of assessors, low quality of included studies.
In practice: Assessing, targeting interventions toward hip muscles may have an impact on PFPS? However, the effects and effectiveness of such interventions is yet unknown.
Barton, C. J., Lack, S., Malliaras, P., & Morrissey, D. (2013). Gluteal muscle activity and patellofemoral pain syndrome: A systematic review. British Journal of Sports Medicine, 47(4), 207–214. https://doi.org/10.1136/bjsports-2012-090953
Aims: Present a comprehensive model of potential individual mechanisms of MT that the current literature suggests as pertinent and the potential interaction between these individual mechanisms.
Methods: Expert Literature review.
Results: The literature suggests:
Biomechanical effect of MT; however, lasting structural changes have not been identified, clinicians are unable to reliably identify areas requiring MT, the forces associated with MT are not specific to a given location and vary between clinicians, choice of technique does not seem to affect outcomes, and sign and symptom responses occur in areas separate from the region of application. The effectiveness of MT despite the inconsistencies associated with a purported biomechanical mechanism suggests that additional mechanisms may be pertinent.
-Peripheral mechanisms: Studies suggest a potential mechanism of action of MT on MSK pain potentially mediated by the peripheral nervous system through cytokines, b-endorphin, anandamide, N-palmitoy- lethanolamide, serotonin, endogenous cannabinoids and substance P levels.
-Spinal mechanisms: MT may exert an effect on the spinal cord. MT may decrease activation of the dorsal horn of the spinal cord (shown in rats). MT is associated with hypoalgesia, afferent discharge, motoneuron pool activity, and changes in muscle activity all of which may indirectly implicate a spinal cord mediated effect.
-Supraspinal mechanisms: Literature suggests the influence of specific supraspinal structures such as the anterior cingular cortex (ACC), amygdala, periaqueductal gray (PAG), and rostral ventromedial medulla (RVM) in response to pain. A trend was noted towards decreased activation of the supraspinal regions responsible for central pain processing. The model accounts for direct measures of supraspinal activity along with associated responses such as autonomic responses and opiod responses to indirectly imply a supraspinal mechanism.
Biases: Expert’s review = low level of evidence.
In practice: This model suggests a mechanical stimulus initiates a number of potential neurophysiological effects which produce the clinical outcomes associated with MT in the treatment of musculoskeletal pain.
Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy, 14(5), 531–538. https://doi.org/10.1016/j.math.2008.09.001
Do spinal mobilization / manipulation techniques have
a role in treatment of patients with LBP?
When I first trained to graduate as a physiotherapist,
I learned techniques to mobilize joints of the back. At this point of my life I
had absolutely no idea of any form of critical thinking. When I began my MSc, I
discovered that physiotherapy existed in social media. I started to witness a
debate opposing those for and those against manual therapy. I could not know
who was right, so I probably decided to believe the group that created the less
“dissonance” with what I learned, and the postgraduate courses I paid for. Then
during my MSc postgraduate training, I have been asked to explain why I was
using such techniques. This question made me stop and realize that I did not
know why I used them. I just did it because I was taught to and because I read
experts physios on social media that seemed to encourage it. With some step
back and information about cognitive bias, I then reached the following
conclusion. I did not know why I used these techniques, and my relationship
with manual therapy belonged more to faith than science. Now that I learned to
think, research and critique information, I will attempt to give some insights
on the effects of spinal mobilizations and manipulations techniques in the
field of manual therapy, hoping that it will encourage readers to reflect on
their own practice too. The techniques discussed in my blog will be the passive
accessory intervertebral movements (PAIVMS), passive physiological
intervertebral vertebral movements (PPIVMS), the mobilization with movement
(MWM) called sustained natural apophyseal glide (SNAG) when applied to the
spine and grade 5 manipulation techniques. I will use the “spinal mobilization
and manipulation therapy” SMMT acronym to encompass the aforementioned
Why do spinal
mobilization and manipulation techniques work? What are the current hypotheses
regarding their effects?
When I reviewed literature, I found that the
mechanisms underlying SMMT are not yet fully understood. However, three main
mechanisms are used to discuss their effects. The mechanical effects, the
neurophysiological effects and the non-specific effects. Each of these will be
discussed in a separate paragraph through the blog.
The mechanical effects are all effects that can be
produced only by mechanical and biomechanical properties of tissues affected by
the technique. One of the first hypothesis regarding the manual therapy’s
techniques was that they could “detect and correct biomechanical faults” (Joel E. Bialosky, George, & Bishop, 2008). It also
was first hypothesis of Brian Mulligan to explain the good outcomes he had with
his MWM as he proposed the “positional fault hypothesis” (PFH) in 1989. These similar
hypotheses seem not supported by evidence for several reasons. First because
the existence of the “faults” has not yet been demonstrated. Measuring them
validly and reliably remains difficult even when using powerful imagery
techniques, although it was studied in peripheral superficial joints (Vicenzino, Hing, Rivett, & Hall, 2011). This is
all the more complicated for clinicians and regarding the lumbar spine’s joints
that are not directly accessible to visual inspection and manual palpation. Secondly,
in lumbar spine, clinicians seem unable to agree on the location of the “fault”
(Seffinger et al., 2004). In this
systematic review the research team noticed that the majority of spinal
palpatory diagnostic procedures are not reliable and regarding lumbar spine,
that regional is superior to segmental range of motion assessment. In other
words, we could say that it is not possible to identify reliably a segmental
“fault” in the lumbar spine through manual palpation. Another interesting
element that is discussed by (Seffinger et al., 2004) is: what
is the clinical relevance of the “fault” ? Only 26% of included studies
recruited only symptomatic subjects and 17% had recruited both symptomatic and
asymptomatic persons. This information leads to a major questioning of the
relevance of what clinicians may find during these types of palpatory
procedures. Furthermore, it is not yet understood how positional faults could
impact pain and range of motion. Some authors proposed models in which the
positional faults could contribute to repetitive stress potentially leading to
pain and / or tissue failure (Comerford & Mottram, 2001; Dye, 2005). Even
though the theory is conceptually attracting, it remains experts’ opinion and low-level
evidence. The third point that tends to be conflicting regarding the
biomechanical fault hypothesis is about the specificity of the intervention
itself. Indeed, the application of a passive physiological or accessory
movement to a precise segmental joint in the lumbar spine may not be supported
by literature (Lee & Evans, 1997). For
example, during a prone posteroanterior mobilization, the force spreads through
a large area moving several joints and all surrounding soft tissues. The
movement affects every joint of the lumbar spine. The whole extension movement
is a three-point bending between the ribcage and the pelvis. A posterior
translation of vertebras superior to the point of applied force occurs while
the inferior joints translate anteriorly (Lee & Evans, 1997). It is
then difficult to admit that a technique that cannot aim a specific area could
correct a “positional fault” which is barely identifiable with extremely
developed imagery. All this again shows that the hypothesis of a biomechanical
fault that would be corrected through manual therapy by the clinician cannot
currently be identified as a fully or partly responsible for SMMT’s effects.
The lack of support of this theory does not imply that
SMM techniques do not have any mechanical
effect. Indeed, human tissues demonstrate viscous and elastic characteristics
and hence react to viscoelastic properties like “creep” and “preconditioning”.
The creep phenomenon is the elongation of a viscoelastic structure subject to a
constant force which is lesser than its rupture point (Twomey & Taylor, 1982). In other
words, while applying a constant strain on a tissue, it will elongate through
time. This phenomenon is probably due to the modification of water distribution
and collagen fibers’ position within the structure (Carlstedt & Nordin, 1989). Creep
increases with load, progresses with time and is age dependent (Twomey & Taylor, 1982).In lumbar spine, sustained loading of a
posteroanterior force at L4 level during 30 seconds showed the greatest amount
of creep and then decreased with time (Evans, 1992). The
preconditioning phenomenon occurs when applying a cyclic loading to a vertebra
leading to an increase of displacement with each loading cycle. The effect of
preconditioning decreases with each cycle (Evans, 1992; Lee & Evans, 1994). Nevertheless,
the effects of creep and preconditioning are reversible, and unloaded
structures tend to return to their original size (Lee & Evans, 1994). Recovery
time has been shown to be longer than creep to occur, but half of the creep
effects disappears within two minutes in lumbar spine of young subjects after
twenty minutes of seated full flexion. (McGill & Brown, 1992). In study
by (Solomonow et al., 2000) after 50
minutes of cyclic loading of cats’ supra-spinal ligament 17% of creep had
recovered after 10 minutes and 92% after 7 hours. In the study by (Lu, Solomonow, Zhou, Baratta, & Li, 2004), after 7
hours rest, 64,4% of creep effect was still present. The duration of creep or
preconditioning cannot be precisely estimated clinically because the studies
mentioned above are laboratory studies, some studied animals’ tissues, and the
holding duration is not representative of the clinical encounter. The point I
am trying to raise is simply that some (temporary) mechanical effect is
produced during mobilization and cannot be denied, however it does not seem
responsible for the efficacy of the techniques alone either.
To summarize this paragraph, it can be said that
transient mechanical effects are likely to happen during mobilization and may
be sufficient to produce immediate increase in range of motion but there is insufficient evidence to
support the positional-fault hypothesis and their correction with SMMT.
With the increasing knowledge in neuroscience and the
difficulties faced when trying to prove the biomechanical effects of manual
therapy; new hypothesis emerged. The neurophysiological effects are the other
main category of effects that could be responsible for the efficacy of manual therapy
techniques. They are mainly subdivided in three areas. The local analgesic
mechanisms, the spinal cord mediated mechanisms and the supra-spinal
Regarding the local analgesia, evidence is lacking.
The theory is that mobilizations and manipulations could have an
anti-inflammatory effect. This explanation was developed because some studies
showed concurrent to local hypoalgesia measured through pressure pain threshold
: an increase in blood’s substance P level following cervical and dorsal
manipulation (Molina-Ortega et al., 2014); or a
raise in blood’s production of inflammatory cytokines unrelated to substance P
levels following upper thoracic manipulation (Teodorczyk-Injeyan, Ruegg, & Injeyan, 2006) or sympathoexcitation
after MWM. The primary hypoalgesia does not appear linked with endogenous
opioid system (Vicenzino, Paungmali, & Teys, 2007). However,
this theory implies that an inflammatory response is the origin of low back
pain which has not been demonstrated. In addition, the aforementioned studies
were done on asymptomatic subjects and the measures were at a global scale
(blood level) and not locally. It is then difficult to link these observations
with the local hypoalgesic effect. Moreover, we don’t know to what extent this
increase in substance P in the participants’ blood can affect pain or range of
motion in patients. More research is needed to ascertain the involvement of
these local analgesic mechanisms, but literature tends to show their existence
without explaining their impact. In conclusion, local analgesia measured with
pressure pain thresholds exists after mobilizations and manipulations, but we
are unable to understand the mechanisms explaining it at a local level.
The spinal cord-mediated mechanisms are another area
studied that is thought to be involved in effects of SMMT. According to (Pickar
& Bolton 2012) manipulations could stimulate joint’s mechanosensitive
paraspinal primary afferent neurons. They then hypothesized that this primary
afferent discharge could inhibit joint’s nociceptors’ activity. Their reasoning
relies on the “Pain Gate Theory” of (Melzack & Wall 1965) in which mechanoreceptors
could, in dorsal horn of spinal cord, inhibit the afferent activity of
nociceptors. Other studies showed that SMMT could impact temporal summation.
Temporal summation is a phenomenon of increase in pain when a constant
nociceptive stimulus is applied with a precise frequency. It is a phenomenon
known to be occurring in central sensitization and this wind-up phenomenon is happening
at level of spinal horn (J. E. Bialosky, Bishop, Robinson, Zeppieri, &
George, 2009; Bishop, Beneciuk, & George, 2011). In
studies on healthy participants, decrease in temporal summation has been showed
after manipulation at lumbar and thoracic levels (Bishop et al., 2011; George, Bishop, Bialosky,
Zeppieri, & Robinson, 2006). It was
also shown to be reduced after SMMT in low back pain participants (J. E. Bialosky et al., 2009). The
effect is thought to be local, as the measures taken above the manipulated area
had no change in temporal summation. However, it is yet unknown how a short
stimulus could modify efferent pathways for a longer duration lasting after the
end of the mobilization or manipulation. (Boal & Gillette, 2004) studied
the neuronal plasticity of spinal cord’s neurons. They suggested that manual
therapy could provoke long term depression of neurons in dorsal horn leading to
reduced central sensitization. In the other hand, an animal study (Skyba, Radhakrishnan, Rohlwing, Wright, & Sluka,
in which they blocked specific neurotransmitters showed that the analgesia
obtained after mobilization does not seem affected by dorsal horn mechanisms.
So, it is currently still unclear how this hypothesis of spinal cord mediation
of pain could be responsible for SMMT’s efficacy.
The third theory that has been studied is involving
the supraspinal mechanisms. It is thought that SMMT can stimulate descending
pain inhibitory pathways from periaqueductal grey matter (PAG). The study of (Hosobuchi, Adams, & Linchitz, 1978) showed
that electric stimulation of periventricular and periaqueductal gray matter can
create hypoalgesia in human. This reduction in pain can be inhibited by
naloxone which implies that brain can produce analgesia through morphine-like
substances. (Skyba et al., 2003) showed
that SMMT is likely to stimulate the PAG increasing release of spinal serotonin
and noradrenalin hence hypoalgesia, but they showed that this pathway was
non-opioid mediated. Systematic reviews seems to agree on the fact that SMMT
creates immediate hypoalgesia effect (Lascurain-Aguirrebena, Newham, & Critchley, 2016;
Millan, Leboeuf-Yde, Budgell, & Amorim, 2012; Voogt et al., 2015) at least
on some nociceptive stimuli like pressure pain threshold but not thermal pain
threshold. In contrast, research is conflicting regarding the location of
effects as some authors claim that the effect is global with increased PPT at
remote location (Coronado et al., 2012; Lascurain-Aguirrebena et al.,
2016; Vicenzino, Collins, & Wright, 1996) while other
systematic reviews are less conclusive saying that evidence is conflicting (Millan et al., 2012; Voogt et al., 2015). When
using SMMT, in addition to hypoalgesia, concurrent sympathoexcitation has been
demonstrated (Kingston, Claydon, & Tumilty, 2014) and seem
correlated with it. Indeed, increase in skin conductance and decreased skin
temperature has been measured in a RCT following cervical mobilization on 30
patients (Sterling, Jull, & Wright, 2001). They also
measured decreased motor activity of neck flexor leading to hypothesize that
the effects of manual therapy could be partly due to changes in muscles’ motor
activity. This could be another element that might be a factor in reduction in
pain and increase in patient’s ability to move following SMMT (Zusman, 1986). The model
proposed is that muscle inhibition could concurrently to changes in
nociception, reduce periarticular pressure hence reduction in pain.
To conclude, I would say that currently, precise
supraspinal mechanisms responsible for effects of SMMT are unknown, but some
evidence of its role has clearly been demonstrated and it is currently the most
plausible hypothesis that has been investigated. However, a combination of all
the previous hypothesis cannot be excluded either. The final effect might also
be reached by a combination of many mechanisms from local, spinal-cord and
The last point I would like to raise is about the nonspecific
effects. As any type of treatment, it generates non-specific effects, so it is
important to mention it. Placebo effect and other effects as patient-clinician
relationship, expectations etc. are present in all type of treatment and cannot
be avoided; so, we should always keep them in mind. In addition, non-specific
effects are the reason why RCT that does not include control group and placebo
like intervention group should be interpreted with caution. Manual contact has
been proven to induce sympathoexcitation measured with increased skin
conductance (Moulson & Watson, 2006; Petersen, Vicenzino,
& Wright, 1993); but also
increased activity of superficial neck flexors when hand contact with neck (Sterling et al., 2001). The
patient’s beliefs about the benefits of the intervention seems linked with its
results. In patients with neck pain, differences were found when comparing
results of an intervention with patient’s expectation about it, showing better
results when the patient had good expectations of relief from the technique (Bishop, Mintken, Bialosky, & Cleland, 2013). Another
study was performed on patients with chronic low back pain and also showed
better outcomes when the patient had good expectations of outcome. It also
showed that the patient’s preference may influence the outcome. Patients
expecting one type of treatment and receiving another one were less likely to
improve than the one receiving the treatment they expected (Kalauokalani, Cherkin, Sherman, Koepsell, & Deyo,
This is why it is an important part of evidence based practice to assess
patients’ expectations and preferences and discuss treatment options with them (Sackett, Rosenberg, Gray, Haynes, & Richardson,
The famous, well documented placebo effect also takes part into the global
effect of SSMT. Its precise psychological mechanism of action is not fully
understood but there is evidence of a lot of elements involved (Benedetti, 2005) that
cannot be developed in this blog, as it is not its primary aim. Clinical
outcomes are influenced by all kind of contextual elements ranging from the
patient-physiotherapist’s relationship, the care settings, or personal features
(of patient or therapist) (Testa & Rossettini, 2016). It has
been shown that clinicians can positively or negatively influence outcomes with
verbal suggestions (Van Laarhoven et al., 2011). All this
illustrates well that SMMT’s efficacy can also be influenced positively or
negatively with non-specific effects. So, there is no reason they would not be
a part of SMMT’s efficacy and be reminded in their mechanisms of action.
Now that I have written this blog, I can eventually
explain what science has proven regarding the effects of spinal mobilization
and manipulation techniques. It has been proven that mechanical effects exist
following SMMT. That neurophysiological effects like hypoalgesia (measured with
increased pressure pain threshold, reduction in VAS scores and functional
scores); sympathoexcitation (measured through skin temperature changes, skin
conductance), and muscles motor activity changes are happening following SMMT.
However, it is not precisely known yet how these parameters are modified at
local, spinal-cord and supraspinal levels although some hypotheses have been
formulated. From now on, every time I will use manual therapy techniques, I
will be able to explain what I expect from it and be aware of current evidence
regarding effects of spinal mobilization and manipulation techniques. This
makes me less of a believer and more of an evidence based driven clinician.
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An interesting read. I just have a couple of questions and I will try to keep them short! You start talking about the accuracy of using palpation as a diagnostic tool to identify the structure at fault. You ask “How can I know that the ‘restriction’ noticed during my assessment is related to the patient’s presentation if it can be found in asymptomatic persons?” I would like to ask you isn’t this a similar issue to a lot of diagnostic testing in the physiotherapy world? Therefore, do you think you can still use this along with other subjective/objective information to support your hypothesis? If so, could you expand on how you would do this and what other information you could use to support your clinical rationale? Finally, I would ask how relevant is knowing the exact structure at fault in relation to getting the patient better and do you know of any evidence looking at this?
There are a few questions there which roll into one and hopefully you get my point.
Thank you for your questions
Regarding the first part of
your first question about the use of palpation: I completely agree with the
fact that this issue is common in our practice. But knowing this does not give
any justification for or against the use of palpation as a diagnostic tool. I
would like to specify that I do not condemn the use of palpation for diagnostic
purpose. My aim was to inform that alone, palpation of a hypothetical
“positional fault” is not enough to link it with the patient’s issue, as these
“faults” can be found in asymptomatic population. Therefore, it cannot be used
to validate the hypothesis of positional faults to explain the efficacy of
However, as you mentioned in the second part of
your question, if these findings are linked with subjective assessment or
symptom reproduction; then they might be useful for the clinician. (Rabey et
al., 2017) Not that they would indicate a positional fault, but they could
indicate a local tenderness to mobilisation or pressure that could be linked
with other elements of the assessment. They could be used as an asterisk marker
for the clinician and reassessed after SSMT treatment for example. So, I could
use palpation in combination with symptom reproduction, limited range of
motion, elements from the subjective assessment to get a global picture of the
patient. But it would still not provide any information to support a positional
misalignment of a vertebral segment. Indeed, there is no evidence of this
theory as I explained it in the paragraph. To conclude, my point was not to
blame the use of palpation in clinical practice as it provides information; it
simply was to illustrate that it cannot explain in itself the theory proposed
to explain the “positional fault hypothesis” which still has not been
Then to answer your second question about
knowing the exact structure at fault, it is a really interesting topic even
though it is more related to diagnosis of LBP and efficacy of SSMT than their
effects. However, the assumption according to which knowing which structure is
responsible for the patient’s issue is attractive. Especially when trying to
figure out what is happening during the technique we perform. However, we saw
in the blog that we cannot reliably identify the restricted level with
palpation nor with imagery. Let’s imagine we could, would it be more efficient
than applying SMMT randomly on the spine? Some articles seem to lead in this
direction. (Aquino et al., 2009) showed in the cervical spine that improvement
in pain is achieved irrespective of the location of the mobilisation in one
session in a chronic cervical pain sample of patient. Regarding this study,
several elements should be considered. The sample is relatively small. The
random location is not developed and could be close enough to the most
restricted segment to mobilise it too, especially in such a small area as
cervical spine. As it has been shown in lumbar spine, mobilisation do not
affect a precise joint but multiple joints around the point of application (Lee
& Evans, 1997). Aquino’s study measured only pain response and did not
evaluate mobility, and it was measured in chronic patients on the results of
only one session of treatment without developing how long and how many
repetitions were used. Then, it is difficult to draw firm conclusions against
the use of targeted mobilisation. Another study also seems to suggest that
directing a manipulation technique towards a precise or random location has the
same effects. This study should also be interpreted carefully as the specific
treatment used is not specific. Indeed, manipulations have been showed to occur
in the whole thoracolumbar spine but that they could not be aimed at a
segmental level (Bialosky, George, & Bishop, 2008). So, this study compares
two non-specific techniques. Then it cannot be concluded that all SMMT can
randomly be applied to produce effects. The third study is the most interesting
and best conducted one. A study by (Donaldson, Petersen, Cook, & Learman,
2016), showed that lumbar segmental mobilisation in chronic low back pain
patients do not differ whether it is performed on the most provocative level or
on L4-5. One issue here is that the most painful level has not been assessed in
patients receiving L4-5 mobilisation and a part of this group could have their
tender spot on this location. The study showed no difference between groups.
But it can be due to the absence of selection of patients that might be better
responders to this type of treatment. Maybe if correctly identifying responders
to SSMT, targeting the mobilisation on this subgroup of patient would be more
beneficial; but this is still an under-studied area (Rabey et al., 2017) and it
does not refute the study’s results in anyway. However, interestingly even
though the study showed no difference in outcomes between groups, it still
revealed a significantly better global rate of change (GROC) in the targeted
mobilisation group at the 4th session and six-month follow-up. This result
indicate that a difference might be achieved in some way. The GROC might be a
tool which is global, it is still interesting. Indeed, as will be developed in
part two and three and already mentioned in the previous part, SMMT needs to be
viewed as a tool to improve the patient as a whole. Within a new framework in
which through SMMT we can modify the patient’s symptom, and in combination with
explanation about pain, bringing confidence in movement and empowering the
patient to move; SMMT may still have an important role to play in
To conclude I would say that these techniques
have effects on the person for sure, but its mechanisms of action are more
global than explained by “positional fault” theory initially introduced in
1989. However, even though SMMT cannot affect a precise vertebra, it is worth
considering the location of maximal stiffness and symptoms while applying them.
First because it is more likely to fit with the patient’s expectation or belief
and hence increase non-specific effects (see part 3). Secondly, because we are
not sure yet whether it can improve outcomes or not. If targeting a spinal
level may or not improve outcome for some patients, it surely does not worsen
results either. So, it is worth applying them on the most provocative location
rather assuming that it does not make a difference. It does not require much
more effort from the clinician to apply pressure on a spot or another, but it
might lead to better outcomes. Then, I would definitely go for the most
Aquino, R., Caires, P., Furtado, F., Loureiro,
A., Ferreira, P., & Ferreira, M. (2009). Applying Joint mobilization at
Different Cervical vertebral Levels does not Influence Immediate Pain Reduction
in Patients with Chronic Neck Pain: A Randomized Clinical Trial. The Journal of
Manual & Manipulative Therapy, 17(2), 95–100. https://doi.org/DOI:
Bialosky, J. E., George, S. Z., & Bishop, M. D.
(2008). How Spinal Manipulative Therapy Works: Why Ask Why? Journal of
Orthopaedic & Sports Physical Therapy, 38(6), 293–295.
Donaldson, M., Petersen, S., Cook, C., &
Learman, K. (2016). A Prescriptively Selected Nonthrust Manipulation Versus a
Therapist-Selected Nonthrust Manipulation for Treatment of Individuals With Low
Back Pain: A Randomized Clinical Trial. Journal of Orthopaedic & Sports
Physical Therapy, 46(4), 243–250. https://doi.org/10.2519/jospt.2016.6318
Rabey, M., Hall, T., Hebron, C., Palsson, T. S., Christensen, S. W., & Moloney, N. (2017). Reconceptualising manual therapy skills in contemporary practice. Musculoskeletal Science and Practice, 29, 28–32. https://doi.org/10.1016/j.msksp.2017.02.010