Management of Lumbar Spinal Stenosis through the Use of Translatoric Manipulation and Lumbar Flexion Exercises: A Case Series

Abstract

Lumbar spinal stenosis is a narrowing of the spinal canal or intervertebral foramen that can produce low back pain and leg pain and weakness. Surgical intervention is commonly performed to relieve these symptoms. Symptom reduction and longitudinal management of functional deficits with conservative care is less well documented. The purpose of this case series was to describe the outcomes of a conservative physical therapy program consisting of low- and high-velocity translatoric manipulations of T1-T9 and L1-L3, and two lumbar flexion exercises on 6 subjects diagnosed with lumbar spinal stenosis and neurogenic claudication. A treadmill test was repeated on a weekly basis and at discharge for each patient. All six subjects demonstrated improvements in treadmill walking time prior to the onset of neurogenic claudication (range: 1 min 34 sec to 26 min); in Oswestry Low Back Pain Disability Index scores (range: 7.5% to 64.7%); and in McGill Pain Questionnaire scores (range: 25% to 57%). Five subjects were measured using the Schober technique, and all showed improvement in thoracolumbar flexion mobility. Combined use of translatoric manipulation and spinal flexion exercises may have resulted in improved spinal flexibility, ambulatory abilities, and pain and functional status in six subjects with lumbar spinal stenosis.     

Spinal manipulative therapy for low back pain: A systematic review

Abstract

Objectives: Gather and analyse relevant literature on spinal manipulative therapy for low back pain through systematic review to present a balanced and impartial summary of the findings. The aim of this systematic review was to investigate the efficacy of spinal manipulative therapy in patients with low back pain.

Methods: Databases searched included COCHRANE, MEDLINE, EMBASE, PEDro, PUBMED, WEB OF KNOWLEDGE, INGENTA CONNECT and GOOGLE SCHOLAR between January 2000 and January 2008. Sixteen articles were retrieved. Standardised inclusion and exclusion criteria were applied to select articles relevant to the review question. Seven studies were excluded and nine studies were included. In the next step, the methodological quality of the included studies was assessed with the PEDro scale, which rated the studies from 0 to 10.

Results: Methodological quality scores ranged from 4 to 8 out of a possible 10. Spinal manipulative therapy can be preferred for short-term relief of low back pain when compared with general exercise and dynamic strengthening exercises, which is revealed by a high quality study, moderate quality studies and a low quality study. Spinal manipulative therapy combined with exercise is more effective than exercise alone, which is revealed by a high quality study.

Conclusions: Further studies are needed to improve the quality of the evidence. There is evidence that spinal manipulative therapy combined with exercise is more effective than other procedures like spinal manipulative therapy, exercise or physician consultation alone.     

Coupling Behavior of the Lumbar Spine: A Literature Review

Abstract

Coupling behavior has been described as fundamental to the theory of lumbar biomechanics. Different manual therapy approaches use discrepant coupling biomechanical models. Despite these inconsistencies, coupling models have been frequently used in the management of low back pain. The purpose of this paper is to investigate evidence for the use of coupling biomechanical modeling in manual therapy assessment and treatment. The findings of this paper suggest that use of a single dogmatic lumbar spinal coupling approach utilizing a side-bend initiation may not be appropriate and could lead to unreliable findings. The use of rotation initiation needs further consideration. Coupling behavior may be more consistent if rotation is initiated first, however there is insufficient evidence to substantiate this view.     

The temporal effects of a single session of high-velocity,low-amplitude thrust manipulation on subjects with spinal pain

Abstract

Background: A high velocity, low amplitude thrust manipulation (HVLAT) is an intervention commonly used in the treatment of patients with spinal pain. Recent studies have reported on the possible neurophysiological effects of this technique which may be pertinent to the therapeutic value of these procedures. However, few studies have examined the temporal neurophysiological nature of a HVLAT beyond the immediate effects.

Objectives: The purpose of this review is to summarize the literature on the temporal neurophysiological effects of a single HVLAT in patients with spinal pain.

Methods: A systematic search of English articles was conducted using MEDLINE, CINAHL, and PEDro. Additional studies were identified with a hand search of the references of relevant articles. Search terms included spinal manipulation, chiropractic manipulation, osteopathic manipulation, spinal adjustment, cervical manipulation, lumbar manipulation, sacroiliac manipulation, neck pain, back pain, and sacroiliac pain. Quality scoring of the included articles was based on the Newcastle–Ottawa criteria.

Results: Of the 478 articles identified, five articles ultimately met inclusion criteria into this review. These studies were of moderate to high quality. In all, follow-up measures after a single HVLAT were taken within a 30-minute to 5-hour period.

Conclusion: In the absence of concurrent intervention, the neurophysiological effects seen after administration of a HVLAT were observed to be immediate in nature, with a return to baseline or reduction in effect noted at follow-up. Future studies examining the mechanisms of HVLAT should include dedicated follow-up periods to establish the temporal changes related to these techniques.     

Lumbar Spinal Stenosis: Therapeutic Options Review

Lumbar spinal stenosis (LSS) functionally impacts significant numbers of Americans per year. Current estimates place the number of Americans suffering from senescent lumbar spinal stenosis at 400,000. The prevalence of this disorder in patients ranging from 60 to 69 years of age is very high. Forty‐seven percent of this age group have mild to moderate stenosis, and 19.7% have severe stenosis. As the baby boomer generation gets older, 10,000 individuals attain the age of 65 years every day in United States. LSS is becoming very common and will be a major healthcare issue as the population ages. Although LSS is not life threatening, it can cause substantial disability with limitations to performing daily activities, and thus, the associated negative impact on quality of life (QOL). This article reviews the pathophysiology and current treatment options for LSS, focusing on evidence‐based treatment options.     

Abstracts of Current Literature

Abstract

The objective of our study was to determine the effectiveness of manual therapy for balancing C1 and a home exercise program, including active neck retraction exercises performed in a series of progressions, in the treatment of cervicogenic headache. The subjects included a 42-year-old male (Subject 1) and a 25-year-old female (Subject 2), both with a primary complaint of right-side suboccipital headache. Subject 1 was functionally limited in reading, sleeping, and playing basketball. Subject 2 reported problems with working, sleeping, and running on a treadmill. Both subjects met the criteria for cervicogenic headache as adapted from the International Headache Society. On Day 1, each subject completed three self-report measures: a numeric pain scale for both worst and average headache pain as well as the Patient Specific Functional Scale. Each subject was treated on Days 1, 3, and 5. Intervention included using a muscle energy technique for balancing C1 and a home program consisting of a progression of McKenzie's retraction/extension/rotation exercises. Each subject was told he/she may continue the home program on his/her own accord every 2 hours or as a headache occurred. On days 12 and 26, each subject completed the previous three self-report measures as well as the Global Rating Scale during blinded follow-up phone visits. The subjects demonstrated an increase in functional activities, a decrease in average and worst headache pain, and an overall improvement in their perception of change in the headache. Manual therapy in addition to a home program of active neck retraction exercises in a series of progressions was successful in relieving cervicogenic headache and improving function in two subjects. Patients with cervicogenic headaches could be empowered to alleviate their own symptoms with decreased physical therapy visits and decreased cost by having a manual therapy technique performed on them followed by a home exercise program.     

Lumbar Spinal Stenosis

Questions from patients about pain conditions and analgesic pharmacotherapy and responses from authors are presented to help educate patients and make them more effective self-advocates. In reply to a question, lumbar spinal stenosis, commonly a multifactorial disease that can have profound functional consequences, is considered, along with a discussion of physical and pharmacologic treatments and quality of life.     

Neuroanatomical Review of Visceral Pain

Abstract

Visceral afferent information is processed centrally by the nervous system. The central connections of these afferents are widespread. Although the encoding of visceral pain is still creating much debate, evidence exists for mechanisms of central sensitization and mechanisms of referred pain to somatic structures, leading to possible trophic changes in these structures.

The autonomic nervous system innervates the viscera. As with the somatic nervous system, it too is vulnerable in certain areas to compromise, within the thoracic, abdominal and pelvic cavities for example. If the sympathetic nervous system is sensitized then alterations in sympathetic outflow could lead to trophic alteration in target tissue, as well as the maintenance of pain states.

If, at a physical level, manual therapists are to evaluate these central and sympathetic changes that may take place due to sensitized visceral and sympathetic input in the generation and maintenance of pain, then a physical assessment of the visceral and supporting fascial network must be made in the management of chronic pain states.     

A Multi-Structural Approach to Treatment of a Patient With Sub-Acromial Impingement: A Case Report

Abstract

Sub-acromial impingement is a condition commonly seen by physical therapists, however little evidence is available regarding the efficacy of this treatment. This case report describes the use of manual therapy and exercise, using a multi-structural approach to manage this condition. The subject was a 48-year-old retired physiotherapist complaining of recurrent shoulder pain during daily activities, although her daily function was not limited. Passive joint mobilization techniques of the cervical spine, costovertebral joints, and the glenohumeral joint as well as soft tissue mobilization techniques of the rotator cuff muscles were used. Exercises were prescribed to “set” the scapula in an optimal position and to facilitate and strengthen the rotator cuff muscles. After two treatments, the patient consulted an orthopaedic surgeon due to imminent decrease in funding for her treatment and a cortisone injection was administered. This decreased her pain immediately by 90%. However, two months later she attended three further physical therapy treatments because of recurrence of the pain. Six months after these treatments she was still pain-free. This case illustrates that physical therapy can be effective in the treatment of sub-acromial impingement, using a multi-structural approach to treatment.     

Cervicogenic Dizziness: A Case Report Illustrating Orthopaedic Manual and Vestibular Physical Therapy Comanagement

Abstract

The diagnosis and treatment of patients with dizziness of a cervical origin may pose a challenge for orthopaedic and vestibular physical therapy specialists. A thorough examination, which consists of a screening examination to rule out pathologies not amenable to sole physical therapy management and, if indicated, a physical therapy differential diagnostic process incorporating both cervical spine and vestibular tests and measures, may indicate an appropriate course of management. The treatment progression is then based on patient signs, symptoms, and response to physical therapy interventions. This case study describes the diagnosis, treatment, and outcomes of a patient with cervicogenic dizziness co-managed by a vestibular and an orthopaedic manual physical therapist.     

Thumb Pain in Physiotherapists: Biomechanical Causes of Pain and Alternate Methods of Preventing Distress in Treatment

Abstract

Many therapists have been burdened with the danger of developing trauma of the thumb following continuous mobilizing with the thumb. This paper discusses the anatomical and arthrokinematic implications of using longitudinal pressure through the thumbs in manual therapy. Alternative methods performed not using the thumb in this manner may be of more benefit to the therapist. The use of arthrokinematic principles may assist the therapist to minimize strength of force required to achieve the same results.     

Interaction between Trigger Points and Joint Hypomobility: A Clinical Perspective

Abstract

The relationship between muscle trigger points (TrPs) and joint hypomobility is frequently recognized by clinicians. Among different manual therapies aimed at inactivating muscle TrPs, ischemic compression and spinal manipulation have shown moderately strong evidence for immediate pain relief. Reduction of joint mobility appears related to local muscles innervated from the segment, which suggests that muscle and joint impairments may be indivisible and related disorders in pain patients. Two clinical studies have investigated the relationship between the presence of muscle TrPs and joint hypomobility in patients with neck pain. Both studies reported that all patients exhibited segmental hypomobility at C3-C4 zygapophyseal joint and TrPs in the upper trapezius, sternocleidomastoid, or levator scapulae muscles. There are several theories that have discussed the relationship between TrP and joint hypomobility. First, increased tension of the taut muscular bands associated with a TrP and facilitation of motor activity can maintain displacement stress on the joint. Alternatively, it may be that the abnormal sensory input from the joint hypomobility may reflexively activate TrPs. It is also conceivable that TrPs provide a nociceptive barrage to the dorsal horn neurons and facilitate joint hypomobility. There is scientific evidence showing change in muscle sensitivity in muscle TrP after spinal manipulation, which suggests that clinicians should include treatment of joint hypomobility in the management of TrPs. Nevertheless, the order in which these muscle and joint impairments should be treated is not known and requires further investigation.     

腰椎管狭窄症的运动处方：附9例报告

为了评价腹肌锻炼对腰椎管狭窄症的疗效，我们选了９例患者。并对治疗前后静态和动态肌力，椎管矢状径等进行了比较。结果显示：疗效优３例，良５例，差１例。治疗后腹肌肌力增强。治疗前、后椎管矢状径分别为（８．７２±０．４４）ｍｍ和（１０．７８±０．４４）ｍｍ，有显著性差异（Ｐ＜０．００１）。所以，我们认为腹肌锻炼是腰椎管狭窄症的一种有效治疗方法。     

腰椎管狭窄症并腰椎不稳的手术治疗

目的:探讨腰椎管狭窄症合并腰椎不稳的诊断和治疗。方法:52例腰椎管狭窄症合并腰椎不稳,男31例,女21例,平均年龄58.7岁,采用双侧半椎板有限元减压保留棘突韧带同时加椎弓根螺钉内固定植骨术治疗。结果:随访1.5～4.5年,平均2年7个月,植骨全部愈合,内固定位置正常,但有4例延迟愈合。术前JOA评分平均3.2分,术后平均13.8分,平均改善率89.83%,优良率94.23%。结论:在充分减压的同时保留棘突韧带,提供椎弓根螺钉内固定并植骨,能保持脊柱的稳定性,临床应用疗效肯定。     

Short-Term Effect of Muscle Energy Technique on Pain in Individuals with Non-Specific Lumbopelvic Pain: A Pilot Study

Abstract

Muscle energy technique (MET) is a form of manual therapy frequently used to correct lumbopelvic pain (LPP), herein the patient voluntarily contracts specific muscles against the resistance of the clinician. Studies on MET regarding magnitude and duration of effectiveness are limited. This study was a randomized controlled trial in which 20 subjects with self-reported LPP were randomized into two groups (MET or control) after magnitude of pain was determined. MET of the hamstrings and iliopsoas consisted of four 5-second hold/relax periods, while the control group received a sham treatment. Tests for current and worst pain, and pain with provocation were administered at baseline, immediately following intervention and 24 hours after intervention. Separate 2x3 ANOVAs were used to assess results as change scores. Visual analog score (VAS) for worst pain reported in the past 24 hours decreased for the MET group (4.3mm±19.9, p=.03) and increased for the sham (control) group (17.1mm±21.2, p=.03). Subjects receiving MET demonstrated a decrease in VAS worst pain over the past 24 hours, thereby suggesting that MET may be useful to decrease LPP over 24 hours.     

Systematic Review of Effects of Manual Therapy in Infants with Kinetic Imbalance due to Suboccipital Strain (KISS) Syndrome

Abstract

The goal of this systematic literature review was to establish the effects of manual therapy, chiropractic, or osteopathic treatment of the kinetic imbalance due to suboccipital strain (KISS) syndrome in infants with positional preference, plagiocephaly, and colic. We searched PubMed, Embase, and the Cochrane Library for articles on the effects of manual therapy, chiropractic, and osteopathy for the KISS syndrome. In addition, experts in the field of manual medicine and osteopathy were asked to provide relevant articles, and the bibliography in a textbook of manual therapy for children was hand-searched for additional references to the syndrome. This search strategy located no clinical trials that evaluated the effects of manual therapy or osteopathy on either the KISS syndrome or its symptoms. However, pooled analysis of two randomized clinical trials on the effects of chiropractic in infantile colic showed no statistically significant difference between active and control treatments. In addition, we found that 22% of infants showed short episodes of apnea during manual therapy of the cervical spine and that one case has been described in which apnea after Vojta therapy resulted in death. Given the absence of evidence of beneficial effects of spinal manipulation in infants and in view of its potential risks, we conclude that manual therapy, chiropractic, and osteopathy should not be used in infants with the KISS-syndrome outside the context of randomized double-blind controlled trials.