This document describes a preliminary study investigating the effectiveness of Translatoric Spinal Manipulation (TSM) techniques for improving cervical range of motion and pain. The study compared the effects of high velocity (HV) and low velocity (LV) TSM techniques in participants with neck pain and stiffness. The results showed that both HV and LV TSM techniques improved cervical range of motion, reduced pain, and improved function, with no significant differences between the techniques. The LV techniques showed a greater reduction in pain levels compared to HV techniques. No adverse events were reported.

1. ERIK DE MEULEMEESTER, PT, DSCPT, OMPT
Oakland University

2.  Translatoric Spinal Manipulation¹ or ‘TSM’ was
developed by Olaf Evjenth, PT, OMT and Freddy
Kaltenborn, PT, OMT
 TSM² can be performed at low velocity (LV) or a high
velocity (HV)
 LV: long amplitude; end of grade 2
 HV: amplitude of impulse is short as possible; end of
grade 2, across the final stop
2

3.  Mechanical:
 Enhance fluid movement through the joint⁴
 Stretch joint capsule and muscles crossing the joint
 Increase ROM
 Neurophysiological⁴ :
 Muscle relaxation and pain reduction may be
facilitated at both the spinal and supraspinal levels
3

4.  The effect of spinal manipulation on cervical mobility
 Kondratek et al⁷ in 2006, Creighton et al⁸ in 2005
described pre-positioned C0 & C1 traction for
improvement of neck pain and mobility
 Krauss et al⁹ in 2008 has described the effect of
thoracic manipulation on the relief of cervical
symptoms.
 Puentedura et al¹º in 2011 demonstrated the
effectiveness of cervical manipulation on pain
4

5.  Use of TSM techniques to improve cervical mobility and
pain
 No adverse events were are recorded when
practicing TSM techniques
 Limited cervical mobility may be treated safely with
TSM techniques ⁷,⁸,⁹
 The VA is not compromised with non-thrust TSM
techniques¹¹
5

6.  No studies were found that describe cervical traction
manipulation (TSM), as a single-modal treatment in a
study with randomized group assignment.
 This information suggests a significant gap in the current
literature in the research of cervical manual therapy.
 The need to support the effects of cervical manual
traction is indicated to establish the use of cervical
traction manipulation as an efficacious intervention
option.
6

7. 1. To demonstrate the effectiveness of Translatoric Spinal
Manipulation (TSM) to reduce cervical pain and
stiffness.
2. To compare the effectiveness of a high velocity (HV)
and low velocity (LV) versions of the same cervical
traction technique.
7

8.  Approval was obtained from the respective ethics
committees
 Participants were recruited through a sample of
convenience, 3 subjects for each group
 Informed consent and screening forms were completed
by each participant
 Participants were randomly assigned to either ‘HV’ or
‘LV’
8

9.  Inclusion criteria:
 18 through 80 years of age
 primary complaint of neck pain and/or stiffness.
 Exclusion criteria:
 current infection, tumor,
 spinal fracture
 concurrently receiving manipulative treatment from
another practitioner,
 involvement in litigation, and/or currently involved in
workers compensation cases.
9

10.  TSM was performed in sitting, side lying, or supine, as
selected by the RA.
 After data collection:
 The therapist completed the intervention using other
interventions as selected by the treating therapist.
 The only limitation:
 participants from the HV group only received HV
interventions
 participants from the LV group only received LV
interventions
10

11. 11

12.  Data collection performed at the beginning of each of 6 PT
visits
 CROM measurements: flexion, extension, right /left side
bending, right / left rotation
 3 warm-up repetitions - stop at the onset of pain.
 Measure and record 4th, 5th, and 6th repetitions.
 Record the NPRS at the onset of pain
 Post intervention: CROM was used to guide the participant
to return the neck to the point where pain was produced
prior to intervention.
 NPRS value is reported at this point in the range 12

13.  Actively move the neck further, if possible; record CROM
 Record the NPRS at the end range of motion
 Each participant was followed for a total of six visits
within their rehabilitation period.
 NDI was completed before the first / after the sixth visit
13

14.  The difference between pre- and post intervention was
compared per visit for each direction (ANOVA, graph
chart)
 Pre- and post intervention pain levels were compared
(table comparison)
 NDI levels were compared pre visit 1 and post visit 6(bar
graph)
14

15. HV/LV Sex Weight Height Work Smoking Pain/Stiff/
Combo
Age
HV1 M 185 6.0 y y c 58
HV2 F 155 5.6 n n s 62
HV3 F 201 5.8 n n c 53
LV1 F 147 5.9 y y c 59
LV2 F 124 5.5 y n c 60
LV3 M 200 5.8 y y c 64
15

16. N Mean SD SEM MDC
Flex-HV 16 1.6281 3.24725 1.214 3.363
Flex-LV 18 2.6689 5.52631 2.066 5.724
Ext-HV 18 5.0033 3.00966 1.125 3.117
Ext-LV 18 5.2250 3.35431 1.254 3.474
RSB-HV 17 5.4141 4.26252 1.474 4.084
RSB-LV 17 3.6706 4.41374 1.527 4.231
LSB-HV 17 3.6494 2.99323 1.553 4.303
LSB-LV 18 4.8561 3.94564 2.047 5.672
RROT-HV 18 4.1522 5.75582 1.623 4.497
RROT-LV 18 5.9306 5.94848 1.677 4.646
LROT-HV 18 3.4661 3.17795 1.347 3.732
LROT-LV 18 3.7072 7.11838 3.018 8.363
16

17. FLEXION
0
1
2
3
4
5
6
7
8
9
10
11
12
TX1 TX2 TX3 TX4 TX5 TX6
EXTENSION
0
1
2
3
4
5
6
7
8
9
10
11
12
TX1 TX2 TX3 TX4 TX5 TX6
17
HV: Mean: 5.00 MDC95: 3.11
LV: Mean: 5.22 MDC95: 3.47

18. RIGHT SIDE BENDING
0
1
2
3
4
5
6
7
8
9
10
11
12
TX1 TX2 TX3 TX4 TX5 TX6
LEFT SIDE BENDING
0
1
2
3
4
5
6
7
8
9
10
11
12
TX1 TX2 TX3 TX4 TX5 TX6
18
HV: Mean: 5.41 MDC95: 4.08

19. RIGHT ROTATION
0
1
2
3
4
5
6
7
8
9
10
11
12
TX1 TX2 TX3 TX4 TX5 TX6
LEFT ROTATION
0
1
2
3
4
5
6
7
8
9
10
11
12
TX1 TX2 TX3 TX4 TX5 TX6
19
LV: Mean: 5.93 MDC95: 4.64

20.  No significant difference between the effects of HV and
LV on the change of Cervical ROM in any direction
(p<.05)
 Time had no significant effect on CROM for either HV
and LV (p<.05)
 The interaction between time and velocity failed to reach
statistical significant difference (p<.05)
20

21. Pre NPRS
level of 2 or
more
↓ 2 or more ↓ 1 or less ↑ 1 or more
HV LV HV LV HV LV HV LV
N % N %
Flex 8/18 4/18 3/8 37 3/4 75 4 1 1 0
Ext 6/18 6/18 0/6 0 1/6 17 6 5 0 0
RSB 9/18 6/18 4/9 44 6/6 100 5 0 0 0
LSB 9/18 6/18 4/9 44 5/6 83 5 1 0 0
RROT 6/18 6/18 4/6 66 4/6 66 2 2 0 0
LROT 6/18 7/18 3/6 50 5/7 71 3 2 0 0
18/44 24/35 25/44 11/35 1/108 0/108
41% 69% 57% 31% <1% 0%
21

22. 22
0
10
20
30
40
50
60
70
80
90
100
FLEX EXT RSB LSB RROT LROT
HV
LV
Percent

23. 0
5
10
15
20
25
HV1 HV2 HV3 LV1 LV2 LV3
NDI PreV1
NDI PostV6
23

24.  Effectiveness of TSM
 Both treatment groups showed a favorable response to
the intervention for ROM, pain, function
 No significant differences in cervical range of motion
within participants or between participants
 The LV group showed a larger reduction in pain than
the HV group.
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25.  To the best of my knowledge this is the first randomized
study to use the CROM-device as an outcome measure
for manipulative cervical traction techniques.
 Other studies have used the CROM device as an
outcome measurement tool, to investigate either a
thoracic manipulation or contra-lateral gapping in the
lower cervical spine.
 The studies that have investigated the effect of cervical
traction and traction manipulation, used functional
outcome measures (Neck Disability Index) and self-
report of pain (VAS and NPRS).
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26.  In the preliminary study we have a small sample size
which will make it difficult to detect any significant
changes with an ANCOVA analysis
 We did not ask the RA to report the position of the
intervention. It is possible the position of the intervention
may have an effect upon the outcome.
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27.  Orthopedic manual therapists use several manipulative
techniques for the treatment of pain and movement
impairments of the cervical spine.
 This preliminary study demonstrates that cervical
traction manipulation has a favorable response on
cervical range of motion, pain and function.
 No participant reported a significant increase in level of
pain or any adverse events during the interventions.
27

28.  1) Kaltenborn F. The Spine Basic Evaluation and Mobilization
Techniques. 5th ed. Olso, Norway: . OPTP Minneapolis, Minnesota.
2009.
 2) Krauss J., Evjenth O., Creighton D. TSM Translatoric spinal
manipulation for physical therapists Lakeview Media. 2006
 3) Evans DW. Review of the literature. Mechanisms and effects of
spinal high-velocity, low-amplitude thrust manipulation: previous
theories. Journal of Manipulative & Physiological Therapeutics.
2002;25(4):251-262.
 4) Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The
mechanisms of manual therapy in the treatment of musculoskeletal
pain: A comprehensive model. Manual Therapy. 2009;14(5):531-538.
28

29.  5) Constantoyannis C, Konstantinou D, Kourtopoulos H, Papadakis
N. Intermittent cervical traction for cervical radiculopathy caused by
large-volume herniated disks. Journal of Manipulative and
Physiological Therapeutics. 2002;25(3):188-192.
 6) Cleland JA, Childs MJD, McRae M, Palmer JA, Stowell T.
Immediate effects of thoracic manipulation in patients with neck
pain: a randomized clinical trial. Manual Therapy. 2005;10(2):127-
135.
 7) Kondratek M., Creighton D., Krauss J. Use of translatoric
mobilization in a patient with cervicogenic dizziness and motion
restriction: A case report. Journal of manual and manipulative
therapy 2006;13:140-51. Journal of Manual & Manipulative Therapy
(Journal of Manual & Manipulative Therapy). 2006.
29

30.  8) Creighton D, Viti J, Krauss J. Use of translatoric mobilization in a
patient with cervical spondylotic degeneration: a case report.
Journal of Manual & Manipulative Therapy. 2005;13(1):12-26.
 9) Krauss J, Creighton D, Ely JD, Podlewska-Ely J. The immediate
effects of upper thoracic translatoric spinal manipulation on cervical
pain and range of motion: a randomized clinical trial. Journal of
Manual & Manipulative Therapy (Journal of Manual & Manipulative
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 10) Puentedura EJ, Landers MR, Cleland JA, Mintken P, Huijbregts
P, Fernandez-De-Las-Penas C. Thoracic Spine Thrust Manipulation
Versus Cervical Spine Thrust Manipulation in Patients With Acute
Neck Pain: A Randomized Clinical Trial. Journal of Orthopaedic &
Sports Physical Therapy. 2011;41(4):208-220.
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31.  11) Creighton D, Kondratek M, Krauss J, Huijbregts P, Qu H.
Ultrasound analysis of the vertebral artery during non-thrust cervical
translatoric spinal manipulation. Journal of Manual & Manipulative
Therapy (Maney Publishing). 2011;19(2):84-90.
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