Presented at Low Back Pain Webinar (Indonesian Physiotherapy Association Chapter Bali Barat) 2023

1. Spinal
Manipulative
Therapy for
Low Back Pain
Firmansyah Purwanto
Pain Specialist Physiotherapist

2. Critical point of view for spinal manipulative
therapy
● Palpation, detect the
source of pain? – No!
● Correct positional
fault? – No!
● Fix posture? – No!
● Cure disease? – No!

3. Manual palpation
“Reliability of manual palpation tests in the assessment of LBP patients varies greatly.. Little is
known about the validity of these tests; therefore, their clinical utility is uncertain.”
Nolet et al. Chiropractic & Manual Therapies. 2021

4. When a clinician makes contact with the skin of the body,
the force crossing this thoracic skin–fascia interface would
be dominated by normal force components, while the shear
forces would be transmitted to the surrounding skin.
Bereznick et al. Clin Biomech. 2002.
Frictional properties of skin-fascia interface

5. Bishop, 2022.
Success in the treatment does not validate the theory!

6. The mechanism of spinal manipulative therapy
Central mediators:
● Changes in spinal excitability
● Changes in motor function
● Decrease in cortical
excitability
● Decreased activation in brain
pain processing areas
● Decreased activation of
facilitatory/increase in
inhibitory pathways
● Changes in resting state
brain functional connectivity
Top-down modulators:
● Habituation
● Graded exposure to mechanical stimuli
● Sensory discrimination training
● Cognitions & Expectations
● Placebo/meaning response
● Contextual factors
● Therapist effect
Biomechanical:
● Increase ROM
● Decrease passive
stiffness & active
stiffness
Neurophysiological:
● Changes the
concentration of
inflammatory and
pain mediator
substances
Peripheral mediators:
Bishop et al. Pain Manag. 2015

7. Contextual contributing factors in clinical setting
Verbal suggestion:
- This is going to help you
move better and have
less pain
Social cues:
- Eye gaze
- Body language
Treatment cues:
- Touch
External context:
Outcome expectation:
- My pain will go
away
Emotions:
- I am less anxious
Meaning schema:
- I am being cared
for
Internal context:
Wager & Atlas. 2015

8. Paradigm shift for spinal manipulative therapy
Structural model Process approach

9. SMT is a process not a product!

10. The power of touch
Roger et al, 2006; Miciak et al 2019
Patient Therapist
Acknowledging the individual
Giving-of-self
Using the body as a pivot point
Touch as therapeutic intervention – task-oriented
Touch used to physically aid a patient (assistive)
Touch used to gain information
Touch used to convey a message - how to perform activity
Touch used to encourage & show a caring attitude
Touch used to build a relationship
Touch used to produce a feeling of safety

11. Louw et al, 2016; Louw et al. 2018
Temperature Stress Movement Immune Blood flow
Pain neuroscience education to SMT

12. Louw et al, 2016; Louw et al. 2018
Pain neuroscience education to SMT
Stress
Temperature Movement Immune Blood flow

13. Louw et al, 2016
Pain neuroscience education to SMT

14. 1. What are possible causes and
contributing factors to the
patient's disorder?
2. Which treatment approaches
may be most effective?
3. How can patients be actively
engaged in the therapeutic
process?
The clinical hypothesis

15. 1. Screening for red flags
2. Screening for psychosocial contributing factors (e.g anxiety, fear of
movement, negative beliefs, work-related stress), lifestyle factors
(e.g level of physical activity, sedentary behavior) & health
comorbidities (e.g diabetes melitus, osteoarthritis, hypertension etc)
3. Assess if any functional impairment & neurological deficits
4. Assess if any specific lumbar dysfunction – use clusters of special
tests to rule in & rule out
5. Assess the patient’s expectation of recovery & the patient’s values &
goals
Principle of Assessment

16. IFOMPT Framework for Spinal Red Flags
Finucane et al, JOSPT. 2020.

17. Treatment-based classification
Cook, 2012.

18. 4/5 criteria present to predict a favourable
outcome (45% -95%) from manual therapy
1. Duration of symptoms <16 days
2. FABQ work subscale score <19
3. At least one hip with ≥ 35° of internal rotation
4. Hypomobility in the lumbar spine
5. No symptoms distal to the knee
Clinical prediction rules
CPRs are not a substitute for good clinical decision making; CPRs are a “process modifier”
within the clinical decision- making sequence.
Flynn et al. Spine. 2002; Delitto et al. JOSPT. 2012.

19. Using MT based on individual’s pain presentation - symptom modification
My Rule
Pain with no
limitation ROM
Pain with
limitation ROM
Exercise/Graded
Activity
Manipulation
Mobilisation
Self-mobilisation
* If good response after MT always progress to exercise. If negative response after exercise, add MT
as adjunct then evaluate. If negative response after MT? Try next session then evaluate.
Negative
response?
Negative
response?

20. Grades of oscillations
Beginning
range of motion
Point of limitation
Anatomic
limitation
Normal tissue Tissue resistance
(Stretch)
I
II
III
IV
V
Range of motion
Range of motion with over-pressure

21. Matching technique
Normal tissue Tissue resistance
(Stretch)
Pain
Pain
Pain

22. Practical
Hengeveld & Banks, 2013.
Assessment – Treatment dosage:: 2Hz (cycle/sec), Oscillating duration: 60s, Rest: 30s,
Repeat: 2x – Evaluation
PA central vertebral mobs PA unilateral vertebral mobs

23. Practical
Gyer & Michael. 2020
Specific lumbar mobilisation/
manipulation (rotation)
Contact: ipsilateral side
of processus spinosus
(targeted)
Always start with
mobilisation light to
moderate force then
HVLA
Remember not to keep
the patient at the barrier
for too long

24. Practical
Dynamic opener
5-6 gentle movements then reassess. if there is an
improvement, repeat several more movements. If the
same after mobilisations, repeat sets of mobilisations,
stop and reassess at next session.
Static opener
30-60 seconds at first. If better, repeat several times.
If the same, still repeat once more and reassess at
the next session.
Shacklock, 2005.

25. Lumbar manipulation
(rotation)
Gyer & Michael. 2020
Practical

26. Practical
Lumbopelvic
mobilisation/manipulation
Flynn et al, 2002; Cook, 2017.

27. “Cracking” sound
No direct evidence for the physiological
therapeutic benefit of the audible release
associated with the spinal manipulation.
Therapeutic benefits of the audible release are
likely to be psychological, and not physiological
⚠ Repeating manipulation shortly after the
joint has cavitated without an audible release,
aiming to “get an audible”, may even cause
damage as the joint is potentially stretched
beyond its anatomical range of movement.
Bakker & Miller. J Can Chiro Assoc. 2004

28. Early change after spinal manipulative therapy
predicts long-term improvements?
Cook et al. PTP. 2017.

29. Total: 5x session
Week 1: 2x/week
Week 2-4: 1x/week
Childs et al. Ann Intern Med. 2004.
Expected MT session for optimal outcome

30. What is the best technique for LBP?
Specific techniques proved no
better than a simple, general thrust
technique.
Manipulation and mobilization are
likely to reduce pain and improve
function for patients with chronic
low back pain; manipulation
appears to produce a larger effect
than mobilization, but the
difference considered ‘small’.

31. Current evidence of effectiveness of MT for LBP?
Acute LBP — Strong evidence - short term (1-3
months) - pain, function & health improvements
Chronic LBP
● Moderate to strong evidence - short term
- pain, function & quality of life
● Limited evidence - long term
Hidalgo et al, 2013; Aboagye et al, 2022.

32. Better outcome and lower costs with
manual therapy and home exercise
(Leininger et al, 2016)
Manual therapy is more cost-effective
than usual care, spinal stabilization,
advice to stay active (Tsertsvadze et
al, 2014).
Manual therapy is less expensive than
opioid initiated care for back pain
(Whedon et al, 2021)
Evidence of cost-effectiveness of MT for LBP?

33. Self-reflection
When? — Clinical reasoning
Why? — Clinical reasoning
What? — Clinical reasoning
How? — Knowledge-derived skills

34. NO long lasting effects occur as a result of
manual therapy to encourage the healing
process, to strengthen muscles, maintenance of
ROM, muscle length or muscle tone, and thus do
not result in the long term adaptation or
modification required to address the
CONTRIBUTING FACTORS of the condition or
dysfunction
Manual therapy MUST be used in conjunction
with an exercise or rehabilitation programme -
multimodal approach.
Spinal manipulative therapy = a tool in the toolbox

35. Any questions?