DO SPINAL MANIPULATIONS HAVE TO BE SPECIFIC FOR EFFECTIVENESS?
Physiotherapists and other clinicians are taught how to identify specific joint levels that are ‘injured’ or ‘stiff’, so that they can apply specific treatments to that area to ‘fix your back pain’.
But how crucial is specificity when it comes to treatment effectiveness?
Should you pick your healthcare provider based on their claim that they can:
1: Identify which specific level you have ‘injured’
2: Treat that specific level to give you the desired outcome (pain reduction/more mobility/’re-aligning’ etc).
OR does it not matter as much?
BACKGROUND: USE OF SPINAL MANIPULATIONS
Spinal manipulations, also known as spine cracking or clicking, have been used by manual therapists all over the world to help relieve pain and stiffness in people suffering from spinal pain. Read more about what Spinal Manipulations are here.
It is still a recommended treatment option by clinical practice guidelines (based on research) to be included as PART of the overall management of someone with spinal pain.
That means that spinal manipulations should NOT be the ONLY treatment/management tool that you use to treat somebody with spinal pain.
Current best practice guidelines recommend a combination of manual therapy, including spinal manipulations where indicated, with exercise rehabilitation protocols for the best long term benefits.
Personally, I do use spinal manipulations as part of my practice, and also teach it to students and newly graduated Physiotherapists as I believe it to be a helpful tool for the right patient, at the right time.
PROPOSED MECHANISM OF EFFECTIVENESS OF SPINAL MANIPULATIONS
In recent years, it’s been widely accepted that the actual mechanism of how spinal manipulations (and other manual therapy techniques) create benefit is through ‘neuromodulation’.
NOT actual physical changes.
That means - spinal manipulations are NOT realigning joints that are ‘out of place’, and they’re not directly ‘loosening’ joints.
Neuromodulation is the term that describes the neurochemical effects as a result of the spinal manipulation.
This is how I describe neuromodulation to a client:
Simply, once a manipulation is applied (mechanical stimulus in diagram), a neural stimulus has been inputted to the spinal segment and its surrounding area, in turn sending inhibitory signals to the brain which helps the brain perceive ‘less pain’, achieving a clinical outcome.
Once the brain perceives less pain, it will reduce the level of neural activity sent back down to the spine, therefore reduce its level of ‘tone’, making it feel more relaxed, less pain and more mobility.
Diagram showing the pathways of effect of Manual Therapy (MT), including spinal manipulations.
ONE OTHER POSSIBLE EFFECT OF SPINAL MANIPULATIONS
We also cannot ignore the fact that spinal manipulations ARE highly skilled procedures.
Many therapists even choose NOT to utilise them as they do take lots of time and effort to become competent in.
Knowing this, clients who choose a therapist who CAN do manipulations view them as being ‘skilled’ and more trustworthy, adding to their confidence in their therapist. They’ll be more likely to listen to their therapist's advice, and are more likely to have a better recovery outcome.
THE VERDICT - SPECIFIC VS NON SPECIFIC MANIPULATIONS
A recent review by Nim C.G et al 2021 looked at 10 research reviews that compares the effects of Specific vs Non Specific spinal manipulations, to determine if there is any clinical difference between the two.
The answer?
No clinical significant difference between the two.
This meant that if a client had pain or symptoms at a particular level, say L5, and the therapist applied a thrust that was actually at L3…there was still a reduction in the client's pain and symptoms!
CLINICAL IMPLICATIONS
Every physiotherapist will still have his or her own ‘style’ or method. And we can choose how we interpret and let new research studies guide our clinical practice.
Personally, I still try to be ‘specific’, more so that I can maintain my clinical skills, but I definitely do NOT claim that I’m able to target each specific segment to treat specific symptoms.
I understand that the effects of the manipulations are mostly from neuromodulation, as long as I’m in the general vicinity of the affected area, I can be confident that I’ll be creating some positive change in the clients symptoms.
CONCLUSION
Spinal manipulations are an advanced skill that some therapists will use as part of the treatment plan for clients with spinal pain.
The recent research that suggests segment specificity is NOT required to good effects should actually be viewed in a positive light.
This should give clinicians confidence that even if they don’t happen to manipulate the ‘specific’ segment, they will still be getting a positive effect from their treatment.
After all, the main goal of utilising these treatment techniques is to help reduce your clients pain, so that you give them a window of opportunity to be more willing to participate in active rehabilitation, which we know is the best option for long term results and injury resilience.
If you’re unsure if Spinal Manipulations are right for you, contact us to see what your options are, and whether or not they could benefit you!
References:
Corp N et al 2020. Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. European Journal of Pain.
Nim C G et al 2021. The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: Myth or reality? A systematic review.
ABOUT THE AUTHOR
Ryan Tan is our Clinical Director and Physiotherapist here at Physiologic Hong Kong. He’s had over 10 years of experience as a sports and spinal Physiotherapist. He has acquired his Certificate of Spinal Manual Therapy (COSMT), which is an intensive course focussing purely on treating spinal conditions. He has extensive experience working in Complex Pain Clinics in London, treating complex spinal conditions that have been through Spinal Surgeries and procedures. Ryan now works closely with Orthopaedic Spinal Specialists to provide collaborative care and expert Physiotherapy treatment to those suffering from back pain. If you have a complex Spinal injury that hasn’t been able to be resolved, contact us for a no obligation assessment!
