The term mobilization is usually associated with low-velocity rhythmic movements applied in short or large amplitudes, while manipulation involves high-velocity movements applied over small amplitudes.1
According to Maitland spinal manipulative therapy includes techniques based on joint manipulation and mobilization, the main difference being the amplitude and velocity of the force applied to the vertebrae.1
Effects of mobilization and manipulation
Recent studies have shown that spinal manipulation can activate an endogenous, descending, pain-inhibitory system, resulting not only in manipulation-induced hypoalgesia but also in sympatho-excitation and motor effects.2-5
Introduction: Lumbar spine
Every year one in ﬁve adults will have low back pain.6 The back is the second most frequent location
of pain.7 The most common structural sources of chronic back pain (LBP) are the intervertebral disc, the ZJs and the SIJ.12 These structures refer into the pelvis, groin, and lower extremity. Waddell
has been cited that 80-90% of LBP attacks resolve within 6 weeks14, but in fact he refers to return to work – not cessation of pain.15
Range of motion of the lumbar spine
Left side bending
Right side bending
Left axial rotation
Right axial rotation
Pearcy and Hindle8
Hindle et al.9
Peach et al.10
Russell et al.11
Self-mobilization techniques for the lumbar spine
Self-mobilization of the lumbar spine of segments L3-L4, L4-L5 and L5-S1 with patient on his or her back.
Lumbar spine mobilization as an intervention
Lumbar spine manipulation techniques
Many randomized clinical trials have found spinal manipulation to be more effective than placebo or other interventions for patients with LBP.16,19,21,27,28 Conversely, other studies have shown that manipulation is not more effective than other treatments.18,22,23 A few studies have found greater benefit from thrust manipulation techniques versus nonthrust mobilization for the lumbosacral region.24,26 Although manipulation is generally recommended as superior to mobilization procedures,17 there is presently no evidence for the superiority of one manipulation technique over another.20 It is possible that the choice of a specific manipulation technique may not be as important as previously thought.25
Clinical prediction rules for the lumbar spine
A CPR is a tool designed to assist the classification process and improve decision making by using evidence to determine which patients are likely to benefit from a specific treatment strategy.13 The goal of the CPR for the manipulation classification is to identify patients with LBP who are likely to respond to manipulation with rapid and sustained improvement.
Study: A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study Childs et al. 200429
Definition for a positive criteria
Duration of current episode of low back pain
Extent of distal symptoms
Not having symptoms distal to the knee
FABQ work subscale score
Segmental mobility testing
>1 hypomobile segment in the lumbar spine
Hip internal rotation range of motion
>1 hip with .35 degrees of internal rotation range of motion
Comment: If a minimum of 4 to 5 criteria are present, there is a 92% chance of achieving a successful outcome by theend of 1 week.30With less than 3 criteria positive there is a 7% probability of success,indicating the need for alternative treatment.
Maitland G, Hengeveld E, Banks K, English K. Maitland’s Vertebral Manipulation. 6th ed. Woburn, MA: Butterworth Heinemann; 2001.
Korthals-de Bos I, Hoving J, van Tulder M, et al. Cost-effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: Economic evaluation alongside a randomized controlled trial. BMJ. 2003;326:911-917.
Sterling M, Jull G, Wright AMT. Cervical mobilization: Concurrent effects on pain, sympathetic nervous system activity and motor activity. Man Ther. 2001;6:72-81.
Mclean S, Naish R, Lloyd R, Urry S, Vicenzino B. A pilot study of the manual force levels required to produce manipulation induced hypoalgesia. Clin Biochem. 2002;17:304-308.
Mcneely M, Armijo S, Magee D. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther. 2006;86:710-725.
Cassidy JD, Côté P, Carroll LJ, Kristman V. Incidence and course of low back pain episodes in the general population. Spine 2005; 30: 2817-23.
Watkins E, Wollan PC, Melton III J, Yawn BP. Silent pain suﬀerers. Mayo Clin Proc 2006; 81: 167-71.
Pearcy MJ, Hindle RJ. New method for the non‐invasive three‐dimensional measurement of human back movement. Clin Biomech1989;4:73-9.
Hindle RJ, Pearcy MJ, Cross AT, Miller DHT. Three‐dimensional kinematics of the human back. Clin Biomech1990;5:218-28.
Peach JP, Surtane C, McGill S. Three‐dimensional kinematics and trunk muscle myoelectric activity in the young lumbar spine: A database. Arch Phys Med Rehabil1998;79:663-9.
Russell P, Pearcy MJ, Unsworth A. Measurement of the range and coupled movements observed in the lumbar spine. Br J Rheumatol1993;32:490-7.
Bogduk N 1995 The anatomical basis for spinal pain syndromes. Journal of Manipulative and Physiological Therapeutics 18(9):603-605
Laupacis A, Sekar N, Stiell IG. Clinical predictionrules. A review and suggested modificationsof methodological standards. JAMA.1997;277:488-494.
Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman JS (1998) Outcome of low back pain in general practice: a prospective study. BMJ 316:1356–1359
Waddell G (1987) A new clinical model for the treatment of low-back pain. Spine 12:632–644
Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up. Spine. 2003;28:525-531; discussion 531-522.
Bronfort G, Haas M, Evans RL, Bouter LM. Ef-ﬁcacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004;4:335-356.
Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiroprac-tic manipulation, and provision of an education-al booklet for the treatment of patients with low back pain. N Engl J Med.1998;339:1021-1029.
Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain most likely to beneﬁt from spinal ma-nipulation: a validation study. Ann Intern Med. 2004;141:920-928.
Cleland JA, Fritz JM, Childs JD, Kulig K. Com-parison of the eﬀectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: study protocol of a randomized clinical trial [NCT00257998]. BMC Musculoskelet Disord.2006;7:11.
Delitto A, Cibulka MT, Erhard RE, Bowling RW, Tenhula JA. Evidence for use of an exten-sion-mobilization category in acute low back syndrome: a prescriptive validation pilot study. Phys Ther. 1993;73:216-222; discussion 223-218.
Godfrey CM, Morgan PP, Schatzker J. A random-ized trial of manipulation for low-back pain in a medical setting. Spine. 1984;9:301-304.
Goldby LJ, Moore AP, Doust J, Trew ME. A randomized controlled trial investigating the eﬃciency of musculoskeletal physio-therapy on chronic low back disorder. Spine. 2006;31:1083-1093.
Hadler NM, Curtis P, Gillings DB, Stinnett S. A beneﬁt of spinal manipulation as adjunctive therapy for acute low-back pain: a stratiﬁed controlled trial. Spine. 1987;12:702-706.
Kent P, Marks D, Pearson W, Keating J. Does cli-nician treatment choice improve the outcomes of manual therapy for nonspeciﬁc low backpain? A metaanalysis. J Manipulative Physiol Ther. 2005;28:312-322.
Meade TW. Manipulative therapy and phys-iotherapy for persistent back and neck complaints. BMJ.1992;304:1310; author reply 1310-1311.
UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: eﬀectiveness of physical treatments for back pain in primary care. BMJ. 2004;329:1377.
Wreje U, Nordgren B, Aberg H. Treatment of pelvic joint dysfunction in primary care–a controlled study. Scand J Prim Health Care. 1992;10:310-315.
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