Cervical Manipulation and biochemical response

[Eric Magrum]

Pretty interesting article – have a read, post your thoughts on how this piece of evidence changes your thinking about manipulation utility with your patients.

Cheers

Eric

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[Erik Kreil]

A few thoughts here..

It’s really cool to see evidence of chemical changes after a spinal manip – it makes total sense for this case. Non-specific mechanical neck pain can express itself as a deeper, more vague burning sensation so we’d expect to see a modulation of C-pain fibers, which is demonstrated as we see increases in Oxytocin.

Cortisol didn’t change, which tells me how important it is to genuinely pay attention to indications of psychosocial factors – either on the paperwork or in subjective interview – to manage their stress levels. The intangible, qualitative aspects of care play a physical role in a patient’s pain experience.

Finally, here’s kind of a left field idea I had while reading: some professions seem to rely on providing a spinal manip to give value to their service. Patients seems to keep returning for the service, sometimes for years, because they feel better afterwards. In this study, we see evidence of a boost in feel good chemicals after a spinal manip… which makes me feel like if that’s the only service the professional is providing, that professional kind of acts like a pharmacist where the patient returns to “re-up.” So, if we know our patient tried this service for some time and is now seeing us, would the patient go through some withdrawal if we don’t provide a spinal manip in the beginning phase of our plan of care? Would my outcomes be worse off if I don’t take this into account, just because their body is primed differently at that time?

[Laura Thornton]

Thanks for your post Erik – it’s great that you’re posing questions and not taking things at face value. I’ll counterpoint – if the patient who you speak of was satisfied with only getting thrust manipulations for their care, why would they be in our clinic? Are there other components to the patient’s problem (weakness, guarding, decreased mobility) that are the underlying mechanisms for their pain? Are you ever using passive treatments alone in your POC?

HVLA thrust manipulations are valuable, powerful tools that we can use to supplement WITH active, exercise approaches to address patient’s problems. It’s important that we communicate to patients on the rationale behind these techniques, to ultimately help them move better. We, as clinicians, need to know the emerging data to understand the true effect of these techniques to then use them ethically and intentionally in our practice.

With this reasoning, we also have to be judicious about who we decide to perform these techniques on. If you believe that it will do more harm than good, then move in another direction to address the patient’s problems. I think it boils down to two things: what does the patient value in their care and what do you, as a clinician, think they would benefit from to achieve the ultimate goal >> exercise, activity, movement.

On another note, don’t forget about treatment effect sizes in intervention studies if the authors don’t report. Easy calculation that can give you the magnitude of the difference between the groups.

[jeffpeckins]

I thought that the findings of the study were interesting, but do they change my clinical practice or how I think about manips? No not really. It may help with patient education, so I when I tell them why I want to do a manip I can say “there is research that shows that after a manip there is an increase in feel-good hormones, which will decrease your pain and give us a time-frame to work on some exercises to get you stronger.” I already basically say this, but now I can say it more confidently and list off a couple specific hormones to make what I say sound smarter and maybe improve patient buy-in.

I will admit I am likely biased being taught at UF by Steven George, Mark Bishop, and Joel Bialosky who are some of the bigger names when it comes to pain, especially in reference to manual therapy and psychological factors. You guys remember the crazy chart in the Manual Therapy (and probably others) lecture titled “the mechanisms of manual therapy in the treatment of MSK pain: a comprehensive model” (attached). My professors never attempted to have us memorize that insane chart, but rather emphasized that there isn’t a singular reason why manual therapy helps, it is a combination of neurophysiological factors.

With the study itself, I wondered if the changes seen were due to the manip itself, or was it the positive expectation from the manip? The study didn’t seem to look at that, but I wonder if they had captured patient expectations prior to the manip, would there have been a larger change in chemical markers in those who had a positive expectation that the manip would help? This goes along with what Laura was stating, where taking patient preference into consideration will likely improve outcomes, especially when it comes to manips.

In reading the sham protocol, it didn’t seem like a convincing sham. “The clinician conducted the same basic steps as the SM, localizing the appropriate vertebral landmarks but without moving the individual or carrying out the final thrust procedure.” If the patient wasn’t even moved, was this a good sham? I don’t think so.

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