Lumbar manipulation CPR after acute injury

[Steven Lagasse]

Hi all,

I’ve had a few patients meet the CPR for lumbar spinal manipulation. However, I’ve been noticing that being < 16 days since the initial onset of pain (often due to minor acute injury) often has been accompanied with higher symptom severity and irritability. With that, I’ve been timid to perform manipulation.

Thoughts?

Thanks!

[Laura Thornton]

Hey Steven –

This is an interesting thought and made me do a little digging into the literature.

I wonder if there’s a deeper concept here. Have you introduced the techniques to the patients or spoke to them about this intervention choice? What were their responses if so?

Check this study out by Donaldson et al and especially, take a look at their thoughts on “irritability”. Let me know what you think –

Do patient expectations and perceived benefit have any role in hesitancy from them or even from you?

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[Taylor Blattenberger]

Steve, I’ve also come across this dilemma. Why do you think you are timid? For myself, I tend to be timid to introduce a high-velocity passive movement in a population that tends to be slower moving to avoid aggravation. Would you agree?

Laura, very interesting article here. It seems this suggests that we are free to administer the technique that we feel would be best regardless of patient preference. The question asked in the study identified preference, not necessarily fear of a treatment, such as some people may have with manipulation. I wonder if any of these “preferences” were rooted from an aversion as opposed to a partiality and if that would produce any differences.

[Steven Lagasse]

Hey Laura, Thanks for your reply-

The article you provided was quite thought-provoking. Interestingly, patients who were deemed irritable had a proclivity for non-thrust manipulation, yet did not demonstrate improvement over the non-matched group.

One quote that did, however, stand out to me was the following:
“Bishop et al, [13] who indicated that when thrust manipulation was matched to groups who met a clinical prediction rule for spinal thrust manipulation, their outcomes were better after receiving the intervention, regardless of whether they felt thrust manipulation would be useful in their condition.”

My introduction to performing manipulation often starts by providing the JOSPT Patient Perspective. This also provides me with their expectations and beliefs regarding manipulation. From there I’ve tended to rely on my clinical judgment of how irritable the patient is, attempting pre-thrust positions and/or holds, and then, finally, coming to a joint decision.

How would you go about this? I looking forward to hearing your thoughts!

[Steven Lagasse]

Taylor,

I would agree with you. My main hesitancy would be further flaring up symptoms. For me, it seems logical to avoid performing manipulation until symptoms calm down a bit. However, symptom acuity (<16 days) was one of the more predictive variables within the lumbar CPR manipulation CPR. This doesn’t leave a large window of time to allow symptoms to quiet down.

Any additional thoughts?

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