Alexander Gentile

PTH 746

Dr. Zipple

Literature Review of Segmental Manipulations

For this literature review I chose to look into what evidence-based research exists in

relation to the efficacy of segmental mobilizations. The question that I am trying to answer is

what evidence exists that supports the validity of segmental spinal mobilization treatments as

compared to a globalized approach to spinal mobilization treatments. To answer this question I

found and reviewed the article Does the choice of spinal level treated during posteroanterior

(PA) mobilization affect treatment outcome? After completing this article by Chiradejnant et al

I found that segmental spinal mobilization is superior to the globalized approach and should be

preferred over the latter.

For this article the researchers focused on performing posteroanterior (PA) spinal

manipulative therapy (SMT) to treat patients with lower back pain (LBP) and non-specific lower

back pain (NSLBP). Chiradejnant et al focused on patients with LBP and NSLBP because of the

prevalence of both conditions in the general population. The researchers claim that 70% of

people experience LBP during their lifetime and between 10-50% of these patients will seek out

physical therapy (PT) to treat their condition. There are number of other treatments for LBP and

NSLBP that are used in PT such as: exercise therapy, massage, ergonomic advice and

electrotherapy. The researchers chose to ignore an eclectic approach using these alternative

treatments though and chose to focus on just PA SMT and its effects on spinal dysfunction.
 Chiradejnant et al make the claim that the biomechanical effects of PA SMT on the body

are already well known and they are not researching this topic. The researchers state that the

biomechanical effects have been well researched, though not on patients with LBP. They

primarily have been researched on cadavers or cadaveric tissues that cannot display symptoms.

So even though the effects are well researched on the biomechanical end, the treatment outcomes

and efficacy of them are relatively un-researched. Chiradejnant et al cite a pair of researchers in

their studies who discovered that PA SMT create extension moments on the segment above and

flexion moments on the segment below the affected vertebrae. Applying the specific type of

flexion or extension moment through PA SMT to a patient with the matching restriction has

shown to improve the patients range of motion (ROM), decrease their pain levels and decrease

their disability.

While all of that is fine and dandy the efficacy and amount of improvements have not

been heavily researched. As it stands today, applying a passive accessory force to the most

affected vertebral segment is the proper way to treat patients with LBP or NSLBP. It is believed

that the physical therapist (PT) will achieve better results with this method as opposed to treating

adjacent segments or more remote segments with a globalized approach. With that said there is

little to no scientific evidence supporting this belief. So Chiradejnant et al created their study to

discover the efficacy of a treating the most asymptomatic vertebral segment with PA SMT as

compared to a globalized approach.

The study was set up and conducted as a randomized controlled trial with a blind

outcome assessment. There was one PT who was responsible for treating all 120 subjects with

LBP at varying levels. Chiradejnant et al randomly split up the subjects into two groups. One

group would receive treatment to their most asymptomatic vertebral segment and the other
would receive a globalized treatment to a random segment. Baselines where established by the

PT for each individual patients level of pain and ROM. The PT recorded ROM for lumbar

flexion, extension and lateral flexion of each individual patient to identify their most restricted

motion. After the baselines where established an independent investigator was brought in to

record his own measurements of pain levels and ROM. After the investigator was finished he

exited the room and the PT then performed PA SMT at the predetermined level that was either at

the correct or random level unknown to the PT at the time of treatment. Immediately after each

individual treatment session the investigator was brought back in to record the post-intervention

measurements of each patient.

After all of the data was gathered Chiradejnant et al found that significant differences

existed for each group. Within both groups there were significant differences between

preintervention and postintervention for both variables (pain levels, ROM). This proved that PA

SMT has an immediate effect on treating patients with LBP and NSLBP. Though of these

variables only the patients individual pain level was significantly reduced more when treatment

was applied to the correct (most asymptomatic) vertebral segment. On top of this discovery,

Chiradejnant et al also found that patients whose most restricted movement were lumbar flexion

had the greatest decrease in pain levels as compared to lumbar extension and lateral flexion.

This study found that PA SMT did in fact have a significant effect on treating patients

with LBP and NSLBP. Also that examining each patient to find their most asymptomatic

vertebral segment is very important because treating the most asymptomatic segment is the most

efficient method for using PA SMT. These results matched up well with the other articles that

Chiradejnant et al referenced and my own personal knowledge acquired from the Central

Michigan University Doctorate of Physical Therapy program.

 While this study proved the efficacy of treating LBP with PA SMT at a localized segment

as compared to a globalized treatment protocol it did fall short in some aspects. This study only

examined the immediate effects of PA SMT on LBP and gives no indication of any short term,

intermediate or long term effects of this technique. So if a patient was to come into your clinic

with excruciating LBP you could give them almost instant relief but what would be the results

after they leave the clinic. This study only makes PA SMT comparable to short term analgesics

such as heating pads or pain relief medications. I believe that PA SMT performed at a higher

level through the use of more advance techniques is the most efficient way of treating LBP.

However, more research much be performed to determine the long term efficacy of using PA

SMT to treat patients with LBP. Once the long term efficacy is proven then PA SMT can be seen

as more than just an immediate relief treatment.

 References

1. Chiradejnant A, Latimer J, Maher CG, Stepkovitch N. Does the choice of spinal level

treated during posteroanterior (PA) mobilisation affect treatment

outcome? Physiotherapy Theory and Practice. 2002;18(4):165-174.

doi:10.1080/09593980290058544.