Thanks for publishing the article ‘Spinal manipulation for low back pain’ with Dr Leonardo Costa in the August 2020 issue of InMotion.

While I congratulate and support all research relating to manual therapy, I have a few questions relating to the clinical implications posed by the author.

I’m sure it’s not the authors’ intention and perhaps my misinterpretation, but it appears they recommend therapists choose to treat an area they feel most confident in rather than the area that may actually require treatment.

To put this in an analogy, if you were to take your car  to an auto electrician and they told you that they will simply replace the alternator because that’s the thing that they know how to do, you might choose to take your car elsewhere.

Is it possible that manipulating a site some distance away from the painful segment is treating a co-existing dysfunction, which then reduces the nociceptive input sensitising the central nervous system and unloads the fascial chain related to the painful segment?

Perhaps it’s even possible that such a person also has co-existing ankle, pelvis, sacral and lumbar dysfunction above and below the painful (often adaptively hypermobile) segment, which, if treated, will further reduce the load on the painful segment.

This concept is a basic fundamental principle shared by the osteopathic and chiropractic fields that largely seems to have been ignored by the physiotherapy profession.

While it may seem a good idea to treat a distant region because you feel more comfortable with that, or leave the decision of where to treat to the patient themselves, surely it would be better to apply a thorough and accurate assessment, and skilled and specific treatment?

>> Haydn Gambling, APAM, South Australia

REPLY No clinically important difference between specific or non-specific vertebral manipulation.

Thank you for your comments on our paper published in Journal of Physiotherapy. We appreciate your feedback and thoughts on it, and I hope you have read not only the InMotion interview, but also the full paper.

Clinical practice guidelines endorse  the use of spinal manipulative therapy for patients with back pain.

We strongly advise clinicians to keep using this intervention on their patients.

Guidelines also advise clinicians to carefully assess patients and use the best interventions tailored to the patient’s presentation.

We did not advise clinicians to close their eyes and randomly manipulate the spine of any given patient without a proper assessment.

Careful clinical examination and clear clinical reasoning are always needed.

Our data (from two high-quality randomised controlled trials: de Oliveira et al 2013, de Oliveira et al 2020) show that clinicians do not need to be specific while making decisions about spinal manipulation.

It is widely known that although identifying either a hypomobile or painful spinal segment is possible, it is virtually impossible to manipulate a specific vertebral segment. Therefore, clinicians will not be able to be very specific anyway.

Our trials (de Oliveira et al 2013, de Oliveira et al 2020) on this topic measured patient- centred outcomes and the results are consistent: patients improved with both approaches.

We are confident that being specific or non-specific will not make a clinically important difference in the most important outcomes for these patients. Therefore clinicians and patients could share the decision-making regarding the best treatment. 

The message from both trials is clear: patients will get better. At the end of the day, this is what patients want.

>> Dr Leonardo Costa, Universidade Cidade de São Paulo, Brazil

‘Directed vertebral manipulation is not better than generic vertebral manipulation in patients with chronic low back pain: a randomised trial’ was published in the July 2020 issue of the Journal of Physiotherapy. Go to journal.physio to read the research.

References

1.            de Oliveira RF, et al. Journal of Physiotherapy. 2020 Jul;66(3):174-179. 2020.

2.            de Oliveira RF, et al. Phys Ther. 2013;93(6):748-56.