JIMMY MICHAEL

BSc Osteopathy, BSc Sports and Exercise Science

Dip. Medical Acupuncture/Dry Needling

Giles Gyer
BSc Osteopathy, Dip Medical Acupuncture/Dry Needling
Welcome

• Breakout Areas

• Bathrooms

• Fire Safety

• Pictures and Videos

 Insurance to Practice

BGI
• www.omttraining.co.uk
• www.bgi.uk.com

• Spinal manipulation with cavitation – Includes existing therapy.

 Qualification
Post Completion of Post Course &
Course
What Can You Say?

• Certificate in OMT Osteopathic Spinal Manipulation™

• Cert OMT SM
• Use your existing title or Manipulative therapist (example)
• You are NOT an Osteopath or Chiropractor
 Post Completion of Course

Under Section 32(1) of the Osteopaths Act 1993 it is an offence to infer or imply that you
are an Osteopath if you have not carried out the relevant training and the following titles
are prohibited to use;
 Osteopath
 Osteopathic practitioner,
 Osteopathic physician,
 Osteopathist,
 Osteotherapist, or any other kind of Osteopath.
Students who qualify in our courses must ensure that when describing themselves on
their websites and in advertising literature that they are not implying that they are an
Osteopath, but that they are trained in specific osteopathic techniques.
What is Spinal Manipulation?

NHS Definition:
• A therapeutic procedure applied to the patients spine to restore
normal movement
• Involves taking the joint past its normal end range of motion but
not past its anatomical end range of motion
• A universally accepted definition does not currently exist
• (Song et al 2006)
 Why Are You Using Manipulation?
 What do you tell your patients?
◦ Increased range of motion

◦ Pain Reduction

◦ Reduced Muscle Hypertonicity

◦ Activation of Anti Inflammatory Mediators

 What should you tell your patients?

◦ Quality and Quantity of Movement

◦ Everything is temporary??

◦ Pain is in their head?

◦ What's the key??

 EBM – NICE guidelines for HVLA Techniques
Ref - https://files.nccih.nih.gov/s3fs-public/Pain-eBook-2019_06_508.pdf

National Institute for Clinical Excellence Guidelines 2019 for spinal manipulation
states………………….

1. Spinal manipulation can provide mild-to-moderate relief from low-back pain.

2. Recommended spinal manipulation as one of several nondrug treatments that patients with
chronic low-back pain may want to consider (The American College of Physicians)

3. Spinal manipulation may help people with chronic tension-type or cervicogenic (neck-
related) headaches and may also be helpful in preventing migraines. —

4. Evidence that spinal manipulation may help to relieve neck pain.

Terms IN Manipulation?

•High Velocity Low Amplitude Thrust / Low Velocity Low Amplitude

•HVLA / LVLA
•HVT
•Cavitation
•Grade 5 Manipulation
•Adjustment
•Subluxation
•Osteopathic Lesion
•Facilitated Segment
Types of Manipulation

1. Long Lever Manipulation

2. Short Lever Manipulation

Choose the Appropriate

Technique
 Vectors for Manipulation?

Vectors relate to the movements that we use when placing

the joint in to the safe position.
The vectors we tend to use are;
•Flexion
•Side bending
•Rotation
•Compression
Barriers in Manipulation?

•Barrier is when you have used the vectors to

engage the dysfunction.

•When we manipulate we engage the barrier and then

create a short, sharp movement (manipulation) through the barrier.

•This will cause the join to click

Barriers in Manipulation?

•What happens if you do not engage the barrier?

•What happens if you keep the patient at the barrier too long?
•Does this become another technique?
The Click?

• Do you need the “click” for successful manipulation?

YES OR NO?
From Biomechanical Responses
To
Neurophysiological Responses
 What we thought..

Bio-mechanics…………

..

Early theories were heavily focused on the

biomechanical mechanisms – but recent
research has caused a paradigm shift
towards the neurophysiological model

WHY – because research is showing various

neural effects of HVLA..
OF
COMMON SENSE
 Old Theories of Manipulation – “The Biomechanical Model”

Biomechanical Theories

Release of entrapped Restoration of buckled Reduction of Normalisation of

synovial folds or motion segments articular or “hypertonic” muscle by
meniscoids periarticular the reflexogenic effect
adhesions

Are they valid??

Evans DW, Breen AC. A biomechanical model for mechanically efficient cavitation production during spinal manipulation: prethrust position and the neutral zone. Journal of Manipulative & Physiological Therapeutics. 2006; 29(1): 72-82. [PubMed]
https://www.ncbi.nlm.nih.gov/pubmed/16396734., Potter L, McCarthy CH, Oldham J. Physiological effects of spinal manipulation: a review of proposed theories. Physical therapy reviews. 2005; 10(3): 163-170. [ResearchGate]
https://www.researchgate.net/publication/233689100_Physiological_effects_of_spinal_manipulation_A_review_of_proposed_theories. Maigne JY, Vautravers P. Mechanism of action of spinal manipulative therapy. Joint bone spine. 2003; 70(5): 336-341. [PubMed]
https://www.ncbi.nlm.nih.gov/pubmed/14563460.
 Are the Biomechanical Theories
Valid??

• Clinical relevance of these biomechanical theories with regards to therapeutic outcomes remains uncertain.

• The current literature does not validate the explanation that manipulation corrects biomechanical faults

• No plausible evidence has been found in support of a lasting positional change following manipulation

• Palpation is still not a reliable method to identify areas requiring spinal manipulation

• Only the muscular reflexogenic theory has some evidence

Bialosky JE, George SZ, Bishop MD. How spinal manipulative therapy works: why ask why?. J Orthop Sports Phys Ther. 2008;38(6):293-295. [PubMed] https://www.ncbi.nlm.nih.gov/pubmed/18515964.
Colloca CJ, Keller TS. Stiffness and neuromuscular reflex response of the human spine to posteroanterior manipulative thrusts in patients with low back pain. Journal of manipulative and physiological therapeutics.
2001;24(8):489-500. [PubMed] https://www.ncbi.nlm.nih.gov/pubmed/11677547.
Clark BC, Goss DA, Walkowski S, Hoffman RL, Ross A, Thomas JS. Neurophysiologic effects of spinal manipulation in patients with chronic low back pain. BMC musculoskeletal disorders. 2011;12(1):170. [PubMed]
https://www.ncbi.nlm.nih.gov/pubmed/21781310.
Zedka M, Prochazka A, Knight B, Gillard D, Gauthier M. Voluntary and reflex control of human back muscles during induced pain. The Journal of physiology. 1999;520(2):591-604. [PubMed]
https://www.ncbi.nlm.nih.gov/pubmed/10523425.
 Biomechanical Model

How Does it Affect the Neurophysiological Model?

By influencing the
Biomechanical changes The thrust force may
inflow of sensory input
evoked after stimulate or silence
to the CNS.
manipulation may mechanosensitive and
These inputs may
trigger a chain of nociceptive afferent
trigger pain processing
neurophysiological pathways in para spinal
mechanisms associated
responses responsible tissue
with the CNS
for the seen therapeutic
outcomes

Cambridge ED, Triano JJ, Ross JK, Abbott MS. Comparison of force development strategies of spinal manipulation used for thoracic pain. Manual therapy. 2012;17(3): 241-5. [PubMed] https://www.ncbi.nlm.nih.gov/pubmed/22386279/.

Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy. 2009;14(5):531-8. [PubMed]
https://www.ncbi.nlm.nih.gov/pubmed/19027342.

Pickar JG, Bolton PS. Spinal manipulative therapy and somatosensory activation. Journal of electromyography and kinesiology. 2012;22(5):785-94. [PubMed] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399029/.
Nougarou F, Pagé I, Loranger M, Dugas C, Descarreaux M. Neuromechanical response to spinal manipulation therapy: effects of a constant rate of force application. BMC complementary and alternative medicine. 2016;16(1):161. [PubMed]
https://www.ncbi.nlm.nih.gov/pubmed/27249939.
Downie AS, Vemulpad S, Bull PW. Quantifying the high-velocity, low-amplitude spinal manipulative thrust: a systematic review. Journal of manipulative and physiological therapeutics. 2010;33(7):542-53. [PubMed]
https://www.ncbi.nlm.nih.gov/pubmed/20937432/.
Neurophysiological Effects of
Manipulation
 A Synopsis of the Neurophysiological
Theories of Manipulation

• Spinal manipulation exerts its therapeutic effects through several neurophysiological mechanisms
working on their own or in combination.

• These mechanisms involve complex interactions between the PNS & CNS

• They are set in motion when the paraspinal sensory afferents (axons of sensory neurons carrying sensory
information from all over the body, into the spine) are activated by the mechanical force.

• These sensory inputs alter neural integration (input signals) by either directly influencing the reflex
activity or affecting the central neural integration (CNS).

But the research has drawbacks – mechanistic studies cant observe changes in the brain following
HVLA, validity is assumed from associated neural responses, and the theories around the neuro
outcomes remain unclear
 Clinical Relevance of the Neurophysiological
Theories of Manipulation - Summary

• Spinal manipulation results in neuromuscular responses and may reduce muscle hyperactivity.

• Spinal manipulation has been shown to relax or normalise hypertonic muscle through modulating alpha
motor neuron activity.

• Evidence from mechanistic studies suggest that spinal manipulation may function via the pain-spasm-pain
model by attenuating stretch reflex hyperactivity and consequently reducing the hyperexcitability of
gamma motor neurons.

• The effects of spinal manipulation on the ANS might lead to opioid independent analgesia, influencing the
reflex neural outputs on the segmental and extrasegmental levels helping with pain reduction.
 Clinical Relevance of the Neurophysiological
Theories of Manipulation - Summary

• Manipulation may induce nonopioid hypoalgesia by activating the descending pain modulation circuit,
especially serotonin and noradrenaline pathways,

• Spinal manipulation has been shown to influence the activity of both the SNS and HPA axis, modulation of the
SNS and HPA axis response  release of catecholamine and cortisol from the SNS-HPA axis system  anti-
inflammatory and tissue healing actions. (The hypothalamic pituitary adrenal (HPA) axis is our central stress
response system)

• Welch and Boone (2008) suggested that sympathetic responses may arise from thoracic/lumbar
manipulation while parasympathetic responses might result from cervical manipulation

Question! - Consider how multiple manipulations may effect the patients Nervous System……..
Does more manipulation mean better results?
Neurophysiological effects of spinal manipulation. ANS – autonomic nervous system; SNS – sympathetic nervous system; HPA axis – hypothalamic–pituitary–adrenal axis; CRH –
corticotropin-releasing hormone.
 References

Spinal Manipulation Therapy: Is it all About the Brain? A Current Review of the
Neurophysiological Effects of Manipulation

Giles Gyer and Jimmy Michael et al 2019

Journal of Integrative Medicine, Volume 17, Issue 5, p.328-337

 Research Benefits and Harms of Spinal Manipulative Therapy for the
Treatment of Chronic Low Back Pain: Systematic Review and Meta-
Analysis of Randomised Controlled Trials
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l689 (Published 13 March
2019)

Conclusion
• SMT produces similar effects to
recommended therapies for chronic low
back pain.

• SMT seems to be better than non-

recommended interventions for
improvement in function in the short term.

• Clinicians should inform their patients of

the potential risks of adverse events
associated with SMT.
 References

Pickar JG. Neurophysiological effects of spinal manipulation. The Spine Journal. 2002; 2(5): 357-371. [PubMed] https://www.ncbi.nlm.nih.gov/pubmed/14589467.

Sampath KK, Mani R, Cotter JD, Tumilty S. Measureable changes in the neuro-endocrinal mechanism following spinal manipulation. Medical hypotheses. 2015;
85(6): 819-824. [PubMed] https://www.ncbi.nlm.nih.gov/pubmed/26464145.

Lelic D, Niazi IK, Holt K, Jochumsen M, Dremstrup K, Yielder P, Murphy B, Drewes AM, Haavik H. Manipulation of Dysfunctional Spinal Joints Affects Sensorimotor
Integration in the Prefrontal Cortex: A Brain Source Localization Study. Neural Plasticity. 2016; 2016: 3704964. [PubMed]
https://www.ncbi.nlm.nih.gov/pubmed/27047694.

Currie SJ, Myers CA, Durso C, Enebo BA, Davidson BS. The Neuromuscula
r Response to Spinal Manipulation in the Presence of Pain. Journal of Manipulative & Physiological Therapeutics. 2016; 39(4): 288-293. [PubMed]
https://www.ncbi.nlm.nih.gov/pubmed/27059250.

Zafereo JA, Deschenes BK. The Role of Spinal Manipulation in Modifying Central Sensitization. Journal of Applied Biobehavioral Research. 2015; 20(2): 84-99.
[ResearchGate] https://www.researchgate.net/publication/277560942_The_Role_of_Spinal_Manipulation_in_Modifying_Central_Sensitization.

Randoll C, Gagnon-Normandin V, Tessier J, Bois S, Rustamov N, O'Shaughnessy J, Descarreaux M, Piché M. The mechanism of back pain relief by spinal
manipulation relies on decreased temporal summation of pain. Neuroscience. 2017; 349: 220-8. [PubMed] https://www.ncbi.nlm.nih.gov/pubmed/28288900.
The Click?

• Do you need the “click” for successful manipulation?

YES OR NO?
What Is The Click?
 How Much Force Do You Need?

• Manipulation on the facet joints is force threshold-dependent (Evans, 2002).

• Thoracic spine, the threshold is between 450N and 500N (45-50KG)

• Lumbar spine, the threshold is 400N (Brennan, 1995)

When the manipulation force goes beyond the threshold, a separation of the articular surfaces
takes place suddenly, with an audible ‘click’ or ‘crack’ sound (Evans and Lucas, 2010)
 Specificity of Manipulation

• Palpation of joint position and movement is unreliable and varies with

practitioner (Seffinger et al 2004 & Walker et al 2015)
• In the lumbar spine, segmental manipulation was accurate 50%.
• In most cases, at least one cavitation emanated from the target joints.

 
  • In the thoracic spine, manipulation appears to be more accurate
• Manipulation range for the tsp was between 0 - 9.5cm – With an average of
3.5cm error
• Ross et al, 2004
 Safety of Manipulation Therapy

• If administered correctly, manipulation is a safe course of treatment

• Serious complications are rarely reported to manipulation
• Spine manipulation has been associated with strokes, vascular accidents and non-
vascular complications
• Spinal manipulation has been a safe and effective means of treating a variety of
biomechanical problems of the spine. As with all conventional treatments, however,
manipulation also has the potential to cause complications, (Di Fabio, 1999).

Finesse Over Force

 Causes of Complications &
Adverse Effects

• Lack Of Knowledge
• Lack of Treatment Rationale
• Incorrect diagnosis
• Insufficient Examination
• Poor Interprofessional Cooperation
• Inappropriate technique
• Excessive Force
• Data source: Shekelle et al., 1991; Henderson (1992); Refshauge et al. (2002)
 4 Steps to Safe and Effective
Manipulation
1. Screening
a. Red & Yellow Flags
2. Examination
a. Passive / Active / Palpation
b. Special Tests
3. Technique
a. Supine
b. Sidelying
c. Prone
4. Re-Examination
d. Quality & Quantity of Motion
e. Assessment of Pain Levels
f. Patient Trust
Contraindications to Manipulation

ABSOLUTE contraindications to HVT

Bone – any pathology that has resulted in significant bone weakness or weakening:
•Tumour – metastatic deposits
•Metabolic – Osteomalacia
•Congenital – Dysplasias (hip)
•Iatrogenic – Long term Nsaids
•Inflammatory / Infection – Sever RA
•Trauma – fracture
•Pregnancy
•Osteoporosis
Cautions to Manipulation
•Adverse reactions to previous manual therapy
•Disc herniation or prolapse
•Inflammatory arthritides
•Pregnancy
•Spondylolisthesis
•Anticoagulant or long term corticosteroid use
•Advanced degenerative joint disease and spondylosis
•High blood pressure
•Ligament laxity
 Importance of Case History
• 80% diagnosis are made on case history alone
*Ask the appropriate and relevant questions for the presenting complaint
• 5-10% on examination
* Pick the correct tests
• Reminder on investigation
Epstein et al. Clinical Examination 4th Edition, 2008

• You must make sure write everything down

• You should be able to read it
• Someone else taking over your case or requesting the notes should be able
to read it too.
Note Taking in Manipulation
• Everything needs to be written down / How long do you keep notes for?
•Your assessment and special tests need to correlate to your treatment

• Example:

•Tsp – T2-T3 Prone +++ or 

• Lsp – L5 – S1  and 
Testing Before………..

There are many different tests that you can use

•Choose the tests that you feel give you the most effective
information
•Do not choose the tests that tell you the information you
already know.

What is the least invasive test you can do before anything else?
 NICE Guidelines to BP
Please visit NICE.org.uk
Hypertension in Adults: Diagnosis and Management
Guideline: NG136
Published: August 2019

Equipment Used: Any equipment should be well maintained and calibrated in

accordance to manufacturers guidance.
 NICE Guidelines to BP
(2019)

Category Systolic Diastolic

Optimal <120 and <80
Normal 120-129 and/or 80-84
High Normal 130-139 and/or 85-89
Grade 1 140-159 and/or 90-99
Hypertension
Grade 2 160-179 and/or 100-109
Hypertension
Grade 3 >180 and/or >110
Hypertension
Isolated Systolic >140 and <90
Hypertension
WORKSHOPS