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RESEARCH COMMENTARY
Ejona (Ona) Jeblonski, DPT, COMT
Fellow in Training, MAPS Accredited Fellowship in Orthopedic Therapy

Chris R. Showalter, PT, COMT, OCS, FAAOMPT
MAPS Fellowship Program Director

Mobilization Increases Dorsiflexion in Chronic Ankle Instability (CAI) Patients


 
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Lumbar Mobilization: Get in and Get out (Why speed may matter)

February 01, 2017

RESEARCH COMMENTARY

Kate Hoppensteadt, MSPT, Manip.Physio, COMT

Senior MAPS Faculty

A recent study suggests applying a lumbar Maitland mobilization at higher speeds may result in greater sympathetic nervous system activity.

Background

The worldwide popularity of Maitland oscillatory mobilizations as an intervention to treat low back pain is well documented. Most manual therapists trained in this method are familiar with the concepts of changing direction and grade as necessary to 1) find a comparable sign and 2) apply an effective intervention. However, it has been suggested that fewer clinicians give consideration to changing the speed of mobilization. A review article (Snodgrass et al 2006) found that though mobilization speeds tend to vary – most clinicians mobilize at a speed of close to one oscillation per second (1Hz).

In his classic text, Vertebral Manipulation, Geoff Maitland suggested that different speeds of mobilization be utilized for different disorders. Maitland suggested a slower oscillatory speed for pain dominant and irritable disorders, using one oscillation per 2 seconds (0.5Hz) and faster speeds at end range for stiffness dominant disorders using 3 oscillations per second (3 Hz).

Recent research into how manual therapy may relieve pain has shifted somewhat from known local tissue effects (e.g. capsular stretching, stretching fibrotic tissue, restoring range etc.) to centrally mediated pain modulation. One benefit of manual therapy may be in the activation of areas of the brain such as the periaqueductal grey (PAG). Located in the midbrain the PAG is thought to be a key area for descending pain modulation with one of the mechanisms being sympathoexcitatory activation. Activation of the sympathetic nervous system (SNS) not only results in analgesia but also increased heart and respiratory rates, increased blood pressure and increased skin conductance.

In the paper reviewed this month, researchers Victoria Piekarz and Jo Perry from the United Kingdom cite previous studies that have suggested mobilizations at 2 Hz (2 oscillations per second) may excite sympathetic nervous system more than 0.5 Hz (1 oscillation every 2 seconds). The aim of their study was to determine if there was increased SNS activity (as measured by increased skin conductance) with increased speed of mobilization.

Research Design

The study (Piekarz & Perry 2016) was a double-blind, placebo-controlled, independent group experimental design.  Sixty male asymptomatic subjects aged between 18 and 25 years were randomly assigned into 4 groups.

1.     3Hz Central PA Maitland mobilization to L4 (180 oscillations per minute) for 3 minutes in 1 minute increments with a 1 minute break in between.

2.     2Hz Central PA Maitland mobilization to L4 (120 oscillations per minute) for 3 minutes in 1 min. increments

3.     Placebo – replication of same mobilization as a static non-oscillatory force to L4

4.     Control – participant positioned on plinth with no contact for 5 min.

The treating therapist performed a central postero-anterior (CPA) at the L4 spinous process at preset rates determined by a silent (visual) metronome that was concealed from the patient.  Skin conductance was measured on the plantar surface of the 2nd and 3rd toes using a Biopac MP35 electro-dermal activity amplifier. 

Results

Both the 3 and 2 Hz mobilization groups showed an increase in SNS activity as measured by increased skin conductance. The 3Hz (180 oscillations per minute) had an increase SNS activity in the order of 20.1% and the 2 Hz produced a 12.4% response.  The placebo and control groups recorded SNS change values of -1.3% and 3.2% respectively. Only the 3 Hz mobilization was considered statistically significant (p = 0.002) when compared to the placebo treatment. Interestingly, most change in skin conductance occurred within the first minute of mobilization.

Conclusion

A CPA Maitland mobilization on L4 produced greater sympathoexcitatory increase in skin conductance during the 3Hz treatment compared to placebo and control conditions.  The results implicate that a higher frequency CPA mobilization at L4 may stimulate a greater SNS response than slower frequencies.

IMPLICATIONS FOR MANUAL PHYSICAL THERAPISTS (AND SOME CAVEATS)

Speed of mobilization may matter when it comes to SNS activity and hence pain relief. This interesting paper by (Piekarz & Perry 2016) suggests mobilizing the spine at higher frequencies has a greater stimulatory effect on the SNS which may therefore result in a greater general analgesic response than at lower frequencies.

Though this study suggests that high frequency mobilizations produces greater SNS activity and thus by inference may lead to greater analgesia, this research doesn’t necessarily contradict Maitland’s recommendation that slower mobilizations are superior for pain relief. It is important to note that Piekarz and Perry measured skin conductance as a measure of SNS activity on healthy pain free young men. They did not use any quantitative sensory testing (QST) methods to determine if pain thresholds (e.g. pressure, heat or cold) were changed in addition to the SNS activity. As Maitland said `”a technique is the brainchild of ingenuity” – and thus it behooves manual therapists to change the technique (including speed) in order to produce a positive change in the presentation of the individual patient that you are treating.

 

IMPORTANT TAKE HOME MESSSAGE & SUGGESTIONS:

1) If you are not achieving the results you expect with lumbar mobilizations try varying your speed of mobilization.

2) Higher frequency oscillations (3 Hz) have been found to create the most change in the SNS. You could also consider slowing the speed…based upon the patients presenting signs and symptoms, and your CLINICAL REASONING

3) The most change was found in the first minute of treatment, so consider treating your patients for less time – sometimes less is more…get in, get out, assess effect.

4) Mobilizing at 3 Hz is not as easy as you would think. Consider downloading a metronome app to your phone and practice performing 3 Hz CPAs.

5) Finally, this article is not implying use of mobilizations that plow through tissue.  Leave the plow in the barn!  FEEL the tissue and how it is responding to your oscillations. Never forget to LISTEN to the patient’s report of changes in their individual comparable sign

Cheers and enjoy!

Kate

 

References

https://www.ncbi.nlm.nih.gov/pubmed/16690387

Snodgrass S et al  Manual forces applied during posterior-to-anterior spinal mobilization: a review of the evidence. J Manipulative Physiol Ther. 2006 May;29(4):316-29.

 

Maitland G, Hengeveld E, Banks K, English J Maitland’s Vertebral Manipulation 7th edition, Elsevier, London 2005.

 

http://www.mskscienceandpractice.com/article/S1356-689X(16)00002-3/abstract

Piekarz V, Perry J. An investigation into the effects of applying a lumbar Maitland mobilisation at different frequencies on sympathetic nervous system activity levels in the lower limb. Ma

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