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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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Posterior-Anterior (PA) non-thrust mobilization IS SUPERIOR to Prone Press-ups in the treatment of non-specific low back pain (NSLBP)

August 11, 2017

RESEARCH COMMENTARY

Damon Daura PT, DPT, OCS, COMT
Fellow in Training, MAPS Fellowship in Orthopedic Manual Therapy

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


Background

The treatment of low back pain (LBP) can be a costly proposition for society with annual costs in the USA noted at an estimated $50 billion annually (1).  It has also been estimated that up to 85% of LBP is non-specific (NSLBP), that is, not attributable to a recognizable, known specific pathology (2).

The Maitland concept and McKenzie method are two well-known pillars of orthopedic manual therapy philosophy. These approaches are regularly used by physiotherapists/physical therapists to effectively treat non-specific low back pain (NSLNP), as our profession continues to embrace evidenced based practice and move away from passive, modality-based treatment models. Both approaches require manual therapists to develop a treatment hypothesis based upon accurate assessment. Commonly during assessment, decreased spinal motion is identified as either a general loss of spinal movement or specific spinal segmental hypomobility. Maitland’s identification and treatment of the comparable sign within the framework of the patient’s movement deficits and symptom response to functional activities, active, passive, and passive accessory motions, is familiar to manual therapists(3).

The Maitland Concept.  The use of Grades I-IV non-thrust manipulation (aka mobilization), or Grade V thrust manipulation, based upon a focused thorough evaluation, including the patient’s “irritability”, are hallmarks of the Maitland concept. The concept further requires that the therapist understand the relationships between pain, stiffness, muscle spasm and other relevant factors to effectively treat the disorder. 

The McKenzie Approach.  Similarly, McKenzie’s detailed assessment and subsequent classification of the disorder into three (3) spinal syndromes (postural, dysfunction, and derangement syndromes) often uses repeated movements and sustained positions to develop treatment strategies based upon directional preference(4).  Instructing patients in the performance of a prone press-up is a common exercise taught to improve lumbar spinal extension ROM, as lumbar extension loss is commonly seen in the NSLBP population.

Prior investigators (Powers, C. M., et. al. 2008) have studied the effect of a single treatment session of Postero-Anterior (PA) mobilization and prone press ups (PPU) in patients with nonspecific low back pain, and the immediate gains in lumbar extension ROM were noted in both groups, but this could not be extrapolated to determine long term effects (5)

Maitland vs. McKenzie in treating NSLBP

This Research Commentary explores a recent paper (Shah & Kage, 2016) that evaluated the effectiveness of the Maitland and McKenzie approaches to NSLBP after seven (7) sessions of either Maitland PA mobilization to the lumbar spine or performance of McKenzie PPU.   

Research Design (Shah & Kage, 2016)

Forty (40) participants with NSLBP (duration <3 months age 18-45 years) at or above waist level with decreased lumbar extension observed in standing and increased localized pain with lumbar extension in standing, were included in this double blind randomized clinical trial. Participants in the study were blindly assigned to the PA mobilization group or the PPU group.  

In Group A (PA) the “most painful” spinal segment or “comparable sign” was identified and treated at the specific segment for 3 bouts of 40 second oscillations (1-2 Hz) with the remaining lumbar segments receiving 2 bouts of 40 second oscillations. Total treatment time was approximately 10 minutes.

Patients in Group B (PPU) were instructed to perform a prone press-up to maximum pain-free extension and hold for 5 seconds for ten repetitions.  If the patient was able to complete 10 repetitions (Reps) without pain, another set of 10 Reps was repeated a second and third time if pain free. Total treatment time was approximately 10 minutes. 

Outcome measures were:

·         Lumbar extension ROM (measured by marking the 5th lumbar vertebra and 10 cm superior with the reduction in distance with a backward bend being recorded).

·         Visual Analog Scale (VAS) using a 10cm straight line numbered 0-10 with zero representing no pain and 10 being the worst tolerable pain.

·         Modified Owestry Disability Questionnaire (MODI) that is scored 0-50 with zero representing maximum function and 50 representing total disability. 

All outcome measures were obtained:

1) prior to treatment intervention

2) immediately after the first session intervention, and

3) after completion of 7 sessions of intervention.   

Note that baseline measures were not statistically different between groups prior to intervention.

Results and Implications for Physical Therapists

·       Both groups demonstrated intragroup improvements in increased lumbar extension ROM, lower VAS pain scores, and lower MODI disability scores.

·       The PA mobilization group was significantly more improved (p <0.05) than the PPU group in ALL outcome measures (intergroup comparison)

·       Post-treatment outcomes (post treatment 7) for the PA mobilization group versus the press-up group differed significantly in favor of the PA intervention in all categories (ALL p < 0.05) as follows

o   Final VAS 1.6 PA versus 3.2 PPU

o   Final lumbar extension 5.1 cm PA versus 3.2 cm PPU

o   Final disability scores (MODI) 5.3 PA versus 18.6 PPU

·       The most notable change was in the patients perceived rating of disability with the MODI improving 35.4 points for the PA group versus 19.5 points for the PPU group.  Increasing importance is being given to the value of patients’ perceived quality of life questionnaires (6). 


Clinical Significance

What then is more important, general spinal mobility exercises (PPU) or identification of a hypomobile spinal segment (PA)? The results of the Shah & Kage, (2016) study supports the identification and PA treatment of specific hypomobile segment(s) as symptomatic/comparable, which appears to be more important than general spinal mobility exercises. Local mobilization has previously been shown to enhance passive accessory mobility, which in turn improved general spinal ROM, decreased pain, and improved function in the Shah & Kage (2016) study. 

It would have been interesting had the treating therapists treated only the most comparable segment(s) in each session and/or until the patient reported a change. This more pragmatic type of intervention may have yielded more information.  

In our opinion, the Shah & Kage (2016) study used a prescriptive interventional design to provide greater internal validity. Both groups (PA & PPU) were treated for a total of 10 minutes. However, in clinical practice, dosage of mobilization in Maitland concept is determined by continuous re-assessment (not time), and identifying a change or improvement through patient feedback, and the use of functional test movements. This pragmatic approach would be more representative of how therapists treat by adapting to changes in patient presentation and thus allowing for clinical reasoning and treatment modification (3).

Shah & Kage, (2016) suggests that several sessions of spinal mobilization are necessary to produce clinically relevant results, as prior studies of a single bout of mobilization have produced an increase in ROM but lacked any clinically relevant improvements (MODI). These findings are also congruent with a Maitland approach of mobilizing with the least amount of force and moving higher into Grades based upon irritability and the therapist’s intent of treating stiffness or pain.  The author of this study did an admirable job of applying this with grades of mobilization starting at grade I and moving up to the highest grade tolerated that reproduced the pain experienced with an active backward bend.  However, given the nature of pain being non-specific with initial VAS pain ratings averaging 6.9 +- 1.4, exclusion criteria for this study suggest that the majority of these patients may not have been highly irritable, and thus could have been given higher grades of mobilization and into some symptom reproduction.  This may have produced even greater results in the PA mobilization group, and would be an appropriate design for additional studies.

Mechanical and neuro-physiological effects are present in both treatment interventions.  Passive accessory intervertebral mobilization (PAIVM) not only effects mechanical components by restoring joint mobility by breaking down adhesions and stretching or remodeling scar tissue. There is significant evidence that PAIVMs may stimulate areas within the central nervous system.(8).  Localized mobilization reduces dorsal horn activation with a resultant decrease in pain (9). Disinhibiting pain inhibition and improving spinal mobility may be more important initially than prescribing active exercises. The repetitive prone press-up is suggested to stimulate synovial fluid production over the articular cartilage and disc, and potential movement of the nucleus pulposis.

The decision regarding which technique to use (PA vs PPU), and when to use each, is at the discretion of the treating therapist. This decision is influenced by the therapist’s training, knowledge, skills and familiarity with the EBP research. Many Maitland therapists use the PA PAIVM to restore segmental mobility and then transistion to active exercises (PPU) when it is most appropriate as indicated by the patient’s symptom response and progression.  

Important Take Home Messages

·       Both the PA mobilization and active press-up exercise groups improved in this study and this is reflective of real world clinical practice.  If we get our patients moving, things generally start to get better.  

·       But the eye-opening outcome in this study was the dramatic difference in patient’s perceived functional improvement observed in the PA mobilization group with an 87% improvement in the MODI and 77% improvement in VAS for pain. 

·       Beyond the neurophysiological and mechanical effects of orthopedic manual therapy, there is a clear psychological effect that is a component to this difference in perceived improvement compared to the press-up group that showed a 51% improvement in MODI and a 48% improvement in VAS for pain. These results are likely not all attributable to placebo effect (the positive psychosocial and neurobiological effect that the treatment context has on clinical outcomes) (10).

 

Final Thoughts on Patient-Centered Approaches…

Maitland’s number one principle of patient care is to develop an empathetic understanding of the patient’s situation.  Establishing trust and building that alliance between patient and therapist leads to improved outcomes (11). Quite often patients enter our clinics with some degree of skepticism due to a dysfunctional medical system that may have had them being treated with modalities and minimal to no manual treatment interventions or they may have been told by a physician along the way what their problem requires surgery based upon imaging alone.  Disarming the patient when we ask her to describe her problem in her own words and why she is seeking physical therapy using a common Maitland question “As you see it, what is your main problem and why are you here today?” never gets old.  The patient-centered approach is a popular buzzword in healthcare today but has been part of Maitland’s philosophy from the beginning.  Establishing patient-therapist bond of trust and honesty is paramount to a positive outcome.  This therapeutic alliance has been correlated with patient adherence and positive outcomes of improved pain, reduced disability, and higher treatment satisfaction (12)

The ability to weave one’s expertise and skill with a communication style that the patient can relate to requires nuance and attentiveness to the patient’s response that is ongoing throughout our assessment and treatment.  As the Maitland concept stresses, we must always be thinking laterally about our manual treatment interventions because of the very powerful effects that they can have with our patients.  What better way of doing that than identifying a comparable stiff lumbar segment, mobilizing it effectively to reduce pain/increase mobility and providing the patient with the increased confidence to perform the active exercises? 

Cheers

Damon Daura PT, DPT, OCS, COMT

MAPS Fellow in Training

 

Featured Reference:

http://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2016&volume=10&issue=3&page=YC10&issn=0973-709x&id=7485
Shah, Shlesha G and Kage, Vijay. Effect of Seven Sessions of Posterior-to-Anterior Spinal Mobilisation versus Prone Press-ups in Non-Specific Low Back Pain- Randomized Clinical Trial. Journal of Clinical and Diagnostic Research. 2016 March, Vol-10(3): YC10-Yc13

 

Other References:

1.  https://www.ncbi.nlm.nih.gov/pubmed/21109053 
Liliedahl RL1, Finch MD, Axene DV, Goertz CM. Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor/doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer. J Manipulative Physiol Ther. 2010 Nov-Dec;33(9):640-3.

2.  https://www.ncbi.nlm.nih.gov/pubmed/7987418
Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994.
 
3.  Maitland G, Hengeveld E, Banks K, English J Maitland’s Vertebral Manipulation 7th edition, Elsevier, London 2005.
 
4.  https://www.ncbi.nlm.nih.gov/pubmed/16641766
Machado L. A. C. et al, The McKenzie Method for Low Back Pain: A Systematic Review of the Literature with a Meta-Analysis Approach, SPINE Volume 31, Number 9, pp E254–E262. 
 
5. Powers, C. M., Beneck, G. J., Kulig, K., Landel, R. F., & Fredericson, M. (2008). Effects of a single session of posterior-to-anterior spinal mobilization and press-up exercise on pain response and lumbar spine extension in people with nonspecific low back pain. Physical Therapy, 88(4), 485–493. https://doi.org/10.2522/ptj.20070069
 
6. https://www.ncbi.nlm.nih.gov/pubmed/1593914
Ware, J.E. & Sherbourne. C.D. (1992).  The MOS 36-item short-form health survey (SF-#6). Medical Care, 30(6), 473-483.
 
7. Maitland G, Hengeveld E, Banks K, English J Maitland’s Vertebral Manipulation 7th edition, Elsevier, London 2005.
 
8. https://www.ncbi.nlm.nih.gov/pubmed/18316238
Schmid, A., Brunner, F. Wright, A. & Bachman, L.M (2008). Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilization. Manual Therapy, 13(5), 387-396.
 
9. https://www.ncbi.nlm.nih.gov/pubmed/26817644
Treede, R. D. (2016). Gain control mechanisms in the nociceptive system. Pain, 157(6), 1199-1204.
 
10. Benedetti F. Placebo and endogenous mechanisms of analgesia. Handbook Exp.     Pharmacol. 2007;177:393– 413.   
 
11. https://academic.oup.com/ptj/article-lookup/doi/10.2522/ptj.20130118
Fuentes, J. et al, Enhanced therapeutic alliance modulates pain intensity and muscle sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014; 94(4): 477-489.
 
12. https://www.ncbi.nlm.nih.gov/pubmed/20576715
Hall AM, Ferreira PH, Maher CG, et al. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther. 2010;90:1099 –1110

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