Lumbosacral Radicular Syndrome (LSRS) is a condition characterized by pain radiating in one or more dermatomes (Radicular Pain) and/or the presence of neurological impairments (Radiculopathy). So far, different reviews have investigated the effect of HVLA (high-velocity low-amplitude) spinal manipulations in LSRS. However, these studies included ‘mixed’ population samples (LBP patients with or without LSRS) and treatments other than HVLA spinal manipulations (e.g., mobilisation, soft tissue treatment, etc.). Hence, the efficacy of HVLAT in LSRS is yet to be fully understood.
This review investigated the effect and safety of HVLATs on pain, levels of disability, and health-related quality of life in LSRS, as well as any possible adverse events.
Randomized clinical trials (RCTs) published in English in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), EMBASE, PEDro, and Web of Science were identified. RCTs on an adult population (18-65 years) with LSRS that compared HVLATs with other non-surgical treatments, sham spinal manipulation, or no intervention were considered. Two authors selected the studies, extracted the data, and assessed the methodological quality through the ‘Risk of Bias (RoB) Tool 2.0’ and the certainty of the evidence through the ‘GRADE tool’. A meta-analysis was performed to quantify the effect of HVLA on pain levels.
A total of 308 records were retrieved from the search strings. Only two studies met the inclusion criteria. Both studies were at high RoB. Two meta-analyses were performed for low back and leg pain levels. HVLA seemed to reduce the levels of low back (MD = -1.48; 95% CI = -2.45, -0.50) and lower limb (MD = -2.36; 95% CI = -3.28, -1.44) pain compared to other conservative treatments, at three months after treatment. However, high heterogeneity was found (I² = 0.0%, p = 0.735). Besides, their certainty of the evidence was ‘very low’. No adverse events were reported.
The authors stated that they cannot conclude whether HVLA spinal manipulations can be helpful for the treatment of LSRS or not. Future high-quality RCTs are needed to establish the actual effect of HVLA manipulation in this disease with adequate sample size and LSRS definition.
Chiropractors earn their living by applying HVLA thrusts to patients suffering from LSRS. One would therefore have assumed that the question of efficacy has been extensively researched and conclusively answered. It seems that one would have assumed wrongly!
Now that this is (yet again) in the open, I wonder whether chiropractors will, in the future, tell their patients while obtaining informed consent: “I plan to give you a treatment for which sound evidence is not available; it can also cause harm; and, of course, it will cost you – I hope you don’t mind.”
19 Responses to SPINAL MANIPULATIONS FOR LUMBAR RADICULAR SYNDROME?
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As far as I thought I knew, HVLA is absolutely contraindicated in the presence of radicular symptoms, because the underlying pathology might be aggravated.
But I was wrong?
most physios seem to see it that way; most chiros not.
PT clinical guidelines for those with cLBP with “leg pain”
“Physical therapists may use thrust or nonthrust
joint mobilization to reduce pain and disability in
patients with chronic LBP with leg pain.”
https://www.orthopt.org/uploads/content_files/files/jospt.2021.0304.pdf
NASS
“Spinal manipulation is an option for symptomatic relief in patients with
lumbar disc herniation with radiculopathy.”
https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf
“Spinal manipulation is an option for symptomatic relief in patients with lumbar disc herniation with radiculopathy.”
Lying by omission, again.
SOK: HVLA is absolutely contraindicated in the presence of radicular symptoms
I provided the information needed to address the statement of SMT being an absolute contraindication for lumbar radiculopathy. It appears it is not, at least to the NASS and PT clinical guidelines.
“I provided the information needed to address the statement…”
No, you didn’t.
QUOTE
Lying by omission, otherwise known as exclusionary detailing, is lying by either omitting certain facts or by failing to correct a misconception.
https://rationalwiki.org/wiki/Lying_by_omission
QUOTE
Quote mining (also contextomy) is the fallacious tactic of taking quotes out of context in order to make them seemingly agree with the quote miner’s viewpoint, to make the comments of an opponent seem more extreme, or to make it seem that the opponent holds positions they don’t in order to make their positions easier to refute or demonize. It’s a way of lying. …
Quote mining is an informal fallacy and a fallacy of ambiguity, in that it removes context that is necessary to understand the mined quote.
https://rationalwiki.org/wiki/Quote_mining
“As far as I thought I knew, HVLA is absolutely contraindicated in the presence of radicular symptoms, because the underlying pathology might be aggravated.
But I was wrong?”
It’s strange to expect someone to answer unasked questions. But that’s seems to be Pete’s desperate attempt to appear relevant.
The answer to SOK question seems to be “yes, you were wrong, it’s not an absolute contradiction” if one goes by the sources I provided.
chiro-troll has spammed Edzard’s blog with this quote‑mined sentence
on Monday 12 June 2023 at 17:17 above
on Friday 07 April 2023 at 18:22
https://edzardernst.com/2023/04/effects-of-spinal-manipulation-or-mobilization-for-lumbar-disc-herniation-with-radiculopathy/#comment-145450
on Tuesday 17 January 2023 at 01:09
https://edzardernst.com/2022/03/lumbar-disc-herniation-treated-with-scam-10-year-results-of-an-observational-study/#comment-143490
on Thursday 31 March 2022 at 12:16
https://edzardernst.com/2022/03/lumbar-disc-herniation-treated-with-scam-10-year-results-of-an-observational-study/#comment-138438
chiro‑troll spammed, yet again, and in the wrong subthread:
“Spinal manipulation may be an option for symptomatic relief (Kreiner et al., 2014)”
https://edzardernst.com/2023/06/spinal-manipulations-for-lumbar-radicular-syndrome/#comment-146474
Lying by omission, again!
As usual, in chiro‑troll’s knee jerk defence of the indefensible, the anonymous troll didn’t bother to actually read and comprehend the sources from which it quote mined.
DC,
Are you implying that HVLA techniques: https://www.spine-health.com/treatment/chiropractic/spinal-manipulation-high-velocity-low-amplitude-hvla chiros use is same as “thrust or nonthrust joint mobilization” recommended in PT clinical guidelines? If yes, evidence please. If not, clarify your statement.
PTs have a five graded manual therapy approach. Grade 5 is HVLA (thrust).
“Subjects in this group received thrust mobilization/manipulation targeting the upper thoracic spine and thrust mobilization/manipulation targeting the middle thoracic spine.”
“The therapist’s manipulative hand was used to stabilize the inferior vertebra of the targeted motion segment, and his or her body applied force through the subject’s arms to produce a high-velocity, low-amplitude thrust (Fig. 2).“
https://academic.oup.com/ptj/article/87/4/431/2742128
“Thrust joint manipulation techniques involve the application of high-velocity low-amplitude forces directed to spinal joints with the intent of achieving joint cavitation or an audible pop.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4534851/
“While maintaining the secondary levers, the therapist performed a single HVLA thrust manipulation to the left atlanto-axial joint, using the combined thrusting primary levers of right rotation in an arc toward the underside eye and translation toward the table”
https://www.jospt.org/doi/10.2519/jospt.2012.3894
[my emphasis]
In my area of the USA it is not within their scope of practice.
Absolute contraindication? (SOK question). Appears not.
“Spinal manipulation may be an option for symptomatic relief (Kreiner et al., 2014).”
https://www.pt.or.th/PTCouncil/download/cpg/M_06.pdf
“This guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS’ Evidence-Based Guideline Development Committee.”
https://www.thespinejournalonline.com/article/S1529-9430(13)01450-2/fulltext
“PTs have a five graded manual therapy approach. Grade 5 is HVLA (thrust).”
BUT NOT IN YOUR AREA because “it is not within their scope of practice”.
Area=state, example Utah.
Yes, in some states of the USA, physical therapists were/are prohibited from performing all spinal manipulation, not just HVLA thrusts. In some states, physical therapists were/are prohibited from performing things that are deemed to encroach upon the turf of the local chiroquackers — a sort of quasi state-sanctioned protection quacket.
chiro‑troll wrote: “PTs have a five graded manual therapy approach. Grade 5 is HVLA (thrust).”, which, obviously, is BS: Lying by omission, again.
————⸻
@Talker,
You started this subthread by asking: “Are you implying that HVLA techniques: https://www.spine-health.com/treatment/chiropractic/spinal-manipulation-high-velocity-low-amplitude-hvla chiros use is same as “thrust or nonthrust joint mobilization” recommended in PT clinical guidelines? If yes, evidence please. If not, clarify your statement.”
I think the following exchange will shed some light on a difference between the techniques; in this case, treatment of the cervical spine:
Well, let me help with some of the specifics…
“…In the neck this is around 150N…”
Utter BS — chiro‑troll is just expressing its general opinion/beliefs.
It is somewhat amusing, in a pathetic sort of way, that chiro‑troll gave to David Nette, as an example of “chiropractors who have an interest in researching and educating peers on the topic”,
Lindsay Gorrell
University of Zurich | UZH
MChiroprac, PhD
Why is that somewhat amusing, in a pathetic sort of way? Because research performed by said Lindsay Gorrell clearly demonstrates that chiro‑troll’s comments contain utter nonsense/rubbish/drivel; total utter BS.
Pete is entitled to his opinion.
@Pete Attkins on Tuesday 13 June 2023 at 07:07
As always, you nailed this charlatan’s @rse to the wall. Unsurprisingly, he/she/it/they/whatever does not understand they have been made to look ridiculous (again). Please don’t stop. I love a good laugh.