If you have performed lumbar manipulations on your patients odds approximately 52% of those patients treated would have a positive MRI for a herniated nucleus pulposus (HNP). According to Jensen et al 1994 “many people without back pain have disk bulges or protrusions but not extrusions. Because bulges and protrusions on MRI scans in people with low back pain or even radiculopathy may be coincidental, a patient's clinical situation must be carefully evaluated in conjunction with the results of MRI studies” (1). In addition Oliphantet al., 2004 found the risk of worsening with lumbar disc herniation with HVLAT is 1 in 3.7 million (2)
With this evidence HNP’s are still a yellow flag (precaution) when considering spinal manipulation as a possible modality. So, how do we bridge this gap of uncertainty to ensure we are delivering the necessary treatments to better our patients’ health. To do this we must put aside our need to categorize patients into groups and treat them as individuals.
Knowing spinal manipulation is generally safe to perform with patients who suffer from HNP’s, let’s consider some of the other variables that may determine our decision to use spinal manipulation as a modality. When performing lumbar spinal manipulation techniques, it is important to consider the patient positioning, movement velocity, and patient perception of the modality.
When considering patient positioning and movement velocity keep in mind the range of motion and speed required to perform these techniques. Many acute low back patients have extremely limited range of motion secondary to the stress placed on the injured disc’s. Those patients who cannot tolerate the range of motion and speed required to perform the technique then it should not be performed. Keep in mind that there are many variations of techniques designed for these exact situations.
Lastly, always consider patients comfort level with performing these techniques. A patient who is not comfortable with these techniques regardless of safety should not have them performed. These techniques require a patient to relax into the movements, and a patient who is fearful will have difficulty receiving the technique properly. If you feel manipulation would benefit the patient then as a health care practitioner you are required to educate these patients and help them manage their fear to prevent it from becoming a barrier to their health.
At Open Packed Spinal Manipulation, we educate all our students on these variables so you can learn to apply these much-needed modalities for a wide range of patient diagnoses and personalities.