A model justifying the use of spinal manipulation and exercise for facilitating locomotor function using a sensory motor approach.
For far too long spinal manipulation has only been associated with the management of painful spinal conditions, and the joint cavitation has been viewed as the holy grail of expert practice.
"Spinal manipulation has a well-established evidence base in contemporary musculoskeletal practice"
However, its clinical objectives are all too frequently attributed to the restoration of joint position or movement of specific spinal segments believed to be misaligned or hypermobile. This limited outlook does not embrace increasing evidence supporting neurophysiological mechanisms affecting pain and sensory motor control after manipulation.
Normal human movement is reliant upon effective sensory motor control. The sensory motor system is responsible for the regulation of posture, joint stability and movement. Manipulation is an effective treatment tool for gaining entry into the sensory motor system to promote normal movement. The capsuloligamentus and myofasical tissues contain mechanoreceptors, which are capable of stimulation by the forces applied through manipulation. Several authors have reported clinically significant changes in post intervention proprioception immediately after lower quadrant joint manipulation and mobilisation.
Absent, reduced or inaccurate sensory information will compromise the sensory equation of the sensory motor system
This system is critical for all components necessary for individuals to move and experience the environment in which they wish to function. All activities of daily living and athletic performance are reliant on afferent input from the periphery to the central nervous system. The spine has a rich source of sensory receptors that convey proprioceptive information from each spinal level about the positional status of the individual. Insult or dysfunction at spinal structures whether due to previous pain or poor postural habits can compromise its mechanical contributions to sensory motor control of the kinetic chain.
Distorted sensory information can affect the planning and organisation of motor behaviours at its higher centres. Poor sensory input at the receptor level has the potential to disrupt processes that are reliant upon its inclusion for voluntary movement, postural adjustments and motor learning. For example, using this approach it would not be unreasonable to assess the spinal articular system of patients presenting with persistent ankle instability. Most therapists would examine the ankle in detail but not consider the regional interdependence of motor control for the whole system. Spinal manipulation with a goal ordinated motor relearning programme provides a rich prioprioceptive training environment. Although, repeated practice is necessary to facilitate long-term motor recovery, an integrated approach should include targeted manipulation, mobilisation and exercise therapy.
This concept of treating the whole person is not new, but is often forgotten in the sprint to rehabilitate the patient.
All regions of the body are interdependent both in terms of physiology and anatomy. The effects in one location are often related to distant locations associate with the patient’s primary complaint. Conceptually, regional interdependence has an abundance of evidence including case reports, descriptive reports and controlled randomised trials. There have been several reports of patients complaining of primary low back pain with hip or knee involvement.
Many studies report clinically significant changes in symptoms and movement behaviors when treatment is directed at distant anatomical locations. In the upper quadrant, studies have reported post intervention treatment success after manual therapy for the thoracic region of patients presenting with primary neck pain and shoulder impingement.
The role of regional interdependence and sensory motor control should be given serious consideration in all musculoskeletal conditions with disturbed motor behaviours. Aberrant motor behaviours could at least in part be caused by dysfunction of the sensory equation of the sensory motor system.
Spinal manipulation is a time efficient and effective treatment modality for stimulating mechanoreceptors and facilitating normal movement behaviours. Therefore, an integrated approach for the clinical management of disordered movement should include spinal manipulation and joint mobilisations employed to prepare patients for exercise therapy and functional activities.
Further reading
Bialosky, J. E., Beneciuk, J. M., Bishop, M. D., Coronado, R. A., Penza, C. W., Simon, C. B., & George, S. Z. (2018). Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. The Journal of Orthopaedic and Sports Physical Therapy, 48(1), 8–18. https://doi.org/10.2519/jospt.2018.7476
Evans, R., Haas, M., Schulz, C., Leininger, B., Hanson, L., & Bronfort, G. (2018). Spinal manipulation and exercise for low back pain in adolescents: A randomized trial. Pain, 159(7), 1297–1307. https://doi.org/10.1097/j.pain.0000000000001211
Ghamkhar, L., Arab, A. M., Nourbakhsh, M. R., Kahlaee, A. H., & Zolfaghari, R. (2020). Examination of Regional Interdependence Theory in Chronic Neck Pain: Interpretations from Correlation of Strength Measures in Cervical and Pain-Free Regions. Pain Medicine (Malden, Mass.), 21(2), e182–e190. https://doi.org/10.1093/pm/pnz206
McDevitt, A., Young, J., Mintken, P., & Cleland, J. (2015). Regional interdependence and manual therapy directed at the thoracic spine. The Journal of Manual & Manipulative Therapy, 23(3), 139–146. https://doi.org/10.1179/2042618615Y.0000000005
Sueki, D. G., Cleland, J. A., & Wainner, R. S. (2013). A regional interdependence model of musculoskeletal dysfunction: Research, mechanisms, and clinical implications. The Journal of Manual & Manipulative Therapy, 21(2), 90–102. https://doi.org/10.1179/2042618612Y.0000000027
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