"I dont manipulate often but when I do, I follow the clinical prediction rule"
Here's a simple case report on the utilization and application of the clinical prediction rule for lumbar manipulation.
A pt arrived with acute (~10 days) idopathic centralized with slight L paracentral sided low back and tenderness to palpation. She runs a daycare but she can not recall any particular activity or lifting that may have caused it. Im not going to list all my objective findings but essentially no particular reduction or reproduction of symptoms and no noticeable movement preference. Dsyfunctional MSF with a core and WB spinal flexion motor control deficit. (Other DNs were noticed but no large DNs or asymmetries were seen). No significant findings with resistance. SIJ provocation tests and hips were ruled out along with having WNL hip motions in all directions.
So what's that leave that is with? A clear cut, 5(ish) for 5 findings for performing a lumbar manipulation according to this Clinical Prediciton Rule:
The 5 rules for Manipulation for Low Back Pain include:
1. Duration of symptoms < 16 days
2. At least one hip with > 35° of internal rotation. Assessed by the SFMA rotation breakout.
3. Lumbar hypomobility. Again, assessed by SFMA, albeit a SMCD leading to the hypomobility, it was still occurring with spinal flexion. Also noted with MSE breakout.
2. At least one hip with > 35° of internal rotation. Assessed by the SFMA rotation breakout.
3. Lumbar hypomobility. Again, assessed by SFMA, albeit a SMCD leading to the hypomobility, it was still occurring with spinal flexion. Also noted with MSE breakout.
4. No symptoms distal to the knee
5. FABQ-W score < 19 (we use FOTO which gave us a low fear avoidance, so I'm gonna count that as well)
5. FABQ-W score < 19 (we use FOTO which gave us a low fear avoidance, so I'm gonna count that as well)
Rx included lumbar manipulation that lead to +3 Cavitaions and symptom alleviation. MSF corrective exercises were performed with a FN MSF retest. Afterwards, pt stated a 75% overall relief. Education on exercises to reinforce MSF was given for home along with additional education on "pain science".
2nd session: Pt returned with 90-95% relief. Reinforced MSF and spent majority of our time educating and training the deadlift/hip hinge and correct lifting mechanics as to prevent future issues and build stability to the low back.
Although, patient preference is paramount and not everyone fits in the perfect lumbar CPR, it can still be utilized as part of your assessment. Furthermore, the manipulation may help the pain threshold but I believe the fact that she made additional gains and stayed pain free was her improvement in her fundamental movement through the SFMA. Additionally, spending the time to retrain lifting mechanics will aide in reinjury prevention as this may of been the main culprit of her previous pain manifestation.
Its not always this easy...
