On this episode of the #AskMikeReinold show we talk about the use of joint manipulations versus mobilizations. As physical therapists, I’d say we have been manipulating less and less as we continue to learn more, but we discuss it a bit more on this episode. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 195: Using Joint Manipulations
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Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about joint manipulations, when we use them, if we use them, why we use them, everything you want to know.
Joe: All right. Nick from New York asks, “What are your opinions on manipulations? Do you use them and how do you incorporate them into your treatments?”
Mike Reinold: Awesome. Lenny, I feel like you’re very manipulative.
Lenny Macrina: I like manipulating people.
Mike Reinold: So joint, we’ll say joint manipulations, not mental manipulations.
Mike Reinold: So what’s our opinions on joint manips, and do we use them? When do we use them? Stuff like that. So all right, who does manipulations? Okay. Happens, right? Yeah, it’s probably less than we had at one point. Okay, so for those that do manipulations, let’s start with that. What do you manipulate and why, and is there anything you won’t manipulate? I don’t know where to start with that, but Mike do you want to start, what are your big joint manips that you perform?
Mike Scaduto: Very often times, say 90% of the time, it’s the thoracic spine, probably a PA manipulation. I’m relying on my assessment techniques to decide if I feel like it’s a hypo mobile segment that is limiting their range of motion grossly to either thoracic extension or thoracic rotation or something like that. I think I try and get a global picture of the patient. Are they more hypo mobile in general, or are they a hyper mobile person with excess motion? Typically, I would steer away from a manipulation in that type of person.
Mike Reinold: Nice, good thought process. I like how you make that decision so it’s not just manip everything. It’s, make sure it’s the right person. And to comment on your thoracic spine manipulation. I mean if there is an area that shows some efficacy in the research, I think thoracic spine manipulations are probably one of the bigger ones. Right? Lots of good manips. Dan, you probably have some references off the top of your head, but doing a thoracic spine manip to increase overhead mobility and to decrease shoulder pain and stuff, it has been shown. So I think that’s a great one right there. Anything else Mike? Other than thoracic?
Mike Scaduto: I don’t think so. So I said 90% of time it’s probably thoracic spine, but I don’t do it 100% of the time.
Mike Reinold: Yeah. Yeah. That makes perfect sense. How about you Dan? Do you manipulate anything else?
Dan Pope: Every so often I’ll manipulate a cervical spine. A couple of thoughts here. I mean it is, I don’t think it’s risky necessarily. The risk of causing more serious effect is very low, although it can happen. The one thing I will say is that I looked into this myself to figure out just how dangerous this is. And again, it’s, it’s not very risky, but you can also cause problems by doing a mobilization of the neck. Right? So I would say that you just have to think about the patient in front of you to figure out whether or not you think you should be doing mobilizations or manipulations of the cervical spine in general.
Mike Reinold: Right.
Dan Pope: A lot of times for me, the cervical spine is more patient buy-in. There’s someone who really wants it, I think it’d be beneficial.
Dan Pope: Certain conditions where it might be helpful and things like TMJ can be a good one.
Dan Pope: Those can be decent areas, but generally if there’s someone who really wants it and I feel is a healthy candidate for it. And then again it has to fall into like critical reasoning process of whether or not, I think there is a joint restriction that can be utilized. You know, it could benefit from that.
Mike Reinold: I like that there’s actually a study that showed that there’s, I don’t know, I’m forgetting off the top of my head, but I think I wrote a blog post about this a while back that one of the primary factors on whether or not a manipulation was something you should include and would have a successful outcome is the person’s perceived benefit of the procedure.
Mike Reinold: So meaning if they didn’t think it was going to work, it didn’t work. And if they did think it was going to work, it did work. So I don’t even know what that says. We can hack that out a lot, but you said that, yeah.
Dan Pope: One of the things I will say really quick is that oftentimes we’re thinking, okay, I have to mobilize a stiff segment. That’s why I’m using manipulation. What we’re probably doing is a short term effect. So again, I don’t know if that would manipulate a hyper mobile joint, especially if I may cause some sort of injury. But what I’m thinking about when I’m doing a manipulation is that I’m probably having a neuro physiologic effect. Right. And I’m guessing this is one of the reasons why people have less pain reaching overhead, less pain-free grip after manipulation.
Dan Pope: If it goes globally, we cause a change in probably sensitivity. Right. And these studies are done in pressure pain threshold. That was my research project that I did for my graduate degree. Is that if you manipulate someone’s spine, right? Let’s say it’s lumbar spine, thoracic spine, or cervical spine, you cause global changes and pressure pain, excuse me, pressure, pain threshold. In other words, you have less pain, your pain threshold goes up, your sensitivity goes down. So if I have somebody who has a pain problem and I’m trying to decrease that pain, albeit maybe temporarily. I don’t think about manipulating and not just because I have a stiff segment per se.
Mike Reinold: Right. And you see here how there’s so many levels of clinical reasoning that we’re kind of talking about here. That was awesome. Any preference? You know, upper versus lower cervical sounds like you’re not scared of manips.
Mike Reinold: Are you afraid of upper cervical or have you already kind of answered that by saying no.
Dan Pope: I guess not. But it’s always in the back of my mind, and I’m doing it very rarely and I’m doing young, healthy people generally. I’m definitely not doing somebody who has cardiovascular disease or you know, obviously any red flags in general, I’m not going to do that.
Mike Reinold: Yeah.
Dan Pope: Yeah.
Mike Reinold: I feel like in my experience with cervical, you know that person that wakes up and they like can’t move their head to the right or whatever, whatever direction they just can’t move their head. A lot of them want to run to a chiropractor or anybody really and try to get that manipulated. But I find that if I try to do that too early in the sequence, that sometimes it helps for a second, right, for a couple of hours, or something like that.
Mike Reinold: But then there’s this reflexive kind of spasm and tone that happens from it and it almost gets worse a little bit here. So I would say, I probably, I don’t manipulate that often. I don’t manipulate as much as I used to. For cervical manipulations, I actually find that I avoided a little bit initially and then if once they’re down and now, okay, the pain and the spasm and the guarding is down, but they still have some hypo mobility, then that’s when I would probably apply it. And that’s very few and far between. Maybe with my patient population too, but I definitely feel like I do it last. Let’s shift gears a little bit. How about lumbar spine? Anybody do lumbar? Dan does. Yeah, you do. Dan does everything, I like it.
Dave Tilley: I’m super unique in this because the people that I treat are hyper mobile gymnasts or dancers and things like that. And you know, so I’ve heard of circumstances where they fit the clinical prediction rule or they had this acute low back pain that wasn’t below their knee and all this kind of stuff, and they got manipped and it’s the worst possible thing that they can do.
Mike Reinold: Right?
Dave Tilley: And I have a lot of people who are hyper mobile, but when they get taken in you’d get a lumbar manip. Either gymnasts or different people or whatever, they’re like, I feel like, like you said with the neck, I feel better for an hour and then I actually feel much, much worse after. So you have to kind of use your critical thinking skills about why is this person having, it’s probably relative hyper mobility at their lumbar spine. Making up for a lack of hip mobility or their core is not stiff enough during their activities whether they’re, so I would say you can’t use them.
Dave Tilley: I think if I have a general popping type patient who has more of a classic disc issue or something like that, it’s more my options. For most people, I’m kind of thinking about some other things first.
Mike Reinold: Yeah, I don’t want to say I ever had strict contraindications. There’s only very few rare things that I kind of feel that way about. But I kind of think in my head I just, I don’t want to do lumbar manips anymore. And just me personally, I just feel like the majority of times somebody has some pain is there’s either some hyper mobility, right? And/or soft tissue restrictions. But it’s not really joint as much in the lumbar spine. So I just feel like, and maybe again, maybe it’s my patient population, but I just feel that’s barking up the wrong tree lot of time. So I’ve stopped. I don’t do lumbar that much. Yeah?
Dan Pope: I was going to say is, if you start looking through the Chocrane reviews about manipulations, they’re not that powerful for the average person in front of you for low back pain. So it’s not, to get rid of that I don’t think is a bad decision. Right?
Mike Reinold: Yeah, sure.
Dan Pope: Yeah.
Mike Reinold: Yeah. I mean, extremity wise, probably not far off, right? I think a lot of times our joints are hyper mobile, right? Not hypo mobile. So you know, a lot of times I think we focus on soft tissue a little bit more here is what I’d say. Anybody else? Anything to add?
Lenny Macrina: I think Dan nailed it. I don’t think I could have said it better. I don’t really think. I used to be in the world of, “Oh, I see a lot of hyper mobile people. Why would I manip?” Are we really making a segment or hyper mobile by a quick manipulation? You’re dealing with bone and collagen and everything else there. When we talk about the knee, we talk about having to load it low-low long-duration for hours at a time and all of a sudden we can do a quick thrust to a lumbar spine and we’ll get, or thoracic spine and we’re creating more mobility. Are we creating more mobility by stretching tissue? Or by what you said, kind of a neurophysiological response where maybe a sensitivity goes down, pain goes down, or the relative, the ability to detect pain goes down so you can do more.
Lenny Macrina: I still, I’m in the world of, and maybe it’s my patients that it’s a soft tissue issue, meaning muscular tightness. So to me doing a manip, yeah, it might feel good. I do thoracic manips a little, and it’s usually by accidentally doing something and their joint pops. I’m like, Oh sweet. You know, and I treat a lot of hypermobile people. Yeah. I mean that’s my joke, I just saved you $35 going to another practice. I don’t know. I think we think about it incorrectly, but the perception that somebody is going to benefit from it, like anything else, if they think it, it’s probably going to be more likely to occur. Like a positive effect. I think, anything else? There’s a reason why people come in here after going somewhere else and we don’t do anything differently than anybody else, but I feel like our results may be a little bit better or at least I perceive that because the person thinks they’re going to get better. So you got to play those mind games.
Mike Reinold: It’s all perception. I think I saw you say no, that you don’t manip.
Lisa Russell: No.
Dave Tilley: What about rowers and stress fractures in the ribs, is that a thing, right?
Lisa Russell: Yeah, I don’t.
Mike Reinold: Well why? Why don’t you manip?
Lisa Russell: I have way more success in getting people to feel better with soft tissue and teaching them self mobility, breathing, any of that kind of stuff. Rowers get low back pain. They’ll come to me and say, “Oh man, can you just crack my back? It’s just, I’m so stiff. Well it’s like, well you’re stiff because your muscles are all tight cause you’re really tired and it’s not… I get way more success in hitting the soft tissue and doing mobility work than manipulating anything. So I haven’t spent the time to get good at it. So I don’t really do it.
Mike Reinold: Yeah, I think a lot of people have that barrier. It’s a little bit harder technically to manip because a lot of people have that barrier. So I guess I’d end it like this. A lot of people don’t manip and they seem to be doing fine. Right? So clearly you don’t need to manip, right? A lot of people think manipulations help them achieve their goals faster too. That’s great too. I guess I would just end with, what I’ve been doing lately a little bit more, is I think I will put people at end range of motion. So whether it be cervical, lumbar, even a joint. End range of motion, and then work a little bit in that position, whether it’s soft tissue, whether it’s deep breath, whatever it may be, and that end range position and maybe even do like a grade three, four kind of like joint mode.
Mike Reinold: In my mind, if they cavitate at that point, so they have a pop that they have from there, then I don’t need to do a thrust, which is I think the question. I don’t need to do a thrust there. They cavitated with a grade three, four manip cause I put them at end range. In my mind, I think that means they got it, right? Versus me. I can just go, “Well, bam,” and just crack everything. I feel like the majority of the time we end up manipulating the hypermobile joints the hypo mobile one doesn’t actually pop.
Dave Tilley: I think there’s research out to that grade four and like they controlled half and half and some got high-grade through grade four. Some got manips and they’re both fine.
Mike Reinold: Right. There’s only one thing though. That if you think you needed the manip, the grade four, it doesn’t work.
Dave Tilley: Right.
Mike Reinold: It’s kind of interesting. So I like to, if it goes, it goes, and in my mind then you got that one segment that needed to go because you put it in the right position and you gently worked on it and manipulated. So I think that’s kind of how we do it here. We’re not against it, but I don’t think it’s a big part of our practice here. And again, I think we’re doing fine. I know a lot of other people that’s kind of their bread and butter and they do great with it too. So it’s definitely a skill set you should look into, but you know, I think it depends a lot on your patient population. Right? So, great. So another good question. Appreciate it. Head to MikeReinold.com, click on that podcast link and you fill out the form to ask us questions and we’ll keep doing this right? Mike?
Mike Scaduto: See you on the next episode.