BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000514 on 5 October 2019. Downloaded from http://bmjopensem.bmj.

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Open access Original article

Comparing targeted thrust

manipulation with general thrust
manipulation in patients with low back
pain. A general approach is as effective
as a specific one. A randomised
controlled trial
Christopher J McCarthy ‍ ‍ ,1,2 Louise Potter,3 Jackie A Oldham4

To cite: McCarthy CJ, ABSTRACT

Potter L, Oldham JA. What are the new findings?
Background  Spinal manipulation is commonly used to
Comparing targeted thrust
treat back pain. The application of spinal manipulation has
manipulation with general ►► A technically difficult targeted manipulation tech-
thrust manipulation in patients traditionally involved an element of targeting the technique
nique that requires specific training was no more ef-
with low back pain. A general to a level of the spine where the proposed movement
fective in reducing back pain than a simple general
approach is as effective as a dysfunction is sited. We evaluated the effects of a targeted
thrust technique, which requires minimal training.
specific one. A randomised manipulative thrust versus a thrust applied generally to the
controlled trial. BMJ Open lumbar region.
Sport & Exercise Medicine Methods  A randomised controlled clinical trial in patients
2019;5:e000514. doi:10.1136/ How might it impact on clinical practice in the
with low back pain following CONSORT (Consolidated
bmjsem-2019-000514
Standards of Reporting Trials) guidelines. Sixty subjects future?

copyright.
were randomly allocated to two groups: one group
Accepted 9 August 2019 received a targeted manipulative thrust (n=29) and the ►► Our data challenge the time-consuming examina-
other a general manipulation thrust (GT) (n=31) to the tion and treatment techniques that target a thrust
lumbar spine. Thrust was either localised to a clinician- technique to a specific region of the lumbar spine
defined symptomatic spinal level or an equal force for back pain, when in our study the specific tech-
was applied through the whole lumbosacral region. We niques proved no better than a simple, general thrust
measured pressure-pain thresholds (PPTs) using algometry technique.
and muscle activity (magnitude of stretch reflex) via
surface electromyography. Numerical ratings of pain and
Oswestry Disability Index scores were collected. as a recommendation for the management
© Author(s) (or their Results  Repeated measures of analysis of covariance of non-specific low back pain.3 Spinal manip-
employer(s)) 2019. Re-use revealed no between-group differences in self-reported ulation (SM) is defined as ‘the application
permitted under CC BY-NC. No pain or PPT for any of the muscles studied. of rapid movement to vertebral segments
commercial re-use. See rights Summary  A GT procedure—applied without any specific
and permissions. Published by
producing joint surface separation, tran-
targeting—was as effective in reducing participants’ pain sient sensory afferent input and reduction in
BMJ.
1
scores as targeted approaches. perception of pain. ​Joint surface separation
School of Physiotherapy, Trial registration number  ISRCTN11994230.
Manchester Metropolitan will commonly result in intra-articular cavita-
University, Manchester, UK tion, which in turn, is commonly accompanied
2
Manchester Metropolitan with an audible pop. ​Postmanipulation reduc-
University, Manchester, UK
3 tions in pain perception are influenced by
Department of Anaesthesia,
School of Medicine, The Introduction supraspinal mechanisms including expecta-
University of Nottingham, Low back pain is extremely common, with tion of benefit’.4
Nottingham, UK at any point in time, approximately 12% of Manual therapists invest considerable time
4
Health Innovation, Manchester the global population suffering from signif- and effort developing psychomotor skills and
Oxford Road Corridor, Faculty of
icant levels of pain.1 Within the sporting clinical reasoning paradigms, based on the
Biology, Medicine and Health,
The University of Manchester, population, low back pain is one of the identification and targeting of specific passive
Manchester, UK more common musculoskeletal conditions movements to a symptomatic spinal level.
affecting athletes.2 In a review of national and However, some authors have shown clinically
Correspondence to
international guidelines, for the management meaningful reductions in spinal pain, with SM
Dr Christopher J McCarthy; of non-specific back pain in primary care, 12 techniques that move a large regions of the
c​ mccarthy@​mmu.a​ c.​uk out of 15 guidelines included manipulation spine, with very little targeting of movement.5

McCarthy CJ, et al. BMJ Open Sp Ex Med 2019;5:e000514. doi:10.1136/bmjsem-2019-000514   1

 BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000514 on 5 October 2019. Downloaded from http://bmjopensem.bmj.com/ on October 6, 2019 by guest. Protected by
Open access

Also, neck pain can be reduced with SM applied to the local nociceptive pain, (2) self-reported back pain and
thoracic spine.6 (3) local muscle stretch-reflex responses. The inter-
Researchers have investigated the efficacy of the spec- vention was compared with a thrust movement of the
ificity of application that has also been considered with same magnitude and acceleration that did not target a
both high (mobilisation) and low velocity (manipulation) spinal level, instead generally moving the lumbar region.
passive movements applied to the spine. Two studies7 8 We noted that the magnitude of the local-muscle EMG
compared the effects of specific manipulation and mobil- stretch-reflex response to manipulative techniques may
isation with a clinician-determined ‘target’ spinal level, be correlated with the severity of pain and disability in
with manipulation/mobilisation applied at random patients with low back pain,9 and that the local stretch-re-
levels or generally through the lumbar spine. Pain and flex response contributes to postreflex relaxation of
disability were equally improved—further challenging muscle,10 thereby contributing to the analgesic effect of
the need for targeting passive movement. Those two SM. Therefore, our study included data that would allow
studies7 8 had not examined the effects of SM on electro- us to compare this local muscle response, between the
myography (EMG) parameters and had not standardised targeted thrust (TT) and GT groups.
the amplitude of the SM movements used.
We believed there was a need to investigate the clin- Methods
ical utility of specific targeting thrust (TT) versus a Subjects were randomly allocated to either a TT or GT
general thrust (GT) movement SM (of equivocal accel- group, using a minimisation technique.11 The Minimisa-
eration). Therefore, this study examined the effect of tion strategy employed two factors: body mass index and
targeting SM to symptomatic lumbar spinal level on (1) gender to govern allocation, as these factors are known

copyright.

Figure 1  The CONSORT statement diagram, detailing the participant flow through the trial. CONSORT, Consolidated
Standards of Reporting Trials; GT, general thrust; TT, targeted thrust.

2 McCarthy CJ, et al. BMJ Open Sp Ex Med 2019;5:e000514. doi:10.1136/bmjsem-2019-000514

 BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000514 on 5 October 2019. Downloaded from http://bmjopensem.bmj.com/ on October 6, 2019 by guest. Protected by
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The TT group received a single high-velocity low-am-

Table 1  Baseline characteristics of the two groups
following randomisation plitude thrust delivered to the subject positioned in a
side lying position. The manipulation was delivered by
TT group, n=31 GT group, n=29
an osteopath with 13 years of clinical experience. The
N=60 Mean SD Mean SD joint targeted for manipulative thrust was the spinal loca-
Age 37.90 12.31 35.66 10.68 tion deemed to be most symptomatic during the clinical
BMI 26.81 4.24 27.09 3.98 examination, using active movement observation, passive
movement assessment of resistance to movement and
SF36 67.40 15.75 64.37 10.78
pain provocation tests.14 The process of identifying the
MSPQ 6.33 6.66 5.96 4.87 spinal level, considered clinically relevant, and thus the
Zung 15.97 10.70 14.82 9.38 target for the manipulative thrust technique was inves-
DRAM total 21.63 13.11 22.11 11.37 tigated in a reliability study prior to the initiation of this
TSK 35.63 6.62 35.58 6.62 work.14 This work established the intrarater reliability of
this judgement to be Intraclass Correlation Coefficient
RM 6.57 3.82 6.48 3.46
(ICC)2,1=0.96 (95% CI 0.87 to 0.99).
VAS 23.95 14.77 27.31 20.74
The GT group received a high velocity movement with
A table showing the mean and SD of the baseline data for the two the subject in the same position as the targeted manip-
groups after randomisation. ulation, but the force of the thrust was not directed
BMI, body mass index; DRAM, Distress and Risk Assessment toward a specific lumbar level. It was hypothesised that
Method;GT, general thrust; MSPQ, Modified Somatic Perception
Questionnaire; RM, Roland Morris Disability Questionnaire;
this would create a similar stimulation of the mechanore-
SF36, Short Form 36; TSK, Tampa Scale for Kinesiophobia;TT, ceptors in the superficial soft tissues but that the kinetic
targeted thrust; VAS, Visual Analogue Scale; Zung, Modified Zung force would be dispersed across a wider area causing less
Depression Index. stimulation to specific, intersegmental joint and muscle
mechanoreceptors. Subjects attended for three repli-
cate sessions, with a minimum of 7 days and maximum
to influence EMG signal conduction velocity.12 Subjects of 9 days interval between visits. The intervention was
were blind to treatment allocation. undertaken in a clinical research facility, sited within a
university teaching hospital.
Participants

copyright.
Subjects, with low back pain, were recruited. On the
Outcome assessment
initial visit, participants were screened for eligibility
Subjects attended for three sessions, where they received
including: being between 20 and 60 years of age, having
the intervention determined at allocation. At each testing
suffered pain for at least 3  weeks, having a Roland
session, subjects completed a RMDQ, in addition to the
Morris Disability Questionnaire (RMDQ)13 score of 4 or
outcome measurements, detailed below.13
above and not having any previous history of significant
illness, bony pathology or any other contraindications
Pain measurements
to manipulation (ie, red flags). The study was approved
Pretreatment and post-treatment pain were assessed by
by a local research ethics committee. Research carried 15 16
Visual Analogue Scale and algometry. Algometry
out with human subjects in compliance with the Decla-
was used to assess pressure-pain threshold (PPT) at the
ration of Helsinki. The study was approved by a local
centre of the muscle belly, for the same muscles evalu-
research ethics committee (North Manchester LREC 02/
ated by EMG (local multifidus and illiocostalis) (model
NM/406).
PTH-AF 2; Pain Diagnostic and Treatment, USA).
Patient involvement The reliability of this measure had been established as
The research was developed using the views of patients very good (ICC2,1=0.87; 95% CI 0.67 to 0.95), with low
involved in an evaluation of back care services in a local measurement error in a study undertaken prior to the
hospital and reflected their desire to understand the trial.17
need for such a long and detailed assessment process,
prior to treatment. Results were fed back via the clinical Electromyography
department at which the service was being undertaken. Surface EMG (sEMG; Biopac Systems, MP150 WSW, Cali-
Being involved in the study did not involve significantly fornia, USA) was employed to assess peak EMG amplitude
more time or inconvenience than routine clinical care at as a measure of muscular reflexogenic responses. Dispos-
the local service. able pregelled, self-adhesive, surface electrodes (Ag/
AgCl, Unilect), were attached bilaterally to prepared
Intervention skin (impedance <10 kΩ), overlying two pairs of muscles:
Participants had been informed that they would receive local multifidus and iliocostalis. Further electrodes were
one of two types of SM technique and were blind to placed on bony prominences to act as ground electrodes.
which type they were receiving. The clinician, under- Recorded signals were low and high bandpass filtered
taking the SM technique, was not blind to allocation. to exclude <8 Hz and >500 Hz, notch filtered (50 Hz) to

McCarthy CJ, et al. BMJ Open Sp Ex Med 2019;5:e000514. doi:10.1136/bmjsem-2019-000514 3

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Table 2  Descriptive statistics for the pain measurements

Test 1 Test 2 Test 3
n Mean SD n Mean SD n Mean SD

PPT Right TT Pretest 31 6.17 2.78 29 6.97 2.91 25 6.70 2.65

iliocostalis TT Post-test 6.95 3.29 7.97 3.72 7.68 2.84
(kg/cm2)
GT Pretest 29 6.61 3.85 28 3.65 3.80 26 6.80 3.48
GT Post-test 6.83 4.08 6.86 3.73 7.62 4.13
Left TT Pretest 31 6.78 2.77 29 7.47 3.33 25 7.67 2.82
TT Post-test 8.40 3.20 8.83 3.16 8.63 2.66
GT Pretest 29 6.62 4.10 28 7.04 3.99 26 7.71 4.15
GT Post-test 7.49 4.34 7.86 4.26 8.28 4.12
PPT Right TT Pretest 31 6.50 2.80 29 7.16 3.21 25 7.36 2.81
multifidus
TT Post-test 7.99 2.97 9.04 3.88 8.90 3.18
(kg/cm2)
GT Pretest 29 7.02 3.86 28 7.36 4.12 26 7.64 4.18
GT Post-test 7.27 4.38 7.89 4.60 8.43 4.76
Left TT Pretest 31 6.91 2.89 29 7.18 3.16 25 7.50 2.68
TT Post-test 8.47 3.47 9.01 3.04 8.84 2.98
GT Pretest 29 6.69 3.74 28 6.88 3.75 26 7.60 4.29
GT Post-test 7.35 3.99 7.95 4.29 8.06 4.40
VAS TT Pretest 31 23.95 14.77 28 19.63 14.26 25 16.18 16.16
(mm)
TT Post-test 23.82 14.82 14.05 16.23 9.65 14.37
GT Pretest 29 26.55 22.86 28 28.89 22.44 24 17.48 13.55
GT Post-test 14.82 15.04 19.48 21.87 15.48 14.85
RM TT 31 5.94 3.76 29 4.38 4.31 25 4.08 4.35

copyright.
GT 29 5.03 3.43 28 4.75 3.23 26 3.33 2.48

A table showing the means and SD of the PPT, RM and VAS measurements, pretest and post-test for the TT and GT manipulation group, for each
experimental visit.
GT, general thrust; PPT, pressure-pain threshold; RM, repeated measures; TT, targeted thrust; VAS, Visual Analogue Scale.

remove ambient electric noise, and A to D converted covariate) was conducted to evaluate the differences in,
at a sampling rate of 1000 Hz. AcqKnowledge software change of pain and disability and differences between
(Biopac Systems) was used for data extraction. Filtered the magnitude of the EMG reflex response to TT and
raw EMG signals were normalised by subtracting the GT at the three different time points for the two groups.
peak-to-peak EMG measurement at rest in side lying from A priori, a decision was made to undertake per-protocol
the peak-to-peak recording of the reflex responses for analysis and compare this with intention-to-treat analysis
each channel. Normalisation allowed for the comparison
of the same muscle/different muscles on different days.18
An accelerometer (triaxial accelerometer TSD109F;
Biopac Systems, California, USA), placed on the iliac Table 3  Repeated measure ANCOVA: pain by time × group
crest, was used to evaluate the rate of acceleration and F value Significance
magnitude of the thrust for both groups.
PPT iliocostalis Right 0.00 0.97
Data analysis Left 0.75 0.39
We used an analgesic effect size of measures using self-re- PPT multifidus Right 0.06 0.81
ported pain (η2=0.25), a two-tailed null hypothesis and Left 0.08 0.78
an alpha of 0.05 to generate a conservative estimate of VAS 3.32 0.08
power. Thirty participants per treatment group were
RM 0.26 0.61
determined to provide greater than 95% power to detect
a group × time interaction in the proposed analysis of A table showing the time × group interaction for the change in
variance (ANOVA) model, based on pilot study point pain and disability over the three sessions of the experiment. The
estimates of group difference and pooled SD. F value and level of significance are displayed for the algometry
(PPT), VAS and RM scores; baseline scores were used as a
All data were normally distributed and all assumptions covariant.
for parametric testing were met. A repeated measure ANCOVA, analysis of covariance; PPT, pressure-pain threshold;
analysis of covariance (ANCOVA) (baseline scores as a RM, repeated measures; VAS, Visual Analogue Scale.

4 McCarthy CJ, et al. BMJ Open Sp Ex Med 2019;5:e000514. doi:10.1136/bmjsem-2019-000514

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Table 4  Descriptive statistics: sEMG responses for TT and GT groups at each visit
Visit 1 Visit 2 Test 3
n Mean n Mean n Mean F value Significance

sEMG reflex iliocostalis Right TT 26 3.72 27 4.55 21 4.75

(V) GT 22 3.55 25 3.55 24 2.94 0.90 0.35
Left TT 28 5.17 26 4.27 23 3.48
GT 23 3.65 25 3.55 23 2.95 0.27 0.61
sEMG reflex multifidus Right TT 27 2.72 29 3.10 21 4.78
GT 27 3.53 28 2.93 25 1.23 9.57 0.00
Left TT 27 2.44 29 2.51 23 5.62
GT 25 3.90 27 2.40 25 1.65 5.01 0.03

Table showing the numbers per group, means of the sEMG response (volts) to TT and GT for each of the eight muscle channels for the three
experimental visits. In addition, the repeated measure ANCOVA for the sEMG time × group interaction, F value and the significance for the TT and
GT groups.
ANCOVA, analysis of variance; GT, general thrust; sEMG, surface electromyography; TT, targeted thrust.

(using last value carried forward imputation of missing Discussion

data) if loss to follow-up was >20%. This trial took two similar groups of subjects with low
back pain and compared the effect of a manipulative
TT technique aimed toward a clinician-defined target
Results versus a similar magnitude thrust technique that was
Participants not targeted toward a specific level of the lumbar spine.
Seventy-six subjects attended for assessment. Fourteen of There were no differences in disability or pain reductions
these volunteers were excluded (these participants had between the groups. Pain was measured as self-reported
a RMDQ score that was too low (<4) for inclusion) and pain levels or in pressure-pain perception in the lumbar
one declined to participate. Sixty-one were allocated and

copyright.
muscles. There was an increase in the stretch-reflex
one withdrew after randomisation. Thus, from a sample sEMG response in the lumbar multifidus muscles of the
of 60, 31 subjects were allocated to the TT group and 29 TT group, across the three visits.
to the GT group. Loss to follow-up after visit 3 was 15% Our data suggest that targeting a manipulative thrust
(see figure 1). technique to a clinician-defined, specific level of the
Both groups of subjects had similar demographic, lumbar spine does not improve self-reported pain or
anthropometric and pain characteristics at the start of disability levels. This extends previous reports that
the trial (see table 1). compared methods of joint mobilisation and manipula-
tion.7 8 19 All these data (our study and related studies)
Changes in pain suggest, it may be necessary for manual therapy scientists
Table 2 summarises differences in pain assessment for to re-evaluate the paradigms traditionally used to explain
both treatment groups at each time point of assessment. the therapeutic mechanisms of applied passive move-
A repeated measures of ANCOVA, including baseline ment to the spine. We report that specifically targeted
scores as a covariate, revealed no between-group differ- manipulation amplified the local stretch-reflex response,
ences in self-reported pain, disability or PPTs for the though it did not reduce pain (compared with the control
muscles studied (see table 3). group), over the course of three visits. One could spec-
ulate that as subjects attended for repeated visits, they
Change in sEMG stretch-reflex responses anticipated that they were to going to receive a thrust to a
There was a statistically significant change in the differ- specific locality resulting in a ‘protective’ muscular excit-
ences in the magnitudes of the sEMG reflex response ability to stretch, via an increase in alpha motor neuro
to TT and GT, over three successive treatment visits, in pool activity, a phenomenon that has been observed with
the multifidus muscles (see table 4). There was a trend, lumbar manipulation previously.10 20 21
in the TT group, toward a larger sEMG reflex response
at test 3, than at test 1. There was no significant differ- Limitation
ence in the magnitude or acceleration of the SM thrust The study had some limitations. A post hoc power calcu-
in between groups (ANOVA time × group, F=0.01, lation, using the observed between group difference and
significance=0.97). The consistency of the magnitude of variance, showed that actually a sample size of 34 in each
acceleration during thrusts (in both GT and TT groups) group would have led to the β value of 20% and an α
(intrarater reliability of the pooled data) was excellent value of 5%, with regards to pain. This study’s α and β
(ICC2,1 =0.96; 95% CI 0.92 to 1.00). values were 0.05% and 32%, respectively, and thus the

McCarthy CJ, et al. BMJ Open Sp Ex Med 2019;5:e000514. doi:10.1136/bmjsem-2019-000514 5

 BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000514 on 5 October 2019. Downloaded from http://bmjopensem.bmj.com/ on October 6, 2019 by guest. Protected by
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study was slightly underpowered, raising the chance (by ORCID iD

12%) of a false negative. The study was single blind, as Christopher J McCarthy http://​orcid.​org/​0000-​0002-​9453-​5326
the experimenter had to know which group the subject
was in to deliver the correct SM thrust. This may have References
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6 McCarthy CJ, et al. BMJ Open Sp Ex Med 2019;5:e000514. doi:10.1136/bmjsem-2019-000514