ERIK DE MEULEMEESTER, PT, DSCPT, OMPT

Oakland University

Translatoric Spinal Manipulation¹ or ‘TSM’ was developed by Olaf Evjenth, PT, OMT and Freddy

Kaltenborn, PT, OMT

TSM² can be performed at low velocity (LV) or a high velocity (HV)

LV: long amplitude; end of grade 2

HV: amplitude of impulse is short as possible; end of grade 2, across the final stop

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Mechanical: Enhance fluid movement through the joint⁴ Stretch joint capsule and muscles crossing the joint Increase ROM

Neurophysiological⁴ : Muscle relaxation and pain reduction may be

facilitated at both the spinal and supraspinal levels

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The effect of spinal manipulation on cervical mobility Kondratek et al⁷ in 2006, Creighton et al⁸ in 2005

described pre-positioned C0 & C1 traction for improvement of neck pain and mobility

Krauss et al⁹ in 2008 has described the effect of

thoracic manipulation on the relief of cervical symptoms.

Puentedura et al¹º in 2011 demonstrated the effectiveness of cervical manipulation on pain

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Use of TSM techniques to improve cervical mobility and pain No adverse events were are recorded when

practicing TSM techniques Limited cervical mobility may be treated safely with

TSM techniques ⁷,⁸,⁹ The VA is not compromised with non-thrust TSM

techniques¹¹ 5

No studies were found that describe cervical traction manipulation (TSM), as a single-modal treatment in a study with randomized group assignment.

This information suggests a significant gap in the current literature in the research of cervical manual therapy.

The need to support the effects of cervical manual traction is indicated to establish the use of cervical traction manipulation as an efficacious intervention option.

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1. To demonstrate the effectiveness of Translatoric Spinal Manipulation (TSM) to reduce cervical pain and stiffness.

2. To compare the effectiveness of a high velocity (HV)

and low velocity (LV) versions of the same cervical traction technique.

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Approval was obtained from the respective ethics committees

Participants were recruited through a sample of convenience, 3 subjects for each group

Informed consent and screening forms were completed by each participant

Participants were randomly assigned to either ‘HV’ or ‘LV’

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Inclusion criteria: 18 through 80 years of age primary complaint of neck pain and/or stiffness.

Exclusion criteria: current infection, tumor, spinal fracture concurrently receiving manipulative treatment from

another practitioner, involvement in litigation, and/or currently involved in

workers compensation cases. 9

TSM was performed in sitting, side lying, or supine, as selected by the RA.

After data collection: The therapist completed the intervention using other

interventions as selected by the treating therapist. The only limitation: participants from the HV group only received HV

interventions participants from the LV group only received LV

interventions

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Data collection performed at the beginning of each of 6 PT visits

CROM measurements: flexion, extension, right /left side

bending, right / left rotation 3 warm-up repetitions - stop at the onset of pain. Measure and record 4th, 5th, and 6th repetitions.

Record the NPRS at the onset of pain

Post intervention: CROM was used to guide the participant to return the neck to the point where pain was produced prior to intervention.

NPRS value is reported at this point in the range

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Actively move the neck further, if possible; record CROM Record the NPRS at the end range of motion Each participant was followed for a total of six visits

within their rehabilitation period. NDI was completed before the first / after the sixth visit

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The difference between pre- and post intervention was compared per visit for each direction (ANOVA, graph chart)

Pre- and post intervention pain levels were compared (table comparison)

NDI levels were compared pre visit 1 and post visit 6(bar graph)

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HV/LV Sex Weight Height Work Smoking Pain/Stiff/

Combo

Age

HV1 M 185 6.0 y y c 58

HV2 F 155 5.6 n n s 62

HV3 F 201 5.8 n n c 53

LV1 F 147 5.9 y y c 59

LV2 F 124 5.5 y n c 60

LV3 M 200 5.8 y y c 64

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N Mean SD SEM MDC Flex-HV 16 1.6281 3.24725 1.214 3.363 Flex-LV 18 2.6689 5.52631 2.066 5.724 Ext-HV 18 5.0033 3.00966 1.125 3.117 Ext-LV 18 5.2250 3.35431 1.254 3.474

RSB-HV 17 5.4141 4.26252 1.474 4.084 RSB-LV 17 3.6706 4.41374 1.527 4.231 LSB-HV 17 3.6494 2.99323 1.553 4.303 LSB-LV 18 4.8561 3.94564 2.047 5.672

RROT-HV 18 4.1522 5.75582 1.623 4.497 RROT-LV 18 5.9306 5.94848 1.677 4.646 LROT-HV 18 3.4661 3.17795 1.347 3.732 LROT-LV 18 3.7072 7.11838 3.018 8.363

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FLEXION

0

1

2

3

4

5

6

7

8

9

10

11

12

TX1 TX2 TX3 TX4 TX5 TX6

EXTENSION

0

1

2

3

4

5

6

7

8

9

10

11

12

TX1 TX2 TX3 TX4 TX5 TX6

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HV: Mean: 5.00 MDC95: 3.11 LV: Mean: 5.22 MDC95: 3.47

RIGHT SIDE BENDING

0

1

2

3

4

5

6

7

8

9

10

11

12

TX1 TX2 TX3 TX4 TX5 TX6

LEFT SIDE BENDING

0

1

2

3

4

5

6

7

8

9

10

11

12

TX1 TX2 TX3 TX4 TX5 TX6

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HV: Mean: 5.41 MDC95: 4.08

RIGHT ROTATION

0

1

2

3

4

5

6

7

8

9

10

11

12

TX1 TX2 TX3 TX4 TX5 TX6

LEFT ROTATION

0

1

2

3

4

5

6

7

8

9

10

11

12

TX1 TX2 TX3 TX4 TX5 TX6

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LV: Mean: 5.93 MDC95: 4.64

No significant difference between the effects of HV and LV on the change of Cervical ROM in any direction (p<.05)

Time had no significant effect on CROM for either HV

and LV (p<.05) The interaction between time and velocity failed to reach

statistical significant difference (p<.05)

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Pre NPRS

level of 2 or

more

↓ 2 or more ↓ 1 or less ↑ 1 or more

HV LV HV LV HV LV HV LV

N % N %

Flex 8/18 4/18 3/8 37 3/4 75 4 1 1 0

Ext 6/18 6/18 0/6 0 1/6 17 6 5 0 0

RSB 9/18 6/18 4/9 44 6/6 100 5 0 0 0

LSB 9/18 6/18 4/9 44 5/6 83 5 1 0 0

RROT 6/18 6/18 4/6 66 4/6 66 2 2 0 0

LROT 6/18 7/18 3/6 50 5/7 71 3 2 0 0

18/44 24/35 25/44 11/35 1/108 0/108

41% 69% 57% 31% <1% 0%

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22

0

10

20

30

40

50

60

70

80

90

100

FLEX EXT RSB LSB RROT LROT

HV

LV Per

cent

0

5

10

15

20

25

HV1 HV2 HV3 LV1 LV2 LV3

NDI Pre V1

NDI Post V6

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Effectiveness of TSM

Both treatment groups showed a favorable response to the intervention for ROM, pain, function

No significant differences in cervical range of motion within participants or between participants

The LV group showed a larger reduction in pain than the HV group.

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To the best of my knowledge this is the first randomized study to use the CROM-device as an outcome measure for manipulative cervical traction techniques.

Other studies have used the CROM device as an outcome measurement tool, to investigate either a thoracic manipulation or contra-lateral gapping in the lower cervical spine.

The studies that have investigated the effect of cervical traction and traction manipulation, used functional outcome measures (Neck Disability Index) and self-report of pain (VAS and NPRS). 25

In the preliminary study we have a small sample size which will make it difficult to detect any significant changes with an ANCOVA analysis

We did not ask the RA to report the position of the

intervention. It is possible the position of the intervention may have an effect upon the outcome.

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Orthopedic manual therapists use several manipulative techniques for the treatment of pain and movement impairments of the cervical spine.

This preliminary study demonstrates that cervical traction manipulation has a favorable response on cervical range of motion, pain and function.

No participant reported a significant increase in level of pain or any adverse events during the interventions.

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1) Kaltenborn F. The Spine Basic Evaluation and Mobilization

Techniques. 5th ed. Olso, Norway: . OPTP Minneapolis, Minnesota. 2009.

2) Krauss J., Evjenth O., Creighton D. TSM Translatoric spinal manipulation for physical therapists Lakeview Media. 2006

3) Evans DW. Review of the literature. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories. Journal of Manipulative & Physiological Therapeutics. 2002;25(4):251-262.

4) Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy. 2009;14(5):531-538.

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5) Constantoyannis C, Konstantinou D, Kourtopoulos H, Papadakis

N. Intermittent cervical traction for cervical radiculopathy caused by large-volume herniated disks. Journal of Manipulative and Physiological Therapeutics. 2002;25(3):188-192.

6) Cleland JA, Childs MJD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Manual Therapy. 2005;10(2):127-135.

7) Kondratek M., Creighton D., Krauss J. Use of translatoric mobilization in a patient with cervicogenic dizziness and motion restriction: A case report. Journal of manual and manipulative therapy 2006;13:140-51. Journal of Manual & Manipulative Therapy (Journal of Manual & Manipulative Therapy). 2006.

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8) Creighton D, Viti J, Krauss J. Use of translatoric mobilization in a

patient with cervical spondylotic degeneration: a case report. Journal of Manual & Manipulative Therapy. 2005;13(1):12-26.

9) Krauss J, Creighton D, Ely JD, Podlewska-Ely J. The immediate effects of upper thoracic translatoric spinal manipulation on cervical pain and range of motion: a randomized clinical trial. Journal of Manual & Manipulative Therapy (Journal of Manual & Manipulative Therapy). 2008;16(2):93-99.

10) Puentedura EJ, Landers MR, Cleland JA, Mintken P, Huijbregts P, Fernandez-De-Las-Penas C. Thoracic Spine Thrust Manipulation Versus Cervical Spine Thrust Manipulation in Patients With Acute Neck Pain: A Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy. 2011;41(4):208-220.

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11) Creighton D, Kondratek M, Krauss J, Huijbregts P, Qu H. Ultrasound analysis of the vertebral artery during non-thrust cervical translatoric spinal manipulation. Journal of Manual & Manipulative Therapy (Maney Publishing). 2011;19(2):84-90.

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