Use of thrust and non-thrust manipulation in recurrent lumbar radiculopathy: a case

report.
Scott A. Burns, PT, DPT and Jill Hangee, SPT 1,2 2
1
Regis University – Fellowship of Orthopaedic Manual Physical Therapy
Physical Therapy Program
2
University of Colorado at Denver and Health Sciences Center, School of Medicine Manual Therapy Fellowship
Physical Therapy Program, Denver, CO

Background Treatment Exercise Program

Conclusion
• Treatment consisted of: • Consisted of (in order):
• This patient experienced a rapid 
• Manual therapy including thrust and non-thrust manipulation/mobilization 2,4,5 • Supine lower extremity nerve glide and extension oriented exercises 1
•
improvement in pain and function after 
Stabilization exercises 7
Treatment­based classification (TBC)  • Extension oriented exercise 1
has been documented in its use for  • Cryotherapy non­thrust and thrust manipulation to the 
patients with acute lower back pain  lumbar spine and supine lower extremity 
Manual Treatment neurodynamic mobilization techniques.  
(LBP) 3.  •  High­velocity, end­range, right­rotational force to the lower lumbar spine on the 
mid lumbar spine in a right side­lying, left lower thoracic lumbar side­bent 
Little evidence exists regarding the use  position
• A combination of non­thrust and thrust 
(Neutral “gapping” or million dollar roll)
of this approach in patients with more  • Muscular spasms/increased symptoms were assessed near end-range manipulation coupled with lower 
recurrent history of LBP. • If present, no thrust was given • Lumbar stabilization 7
extremity nerve glides resulted in 
• If absent, thrust manipulation was given
clinically meaningful improvement in his 
The use of thrust manipulation and non­ Oswestry and return to full work status. 
thrust mobilization and neurodynamic 
mobilization has not been reported. 

Purpose Clinical Significance

To describe use of the treatment-based
classification approach in the treatment of an • A combination of thrust and non­thrust 
acute episode of recurrent low back pain with mobilization/manipulation and lower 
neurological symptoms distal to the knee.
Figure 2: Lumbar sidelying mobilization/manipulation position. extremity neurodynamic mobilization 
From Spinal and Extremity Manipulation: Basic Skill Set for the Physical Therapist CD-ROM.
Manipulations, Inc. technique may be helpful in patients 
with chronic recurrent, low back pain 
with radicular symptoms. 
Outcomes • Individuals who do not fit specifically 
Case Description ROM measures by visit NPRS and numbness rating
into one of the categories presented in 
• A 36 year-old male with an acute episode of the treatment based classification could 
LBP with neurological symptoms to the L 100 8 potentially benefit from similar concepts. 
foot and 5th digit for approximately 30 days.
• This is one case of a positive outcome 
7
80
6
• He is employed as full-time as an Visit 1 5
using the theoretical construct of the 
Degrees

60 NPRS
emergency department nurse – currently
Value
Visit 2 4
having to perform more sedentary tasks 40
Visit 3 3
Numbness
treatment based classification system in 
a patient with recurrent lumbar 
2
• Past medical history: chronic, recurrent LBP 20
1
for 10 years 0 0 radiculopathy. 
• Diagnostics: moderate diffuse disc bulge at Flexion L SLR R Slump L Slump 1 2 3

L4/5 with mild to moderate bilateral Outcome Measure Week

foraminal narrowing.
Figure 3. Range of Motion (ROM) per week Figure 4. NPRS and numbness subjective rating

Oswestry
45   Visit 1 Visit 2 Visit 3
40
SLR L 36 75 86
35
30 References
25
Slump R 46 74 75 • Browder et al. Effectiveness of an Extension-Oriented Treatment Approach in a Sub-
%

group of Subjects with Low Back Pain: A Randomized Clinical Trial. Physical Therapy
Slump L 32 45 80
20
2007. 87(12): 1608-1618.
15 • Childs et al. A Clinical Prediction Rule to Identify Patients with Low Back Pain Most Likely
10
Flexion  30 51 70 to Benefit from Spinal Manipulation: A Validation Study. Ann Int Med 2004. 141(12): 920-
927.
5
• Delitto et al. A Treatment-Based Classification Approach to Low Back Syndrome:
Figure 1. MRI Image of L4/5 (from 10 months ago) 0
NPRS 3 1 0 Identifying and Staging Patients for Conservative Treatment. Physical Therapy 1995. 75
1 2 3
• Previous Treatment: 4 sessions of physical (6): 470-489.
Visit Numbness 7 4 1 • Flynn et al. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who
therapy approximately 10 months prior Demonstrate Short-Term Improvement with Spinal Manipulation. Spine 2002. 27(24):

• PT consisted of: mechanical traction, GROC   +6   •

stabilization and mobility exercises, PA
mobilizations, movement and
neuromuscular re-education
• Lapse in his lumbar stabilization exercises
potentially resulted in current episode
Figure 5. Oswestry Score per visit Oswestry 42
FABQ  12 (w); 16 (pa)
Table 1. Outcome Measures
2835-2843.
Fritz JM, Cleland J and J Childs. Sub grouping of Patients with Low Back Pain: Evolution
of a Classification to Physical Therapy. JOSPT. 2007: 291-302.
12* (after manip) 6 • Fritz JM et al. Is There a Sub-group of Patients with Low Back Pain Likely to Benefit
From Mechanical Traction. Spine 32(26). 2007: E 793-E800.
 Not obtained  Not obtained • Hicks et al. Preliminary Development of a Clinical Prediction Rule for Determining Which
Patients with Low Back Pain Will Respond to a Stabilization Program. Arch Phys Med
Rehab. 2005 (86): 1753-62.
• Hebert et al. Clinical Prediction of Success of Interventions for Managing Low Back Pain.
Clinical Sports Med 2008. 27: 463-479.