Clinical Bottom Line: For the treatment of patients with lumbar impairments, we are able to draw some conclusions on the best possible treatment according to our independent review of the literature. These conclusions are best organized according to the length of time the lumbar impairments have been present. For the treatment of patients with acute lumbar impairments we can conclude that a classification-based treatment approach which includes Maitland based manual therapy and McKenzie-based treatment can be beneficial for short-term pain and disability reduction. For the treatment of sub-acute lumbar impairments, we can conclude that applying treatment to subjects that satisfy clinically predictive criteria produces more favorable treatment outcomes. For the treatment of patients with chronic lumbar impairments, we can conclude that standard physical therapy, manual therapy, dynamic strengthening and McKenzie-based therapy can improve subject rated pain and disability. More research is needed to develop a classification-based treatment approach which matches specific treatments to each patient' s unique clinical presentations.
For the treatment of patients with cervical impairments, we are able to draw some conclusions on the best possible treatment according to our independent review of the literature. For patients with sub-acute and chronic cervical impairments, we can conclude that manual therapy can be beneficial for pain and disability reduction. In addition, there is little clinically significant evidence to support the use a McKenzie-based treatment approach for patients with sub-acute and chronic cervical impairments.
For the treatment of patients with thoracic impairments more research needs to identify the most beneficial treatment approach and to determine if manual therapy directed at the thoracic spine can impact impairments of the thoracic, lumbar and cervical spine.
There are a few special clinical circumstances where we would recommend the use of a McKenzie-based treatment approach over a "hands-on" treatment approach. If repeated movements in a particular direction produce centralization of symptoms, the patients' prognosis is significantly improved, regardless of if the patient is suffering for lumbar or cervical impairments.1,2,3 Another instance in which we would encourage a "hands-off' approach is when a patient presents with psychosocial "yellow flags". The implementation of manual therapy, in this special circumstance, might foster therapist dependence or perpetuate unheaIthy beliefs.4,5
Over all, the evidence for effective strategies for the treatment of spinal impairments is generally lacking. The results of our independent literature review support the need to determine the optimum method for matching specific treatments to each patient's unique clinical presentation in order to obtain the best possible outcomes. In addition, research in this area should determine long-term effects of treatment.
Clinical Scenario: Patients with spinal impairments are often referred to physical therapist for treatment. In the clinical setting, we have observed both "hands-on" and "hands-off' approaches for the treatment of these disorders. We have examined the literature in this area to determine the efficacy of each treatment approach for various patient populations.
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