Report from the

3rd Interdisciplinary

World Congress of Low Back and Pelvic Pain

Robert Schleip

 

First presented to the Rolf Institute Faculty, January 14, 1999

5th Version October 2000

This was the third interdisciplinary conference on low back and pelvic pain. While the two conferences before took place in San Diego in 1992 & 1995, this third conference was held for the first time in Europe (at the impressive Hofburg conference center in Vienna, Austria, November 19-21 1998). What had motivated me to attend this conference?

Lots of potential presenters had apparently applied to present their studies at this conference, yet only a few dozen had been accepted by the advisory board of this conference, which consisted of Andry Vleeming (Univ. Rotterdam), Vert Mooney (Univ. of Calif., San Diego), Hans Tilscher (Univ. of Vienna); as well as Philip Greenman, Richard DonTigny, Stanley Paris from the USA and Serge Gracovetsky from Canada. Their standards were apparently pretty much in line with what is commonly called "evidence based medicine" (i.e. no room for anecdotal reports or for comparison studies without properly matched control groups, etc). So it was no surprise to me - but still a pity - that no presenter from the Rolfing® community, Feldenkrais®, or some other modern somatic practice had been (or would have been?) accepted by their high academic standards.

About 80 presentations were given during those 3 days, of which half of them happened in two parallel groups in separate rooms on the last day of the conference. Presentations lasted exactly 20 minutes each (on the last day only 10 minutes) and were delivered in an almost emotion-less and fact-oriented style, usually enhanced with state of the art slides, videos or other visuals. A 470 pages book with abstracts or transcripts of the presentations was already available during the conference (and can now be ordered for about $50 from the University of California Medical School (address at the end of this report).

Here are some of my edited notes from the conference. Keep in mind that these notes are influenced by my personal selective attention and digestion of the presented material. A much more thorough impression can be gotten by ordering the conference book or the videos from it which are available from the conference organizers.

Michael Adams suggesting a new direction

In his opening lecture Michael Adams from the University of Bristol, England, reviewed what is currently known about the relationship between spinal loading, lumbar disk degeneration, and low back pain. With reference to the many recent studies that show little or no correlation between disk anomalies and backpain, Michael Adams cited the famous quote (from T.Huxley)

"The tragedy of science:

The slaying of a beautiful hypothesis by an ugly fact".

He finished his talk by stating: "Perhaps biomechanics might not have the crucial role in low back pain as we have thought." This signified to me an important shift in orientation at this conference, since the basic bias of the previous two conferences had been that a thorough study and understanding of the biomechanics (with emphasis on bony and ligamentous elements and a focus on the mechanics of the lumbar disks) would be the most needed and sufficient approach for an anatomical understanding of low back pain.

While at least half of the following presentations were then still based on the previous biomechanical model of low back pain research, an increasing number included exploring other approaches such a research into the neurokinetic differences between healthy and symptomatic people (e.g. like the difference in the muscular firing order or timing of various muscles and muscle parts in daily movements), a more detailed exploration of the psycho-social components, or a deeper look at the histochemical processes occurring in low backpain.

 

Arthrokinetic Reflex Arc

Several presenters demonstrated or referred to a reflex arc (now called arthrokinetic reflex or ligamento-muscular reflex) between spinal ligaments and individual segments of the multifidus muscle. E.g. M.Solomonow from New Orleans demonstrated in cats as well as humans that mechanical pull on the supraspinal ligaments with a surgical hook-needle reflectively increased the tonus of the multifidus muscle at this level of the spine. "Prolonged deformation resulted in prolonged activity of the muscles, indicating a robust neurological and mechanical synergy between the muscles and their corresponding ligaments in the lumbar level."

In other words, even a small ligamentous irritation around one of the facet joints could trigger a long-term local muscle spasm in its neighborhood.

Or maybe also the other way around: stimulating mechanoreceptos in those ligaments with osteopathic or other methods might result in a reflectoric tonus change of some deep muscle fibers around these joints, even if the adjustment does not result in any bony position change of the manipulated vertebrae.

Rotterdam school on pelvic instability

Chris Snijders and Andry Vleeming’s concept of the sacroiliac joint needing myofascial force closure for stability has been verified. EMG studies have shown that the piriformis actively provides such force support for the SIJ in standing, as do the transversus abdominis and the internal oblique (IO) - yet not the rectus abdominis. In sitting the IO is also active, yet in crossing legs the IO is less active (speculation that people cross their legs to avoid fatigue of the IO)

So-called ‘pelvic belts’ have been tested now since 1977. As predicted by that model, wearing a pelvic belt lowers the activity of the IO. Chris Snijders from the Univ. of Rotterdam therefore recommended wearing a pelvic belt either for diagnostic purpose (to see if the pain diminishes with the belt, which would then speak more for a hypemobile SIJ as a major root of the pain); or as a temporary treatment for peripartum pain in women who have been diagnosed as having a hypermobile SIJ. Yet he also stated "Because a pelvic belt lowers abdominal muscle activity in an unnatural way and may promote muscle weakness, we advocate against its use as a measure of preventative bracing. Our biomechanical model on SIJ stability rather points to the need of exercises, in particular exercises in extension and torsion instead of flexion."

Peri-Partum-Pelvic-Pain

Peri-Partum-Pelvic-Pain (PPPP) is unlike pelvic pain

PPPP usually shows in pain in the back of the pelvis and legs, sometimes also around the symphysis in the front, yet rarely in the lower back. Lumbar pain can be coupled with PPPP, yet they have different characteristics and epidemiology. Lumbar pain frequency is pretty constant during the different weeks of pregnancy (mean frequency 10%). PPPP increases in frequency in the early weeks (wk 14-22) and then remains pretty constant on a high level of approximately 35% of pregnant women. After delivery lumbar pain does not regress typically, whereas PPP diminishes already in week 11 postpartum to 5%. Lumbar pain is less intense than PPPP during pregnancy, whereas the reverse is true after pregnancy.

PPPP and pelvic instability:

Most likely PPPP is due to a reduced stability, i.e. hypermobility at the intrapelvic joints. This is influenced by the interaction of estrogen, progesteron, and relaxin on the large ligaments of the pelvis. According to H.C.Östgaard from Sweden "The ligaments become less tense to allow an increased range of motion. This increase in motion is highly individual and has not yet been thoroughly been investigated. However, there seems to exist no simple correlation between increased motion and pain intensity, and the biomechanic registration done so far have shown only vague correlations to back pain in pregnancy. Oral contraception has been investigated and has no correlation to back pain in pregnancy." Yet it was also reported that pregnant women with an above average blood level of relaxin have a 7 times higher frequency of PPPP compared with those with a lower level of relaxin.

Typical signs:

Pain tends to be greater in the evening. The strength adductor test and the active Straight Leg Raising test yield positive (painful) results. H.Östgaard additionally recommends the following 'pelvic pain provocation test': patient supine, one hipjoint flexed 90 degrees with knee bent. Practitioner stablizes the pelvis with one hand and then pushes with his other hand on the knee towards the hipjoint. Usually triggers a familiar pain in the posterior pelvis on the examined side only.

 

Panjabi’s conceptual model of 3 systems

Several presenters (I noticed at least three) referred to a conceptual model proposed by M.M. Panjabi in 1992 describing the interaction between the components that provide stability, for example healthy or faulty stability in the lumbar spine or the sacroiliac joints. I’ll better quote Daine Lee from Canada: "In this model he describes three systems, the passive, the active, and the control. The passive system pertains to the osteoarticuloligamentous structures, the active system pertains to the myofascia while the control system through its central and peripheral neural connections co-ordinates the actions of all."

Control System

Nervous

  

Passive System---------------Active System

Osteoarticuloligamentous-------------- Myofascial

 

"In addition, with respect to stability, Panjabi has defined a zone of motion that he called ‘the neutral zone’. This is the small range of displacement near the joint’s neutral position where minimal resistance is given by the osteoligamentous structures. He has found that the range of the neutral zone may increase with injury, articular degeneration and/or weakness of the stabilizing musculature." A new paper from Panjabi claims further: "Increased global co-contraction is indicative of dysfunction".

Diane Lee (who recently published several impressive books and a video on her research and therapeutic work) teaches women with pelvic instability gentle contractions of what the calls ‘the inner unit’ consisting of transversus abdominis, multifidus and the pelvic floor. Subsequently, exercises which facilitate the appropriate motor patterns of what she calls the outer unit (anterior and posterior oblique systems, deep longitudinal and lateral systems) are added. The research either referenced or conducted by her on all the 4 muscles of the inner unit and their contribution to a healthy force closure of the sacroiliac joint (expressed by a fairly small neutral zone) was quite convincing. Nevertheless she was quite frank about her personal bias that it is the inner muscles and their fine motor control that are the main key within the dynamics of Panjabi’s triade model for her. Yet she also acknowledged that "When motor control is abnormal, there may be too much, or too little, approximation of the joint surfaces. In both cases, the resultant afferent input from the joint and surrounding soft tissues is distorted and sustains the abnormal motor control".

 

McKenzie protocol verified

Robin McKenzie from New Zealand had been announced but was replaced by someone else from his school to demonstrate data in support of the McKenzie method of pain management (internet:www.mckenziemdt.org). As a typical element of that system the practitioner tries to find out if the pain syndrome of the patient can be made to ‘centralize’ in response to various repeated a spinal end-range test movements. "Centralization is the relocation of perceived pain from a distal site proximally toward the midline; for example leg/foot pain relocates to the lumbar midline, while arm/hand pain relocates to the cervical midline. () Centralization occurs more often and more readily in patients with acute as opposed to chronic pain. () The direction of movement that centralizes or abolishes pain is referred to as the patient’s ‘directional preference’. For most patients this is extension, although some patients will only centralize their pain with laterally directed movements. A much smaller group requires flexion to centralize and abolish pain." In congruence with their theoretical assumptions their studies showed that pain that centralizes was predominantly discogram-positive (74%), while pain that could not be effected was only 12% discogram-positive. Additionally they showed that patients with back and neck pain that centralizes have a much better prognosis (which is also the majority) than those that that do not centralize. Detailed report and sources are included in the conference handbook.

 

F.M.Kovacs on neuroreflexotherapy

For me one of the most interesting presentations came from Dr. Kovacs from Mallorca, Spain. In his neuroreflexotherapy he implants ‘surgical staples’ in trigger points in the back, plus additionally he implants ‘epidural burins’ into referred tender points in the ear. (Surgical staples are commonly used in surgery for skin closure and are left in place for about 90 days, epidural pins are small metallic punches placed just below the surface of the skin and stay there for about 14 days). The locations for implantations were exclusively defined by their innervation and did not coincide with the Chines acupuncture points. In a well orchestrated double-blind study with 170 patients with chronic low back pain for more than 8 years, he demonstrated that this method lead to a significant pain reduction already within 10 minutes plus also 45 days after implantation.

His explanation for the possible neurophysiological mechanism behind this effect was seen by several other presenters later as a promising explanatory model also for other therapeutic modalities like acupuncture, spinal mobilizations, etc. Here is an excerpt from his explanation in the conference handbook:

"It has been shown that activation of capsaicin-sensitive fibers correlates with episodes of low back pain. Depolarization of these fibers is accompanied by release of substance P and other neuropeptides. Antidromic release of substance P causes neurogenic inflammation of the innervated territory and gives rise to its humoral inflammation. Depolarization of capsaicin-sensitive fibers activates nociceptive neurons in the spinal cord layers I, II, and V resulting in pain and muscle contracture. If activation of capsaicin-sensitive fibers persists, substance P also causes activation of NMDA receptors of spinal nociceptive neurons inducing protooncogens c-fos and c-jun and probably others. As a consequence nociceptive neurons may remain activated although the initial stimulus has disappeared. This mechanism may explain the persistence of these signs and symptoms (painful limitation of motion, muscle contracture, inflammation, referred pain, etc.) in which the absence of an organic cause to which low back pain could be attributed."

"In this situation physical stimulation of dermal nerve endings related to the dermatomes involved could determine release of enkephalins. Binding enkephalins to receptors of capsaicin-sensitive fibers and nociceptive neurons prevents the release of substance P and deactivates nociceptor neurons, inhibiting the mechanism involved in pathophysiology of low back pain. In addition, structures in the thalamus and brainstem activated by stimuli applied far from the painful zone are capable of triggering pain-relieving effects. In this respect, the ear may constitute a suitable territory for stimulation because of the connections of its innervation-related nuclei."

It was later speculated by several other presenters that this new line of research – i.e. a deeper understanding at the neurochemical processes involved – seems to offer promising explanations not only for such treatments as acupuncture but also for most manual manipulation treatments (chiropractic, osteopathic, etc.) that involve stimulation of mechanoreceptors in spinal joints in order to effect not only the muscle tonus of related spinal muscles but also to trigger a changed metabolism and altered histochemical processes in related nerve fibers as well as in the spinal cord.

 

New roentgen analysis questions most SIJ palpation tests

Radiosteriometric analysis (RSA) is today the most used and most exact method in orthopedic research for small movements. It was recently applied to the sacroiliac joint (SIJ) in the following way: tantalum balls with a diameter of less than 1 mm were implanted from a posterior approach into the pelvic bones, geometrically well spread in the 3-D space into the iliac bones and the sacrum, respectively. Measurements with two telescopic roentgen units for simultaneous horizontal and vertical exposure were then processed by a computer. Subjects had enough space to move around freely in front of the films. Movements between the sacrum and each ilium were measured in the Standing Hip Flexion Test (also named Gillet’s test, which is frequently used for analyzing SIJ mobility. Patient stands on one leg and draws the other knee up towards the chest). Twenty-two patients which had been diagnosed as having a sacroiliac problem (by 2 leading manual therapists independently from each other) were examined.

Rotations were equal on both sides with a range between 0,1 and 1,8 degrees and an average of 0,2 degrees. Backwards motion was only 0,2 mm on average. Conclusion of the Swedish researchers: palpation of such small movements seems impossible.

This stirred some hot discussions in the next questioning period, since many schools presented at this conference which use manual palpation of the SIJ as a diagnostic tool. There had been previous studies about the range of motion of the SIJ, some of which had reported much bigger movements. Yet it seemed - if the challenged practitioners liked it or not - that the RSA measurement method was much more exact than any of the previously reported measurements.

The RSA study report included application of this measurement also in the straddle position (in which the patient standing with one leg forward and that hip maximally flexed, and the other leg backwards and that hip maximally extended). The results in this position did not differ much from that in the standing hip flexion test position.

Additionally the measurement had been used to study the range of motion of the SIJ in women with chronic pelvic pain who were wearing a socalled ‘pelvic belt’ in order to help stabilize that joint. Not in all, but in the majority of them, wearing that belt proofed to diminish the range of motion significantly.

 

Posture Related to Sacral Angle?

As most of you know there is a wide range of assumptions on how much lordosis is considered to be 'ideal' for the average human pedestrian. For example Alois Brügger and Hans Flury from Switzerland advocate a relatively large sagittal curvature of the lumbar spine as ideal, yet Kendall & Kendall, Amy Cochran, Ida Rolf, the Pilates method, and many others consider much less lumbar lordosis as desirable for most people.

There seems to be increasing evidence now, that the amount of lumbar lordosis is closely related to the sagittal position of the sacrum. In 1987 an anthropological science magazine published an interesting study of New York gynecologist M. M. Abitbol . The study was called "Evolution of the lumbar sacral angle" (American Journal of Physical Anthropology 72, 361-372). Abitbol used a specific measurement called 'lumbosacral angle' for the sagittal tilt of the upper sacrum (defined by a sagittal line along the anterior surface of S1) in relation to a similar line along the anterior surface of L3. He showed that this angle is directly related to the acquisition of the upright posture and bipedal walking. It is zero in quadruped, low in monkey, and increases in big monkeys which are occasionally biped. In homo sapiens, it develops with the acquisition of the upright position and gait. For example in us humans it increases from an average of 20 degrees at birth to an average of 70 degrees.

A French team of researchers (B. Boisaubert et.al.) presented a x-ray study at this conference which confirmed this thesis by showing a very high correlation between a low sacral angle and lumbar lordosis in humans. In a second study with spondylolisthesis (unstable vertebrae) patients they then showed that these patients tend to have a lower sacral angle. So they speculated that "a low sacral angle might be a factor of bad accommodation with the erect status" which also leads to "an accentuated lumbar lordosis to obtain sagittal balance. This accommodative hyperlordosis has its limits beyond which stress fractures of the neural arch of L5 might occur and sliding until a new balance without excessive lordosis is obtained." So they see spondylolisthesis related to "a particular morphology of the sacrum of a primitive aspect badly adapted to the upright position."

This made we wondering if - apart from the peculiar cases of spondylolisthesis - maybe the biomechanical relationships between lumbars, sacrum and acetabulum in people with a less tilted upper sacrum demand generally a different pelvic and  lumbar posture than in people with a strongly tilted upper sacrum. In other words: The solution to the often debated question ‚How much lumbar lordosis is good for you?’ might depend to a large degree on the shape of the upper sacrum. For one person (with a low sacral angle) a strong lumbar lordosis might be the best support for standing and biped locomotion, for another one (with a strong sacral angle) little or no lumbar lordosis at all.

Gait Mechanics

Howard Dananberg from New Hampshire (USA) presented an interesting study how low back pain patients often show asymetric walk characteristics in which one hipjoint does not extend as well during the toe off phase. While a healthy person lifts the heel of the rear leg before the other leg hits the ground, this is not happening in many low back pain patients. This poor pre-swing mechanism – analogous to hitting a golf ball without the back swing of the club – demands strong jerky contraction from the psoas on the lumbars in order to move the leg forward. His speculation: this strong and abrupt pull on the lumbar structures facilitates back pain. Teaching these patients to walk with full hipextension again seems to give them also pain relief for their back. A nice punch line from him regarding chronic low back pain:

"Many patients do not limp because they hurt;

but they hurt because they limp.

 

Psychological studies

W.S. Vlaeyen, Switzerland: Besides the well known features of ‘catastrophizing’ and ‘doctor shopping’ back pain patients demonstrate a fear of movement as essential element for sustaining and chronifying their pain pattern. The shift from acute back pain to chronic low back pain happens already during 4-6 weeks (and not after 6 months like several authors had suggested in previous years). Appropriate care identifies and addresses these cognitive factors and helps the patient to learn new cognitive patterns as well as to expose them gradually to movements and job related responsibilities. Interesting study: when a compassionate friend is in the room, patients have a much lower pain tolerance than when they are alone. Therefore physiotherapists are now encouraged to give less attention to pain signals but only to the functional performance of the patient (i. e to give appraisal for the amount, force or smooth quality of a movement done in an exercise, yet ignore all pain communications).

 

The two hottest muscles of this conference

Already at the last conference studies had indicated a close correlation between low back pain and a dysfunctional control of the multifidus, plus it had been shown that the transversus abdominis plays an important role in stabilizing the lumbar spine. This had apparently triggered a whole avalanche of research into those two muscles. Let me summarize a few which were presented.

When load is added to a standing person the transversus abd (TrA) contracts in order to stabilize the lumbar spine via the thoracolumbar fascia. This response is the same no matter if the load is added in the front, side or back of the body. If the person sees and expects the load being added then h/shee already contracts the TrA in a feedforward mechanism.

If a standing person rapidly raises one arm (no matter in which direction) the TrA contracts via the same feedforward manner 30 ms before the deltoid. In chronic low back pain patients this is different: in a slow arm raise they do not activate the TrA at all, and in a rapid arm raise the preparatory TrA comes in much later than in healthy people.

When the TrA stablizes the lumbars the diaphragm (and probably also the pelvic floor) co-contract simultaneously in order to increase the intraabdominal pressure. Interestingly this action of a healthy diaphragm happens independently of the breathing action and can be done during inhalation as well as exhalation.

The multifidus is the only back muscle with contractile fibers below L3. It has a dominance of type 1 (tonic) fibers and has been shown to be active in regular standing. Yet studies with low back pain patients have shown that their multifidus is less active in standing and that it fatigues much more rapidly than in controls and that they have less type 1 fibers in them. New ultrasound imaging techniques have now also given evidence that the actual size of the multifidus is significantly diminished at one vertebral level, and usually only on one side. The location of the wasting correlated highly with the most painful place.

 

The hottest ligament at this conference ...

... was the dorsal longitudinal sacroiliac ligament (DLSL). This easily palpable ligament goes from the Posterior Superior Iliac Spine to the largest of the transverse tubercles in the lateral sacral crest at the level of S3. Already at the previous conference an impressive amount of research into this ligament had been documented by a team from the College of Osteopathic Medicine in Main. It seems clear that an anterior torsion of the ilium (or a backward counter-nutation of the sacrum) stretches this ligament. Dissections had also shown that many fibers of the sacrotuberous ligament join this ligament and can transmit pull from the biceps femoris into it. Additionally the Main team has shown that there is an intimate relationship between this ligament and the lateral branches of the first sacral dorsal rami of the sacrococcygeal nerve plexus (S1, sometimes also S2 and S3), which could explain how pressure or swelling of this ligament could be either capable of pressing on these nerves or to compromise the minute blood vascular system that accompanies these nerves.

At this conference they demonstrated further studies that showed a significant association between low back pain and findings of palpatory tenderness in the DLSL when it is stretched. However no association was found between abnormal tension in this ligament and low back pain. Their conclusion: "Based upon these findings it appears that the DLSL contributes to low back pain by virtue of inflammation or irritation to the ligament or to the sacral nerves coursing under it, rather than through instability of the self-locking mechanism.() Mechanical dysfunction of the ligament does not appear to have an association with low back pain."

 

Gracovetsky, the brilliant challenger

A main figure already at both preceding conferences and a well know figure in this field, Serge Gracovetsky from Canada took over the role of the challenger. With several studies and statistics he showed how different clinicians usually come to a different diagnosis in regards to low back pain in a given patients if they don’t know each other’s result. This seemed to apply to all the common diagnostic systems which include the subjective pain reports of the patients. The data that he presented with impressive multimedia visuals were very convincing .... and embarrassing for the current state of manual therapy. He then suggested only using functional data and measurements rather than subjective reports in any clinical evaluations.

 

The new stars of this conference: the Queensland team

Based on the research reported above on the role of multifidus and tansversus abdominis for a healthy lumbar stabilization, a large and active (and mostly female research team at the University of Queensland in Brisbane, Australia had done years of clinical developments to apply this therapeutically. Their current treatment procedure includes teaching the clients a voluntary fine motor-control of the transversus abdominis and the multifidus by using a real-time ultrasound device as biofeedback for the patient. This was a new direction and much different than the muscle-strength oriented exercise machine programs advocated by Vert Mooney and others at this conference. Rather than muscular strength and endurance they teach fine motor coordination. Their videos and graphs showed convincingly how exactly this motor coordination is missing in low back pain patients (which cannot separate for example their transversus abdominis from the oblique abdominals) and how back pain tends to improve when this motor coordination is enhanced. And the most impressive data – which even impressed even their critical opponent Mooney – was their long term effectiveness: While usually the recurrence rate after an acute low back pain episode is staggeringly high (60-80% of patients suffering recurrences within 1 year), their treatment resulted in only 30% recurrences within 1 year.

A new book just came out about this work: Richardson, et al, Therapeutic exercises for spinal segmental stabilization in low back pain: Scientific basis and clinical approach, Churchill Livingstone.

 

Much more to be done

Vert Mooney "Our grandparents all lost their teeth as they aged due to gum infections. Now that seldom happens" in first world countries due to a better understanding in dental medicine, better professional care, plus a generally increased rational self-care in this regard.

He expressed the hope that as the general scientific understanding of the factors influencing the health of lour backs increases, it should be possible to reach a similar improvement in the frequency of back pain in our society. Yet it was clear that while definitely large successes in terms of understanding and treatment methods have been accomplished by this and the previous two conferences, there is still a whole lot more to be done and understood before reaching that public health improvement level as described by Mooney's comparison with dental health.

 

Other bits and pieces

- fatigueable back muscles & quadriceps

- diminished lumbar mobility

- time of day (early morning worse)

 

Conference Organizers:

Official organizer:

> University of California Medical School, Office of Continuing Medical Education

> 9500 Gilman Drive, LA JOLLA, CA 92093 - 0617, U.S.A., or fax: 1-619~534 7672

>

European Conference Organizers

> P.O.Box 4334, 3006 AH Rotterdam, Phone 3 1 ~ 1 0~4133287,

> Fax 3 1 ~ 10~4148059

>

>

The conference is endorsed by:

> American Academy of Osteopathy

> American Association of Orthopaedic Medicine

> Australian Society of Musculoskeletal Medicine

> Austrian Association for Manual Medicine

> Canadian Physiotherapy Association

> Dutch National Institute of Allied Health Professions, Research and

> Development, Postgraduate Education and Documentation

> European Chiropractors' Union

> European Register of Osteopaths

> (mistakenly not included in the poster announcing the congress)

> Free University Brussels, Postgraduate Education in Manual Therapy

> International Federation of Orthopaedic Manipulative Therapists IFOMT-ECE

> International ]ntradiscal Therapy Society

> International Manual Medical Federation of the Mediterranean

> International Society of Biomechanics

> Manipulative Physiotherapists Association of Australia

> Norwegian Manual Therapy Group

> The Manipulation Association of Chartered Physiotherapists

> World Federation of Chiropractic