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Short-Term Effect of Spinal Manipulation on Pain Perception, Spinal Mobility, and Full Height Recovery in Male Subjects With Degenerative Disk Disease: A Randomized Controlled Trial
Abstract
Objective:
To evaluate the short-term effect on spinal mobility, pain perception, neural mechanosensitivity, and full height recovery after high-velocity, low-amplitude (HVLA) spinal manipulation (SM) in the lumbosacral joint (L5-S1).
Design:
Randomized, double-blind, controlled clinical trial with evaluations at baseline and after intervention.
Setting:
University-based physical therapy research clinic.
Participants:
Men (N=40; mean age ± SD, 38 ± 9.14 y) with diagnosed degenerative lumbar disease at L5-S1 were randomly divided into 2 groups: a treatment group (TG) (n=20; mean age ± SD, 39 ± 9.12 y) and a control group (CG) (n=20; mean age ± SD, 37 ± 9.31 y). All participants completed the intervention and follow-up evaluations.
Interventions:
A single L5-S1 SM technique (pull-move) was performed in the TG, whereas the CG received a single placebo intervention.
Main outcome measures:
Measures included assessing the subject's height using a stadiometer. The secondary outcome measures included perceived low back pain, evaluated using a visual analog scale; neural mechanosensitivity, as assessed using the passive straight-leg raise (SLR) test; and amount of spinal mobility in flexion, as measured using the finger-to-floor distance (FFD) test.
Results:
The intragroup comparison indicated a significant improvement in all variables in the TG (P<.001). There were no changes in the CG, except for the FFD test (P=.008). In the between-group comparison of the mean differences from pre- to postintervention, there was statistical significance for all cases (P<.001).
Conclusions:
An HVLA SM in the lumbosacral joint performed on men with degenerative disk disease immediately improves self-perceived pain, spinal mobility in flexion, hip flexion during the passive SLR test, and subjects' full height. Future studies should include women and should evaluate the long-term results.
... The average age of participants was 34.05 years old. Eight trials (27%) included acute or chronic neck pain [38][39][40][41][42][43][44][45]; seven (23%) acute or chronic low back pain [46][47][48][49][50][51][52]; six trials (20%) shoulder pain [53][54][55][56][57][58]; three (10%) headache [59][60][61]; two (7%) primary dysmenorrhea [62,63]; and trials looked at thoracic spine pain (3%) [64]; patellofemoral pain syndrome (3%) [65]; temporomandibular disorder (3%) [66]; and cervical radiculopathy (3%) [67]. ...
... The trials had to perform at least one manipulation in one intervention group and this procedure had to be the only one the subjects received. Most of the trials performed one session of treatment (63%) [38][39][40][41][42][43][44][45]50,52,54,55,[57][58][59]63,[65][66][67], the trial conducted by Senna et al. [51] the longest one, conducted over a 10-month period and completing 48 sessions of manipulations during this time. Concerning the pain emplacement and manipulation location: five trials (63%) which presented subjects suffering from neck pain performed cervical spine manipulation [38][39][40]43,44] and three (37%) applied thoracic spine manipulation [41,42,45]; in low back pain trials applied lumbar manipulation in all interventions [46][47][48][49][50][51][52]; ...
... Most of the trials performed one session of treatment (63%) [38][39][40][41][42][43][44][45]50,52,54,55,[57][58][59]63,[65][66][67], the trial conducted by Senna et al. [51] the longest one, conducted over a 10-month period and completing 48 sessions of manipulations during this time. Concerning the pain emplacement and manipulation location: five trials (63%) which presented subjects suffering from neck pain performed cervical spine manipulation [38][39][40]43,44] and three (37%) applied thoracic spine manipulation [41,42,45]; in low back pain trials applied lumbar manipulation in all interventions [46][47][48][49][50][51][52]; ...
Purpose:
Background: Evaluate whether the design of placebo control groups could produce different interpretations of the efficacy of manual therapy techniques.
Methods:
Nine databases were searched (EMBASE, CINAHL, PsycINFO, MEDLINE, PubMed, SCOPUS, WEB of SCIENCE, COCHRANE, and PEDro). Randomized placebo-controlled clinical trials that used manual therapy as a sham treatment on subjects suffering from pain were included. Data were summarized qualitatively, and meta-analyses were conducted with R.
Results:
53 articles were included in the qualitative analysis and 48 were included in the quantitative analyses. Manipulation techniques did not show higher effectiveness when compared with all types of sham groups that were analyzed (SMD 0.28; 95%CI [-0.24; 0.80]) (SMD 0.28; 95%CI [-0.08; 0.64]) (SMD 0.42; 95%CI [0.16; 0.67]) (SMD 0.82; 95%CI [-0.57; 2.21]), raising doubts on their therapeutic effect. Factors such as expectations of treatment were not consistently evaluated, and analysis could help clarify the effect of different sham groups. As for soft tissue techniques, the results are stronger in favor of these techniques when compared to sham control groups (SMD 0.40; 95%CI [0.19, 0.61]). Regarding mobilization techniques and neural gliding techniques, not enough studies were found for conclusions to be made.
Conclusions:
The literature presents a lack of a unified placebo control group design for each technique and an absence of assessment of expectations. These two issues might account for the unclear results obtained in the analysis.
... Standard medical care based on medication is more frequently used during the early stages of LBP (79,83,85), while interventions based on exercise therapy are commonly prescribed for chronic primary LBP (81,82,86,87). Fewer studies have examined the differences with sham/placebo interventions (88)(89)(90)(91)(92)(93), and a handful have contrasted SMT to mobilization techniques for LBP (94)(95)(96). The outcome measures generally assessed include subjective reports of pain intensity and disability (the latter via the use of the Roland-Morris and Oswestry questionnaires), which are also the outcomes of interest for the present review. ...
... Sham SMT has been more frequently explored as a placebo comparator in efficacy trials of SMT for LBP (108). It is common to use a similar hand placement and patient position for sham SM while applying biomechanically different forces (e.g., lower force or velocity, non-therapeutic direction, or point of application) or no force at all (88)(89)(90)92). Figure 2 illustrates the direction of the findings for each of the studies discussed below. ...
... The immediate efficacy of a single SM for LBP of unspecified duration was compared against a sham manipulation, positioning the patient but not applying any force (92). Patients reported immediate pain relief after SMT compared to sham; however, these results may or may not be transferable to the clinical setting. ...
Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.
... In particular, structural changes observed in degenerative disc disease decrease the intervertebral height as well as spinal mobility [19]. It would also be significant to verify the effects of flexion-distraction spinal manipulation on lumbar joints of patients with degenerative disc disease since decreased hip flexion mobility influences the load on the lumbar vertebrae [19][20]. In addition, a study applied flexion-distraction spinal manipulation to patients with herniated discs in straight leg raise range [21]. ...
... Flexiondistraction spinal manipulation regulates the somatosensory system and suppresses the hyperactivity of paraspinal muscles, thus leading to functional improvement [38]. Spinal manipulation recovers the free range of motion of joints to recover the mobility of fixed joints, decreases muscular hyperactivity, decreases hyperstimulation and hyper irritation of nerves, and recovers normal reflexes [20]. Direct mechanical flexion on certain spinal segments would have improved the intersegmental flexion range [39], which would have lengthened the surrounding tissues and increased the flexion mobility of the lumbar spine [40]. ...
... and this result was similar to previous research findings and was clinically significant as defined by MCID. In this study, spinal manipulation would have increased the mobility of spinal facet joints and decreased the protective reflex muscle contraction [20]. In another study reporting that the straight leg raise range increased from 35.60°±9.85 to 70.73°±14.46 ...
... The search identified 1039 articles (Figure 1), and 8 RCTs were included in the review [56][57][58][59][60][61][62][63]. One author provided additional detail from their thesis [64]. ...
... Participants (aged 22-57 years) were mostly (n = 7) recruited from private settings (universities, private practices, research clinics), except one, that recruited from a secondary care setting [59]. Two of the studies only recruited male participants, attempting to limit variation due to gender [62,63]. Half of the studies recruited asymptomatic participants [58,60,61,63]. ...
... Half of the studies recruited asymptomatic participants [58,60,61,63]. The other studies recruited participants with back-related leg pain (90% chronic [57]), degenerative lumbar disc disease at L5/S1 ± above-knee radiating leg pain (unknown duration [62]), intervertebral disc prolapse (L4/5 or L5/S1) with radiculopathy (average >3 years, i. e. chronic [59]), or low back pain (3 weeks to 6 months, i.e. acute to chronic) without signs of nerve root compression [56]. One study identified baseline significant differences in PSLR ROM (SMT group higher than Sham SMT group [62]), potentially overestimating treatment effects [65]. ...
Objective: Spinal Manipulative Therapy (SMT) is a routinely applied treatment modality for various musculoskeletal conditions, including low back pain. The precise mechanisms by which SMT elicits its effects are largely unknown, but recent research supports a multi-system explanation recognizing both biomechanical and neurophysiological mechanisms. Although the evaluation of changes in clinical presentation is complex, objective neurophysiological measures of sensitivity to movement (e.g. neurodynamic tests) can be a valuable clinical indicator in evaluating the effects of SMT. This review aimed to synthesize current literature investigating the effects of SMT on lower limb neurodynamics.
Method: Eight electronic databases were systematically searched for randomized controlled trials (RCT) that applied SMT (against any control) and evaluated lower limb neurodynamics (Passive Straight Leg Raise or Slump Test). Selection and data extraction were conducted by one researcher, reviewed by a second author. Risk of bias (RoB) was assessed using the Cochrane Back Review Group criteria.
Results: Eight RCTs were included, one with high RoB. SMT produced a clinically meaningful (≥6⁰) difference in five of these studies compared with inert control, hamstring stretching, and as an adjunct to conventional physiotherapy, but not compared with standard care, as an adjunct to home exercise and advice, or when comparing different SMT techniques. Findings compared to sham were mixed. When reported, effects tentatively lasted up to 6 weeks post-intervention.
Conclusion: Limited evidence suggests SMT-improved range of motion and was more effective than some other interventions. Future research, using standardized Neurodynamic tests, should explore technique types and evaluate longer-term effects.
Level of Evidence: 1a
... 1,10 Manipulative distraction thrusts are performed in 3D spinal position of extension, lateral flexion, and rotation to increase spinal height and improve water diffusion in lumbar spine IVDs 11 and decrease LBP. 12 Application of distraction techniques using a sustained 3D spinal position and its consequences on spine height changes has not been investigated. Although 3D spinal position applied with manipulative thrusts has been shown to produce minimal increased spinal height, 11,13 no study to date has evaluated if such a 3D spinal position performed with or without manual distraction would produce similar spinal height gains. Therefore, the purposes of this study were to assess (1) spinal height changes in response to a 3D spinal position with and without manual distraction load that followed a standardized period of spinal loading aimed at shrinking the spine, and (2) whether degrees of trunk rotation correlated with the spinal height changes. ...
... Vieira-Pellenz et al 13 observed increased spinal height of only 4 mm after performing a spinal manipulative maneuver, which is lower than the average spine height change noted in the current study (5.7 mm). The current study preceded the intervention by normalizing spine height and by a seated loaded position aimed at shrinking the spine, which was not performed by Vieira-Pellenz et al. 13 The IVD has the ability to absorb and dispel fluid during unloaded and loaded activities, creating spine height changes. 7 Water diffusion across the IVD after spinal manipulative maneuvers could potentially affect spinal height changes. ...
Objective
The purpose of this study was to investigate if spinal height increases using 3-dimensional (3-D) spinal position with and without manual distraction load and to assess the correlation between spine height changes and degrees of trunk rotation.
Methods
Fifty-six participants were randomly placed in one of two groups: (1) 3-D spinal position with manual distraction load, and (2) without manual distraction load. Spinal height was measured before and after the interventions using a stadiometer. For the statistical analysis, we used a 2 (Loading status: pre- versus post-intervention height) X 2 (3-D spinal position: with versus without manual distraction load) repeated measures Analysis of Variance (ANOVA) was used to identify significant interaction and main effects. Paired t-tests were used to calculate differences in spinal height changes between the two interventions. Pearson correlation coefficient was used to measure correlations between changes in spinal heights and degrees of trunk rotation.
Results
Mean spinal height increase with 3-D spinal position with and without manual distraction load was 6.30 mm (±6.22) and 5.69 mm (±4.13), respectively. No significant interaction effect was present between loading status and 3-D spinal position but a significant main effect in loading status was. Paired t-tests revealed significant differences in spinal heights between pre-and post-3-D spinal position with and without manual distraction load. No significant correlation was measured between trunk rotation and spinal height changes.
Conclusion
3-D spinal position with or without distraction load increased spinal height. This suggests that 3-D spinal positioning without manual distraction could be used in home settings to help maintain intervertebral disc (IVD) health.
... No significant effects of sex, age, and side on ISE data were observed (P N .05). Level of manipulation had no effect on the ISE except for the handling (F [1,55] = 7.45, P b .01) and consequently on factor 2 (F [1,79] = 3.91, P = .05). ...
... Level of manipulation had no effect on the ISE except for the handling (F [1,55] = 7.45, P b .01) and consequently on factor 2 (F [1,79] = 3.91, P = .05). Manipulations on C3 tended to be experienced as more precise than manipulations on C5. ...
Objective:
The purpose of this study was to assess individual subjective experience (ISE) of the recipients of a cervical manipulation and to analyze the influence of kinematics, cavitation occurrence, and practitioner seniority on individual experience.
Methods:
Practitioners with different seniority (years of experience) manipulated 20 asymptomatic volunteers at C3 and C5 on both sides. Kinematics were recorded using a 3-dimensional electrogoniometer, and ISE data were gathered through a questionnaire to explore the subjects' experiences of manipulation in terms of tactile sensations, relaxation, perception of the task, and therapist handling. Kinematics, occurrence of cavitation, practitioner's seniority, and ISE data were analyzed concurrently.
Results:
Motion parameters obtained during manipulation were found to be influenced by cavitation occurrence and differences between practitioners. Data analysis indicated that ISE could be grouped into 2 factors. The first revolved around grip firmness and range and speed of practitioner's gesture. The second factor represented patient's relaxation and the precision of handling. Also, most ISE data correlated with kinematics, although a subjective measurement did not always correlate the highest with its objective counterpart. When cavitation occurred, ISE ratings were higher, suggesting that participants may associate cavitation with the success of manipulations. Higher practitioner seniority (more years of experience) induced feelings of higher speed, amplitude, firmness, and precision.
Conclusions:
Recipients of cervical manipulation experienced different subjective feelings that can be expressed in 2 dimensions. These feelings are influenced by cavitation occurrence and practitioner's seniority. A better understanding of an individual's subjective experience related to cervical manipulation could increase confidence and improve the patient-therapist relationship, and it may provide further therapeutic perspectives for the practitioners.
... A previous study has evaluated the short-term effect of HVLA thrust manipulation on flexion spinal mobility, pain perception, neural mechanosensitivity, and height recovery in patients with disc degeneration where there was immediate improvement after one single HVLA thrust technique [10]. Another study has compared between MET performed with strengthening and neuromuscular training versus strengthening and neuromuscular training alone in patients with acute LBP. ...
... Vieira-Pellenz et al. [10] supported our results where they evaluated the short-term effect of HVLA thrust manipulation on spinal mobility, pain perception, neural mechanosensitivity, and height recovery on 40 males with disc degeneration at L5-S1. The study revealed that the treatment group that received HVLA thrust manipulation had significant improvements in all variables while there was no change in the control group that received placebo intervention except for spinal mobility in flexion. ...
... 14 Vieira-Pellenz ve ark., dejeneratif disk hastalığı olan erkek bireylere uygulanan lumbosakral HVLA manipülasyonlarının ağrıyı azalttığı, spinal mobiliteyi artırdığı ve pasif düz bacak kaldırmada kalça fleksiyonunu artırdığını tespit etmişlerdir. 7 Lumbal disk dejenerasyonu tanısını almış hastalarda yapılan başka bir çalışmada ise spinal manipülasyonun intervertebral yükseklik, ağrı ve omurga mobilitesine etkisinin değerlendirilmesi amaçlanmıştır. Katılımcıları rastgele iki gruba ayırarak, bir gruba fleksiyon distraksiyon spinal manipülasyonu uygulanırken, diğer grup uygulama almaksızın aynı pozisyonda bir süre tutulmuşlardır. ...
ABSTRACT
Objective: The effect of chiropractic manipulation with high velocity low amplitude (HVLA) technique on lumbar vertebrae (L2-L3-L4) on hamstring and quadriceps muscle strength in healthy subjects was evaluated. Material and Methods: Fifty four volunteers and healthy individuals were divided into chiropractic manipulation and sham groups. Measurements and tests of the participants were repeated twice, 24 hours apart. Chiropractic HVLA techniques were applied to the L2-L3-L4 vertebrae of the chiropractic manipulation group, while positioning and no pushing maneuvers were applied in the sham group. Before and after the application of both groups; lumbar range of motion was measured with goniometric measurements and Schober test, and quadriceps and hamstring muscle strength were measured with isokinetic dynamometer (CSMI Humac-Norm). Results: While statistically significant increases were detected after treatment compared to pre-treatment in all variables examined in the chiropractic manipulation group (p<0.05); there was no significant difference in the control group except for muscle strength in trunk flexion and extension angle value, Schober test, hamstring-left 60°/sec and hamstring-left 240°/sec angular velocity (p>0.05). In the chiropractic manipulation group, straight leg raise (SLR)- right, SLR-left, Schober, quadriceps-right 60°/sec, quadriceps-left 60°/sec, quadriceps-right 240°/sec, quadriceps-left 240°/sec, hamstring-right 60°/sec, hamstring- there was a significant increase in the right 240°/sec parameters after the treatment compared to the control group (p<0.05). Conclusion: It has been
concluded that the positive effect on quadriceps and hamstring muscle strength can prevent possible injuries by protecting the knee joint, increase in lumbar joint range of motion and healthy vertebral alignment can delay spinal degeneration.
Keywords: Chiropractic; manipulation; lumbar vertebra;
muscle strength; range of motion
... The experimental group registered statistically significant improvement in disability, but the improvement was modest and did not achieve the minimum clinically important difference compared to the control group [12]. Furthermore, other studies reported the benefits of manual therapy (spinal mobilization) vs. conventional physiotherapy or exercises in the management of LBP and associated disc degeneration [13][14][15][16][17][18]. Moreover, the superiority of spinal mobilizations over ET was reported [19,20]. ...
(1) Background: Due to its frequency and possible complications, low back pain (LBP) has a high social impact, it is a common problem of the active population and the second reason for visiting a physician. In patients with lumbar disc protrusion (LDP), one of the most common causes of LBP, the nucleus pulposus bulges against the disc and then protrudes into the spinal cord, but the annulus fibrosus remains intact; (2) Objectives: The primary objective of this study was to determine the efficacy of a rehabilitation treatment (RT) comprising electrotherapy (ET), hydrotherapy (HT) and individualized physical therapy (PT) versus ET alone in patients with LDP. The second objective was to investigate whether there is a correlation between early RT and the symptomatology of patients with LDP; (3) Methods: The research was conducted between July 2021 and January 2022 at the Ceres Hotel Treatment Centre from Baile 1 Mai, Romania, and all the study subjects signed an informed consent form. For this study, the block randomization method was used to randomize subjects into groups that resulted in equal sample size, in order to maintain a reasonably good balance among groups. Therefore, the two groups had the same number of subjects (30 subjects) and the randomization was made taking into account the patient’s motivation or the subject’s willingness to receive not only electrotherapy treatment, but also the physical exercises and hydrotherapy. The eligibility criteria were: low back pain for more than three months, an MRI confirmed diagnosis of LDP (without dural compression), and ability to perform a PT program. The control group received only a classical ET program. In addition, the patients in the experimental group received a complex individualized PT program associated with HT and ET. To achieve these objectives, the study subjects were monitored for spinal mobility (lateral lumbar flexion—LLF, index fingers-ground—IFG, lumbar Schober tests for flexion—LS, Inverted Schober test for extension—ILS), trunk flexor and extensor muscle strength (LF strength, LE strength), level of pain (Short Form McGill Pain Questionnaire—SF-MPQ, Visual Analogue Scale—VAS), and the degree of limitation in activities of daily living (Oswestry Disability Index—ODI); (4) Results: Comparing the evolution of the subjects, using the One-Way ANOVA between groups, we observed a significant improvement in all variables [SF-MPQ (95% CI, 7.996/11.671), VAS (95% CI, 1.965/3.169), mobility FTF (95% CI, −7.687/−3.940), LS (95% CI, 2.272/2.963), LE strength (95% CI, −5.676/−3.324), LF strength (95% CI, −5.970/−3.630), disability (95% CI, 8.026/10.441) after six months of treatment for the experimental group subjects. A clear correlation was found, using the Bravis–Pearson test, between the earliest possible initiation of RT and improvement of patients’ symptoms; (5) Conclusion: The current study proves the importance of combining ET with HT and PT. The earlier the RT is implemented, the lower the pain perception and level of disability associated with the lumbar disease.
... Non-drug therapy mainly includes bed rest, traction, stent fixation, exercise therapy, acupuncture, massage, electromagnetic or electrothermal therapy, psychotherapy, and so on. [25][26][27] These methods are used in many disciplines and fields and are often combined with drug therapy or surgery. Guo et al. 28 studied the difference between low-tension traction mode and high-tension traction mode in traction therapy by establishing a mechanical degeneration model of IVD. ...
Intervertebral disc degeneration (IDD) causes a variety of signs and symptoms, such as low back pain (LBP), intervertebral disc herniation, and spinal stenosis, which contribute to high social and economic costs. IDD results from many factors, including genetic factors, aging, mechanical injury, malnutrition, and so on. The pathological changes of IDD are mainly composed of the senescence and apoptosis of nucleus pulposus cells (NPCs), the progressive degeneration of extracellular matrix (ECM), the fibrosis of annulus fibrosus (AF), and the inflammatory response. At present, IDD can be treated by conservative treatment and surgical treatment based on patients' symptoms. However, all of these can only release the pain but cannot reverse IDD and reconstruct the mechanical function of the spine. The latest research is moving towards the field of biotherapy. Mesenchymal stem cells (MSCs) are regard as the potential therapy of IDD because of their ability to self‐renew and differentiate into a variety of tissues. Moreover, the non‐coding RNAs (ncRNAs) are found to regulate many vital processes in IDD. There have been many successes in the in vitro and animal studies of using biotherapy to treat IDD, but how to transform the experimental data to real therapy which can apply to humans is still a challenge. This article mainly reviews the treatment strategies and research progress of IDD and indicates that there are many problems that need to be solved if the new biotherapy is to be applied to clinical treatment of IDD. This will provide reference and guidance for clinical treatment and research direction of IDD. The clinical treatment of IDD includes conservative therapy and surgical therapy. Currently, treatments based on MSCs and ncRNAs are regarded as potential targets. Some ncRNAs verified by clinical trials can be used in gene therapy, and drugs targeting those ncRNAs can also be designed to treat IDD.
... female final) past study illustrated that number of SM visits had modest effects on chronic low back pain. 21 Study has found short term effects with SM. But their results cannot be directly compared with our study due to exclusion of men and the inclusion of the patients with degenerative disk disease. ...
p> Background: Chronic postural low back pain (CPLBP) is one of the common health problems worldwide. The aim of the study was to compare the spinal manipulation (SM) and short-wave diathermy (SWD) in patients with CPLBP in department of physical medicine at teaching hospital, Kandy, Sri Lanka.
Methods: Observational study was conducted. Patients diagnosed as CPLBP, who referred to the department of physical medicine (DPM), teaching hospital Kandy, were observed in the study (n=140). Seventy (70) patients were allocated for SWD and 70 for SM by the consultant. Two physiotherapists were routinely appointed for the treatments and SWD treatment by group 1 and SM was carried out by group 2. The two treatment sessions were continued once a week through four weeks. Outcomes were measured by numerical pain scale to compare with initial pain.
Results: Group 1, SM consisted 39 females and 31 males, group 2, SWD 40 females and 30 males. After 4 sessions, the mean value of pain reduction from initial pain was significantly high (p<0.001) in SM group than the short-wave diathermy group in both genders. (Female: 6.410 (SM) and 4.625 (SWD), Male:6.710 (SM) and 4.333 (SWD). Further the mean values showed that there was a significant pain reduction during the initial treatment session than 2<sup>nd</sup>, 3<sup>rd</sup>and final sessions in both treatment groups.
Conclusions: Pain reduction was more pronounced in the first treatment session in both methods. SM is more effective for the treatment of CPLBP irrespectively the age and gender when compare to the SWD in the study population. Therefore, SM could apply on CPLBP patients with higher effective treatment.</p
... Three trials did not report in which clinical setting they were conducted. 29 33 34 Eight trials were conducted in Europe, 27 28 30 35-39 five in the USA, 24 25 31 40 41 three studies in Brazil, [42][43][44] one in the UK, 26 Egypt, 32 Japan 45 and Australia. 46 No ongoing or unpublished trials were found. ...
Objective
To assess the effects and reliability of sham procedures in manual therapy (MT) trials in the treatment of back pain (BP) in order to provide methodological guidance for clinical trial development.
Design
Systematic review and meta-analysis.
Methods and analysis
Different databases were screened up to 20 August 2020. Randomised controlled trials involving adults affected by BP (cervical and lumbar), acute or chronic, were included.
Hand contact sham treatment (ST) was compared with different MT (physiotherapy, chiropractic, osteopathy, massage, kinesiology and reflexology) and to no treatment. Primary outcomes were BP improvement, success of blinding and adverse effect (AE). Secondary outcomes were number of drop-outs. Dichotomous outcomes were analysed using risk ratio (RR), continuous using mean difference (MD), 95% CIs. The minimal clinically important difference was 30 mm changes in pain score.
Results
24 trials were included involving 2019 participants. Very low evidence quality suggests clinically insignificant pain improvement in favour of MT compared with ST (MD 3.86, 95% CI 3.29 to 4.43) and no differences between ST and no treatment (MD -5.84, 95% CI −20.46 to 8.78).
ST reliability shows a high percentage of correct detection by participants (ranged from 46.7% to 83.5%), spinal manipulation being the most recognised technique.
Low quality of evidence suggests that AE and drop-out rates were similar between ST and MT (RR AE=0.84, 95% CI 0.55 to 1.28, RR drop-outs=0.98, 95% CI 0.77 to 1.25). A similar drop-out rate was reported for no treatment (RR=0.82, 95% 0.43 to 1.55).
Conclusions
MT does not seem to have clinically relevant effect compared with ST. Similar effects were found with no treatment. The heterogeneousness of sham MT studies and the very low quality of evidence render uncertain these review findings.
Future trials should develop reliable kinds of ST, similar to active treatment, to ensure participant blinding and to guarantee a proper sample size for the reliable detection of clinically meaningful treatment effects.
PROSPERO registration number
CRD42020198301.
... Of these tissues, the intervertebral disc is the largest soft tissue structure in the spine and the one most likely to affect segmental stiffness when deformed. Forceful stretching of a disc caused by SMT could increase the disc height temporarily [29], which may impact stiffness. In addition, SMT is known to affect disc diffusion in SMT responders [10,30], and a degenerated disc alters lumbar spine segmental stiffness [31]. ...
Introduction:
In individuals having low back pain, the application of spinal manipulative therapy (SMT) has been shown to reduce spinal stiffness in those who report improvements in post-SMT disability. The underlying mechanism for this rapid change in stiffness is not understood presently. As clinicians and patients may benefit from a better understanding of this mechanism in terms of optimizing care delivery, the objective of this scoping review of current literature was to identify if potential mechanisms that explain this clinical response have been previously described or could be elucidated from existing data.
Methods:
Three literature databases were systematically searched (MEDLINE, CINAHL, and PubMed). Our search terms included subject headings and keywords relevant to SMT, spinal stiffness, lumbar spine, and mechanism. Inclusion criteria for candidate studies were publication in English, quantification of lumbar spinal stiffness before and after SMT, and publication between January 2000 and June 2019.
Results:
The search identified 1931 articles. Of these studies, 10 were included following the application of the inclusion criteria. From these articles, 7 themes were identified with respect to potential mechanisms described or derived from data: 1) change in muscle activity; 2) increase in mobility; 3) decrease in pain; 4) increase in pressure pain threshold; 5) change in spinal tissue behavior; 6) change in the central nervous system or reflex pathways; and 7) correction of a vertebral dysfunction.
Conclusions:
This scoping review identified 7 themes put forward by authors to explain changes in spinal stiffness following SMT. Unfortunately, none of the studies provided data which would support the promotion of one theme over another. As a result, this review suggests a need to develop a theoretical framework to explain rapid biomechanical changes following SMT to guide and prioritize future investigations in this important clinical area.
... Such distinct mechanical responses may explain the differential SMT responses. Additionally, Vieira-Pellenz found that male LBP patients with degenerative discs who demonstrated greater increases in body height (a proxy of improved disc height) after a single session of SMT were associated with less LBP prevalence [44]. Given these results, further studies with larger sample sizes are warranted to determine the causal relations among spine degeneration, post-SMT mechanical responses and LBP. ...
Purpose
Our prior study revealed that people with non-specific low back pain (LBP) who self-reported a > 30% improvement in disability after SMT demonstrated significant post-treatment improvements in spinal stiffness, dynamic muscle thickness and disc diffusion, while those not having self-reported improvement did not have these objective changes. The mechanism underlying this differential post-SMT response remains unknown. This exploratory secondary analysis aimed to determine whether persons with non-specific LBP who respond to spinal SMT have unique lumbar magnetic resonance imaging (MRI) findings compared to SMT non-responders.
Methods
Thirty-two participants with non-specific LBP received lumbar MRI before and after SMT on Day 1. Resulting images were assessed for facet degeneration, disc degeneration, Modic changes and apparent diffusion coefficient (ADC). SMT was provided again on Day 4 without imaging. SMT responders were classified as having a ≥ 30% reduction in their modified Oswestry disability index at Day 7. Baseline MRI findings between responders and non-responders were compared. The associations between SMT responder status and the presence/absence of post-SMT increases in ADC values of discs associated with painful/non-painful segments as determined by palpation were calculated. In this secondary analysis, a statistical trend was considered as a P value between 0.05 and 0.10.
Results
Although there was no significant between-group difference in all spinal degenerative features (e.g. Modic changes), SMT responders tended to have a lower prevalence of severely degenerated facets (P = 0.05) and higher baseline ADC values at the L4-5 disc when compared to SMT non-responders (P = 0.09). Post hoc analyses revealed that 180 patients per group should have been recruited to find significant between-group differences in the two features. SMT responders were also characterized by significant increases in post-SMT ADC values at discs associated with painful segments identified by palpation (P < 0.01).
Conclusions
The current secondary analysis suggests that the spines of SMT responders appear to differ from non-responders with respect to degeneration changes in posterior joints and disc diffusion. Although this analysis was preliminary, it provides a new direction to investigate the mechanisms underlying SMT and the existence of discrete forms of treatment-specific LBP.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material. Open image in new window
... Prevailing theories on the mechanisms of SMT have historically focused on two primary effects resulting from SMT: (1) biomechanical effects on spinal kinetics and stiffness characteristics [19][20][21]; and (2) neuro-physiologic effects on primary afferent neurons leading to altered motor neuron excitability [18,22]. Support for these theories comes from studies documenting that SMT can alter spinal stiffness [23][24][25][26][27] and that afferent stimulation from SMT impacts reflex motor activity and moto-neuron excitability [23,[28][29][30][31][32]. It remains uncertain if these effects represented mechanisms of therapeutic benefit or epiphenomena unrelated to clinical outcomes. ...
Background:
Low back pain is a common and costly condition. Spinal manipulative therapy (SMT) is a treatment supported in some guidelines, although most clinical trials examining SMT report small effect sizes. Enhancing the effects of SMT requires an understanding of underlying mechanisms and a systematic approach to leverage understanding of mechanisms to create more effective treatment protocols that are scalable in clinical practice. Prior work has identified effects on spinal stiffness and lumbar multifidus activation as possible mechanisms. This project represents a refinement phase study within the context of a multi-phase optimization strategy (MOST) framework. Our goal is to identify an optimized SMT treatment protocol by examining the impact of using co-intervention exercise strategies that are proposed to accentuate SMT mechanisms. The optimized protocol can then be evaluated in confirmation phase clinical trials and implementation studies.
Methods:
A phased, factorial randomized trial design will be used to evaluate the effects of three intervention components provided in eight combinations on mechanistic (spinal stiffness and multifidus muscle activation) and patient-reported outcomes (pain and disability). All participants will receive two sessions then will be randomly assigned to receive six additional sessions (or no additional treatment) over the next three weeks with factorial combinations of additional SMT and exercise co-interventions (spine mobilizing and multifidus activating). Outcome assessments occur at baseline, and one week, four weeks, and three months after enrollment. Pre-specified analyses will evaluate main effects for treatment components as well as interaction effects.
Discussion:
Building on preliminary findings identifying possible mechanisms of effects for SMT, this trial represents the next phase in a multiphase strategy towards the ultimate goal of developing an optimized protocol for providing SMT to patients with LBP. If successful, the results of this trial can be tested in future clinical trials in an effort to produce larger treatment benefits and improve patient-centered outcomes for individuals with LBP.
Trial registration:
ClinicalTrials.gov, NCT02868034 . Registered on 16 August 2016.
... Randomized controlled trials investigating the effects of spinal manipulative therapy (SMT) on the spine have reported conflicting evidence. Although some studies observed significant improvement in low back pain following SMT interventions [1][2][3][4], other studies reported that SMT was not significantly superior to other types of intervention (e.g., exercise; standard medical care) [5][6][7]. Although this conflicting evidence can be explained partially in light of recent findings that suggest SMT affects some, but not all, patients with low back pain [8], another explanation is that variability in SMT applications may create varied responses to this popular therapy [9]. ...
Background context:
Previous studies found that the intervertebral disc (IVD) experiences the greatest loads during spinal manipulation therapy (SMT).
Purpose:
Based on that, this study aimed to determine if loads experienced by spinal tissues are significantly altered when the application site of SMT is changed.
Study design:
A biomechanical robotic serial dissection study SAMPLE: 13 porcine cadaveric motion segments OUTCOME MEASURES: Forces experienced by lumbar spinal tissues METHODS: A servo-controlled linear actuator provided standardized 300N SMT simulations to 6 different cutaneous locations of the porcine lumbar spine: L2/L3 and L3/L4 facet joints (FJ), L3 and L4 transverse processes (TVP), and the space between the FJs and TVPs (BTW). Vertebral kinematics were tracked optically using indwelling bone pins, the motion segment removed and mounted in a parallel robot equipped with a 6-axis load cell. Movements of each SMT application at each site were replayed by the robot with the intact specimen and following the sequential removal of spinal ligaments, FJs and IVD. Forces induced by SMT were recorded and specific axes were analysed using linear mixed models.
Results:
Analyses yielded a significant difference (p<0.05) in spinal structures loads as a function of the application site. SMT application at the L3 vertebra caused vertebral movements and forces between L3 and L4 spinal segment in opposite direction to when SMT was applied at L4 vertebra. Additionally, SMT applications over the soft tissue between adjacent vertebrae significantly decreased spinal structure loads.
Conclusion:
Applying SMT with a constant force at different spinal levels create different relative kinetics of the spinal segments and load spinal tissues in significantly different magnitudes.
... IVD dehydration and resultant loss in intervertebral segmental height have been suggested as a cause of pain (Zhao et al., 2005). Reduced LBP/radicular pain with associated increased IVD height have been demonstrated following lumbar directed manual therapy (Beattie et al., 2010;Viera-Pellenz et al., 2014), aquatic vertical traction (Simmerman et al., 2011) and bariatric surgery for obesity (Lidar et al., 2012). Thus PSS postures may have a therapeutic role in lumbar spine pathology by temporarily recovering spinal height. ...
Background:
Upright and slouched sitting are frequently adopted postures associated with increased intradiscal pressure, spinal height loss and intervertebral disc pathology.
Objectives:
To examine the effects of two sustained propped slouched sitting (PSS) postures on spinal height after a period of trunk loading.
Methods:
Thirty-four participants without a history of low back pain (LBP) were recruited (age 24.4 ± 1.6 years). Subjects sat in (1) PSS without lumbar support and (2) PSS with lumbar support for 10 min, after a period of trunk loading. Spinal height was measured using a stadiometer.
Results:
Mean spinal height increase during PSS without lumbar support was 2.94 ± 3.63 mm and with lumbar support 4.74 ± 3.07 mm.
Conclusions:
Both PSS with and without lumbar support significantly increased spinal height after a period of trunk loading (p < 0.001). Such PSS postures can provide a valuable alternative to upright sitting and may be recommended for recovering spinal height in the working environment following periods of loading.
... Trial characteristics are detailed in Table 1. Of the 25 included studies, 16 of the trials were specifically assessing LP-SMT [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31]. There were three trials where subjects in the active treatment group could also receive thrust manipulation to joints other than those in the lumbar spine and pelvis [32][33][34], and two trials that were assessing LP-SMT and medications [35,36]. ...
Background context:
Spinal manipulative therapy (SMT) has been attributed with substantial non-specific effects. Accurate assessment of the non-specific effects of SMT relies on high-quality studies with low risk of bias that compare with appropriate placebos.
Purpose:
This review aims to characterize the types and qualities of placebo control procedures used in controlled trials of manually applied, lumbar and pelvic (LP)-SMT, and to evaluate the assessment of subject blinding and expectations.
Study design:
This is a systematic review of randomized, placebo-controlled trials.
Methods:
We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature, and relevant bibliographies. We included randomized, placebo or sham-controlled trials where the index treatment was manually applied LP-SMT. There were no restrictions on the type of condition being investigated. Two independent reviewers selected the studies, assessed study quality, and extracted the data. Relevant data were the type and quality of placebo control(s) used, the assessment of blinding and expectations, and the results of those assessments.
Results:
Twenty-five randomized, placebo-controlled trials were included in this review. There were 18 trials that used a sham manual SMT procedure for their placebo control intervention; the most common approach was with an SMT setup but without the application of any thrust. One small pilot study used an unequivocally indistinguishable placebo, two trials used placebos that had been validated as inert a priori, and eight trials reported on the success of subject blinding. Risk of bias was high or unclear, for all included studies.
Conclusions:
Imperfect placebos are ubiquitous in clinical trials of LP-SMT, and few trials have assessed for successful subject blinding or balanced expectations of treatment success between active and control group subjects. There is thus a strong potential for unmasking of control subjects, unequal non-specific effects between active and control groups, and non-inert placebos in existing trials. Future trials should consider assessing the success of subject blinding and ensuring inertness of their placebo a priori, as a minimum standard for quality.
... To date, no curative treatment is available for IVDD and the management includes bed rest, physiotherapy, and analgesic pain relief [5]. Traditional treatments, including surgical and pharmacological therapy, target pain relief but fail to address the underlying pathology due to the lack of understanding the properties of IVD cells [6]. ...
Objective . Nucleus pulposus (NP) and annulus fibrosus (AF) are two main components of intervertebral disc (IVD). We aimed to figure out whether NP and AF also contain stem cells and whether these stem cells share common properties with chondrocytes and/or fibroblasts in their phenotypes or whether they are completely different types of cells with different characteristics. Design . The disk cells were isolated from AF and NP tissues of the same lumbar spine of the rabbits. The properties of these disk cells were characterized by their morphology, population doubling time (PDT), stem cell marker expression, and multidifferentiation potential using tissue culture techniques, immunocytochemistry, and RT-PCR. Results . Both disk cells formed colonies in culture and expressed stem cell markers, nucleostemin, Oct-4, SSEA-4, and Stro-1, at early passages. However, after 5 passages, AFSCs became elongated and NPSCs appeared senescent. Conclusion . This study indicated that IVD contains stem cells and the characteristics of AFSCs and NPSCs are intrinsically different. The findings of this study may provide basic scientific data for understanding the properties of IVD cells and the mechanisms of lower back pain.
... IVD dehydration and resultant loss in intervertebral segmental height have been suggested as a cause of pain (Zhao et al., 2005). Reduced LBP/radicular pain with associated increased IVD height have been demonstrated following lumbar directed manual therapy (Beattie et al., 2010;Viera-Pellenz et al., 2014), aquatic vertical traction (Simmerman et al., 2011) and bariatric surgery for obesity (Lidar et al., 2012). Thus PSS postures may have a therapeutic role in lumbar spine pathology by temporarily recovering spinal height. ...
... 24 Participants were asked about the current intensity of pain. 21 A 50% decrease of the baseline score, or a change of at least 20 mm, can be considered as meaningful clinical changes in subjects with lower spine pain. 22,25 ...
Objective:
To assess the short-term efficacy of transregional interferential current therapy on pain perception and disability level in chronic non-specific low back pain.
Design:
A randomized, single-blinded (the assessor collecting the outcome data was blinded), controlled trial.
Setting:
A private physiotherapy research clinic.
Subjects:
A total of 64 individuals, 20 men and 44 women, mean (SD) age was 51 years (11.93), with low back pain of more than three months, with or without pain radiating to the lower extremities above the knee, were distributed into a control (n = 20) or an experimental group (n = 44). A 2:1 randomization ratio was used in favour of the latter.
Interventions:
A transregional interferential current electrotherapy protocol was performed for participants in the experimental group, while the control group underwent a 'usual care' treatment (massage, mobilization and soft-tissue techniques). All subjects received up to 10 treatment sessions of 25 minutes over a two-week period, and completed the intervention and follow-up evaluations.
Outcome measures:
Self-perceived pain was assessed with a Visual Analogue Scale. Secondary measure included the Oswestry Low Back Disability Index. Evaluations were collected at baseline and after the intervention protocol.
Results:
Significant between-group differences were found for interferential current therapy on pain perception (p = 0.032) and disability level (p = 0.002). The observed differences in the between-group mean changes were of 11.34 mm (1.77/20.91) and 13.38 points (4.97/21.78), respectively.
Conclusions:
A two-week transregional interferential current treatment has shown significant short-term efficacy, when compared with a 'usual care' protocol, on self-perceived pain and functionality in subjects with chronic low back pain.
... Osteopathic manipulation still is under critical scrutiny and needs evidence-based assessment. This treatment has been shown moderately effective in patients with low-back pain, whereby several methods of pain scoring [4][5][6], pain pressure thresholds [7], neural mechanosensitivity [8], or biomechanical parameters during flexion were assessed [9]. Also a favourable effect of osteopathic manipulation on cervical hysteresis [10] and inter-vertebral range of motion [11] has been reported. ...
Aim: To investigate whether standard general osteopathic treatment can influence the static
configuration of the vertebral column or pelvis.
Material and Methods: One hundred thirteen persons, 72 females and 41 males, either symptomfree
volunteers or patients with mild idiopathic back pain, were investigated using the DIERS
formetric® system, before and immediately after a single session of general osteopathic treatment.
Variables of static assessment of the thoraco-lumbar vertebral column and of the pelvis were
compared before and after treatment, using paired statistics.
Results: There was no difference between observations in the healthy controls and the
symptomatic patients. The sagittal imbalance decreased significantly (two sided student’s t-test:
P=0.034), apical deviation diminished (one sided student’s t-test: P= 0.047) after treatment and
lordotic apex position increased (one sided student’s t-test: P=0.028). Since such changes have
not been observed in a previous trial of repeat measurements without treatment, the observations
in the present study suggest an effect of treatment. This effect was, however, limited to persons
Short Research Article
Comhaire et al.; BJMMR, 6(7): 709-714, 2015; Article no.BJMMR.2015.247
710
with sagittal imbalance not exceeding the 62nd percentile.
Conclusion: General osteopathic treatment is associated with reduced sagittal imbalance and
apical deviation and increased lordotic apex position, but this effect is demonstrable only in
persons whose sagittal imbalance ranks in the lower or median tertile.
Background
Lumbar disc herniation (LDH), as one of the most common causes of lower back pain, imposes a heavy economic burden on patients and society. Conservative management is the first‐line choice for the majority of LDH patients. Traditional Chinese medicine (TCM) is an important part of conservative treatment and has attracted more and more international attention.
Study design
Evidence‐based guideline.
Methods
We formed a guideline panel of multidisciplinary experts. The clinical questions were identified on the basis of a systematic literature search and a consensus meeting. We searched the literature for direct evidence on the management of LDH and assessed its certainty‐generated recommendations using the grading of recommendations, assessment, development, and evaluation (GRADE) approach.
Results
The guideline panel made 20 recommendations, which covered the use of Shentong Zhuyu decoction, Shenzhuo decoction, Simiao San decoction, Duhuo Jisheng decoction, Yaobitong capsule, Yaotongning capsule, Osteoking, manual therapy, needle knife, manual acupuncture, electroacupuncture, Chinese exercise techniques (Tai Chi, Baduanjin, or Yijinjing), and integrative medicine, such as combined non‐steroidal anti‐inflammatory drugs, neural nutrition, and traction. Recommendations were either strong or weak, or in the form of ungraded consensus‐based statement.
Conclusion
This is the first LDH treatment guideline for TCM and integrative medicine with a systematic search, synthesis of evidence, and using the GRADE method to rate the quality of evidence. We hope these recommendations can help support healthcare workers caring for LDH patients.
The aim of this study is to examine the acute effects of thoracic manipulation on trunk flexion and balance characteristics in athletes. 60 male team athletes with a mean age of 22.60±0.32 years participated in the study voluntarily. Trunk flexion values and balance levels of all participants were determined before manipulation. After the measurements, the participants were randomly divided into two groups as the thoracic manipulation group (TMG) and the placebo manipulation group (PMG). Then, as a single session, thoracic manipulation was applied to the TMG group and placebo thoracic manipulation was applied to the PMG group. The trunk flexions and balance levels of each participant were remeasured after the application, and the differences before and after the application were examined. Since the data analyzed via SPSS 25.0 package program showed normal distribution, paired-t test was used to evaluate the pre-application and post-application results. The results were analyzed at the p
Objective:
To evaluate the existing body of trials assessing manual therapy for low back pain (LBP) to determine where it falls on the efficacy-effectiveness continuum.
Design:
Methodology systematic review.
Literature search:
PubMed, CINAHL, CENTRAL, and PEDro were searched for trials published between January 1, 2000, and April 30, 2021.
Study selection criteria:
We included randomized clinical trials investigating joint mobilization and manipulation for adults with non-specific LBP that were available in English.
Data synthesis:
We used the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool to score included trials across 4 domains: Participant Characteristics, Trial Setting, Flexibility of Intervention(s), and Clinical Relevance of Experimental and Comparison Intervention(s). Proportions of trials with greater emphasis on efficacy or effectiveness were calculated for each domain.
Results:
Of 132 included trials, a greater proportion emphasized efficacy than effectiveness for the domains of Participant Characteristics (50% vs 38%), Trial Setting (71% vs 20%), and Flexibility of Intervention(s) (61% vs 25%). The domain Clinical Relevance of Experimental and Comparison Intervention(s) had a lower emphasis on efficacy (41% vs 50%).
Conclusions:
Most trials investigating manual therapy for LBP lack pragmatism across the RITES domains (i.e., they emphasize efficacy). To improve real-world implementation, more research emphasizing effectiveness is needed. This could be accomplished by recruiting from more diverse participant pools, involving multiple centers that reflect common clinical practice settings, involving clinicians with a variety of backgrounds/experience, and allowing flexibility in how interventions are delivered.
Hintergrund: Physiotherapeut*Innen verwenden die spinale Gelenkmanipulation u.a. zur Behandlung bestimmter arthrogener Dysfunktionen. Postmanipulativ verändert sich neben dem Schmerz- und Beweglichkeitsstatus häufig das Aktivierungsmuster bestimmter Muskeln.
Ziele: Detektion kurzfristiger Auswirkungen spinaler Gelenkmanipulation auf die EMG-Aktivität, Schmerz und die aktive Beweglichkeit bei erwachsenen Menschen und der Unterschied zu anderen therapeutischen Maßnahmen.
Design: Systematisches Review
Informationsquellen: Primäre Informationsquellen (MEDLINE, EMBASE, CINAHL, PEDro), sekundäre Informationsquellen (Open Grey, Dart-Europe, Expertenbefragungen, clinicaltrials.gov, ICTRP, Referenzlisten)
Auswahlkriterien: Design (RCTs, randomisierte Cross-Over-Studien), Spezies (Humanstudien), Sprachen (Deutsch, Englisch), Publikationszeitraum (01/2000 – 03/2020)
Studienbewertung: Evidenzklassen nach CEBM (relative Beweiskraft), PEDro-Skala (methodologische Qualität), modifizierte CIRCLe SMT (interventionsspezifische Berichterstattung)
Ergebnisse: Von insgesamt 901 Treffern wurden 13 Primärarbeiten mit akkumuliert 443 Proband*Innen zur Bearbeitung dieser systematischen Übersichtsarbeit inkludiert. Die vorliegende Arbeit konnte keine generalisierbare Aussage über die kurzfristigen Auswirkungen spinaler Gelenkmanipulation auf die EMG-Aktivität, Schmerzen und die aktive Beweglichkeit bei erwachsenen Menschen liefern, indizierte aber schwache Evidenz für jeden Ergebnisparameter. Das detektierte postmanipulative Aktivierungsverhalten der Muskulatur konnte sowohl exzitatorisch als auch inhibitorisch sein. Mittels Subgruppenanalysen wurde ein potentieller Einfluss der Krankheitsbilder auf die postmanipulative EMG-Aktivität eruiert. Es gibt moderate Evidenz dafür, dass eine lumbale Rotationsmanipulation bei Patient*Innen mit nichtspezifischen Rückenschmerzen zu einer signifikanten Reduktion der EMG-Aktivität der paravertebralen Muskulatur während des Haltens in voller Rumpfflexion und der Extensionsbewegung aus der vollen Flexion führt. Ebenso besteht moderate Evidenz dafür, dass eine lumbopelvine Rotationsmanipulation der betroffenen Seite bei Patient*Innen mit einem Patellofemoralen Schmerzsyndrom zu einem signifikanten An-stieg der EMG-Aktivität des M. gluteus medius führt. Schwache Evidenz besteht da-für, dass segmentspezifische Manipulationen im Bezug auf die EMG-Aktivität und Schmerzen keinen Benefit im Vergleich zu global ausgeführten Techniken bringen. Unklar bleibt, ob eine spinale Gelenkmanipulation kurzfristig signifikante Benefits im Vergleich zu Placebo-, Pseudoplacebo- oder anderen therapeutischen Kontrollinterventionen im Bezug auf die EMG-Aktivität, Schmerzen und die aktive Beweglichkeit bei erwachsenen Menschen bietet.
Limitationen: Die methodologische Qualität über die Studien hinweg lag bei 5,77/10 Punkten und war mäßig. Das Risiko für Performance Bias über die Studien hinweg war sehr hoch. Das Risiko für Spectrum bzw. Detection Bias war moderat. Das Risiko der Verzerrungen aufgrund der interventionsspezifischen Berichterstattung über die Studien hinweg wurde als gering angesehen. Die individuellen Primär-arbeiten waren hinsichtlich der wichtigsten Studienmerkmale heterogen.
Schlussfolgerungen: Die spinale Gelenkmanipulation soll allenfalls supportiv zur überwiegend aktiven Behandlung von veränderten muskulären Aktivierungsmustern, Schmerzen und Bewegungseinschränkungen eingesetzt werden. Die spinale Gelenkmanipulation eignet sich, um Patient*Innen bereits innerhalb einer Therapieeinheit die Adaptabilität des neuromuskuloskelettalen Systems bzw. die Modifikationsmöglichkeit für Symptome und Bewegung zu visualisieren. Somit kann weitere passive, assistive oder idealerweise aktive Bewegung fazilitiert werden.
Registrationsnummer: PROSPERO - CRD42020160690
Stichworte: Spinale Gelenkmanipulation, EMG, Schmerz, aktive Beweglichkeit
Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.
The objective of this study was to catalogue items from instruments used to measure functioning, disability, and contextual factors in patients with low back pain (LBP) treated with manual medicine (manipulation and mobilization) according to the International Classification of Functioning, Disability and Health (ICF). This catalogue will be used to inform the development of an ICF-based assessment schedule for LBP patients treated with manual medicine. In this scoping review we systematically searched MEDLINE, Embase, PsycINFO and CINAHL. We identified instruments (questionnaires, clinical tests, single questions) used to measure functioning, disability and contextual factors, extracted the relevant items and then linked these items to the ICF. We included 95 articles and identified 1510 meaningful concepts. All but 70 items were linked to the ICF. Of the concepts linked to the ICF, body functions accounted for 34.7%, body structures accounted for 0%, activities and participation accounted for 41%, environmental factors accounted for 3.6%, and personal factors accounted for 16%. Most items used to measure functioning and disability in LBP patient treated with manual medicine focus on body functions, and activities and participation. The lack of measures that address environmental factors warrants further investigation.
This chapter deals with the various of forms of therapies given for treating equine lameness. The treatment types include systemic and parenteral therapies, topical and local therapies, intrasynovial therapies, intralesional therapies, oral and nutritional therapies, corrective shoeing and therapeutic shoeing, acupuncture treatments, manual therapies, and rehabilitation and physical therapy. Systemic administration of medications to treat musculoskeletal diseases in the horse mainly encompasses intravenous nonsteroidal anti‐inflammatory drugs (NSAIDS), intramuscular polysulfated glycosaminoglycans, and intravenous hyaluronan. The most commonly used IV NSAIDs are phenylbutazone and flunixin meglumine. The need for systemic NSAID therapy can be reduced and associated edema and tissue damage minimized with effective use of topical therapy. Equine practitioners currently have several options available to treat intrasynovial inflammation. Intrasynovial therapies, specifically corticosteroids, are used frequently in horses to minimize or control pain associated with synovitis and osteoarthritis.
Objective:
To investigate trials abstracts evaluating treatments for low back pain with regards to completeness of reporting, spin (i.e., interpretation of study results that overemphasizes the beneficial effects of the intervention), and inconsistencies in data with the full text.
Data sources:
The search was performed on Physiotherapy Evidence Database (PEDro) in February 2016.
Study selection:
This is an overview study of a random sample of 200 low back pain trials published between 2010 and 2015. The languages of publication were restricted to English, Spanish and Portuguese.
Data extraction:
Completeness of reporting was assessed using the CONSORT for Abstracts checklist (CONSORT-A). Spin was assessed using a SPIN-checklist. Consistency between abstract and full text were assessed by applying the assessment tools to both the abstract and full text of each trial and calculating inconsistencies in the summary score (paired t test) and agreement in the classification of each item (Kappa statistics). Methodological quality was analyzed using the total PEDro score.
Data synthesis:
The mean number of fully reported items for abstracts using the CONSORT-A was 5.1 (SD 2.4) out of 15 points and the mean number of items with spin was 4.9 (SD 2.6) out of 7 points. Abstract and full text scores were statistically inconsistent (P=0.01). There was slight to moderate agreement between items of the CONSORT-A in the abstracts and full text (mean Kappa 0.20 SD 0.13) and fair to moderate agreement for items of the SPIN-checklist (mean Kappa 0.47 SD 0.09).
Conclusions:
The abstracts were incomplete, with spin and inconsistent with the full text. We advise health care professionals to avoid making clinical decisions based solely upon abstracts. Journal editors, reviewers and authors are jointly responsible for improving abstracts, which could be guided by amended editorial policies.
Objectives:
The purpose of this study was to determine the immediate effects of a manual therapy technique consisting of axial traction compared with side lying on increased spine height after sustained loading.
Methods:
Twenty-one asymptomatic participants were included. Participants either received manual therapy technique consisting of manual axial traction force for 2 consecutive rounds of 3 minutes or sustained side lying for 10 minutes. Spine height was measured using a commercially available stadiometer. Spinal height change was determined from measurements taken after loaded walking and measurements taken after manual therapy. A paired t test was performed to determine if a manual therapy technique consisting of axial traction increased spinal height after a period of spinal loading.
Results:
A significant increase in height was found after both manual therapy technique and sustained side lying (P < .0001). The mean height gain was 8.60 mm using 3-dimensional axial separation.
Conclusion:
This study is an initial attempt at evaluating the biomechanical effects of manual therapy technique consisting of axial traction. Both manual axial traction force and sustained side-lying position were equally effective for short-term change in spine height after a loaded walking protocol among healthy asymptomatic individuals. This study protocol may help to inform future studies that evaluate spine height after loading.
Los dolores a nivel lumbar son uno de los problemas que más afecta a la población de forma esporádica o permanente a lo largo de la vida, cuyas causas principales están relacionadas con posturas corporales incorrectas, ejercicios de impacto y rotación superior, lo cual ocasiona un deterioro del disco intervertebral. Este estudio de revisión sistemática tiene como objetivo conocer las diversas prevenciones y tratamientos para mejorar las hernias lumbosacras. Se ha utilizado como principal base de datos la Web of Science (WOS), en la que se han empleado como descriptores claves "Herniated Disc", "Disc herniation" y "Treatment" para el área de investigación "Sport Sciences". Tras la aplicación de los criterios de inclusión y codificación, el cuerpo base de esta investigación se redujo a 15 estudios. Los datos revelan que la preocupación por la temática ha ido evolucionando en sus tratamientos, pasando de la cirugía a utilizar ejercicios terapéuticos, dado los beneficios y ventajas que reportan.
Objective:
The objective of this study is to investigate if sustained and repetitive prone press-ups could reverse decreased spinal height following spinal loading and if there was a correlation between the degree of end range of motion spinal extension and spinal height gains.
Design:
Pretest-posttest crossover design is used in this study.
Setting:
Study was carried out in research laboratory.
Subjects:
Forty-one healthy men and women were included in this study.
Intervention:
Participants were seated in the stadiometer for 5 min with a 4.5-kg weight placed on each shoulder; the load was removed for 5 min and spinal height was measured using a stadiometer before and after 5 min of repetitive or sustained prone press-ups.
Main measures:
Two-by-two repeated-measures ANOVA to identify significant interactions and main effects is used in this study. Significance of α = 0.05. A Pearson correlation coefficient was used to assess the correlation between spinal height changes and spinal extension ROM.
Results:
Participants 24.1 ± 2.03 years grew using both repetitive (4.85 ± 3.01 mm) and sustained press ups (4.46 ± 2.57 mm). There was no significant interaction between the repetitive versus sustained press-ups and the time before and after each prone press-ups strategy and no main effect for strategy (sustained vs. repetitive press-ups). There was a significant main effect for time (before vs. after press-ups) (F(1,30) = 140.771; p < 0.0001; partial η2 = 0.82). No correlation was found between the degree of end ROM spinal extension and spinal height changes following press-ups strategies.
Conclusion:
Following periods of spinal loading, both repetitive and sustained press-ups increased spinal height. Such strategies could be used to help recover spinal height and limit the effects of decreased spinal height as a result of activities of daily living.
Viele Patienten mit Schmerzen im Bewegungssystem suchen einen Manualmediziner, Osteopathen oder Chiropraktiker auf. Diese behandeln jedoch nicht Schmerzen, sondern Funktionsstörungen des Bewegungssystems, wie z. B. Triggerpunkte oder Blockierungen. Bei akuten Schmerzen sind diese Behandlungen oft erfolgreich und auch bei chronischen Schmerzen kann die manuelle Medizin einen wichtigen Beitrag in Diagnostik und Therapie leisten. Auf der anderen Seite hat sich in den letzten Jahren ein neues Fachgebiet, die spezielle Schmerztherapie entwickelt. Insbesondere chronische Schmerzen stellen hier ein eigenständiges Krankheitsbild ohne Einfluss von körperlichen Befunden dar (als Schmerzchronifizierung). In dem Spannungsfeld zwischen (schmerzhaftem) Befund und Schmerzchronifizierung bewegen sich Patienten und Therapeuten und müssen in der Praxis die patientenindividuelle Konstellation täglich neu erarbeiten.
Background: Active exercise therapy is recommended as an efficient conservative approach to improve functional disability in subjects suffering from nonspecific low back pains. The aim of this study is comparing the effects of standard rehabilitation protocol with without exercise therapy in acute nonspecific low back pain.
Methods: 43 volunteers with acute nonspecific low back pain were randomly assigned into experimental group (spinal manipulation plus active exercise, n=21) and control group (spinal manipulation n = 22).After signing formal consent, demographic information was obtained. Immediate analgesic effect was reported measuring pain intensity (VAS) before and immediately after the manipulation in either group. Pain intensity and disability score according to Oswestry Disability Index were reported at the beginning, after the 10th therapeutic session, and at one month follow-up.
Results: Forty subjects completed the study. Pain and functional disability score decreases significantly over time in both groups (P<0.001), although intergroup difference were not significant for pain severity (P=0.24) and functional disability score (P=0.42). Also, in this study, the results showed that the pain after a session of manipulation (P <0.001) was significantly lower than before treatment.
Conclusion: It seems that in spite of immediate significant improvement in pain and functional disability following supplementary exercise therapy protocol, it is not significantly different from manipulation. More studies are recommended to investigate the effect of various exercise protocols in different types of low back pain.
Keywords: Acute low back pain; spinal manipulation; active exercise; pain; functional disability.
Introduction: Distinctive spinal mobility is of significant relevance for our health. Though a few indicators for the long-term impacts of dynamic yoga forms on spinal mobility have been ascertained, they do not allow for generally valid deductions for practice. In the context of the present study, we have examined non-invasive means the extent, to which dynamic yoga forms exhibit a mechanism of action that increases the movement amplitude of the spine. Method: The investigation was designed as a longitudinal comparative study for a period of 10 weeks (n=50). The intervention group (n=30) took part in a ten unit of a yoga-health sports course, while the control group (n=20) participated in no specific health sports programs during the investigation period, but was as physically active as the intervention group. The change in spinal mobility was measured in the pre-post design with the help of Medimouse. Results: The intervention group achieved a significant change in spinal mobility after ten yoga units. No statistically relevant change could be observed in the control group. The improvements referred to the whole movement magnitude as well as to the mobility of the thoracic spine. Discussion: The ascertained effects confirm the present assumptions of the effects of yoga on mobility. The results in the intervention group showed a significant improvement of the entire backbone as well as the area of the thoracic spine. It is to consider that women are over-represented in the intervention group.
Background
Low back pain is very frequent and manual therapy often plays an important role in the management. Against the background of evidence-based medicine a systematic literature search was undertaken to show its effectiveness.
Method
A systematic literature search was carried out in PubMed to assess the current state of knowledge.
Results
A total of 94 relevant clinical studies were found. A sound physiological basis for the use of manual medicine is described in the literature. For acute and chronic low back pain a short lasting effect could be shown. For chronic low back pain complex multimodal treatment programs were more effective. Important further factors influencing treatment outcome are the reaction to the initial manual treatment, the extent of pain, psychosocial factors, the initial pain intensity and degree of disability.
Discussion
The treatment of low back pain by manual medicine techniques has a physiological basis and shows clinically relevant positive effects. More complex pain syndromes require a complex diagnostic and therapeutic approach. Further scientific evaluation of the formation of therapeutic subgroups and individual manual medicine procedures is required.
Single-group, prospective, repeated-measures design.
To determine differences in the changes of diffusion of water in the L5-S1 intervertebral disc between subjects with nonspecific low back pain (LBP) who reported an immediate reduction in pain intensity of 2 or greater on an 11-point (0-10) numeric rating scale after a 10-minute session of lumbar joint mobilization, followed by prone press-up exercises, compared to those who did not report an immediate reduction in pain intensity of 2 or greater on the pain scale.
Combining lumbar joint mobilization and prone press-up exercises is a common intervention for patients with LBP; however, there is conflicting evidence regarding the effectiveness and efficacy of this approach. Increased knowledge of the physiologic effects of the combined use of these treatments, and the relationship to pain reports, can lead to refinement of their clinical application.
Twenty adults, aged 22 to 54, participated in this study. All subjects reported LBP of at least 2 on an 11-point (0-10) verbally administered numeric rating scale at the time of enrollment in the study and were classified as being candidates for the combination of joint mobilization and prone press-ups. Subjects underwent T2- and diffusion-weighted lumbar magnetic resonance imaging scans before and immediately after receiving a 10-minute session of lumbar pressures in a posterior-to-anterior direction and prone press-up exercises. Subjects who reported a decrease in current pain intensity of 2 or greater immediately following treatment were classified as immediate responders, while the remainder were classified as not-immediate responders. The apparent diffusion coefficient, representing the diffusion of water in the nucleus pulposis, was calculated from the midsagittal diffusion-weighted images.
Following treatment, immediate responders (n = 10) had a mean increase in the apparent diffusion coefficient in the middle portion of the L5-S1 intervertebral disc of 4.2% compared to a mean decrease of 1.6% for the not-immediate responders (P<.005).
In a group of subjects with LBP, who were classified as being candidates for extension-based treatment, the report of an immediate reduction in pain intensity of 2/10 of greater after a treatment of posterior-to-anterior-directed pressures, followed by prone press-up exercises, was associated with an increase in diffusion of water in the nuclear region of the L5-S1 intervertebral disc. Subjects who did not report a pain reduction of at least 2/10 did not have a change in diffusion. J Orthop Sports Phys Ther 2010;40(5):256-264, Epub 12 March 2010. doi:10.2519/jospt.2010.3284.
Purpose:
To assess response to osteopathic manual treatment (OMT) according to baseline severity of chronic low back pain (LBP).
Methods:
The OSTEOPATHIC Trial used a randomized, double-blind, sham-controlled, 2×2 factorial design to study OMT for chronic LBP. A total of 269 (59%) patients reported low baseline pain severity (LBPS) (<50 mm/100 mm), whereas 186 (41%) patients reported high baseline pain severity (HBPS) (≥50 mm/100 mm). Six OMT sessions were provided over eight weeks and outcomes were assessed at week 12. The primary outcome was substantial LBP improvement (≥50% pain reduction). The Roland-Morris Disability Questionnaire (RMDQ) and eight other secondary outcomes were also studied. Response ratios (RRs) and 95% confidence intervals (CIs) were used in conjunction with Cochrane Back Review Group criteria to determine OMT effects.
Results:
There was a large effect size for OMT in providing substantial LBP improvement in patients with HBPS (RR, 2.04; 95% CI, 1.36-3.05; P<0.001). This was accompanied by clinically important improvement in back-specific functioning on the RMDQ (RR, 1.80; 95% CI, 1.08-3.01; P=0.02). Both RRs were significantly greater than those observed in patients with LBPS. Osteopathic manual treatment was consistently associated with benefits in all other secondary outcomes in patients with HBPS, although the statistical significance and clinical relevance of results varied.
Conclusions:
The large effect size for OMT in providing substantial pain reduction in patients with chronic LBP of high severity was associated with clinically important improvement in back-specific functioning. Thus, OMT may be an attractive option in such patients before proceeding to more invasive and costly treatments.
Objective:
The purpose of this study was to quantify lumbar zygapophyseal (Z) joint space separation (gapping) in low back pain (LBP) subjects after spinal manipulative therapy (SMT) or side-posture positioning (SPP).
Methods:
This was a controlled mechanisms trial with randomization and blinding. Acute LBP subjects (N = 112; four n = 28 magnetic resonance imaging [MRI] protocol groups) had 2 MRI appointments (initial enrollment and after 2 weeks of chiropractic treatment, receiving 2 MRI scans of the L4/L5 and L5/S1 Z joints at each MRI appointment. After the first MRI scan of each appointment, subjects were randomized (initial enrollment appointment) or assigned (after 2 weeks of chiropractic treatment appointment) into SPP (nonmanipulation), SMT (manipulation), or control MRI protocol groups. After SPP or SMT, a second MRI was taken. The central anterior-posterior joint space was measured. Difference between most painful side anterior-posterior measurements taken postintervention and preintervention was the Z joint "gapping difference." Gapping differences were compared (analysis of variance) among protocol groups. Secondary measures of pain (visual analog scale, verbal numeric pain rating scale) and function (Bournemouth questionnaire) were assessed.
Results:
Gapping differences were significant at the first (adjusted, P = .009; SPP, 0.66 ± 0.48 mm; SMT, 0.23 ± 0.86; control, 0.18 ± 0.71) and second (adjusted, P = .0005; SPP, 0.65 ± 0.92 mm; SMT, 0.89 ± 0.71; control, 0.35 ± 0.32) MRI appointments. Verbal numeric pain rating scale differences were significant at first MRI appointment (P = .04) with SMT showing the greatest improvement. Visual analog scale and Bournemouth questionnaire improved after 2 weeks of care in all groups (both P < .0001).
Conclusions:
Side-posture positioning showed greatest gapping at baseline. After 2 weeks, SMT resulted in greatest gapping. Side-posture positioning appeared to have additive therapeutic benefit to SMT.
In recent years quality of life instruments have been featured as primary outcomes in many randomized trials. One of the challenges facing the investigator using such measures is determining the significance of any differences observed, and communicating that significance to clinicians who will be applying the trial results. We have developed an approach to elucidating the significance of changes in score in quality of life instruments by comparing them to global ratings of change. Using this approach we have established a plausible range within which the minimal clinically important difference (MCID) falls. In three studies in which instruments measuring dyspnea, fatigue, and emotional function in patients with chronic heart and lung disease were applied the MCID was represented by mean change in score of approximately 0.5 per item, when responses were presented on a seven point Likert scale. Furthermore, we have established ranges for changes in questionnaire scores that correspond to moderate and large changes in the domains of interest. This information will be useful in interpreting questionnaire scores, both in individuals and in groups of patients participating in controlled trials, and in the planning of new trials.
Spinal manipulation, one of the oldest forms of therapy for back pain, has mostly been practiced outside of the medical profession. Over the past decade, there has been an escalation of clinical and basic science research on manipulative therapy, which has shown that there is a scientific basis for the treatment of back pain by manipulation. Most family practitioners have neither the time nor inclination to master the art of manipulation and will wish to refer their patients to a skilled practitioner of this therapy. Results of spinal manipulation in 283 patients with low back pain are presented. The physician who makes use of this resource will provide relief for many patients.
The objective of this study was to assess the immediate effect of a sciatic nerve slider technique added to sustained hamstring stretching on lumbar and lower quadrant flexibility.
This was a randomized controlled pilot study.
Eight (8) healthy male soccer players (21 +/- 3 years) were randomly assigned to 2 groups.
Group A received 5 minutes of bilateral sustained hamstring stretching. Group B additionally received 60 seconds of a sciatic nerve slider technique for each leg.
Pre- and postintervention outcomes taken by an assessor blinded to the treatment allocation of the participants included metric distance on finger-to-floor, sit and reach, and the modified Schöber tests and goniometric range of each hip for the straight-leg raise and each knee for seated slump test. Baseline between-group differences were examined with an independent t test and a two-way repeated-measures analysis of variance with p < 0.05 and p < 0.025 analyzed effects of the interventions.
There were no significant between-group baseline differences (p > 0.2). There was a significant effect for time on all outcomes (p < 0.01) other than the sit and reach test (p = 0.8). A significant interaction between group . time with greater improvements in group B was found for the modified Schöber test (F = 5.5; p < 0.05), left straight-leg raise (F = 6.1; p < 0.05) and slump test in either leg (left F = 28.7; p = 0.002; right F = 4.9; p < 0.05).
Adding a sciatic nerve slider technique to sustained hamstring stretching led to greater immediate increases in both lumbar and lower quadrant flexibility in young healthy soccer players as measured by four of the seven outcomes used. Study limitations and suggestions for future studies are discussed.
Cross-sectional, observational study.
To explore how ankle position affects lower extremity neurodynamic testing.
Upper extremity limb movements that increase neural loading create a protective muscle action of the upper trapezius, resulting in shoulder girdle elevation during neurodynamic testing. A similar mechanism has been suggested in the lower extremities.
Twenty healthy subjects without low back pain participated in this study. Hip flexion angle and surface electromyographic measures were taken and compared at the onset of symptoms (P1) and at the point of maximally tolerated symptoms (P2) during straight-leg raise tests performed with ankle dorsiflexion (DF-SLR) and plantar flexion (PF-SLR).
Hip flexion was reduced during DF-SLR by a mean +/- SD of 5.5 degrees +/- 6.6 degrees at P1 (P = .001) and 10.1 degrees +/- 9.7 degrees at P2 (P<.001), compared to PF-SLR. DF-SLR induced distal muscle activation and broader proximal muscle contractions at P1 compared to PF-SLR.
These findings support the hypothesis that addition of ankle dorsiflexion during straight-leg raise testing induces earlier distal muscle activation and reduces hip flexion motion. The straight-leg test, performed to the onset of symptoms (P1) and with sensitizing maneuvers, allows for identification of meaningful differences in test outcomes and is an appropriate end point for lower extremity neurodynamic testing.
To examine the effects of 2 manual therapy methods compared with one counselling session with a physiotherapist with "advice-only to stay active" for treating low back pain/leg pain and disability.
A randomized, controlled trial with a 1-year follow-up.
A total of 134 subjects with low back disorders.
Participants with acute to chronic first or recurrent low back pain, excluding those with "red flag" criteria, were assigned randomly to one of the 3 intervention groups: an orthopaedic manual therapy group (n=45), a McKenzie method group (n=52), and an "advice only to be active" group (advice-only) (n=37). Data on leg and low back pain intensity and disability (Roland-Morris Disability questionnaire) were collected at baseline, and at 3-, 6-, and 12-month follow-up points.
At the 3-month follow-up point, significant improvements had occurred in all groups in leg and low back pain and in the disability index, but with no significant differences between the groups. At the 6-month follow-up, leg pain (-15 mm; 95% confidence interval (CI) -30 to -1), back pain (effect: -15 mm; -27 to -4), and disability index (-4 points; -7 to -1) improved (p < 0.05) more in the McKenzie method group than in the advice-only group. At the 1-year follow-up, the McKenzie method group had (p=0.028) a better disability index (-3 points; -6 to 0) than did the advice-only group. In the orthopaedic manual therapy group at the 6-month and 1-year follow-up visits, improvements in the pain and disability index were somewhat better than in the advice-only group (p=0.067 and 0.068, respectively). No differences emerged between the orthopaedic manual therapy and McKenzie method groups in pain- and disability-score changes at any follow-up.
The orthopaedic manual therapy and McKenzie methods seemed to be only marginally more effective than was one session of assessment and advice-only.
To compare the effectiveness of an upper cervical manipulation and a manipulation of the sacroiliac joint for increasing hip range of motion.
Clinical cohort study.
Macquarie University Centre for Chiropractic Outpatient Clinic.
Fifty-two randomly chosen university students aged 18 to 34 yr.
A reliable hand-held dynamometer was used to determine the end point of range of motion before and after the application of a treatment. Three groups of subjects were created: cervical manipulation, sacroiliac manipulation and sham/placebo. Range of motion of the hip in flexion (SLR) was used as the independent variable.
The two manipulative treatments resulted in increased flexion range of motion at the hip. Statistical analysis revealed that only the upper cervical manipulation procedure increased hip flexion range of motion significantly.
The results suggest that manual therapy of the neck may affect hip range of motion in normal adults. Findings such as these may indicate the existence of a link between the cervical spine and the lower extremity.
When measuring treatment effect in chronic low back pain with multi-item outcome instruments, it is necessary, both for clinical decision-making and research purposes, to understand the clinical importance of the outcome scores. The aims of the present study were three-fold. Firstly, it aimed to estimate the minimal clinically important difference of three multi-item outcome instruments (the Oswestry Disability Index, the General Function Score and the Zung Depression Scale) and of the visual analogue scale (VAS) of back pain. Secondly, it aimed to estimate the error of measurement of these instruments; and its third aim was to describe the clinical meaning of score change. The study population consisted of 289 patients treated surgically or non-surgically in a randomised controlled trial. The minimal clinically important difference was estimated with patient global assessment as the external criterion. It was compared with the standard error of measurement of the instruments. The individual items of the instruments were compared for score changes related to improvement and deterioration. The standard error of measurement of the Oswestry Disability Index, the General Function Score and the Zung Depression Scale was 4, 6 and 3 units, respectively. The 95% tolerance interval was 10, 16 and 8 units, respectively. The minimal clinically important difference was 10, 12 and 8-9 units, respectively, thus not significantly exceeding the tolerance interval. The minimal clinically important difference of VAS back pain was 18-19 units, well exceeding the 95% tolerance interval, which was 15 units. Improvement after treatment for chronic low back pain tends to occur to a greater extent in sleep disturbance, ability to do usual things and psychological irritability, but to a lesser extent in the ability to sit, stand and lift. We conclude that the VAS of back pain is responsive enough to detect the minimal clinically important difference, whereas the smallest acceptable score changes of the Oswestry Disability Index, the General Function Score and the Zung Depression Scale may require an increase to exceed the 95% tolerance interval when used for clinical decision making and for power calculation. Despite improvement after treatment, the ability to sit, stand and lift, remain notable problems.
Retrospective monozygotic twin cohort study.
Our goal was to investigate the associations between different spinal MRI findings and current, past year, and lifetime low back pain after adjusting for occupational physical loading, smoking, genetics, and early family influences.
The role of spinal pathology in back symptoms continues to be controversial.
The study participants consisted of 115 monozygotic male twin pairs 35 to 69 years of age. The qualitatively assessed MRI parameters were as follows: disc height, bulging, herniations, anular tears, osteophytes, spinal stenosis, and endplate changes. Signal intensity was measured quantitatively.
After controlling for age, disc height was associated with all back pain variables studied and anular tears with LBP frequency and intensity during the 12 months before imaging. Both were associated with lifetime frequency of low back pain interfering with daily activities, disability, and intensity of the worst lifetime pain episode. Other MRI findings did not explain the various symptom histories. Adjusting for physical loading in the past 12 months increased the associations of anular tears and "low back pain today" and 12-month low back pain parameters. After controlling for genotype and other familial influences, the within-pair differences in disc height and anular tears accounted for 6% to 12% of the total variance in the within-pair differences of low back pain variables.
These findings raise new questions about the underlying mechanisms of LBP. The sensitivities of the only significant MRI parameters, disc height narrowing and anular tears, are poor, and these findings alone are of limited clinical importance.
[Purpose] The purpose of this study was to compare the immediate changes in subjects with chronic lower back pain following lower back pain exercises and direct stretching of the tensor fasciae latae, the hamstring and the adductor magnus. [Subjects] The subjects were nine sufferers of chronic lower back pain (five female, four male) as well as eight healthy adults (six male, two female) as the control group. [Method] Exercise therapy with proven effectiveness was performed as the control intervention and direct stretching of the tensor fasciae latae, the hamstring and the adductor magnus was performed as the experimental intervention in a randomised controlled trial. Six items of evaluation pain measured on a Visual Analogue Scale (VAS), Finger Floor Distance (FFD), maximum pelvic anterior inclination, maximum pelvic posterior inclination, pelvic range of motion and posterior lumbar flexibility (PLF) The results were compared using Student's were measured before and after the intervention. The six items of evaluation were carried out in a random order. A t-test was used and a significance level was set at below 5%. [Results] A significant improvement in VAS, FFD, maximum pelvic anterior inclination, maximum pelvic posterior inclination, pelvic range of motion and PLF were observed in the chronic lower back pain group after the experimental intervention. However, the only improvement observed after the experimental intervention in the control group was in FFD. There were no significant changes in either group after control intervention. [Conclusion] This study has suggested that direct stretching of the tensor fasciae latae, the hamstring and the adductor magnus may have an immediate effect on chronic lower back pain.
Study Design. The amount of lumbar and hip flexion and the relative contribution within movement during standing forward bending was recorded on a group of asymptomatic men and a group of men with a history of chronic low back pain. Objectives. To compare the relative contribution of the hip and lumbar spine to forward bending in the two groups. Summary of Background Data. The hips and lumbar spine both contribute to the forward bending motion, and an aberrant pattern of contribution in one or both regions could be related to the presence of chronic low back pain. Methods. Thirty-two white men aged 18-36 years (15 with chronic low back pain and 17 asymptomatic) were assessed using a three-dimensional motion analysis system that allowed uninterrupted forward bending. Results. The men with chronic low back pain demonstrated a significant reduction in the mean total range and mean maximum lumbar flexion relative to the asymptomatic group. Mean hip flexion was not significantly different. Data analysis from 120° of gross flexion revealed a subgroup of men with chronic low back pain with a significant decrease in hip flexion. Conclusions. When assessing the relative motion of the lumbar spine and hips in standing forward flexion, there was a measurable difference between asymptomatic men and a group of chronic low back pain patients. In particular, two subgroups of individuals with chronic low back pain appeared; one moved relatively similarly to the asymptomatic group, whereas the other subgroup demonstrated reduced hip mobility. These findings indicate the importance of assessing the lumbar and hip flexion motion in chronic low back pain patients to determine if a movement abnormality is present.
[Purpose] The purpose of this study was to compare the immediate changes in patients with chronic lower-back pain (LBP) following LBP exercises and direct stretching (DS) of the tensor fasciae latae, the hamstrings and the adductor magnus. [Subjects] Five females and five males patients with chronic LBP participated in the study. [Method] Exercise therapy of proven effectiveness was performed as the control intervention and DS of the tensor fasciae latae, the hamstrings and the adductor magnus was performed as the experimental intervention in a randomized controlled trial. Pain on a - Visual Analogue Scale (VAS), Finger Floor Distance (FFD), maximum pelvic anterior inclination, maximum pelvic posterior inclination, pelvic range of motion (ROM) and posterior lumbar flexibility (PLF) - were measured before and after the intervention. The six items measured were evauated in a random order, and analysed using Student's t-test with significance accepted at less than 5%.[Results] Significant improvements in VAS, FFD, maximum pelvic anterior inclination, maximum pelvic posterior inclination, pelvic ROM and PLF were observed after the DS intervention. However, the only improvement observed after the control intervention was in VAS. [Conclusion] The results study has suggest that DS may have an immediate effect on chronic LBP.
Finger-floor distance (FFD), which represents trunk flexibility, is a reliable assessment of lumbar impairment. Although this measurement is easy to test, it is difficult to adopt in a large, epidemiological study because it requires examiners. As an alternative, we developed a simple self-assessment bending scale (SABS). The purpose of the present study was to investigate the validity and reliability of the SABS. The SABS has 7-point grading scheme: (1) Fingertips can not reach beyond the knees; (2) Fingertips can reach beyond the knees but the wrists can not; (3) Wrists can reach beyond the knees, but fingertips can not reach the ankles; (4) Fingertips can reach the ankles, but not the floor; (5) Fingertips can touch the floor; (6) All of the fingers can reach the floor; and (7) Palms can reach the floor. We measured the FFD and SABS in 55 healthy volunteers. SABS assessments were made and documented independently by the subject and examiner. The SABS highly correlated with the FFD (r =0.95). Kappa statistics for the SABS grades given independently by the subjects and the examiner were high at 0.98. These findings suggest that the SABS may be used as an alternative to FFD measurements in epidemiological studies.
High velocity low amplitude (HVLA) thrust techniques are widely used by many manual medicine disciplines to treat spinal dysfunction. Techniques of this type are associated with an audible release in the form of a pop or cracking sound that is widely accepted to represent cavitation of a spinal zygapophyseal joint. This audible release distinguishes HVLA thrust techniques from other manual medicine interventions. Common indications for the use of HVLA thrust techniques are ‘joint fixation’, ‘joint locking’ and somatic dysfunction but various authors have also described other indications for the therapeutic use of these techniques. Despite a wide range of indications, there has been a decline in the use of HVLA thrust techniques. Concern regarding patient safety and the difficulty associated with gaining mastery of HVLA thrust techniques may be reasons for the decline in their use. While there are potential serious sequelae from the use of HVLA thrust techniques, the risks are low provided patients are thoroughly assessed and treated by appropriately trained practitioners. With increasing evidence that spinal manipulation produces positive patient outcomes for acute low back pain and some categories of neck pain and headache, there is a need to look critically at the indications for the use of HVLA thrust techniques as well as the actual risks and potential benefits of this therapeutic modality.
Low back pain (LBP) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses. A common intervention for LBP is spinal manipulation, a technique that is not specific to one scope of practice or profession.
The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain.
A search of the current literature was conducted using PubMed, CINAHL, SPORTDiscus, Pro Quest Nursing and Allied Health Source, Scopus, and Cochrane Controlled Trials Register. Studies were included if each involved: 1) individuals with LBP; 2) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations; 3) measurable clinical outcomes or efficiency of treatment measures, and 4) randomized control trials. The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Database (PEDro).
Six randomized control trials met the inclusion criteria of this systematic review. The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes. Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events resulting from this intervention. Additionally, the manipulation group in one study reported statistically significantly less medication use, health care utilization, and lost work time.
Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain.
Study Design. Systematic review of interventions.Objective. To assess the effects of spinal manipulative therapy (SMT) for acute low-back pain.Summary of Background Data. SMT is one of many therapies for the treatment of low-back pain, which is a worldwide, extensively practised intervention.Methods. Search methods. An experienced librarian searched for randomised controlled trials (RCTs) in multiple databases up to 31 March 2011. Selection criteria. RCTs which examined manipulation or mobilisation in adults with acute low-back pain (< six weeks duration) were included. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life. Data collection and analysis. Two authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the quality of the evidence. The effects were examined for: SMT vs. 1) inert interventions, 2) sham SMT, 3) other interventions, and 4) SMT as adjunct therapy.Results. We identified 20 RCTs (total participants = 2674), twelve (60%) of which were not included in the previous review. In total, six trials (30% of all included studies) had a low risk of bias. In general, for the outcomes of pain and functional status, there is low to very low quality evidence suggesting no difference in effect for SMT when compared to inert interventions, sham SMT or as adjunct therapy. There was varying quality of evidence (from very low to moderate) suggesting no difference in effect for SMT when compared with other interventions. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.Conclusions. SMT is no more effective for acute low-back pain than inert interventions, sham SMT or as adjunct therapy. SMT also appears to be no better than other recommended therapies. Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation.
This article is aimed at critically evaluating the evidence from systematic reviews (SRs) of spinal manipulation in patients with pain.
The study was designed as a SR of SRs.
Four electronic databases were searched to identify all relevant articles of the effectiveness of spinal manipulation for pain. SRs were defined as articles employing a repeatable methods section.
Twenty-two SRs relating to the following pain conditions: low back pain (N = 6), headache (N = 5), neck pain (N = 4), any medical problem (N = 1), carpal tunnel syndrome (N = 1), dysmenorrhea (N = 1), fibromyalgia (N = 1), lateral epicondylitis (N = 1), musculoskeletal conditions (N = 1) and nonspinal pain (N = 1), were included. Positive or, for multiple SR, unanimously positive conclusions were drawn for none of the conditions mentioned earlier.
Publication bias as a well-known phenomenon may have been inherited in this article.
Collectively, these data fail to demonstrate that spinal manipulation is an effective intervention for pain management.
Objectives:
To investigate the validity over time of the fingertip-to-floor test (FTF) and the straight leg raising test (SLR) using the Roland Morris Disability Questionnaire (RMDQ) and correlation coefficient (r), and to assess the predictive value of factors related to the change in RMDQ over 12 months using multivariate regression analysis.
Design:
Longitudinal study.
Setting:
Outpatient physical therapy clinic.
Participants:
Subjects (N=65) with acute/subacute low back pain (≤13 wk of symptoms). Thirty-eight (58%) had radicular pain as determined by the slump test.
Interventions:
Not applicable.
Main outcome measures:
Self-reported disability was used as a reference variable and was measured using the RMDQ at baseline and after 1 and 12 months. The FTF and SLR were measured at baseline and after 1 month. Responsiveness and imprecision were assessed by using effect size (ES) and minimal detectable change (MDC). The sample was stratified by the presence or absence of radicular pain (categorized by the slump test).
Results:
The change in FTF results was significantly correlated to the 1-month change in RMDQ, both in the entire sample (r=.63) and in the group with radicular pain (r=.66). Similar analysis for the SLR showed a weak relationship to RMDQ. FTF showed adequate responsiveness (ES range, 0.8-0.9) in contrast to SLR (ES range, 0.2-0.5). The MDC for FTF and SLR were 4.5 cm and 5.7°, respectively. The change in FTF results over 1 month was independently more strongly associated with the 12-month (R(2)=.27-.31) change in RMDQ than any of the other variables and multivariate combinations.
Conclusions:
Our results suggest that the FTF has good validity in patients with acute/subacute low back pain and even better validity in those with radicular pain. The change in FTF results over the first month was a valid predictor of the change in self-reported disability over 1 year. In contrast, the validity of SLR can be questioned in the present group of patients.
The most common lower quarter neurodynamic test is the straight leg raise (SLR) test. Quantification of limb motion during SLR testing should utilize reliable and valid measurement tools that are highly sensitive to change. The purpose of this study was to determine the psychometric properties of a hand-held inclinometer commonly utilized during SLR testing.
Cross-sectional measurement, intra-rater reliability and validity study.
Research laboratory.
Twenty individuals without pain in their low back or extremities and no history of nerve injury participated in the study.
Two repetitions of the SLR were performed in each limb in two ankle positions (plantar flexion and dorsiflexion). A digital inclinometer and digital goniometer were utilized as the comparisons for range of motion measurements.
Intra-rater reliability for the hand-held inclinometer during SLR testing was excellent (ICCs, 0.95 to 0.98). The standard error of measurement was between 0.54° and 1.22° and the minimal detectable change was between 1.50° and 3.41°. Construct validity revealed hand-held inclinometer measurements were highly correlated with both the digital inclinometer and digital goniometer measures. The mean difference scores between hand-held inclinometer and digital inclinometer (∼1.5°) and digital goniometer (∼10°) suggest that the hand-held inclinometer better matches the construct measured by the digital inclinometer (limb elevation angle) compared to the digital goniometer (hip flexion angle).
The hand-held inclinometer is a valid method for measuring limb elevation angle during the SLR neurodynamic test in a research setting. The hand-held inclinometer has high reliability and low minimal detectable change when used in healthy individuals.
To test the hypothesis that patients with chronic low back pain (CLBP) would have reduced paraspinal muscle activity when wearing a heat wrap and that this would be associated with increased stature recovery and short-term improvements in psychological factors.
A within-subject repeated-measures design. Muscle activity and stature recovery were assessed before and after a 40-minute unloading period, both without a heat wrap and after 2 hours of wear. Questionnaires were completed after both sessions.
Hospital physiotherapy department.
Patients with CLBP (n=24; age, 48.0±9.0 y; height, 166.6±7.3 cm; body mass, 80.2±12.9 kg) and asymptomatic participants (n=11; age, 47.9±15.4 y; height, 168.7±11.6 cm; body mass, 69.3±13.1 kg) took part in the investigation. Patients on the waiting list for 2 physiotherapist-led rehabilitation programs, and those who had attended the programs during the previous 2 years, were invited to participate.
Superficial heat wrap.
Paraspinal muscle activity, stature recovery over a 40-minute unloading period, pain, disability, and psychological factors.
For the CLBP patients only, the heat wrap was associated with a reduction in nonnormalized muscle activity and a positive short-term effect on self-report of disability, pain-related anxiety, catastrophizing, and self-efficacy. Changes in muscle activity were correlated with changes in stature recovery, and both were also correlated to changes in psychological factors.
Use of the heat wrap was associated with a decrease in muscle activity and a short-term improvement in certain aspects of well-being for the CLBP patients. The results confirm the link between the biomechanical and psychological outcome measures.
Individuals with low back pain (LBP) often exhibit elevated paraspinal muscle activity compared to asymptomatic controls during static postures such as standing. This hyperactivity has been associated with a delayed rate of stature recovery in individuals with mild LBP. This study aimed to explore this association further in a more clinically relevant population of NHS patients with LBP and to investigate if relationships exist with a number of psychological factors. Forty seven patients were recruited from waiting lists for physiotherapist-led rehabilitation programmes. Paraspinal muscle activity while standing was assessed via surface electromyogram (EMG) and stature recovery over a 40-min unloading period was measured on a precision stadiometer. Self-report of pain, disability, anxiety, depression, pain-related anxiety, fear of movement, self-efficacy and catastrophising were recorded. Correlations were found between muscle activity and both pain (r=0.48) and disability (r=0.43). Muscle activity was also correlated with self-efficacy (r=-0.45), depression (r=0.33), anxiety (r=0.31), pain-related anxiety (r=0.29) and catastrophising (r=0.29) and was a mediator between self-efficacy and pain. Pain was a mediator in the relationship between muscle activity and disability. Stature recovery was not found to be related to pain, disability, muscle activity or any of the psychological factors. The findings confirm the importance of muscle activity within LBP, in particular as a pathway by which psychological factors may impact on clinical outcome. The mediating role of muscle activity between psychological factors and pain suggests that interventions that are able to reduce muscle tension may be of particular benefit to patients demonstrating such characteristics, which may help in the targeting of treatment for LBP.
Hamstring strain (HS) is a common musculoskeletal condition and abnormal neurodynamics has been shown to influence HS and delay recovery. The efficacy of stretching for preventing and treating HS remains uncertain despite extensive research and wide-spread use. The effects of cervical spine mobilisation on peripheral nervous system function, neurodynamics and muscle force in the upper limb have been reported. Very few studies have reported effects of lumbar spine mobilisation on these variables in the lower limb. This study aimed to determine immediate effects of either a unilateral zygopophyseal joint posteroanterior mobilisation or a static posterior chain muscle stretch on the range of passive straight leg raise (SLR) in comparison to a non-treatment control. Using a single-blinded, randomised controlled study design, 36 healthy participants were allocated into one of three groups (control; mobilisation; static posterior chain muscle stretch). Measures of SLR were taken before and after intervention for each group on the day of testing. A General Linear Model (GLM) and a paired sample t-test showed a significant difference between base line and post-intervention for the mobilisation group only (p < 0.001), and suggests that unilateral lumbar spine zygopophyseal joint mobilisation can immediately restore posterior chain neurodynamics.
Systematic review of interventions.
To assess the effects of spinal manipulative therapy (SMT) for chronic low-back pain.
SMT is one of the many therapies for the treatment of low-back pain, which is a worldwide, extensively practiced intervention.
Search methods. An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to June 2009. Selection criteria. RCTs that examined manipulation or mobilization in adults with chronic low-back pain were included. The primary outcomes were pain, functional status, and perceived recovery. Secondary outcomes were return-to-work and quality of life. Data collection and analysis. Two authors independently conducted the study selection, risk of bias assessment, and data extraction. GRADE was used to assess the quality of the evidence.
We included 26 RCTs (total participants = 6070), 9 of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. There is a high-quality evidence that SMT has a small, significant, but not clinically relevant, short-term effect on pain relief (mean difference -4.16, 95% confidence interval -6.97 to -1.36) and functional status (standardized mean difference -0.22, 95% confidence interval -0.36 to -0.07) in comparison with other interventions. There is varying quality of evidence that SMT has a significant short-term effect on pain relief and functional status when added to another intervention. There is a very low-quality evidence that SMT is not more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.
High-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority.
A prospective single blinded placebo controlled study was conducted.
To assess the effectiveness of spinal manipulation therapy (SMT) for the management of chronic nonspecific low back pain (LBP) and to determine the effectiveness of maintenance SMT in long-term reduction of pain and disability levels associated with chronic low back conditions after an initial phase of treatments.
SMT is a common treatment option for LBP. Numerous clinical trials have attempted to evaluate its effectiveness for different subgroups of acute and chronic LBP but the efficacy of maintenance SMT in chronic nonspecific LBP has not been studied.
Sixty patients, with chronic, nonspecific LBP lasting at least 6 months, were randomized to receive either (1) 12 treatments of sham SMT over a 1-month period, (2) 12 treatments, consisting of SMT over a 1-month period, but no treatments for the subsequent 9 months, or (3) 12 treatments over a 1-month period, along with "maintenance spinal manipulation" every 2 weeks for the following 9 months. To determine any difference among therapies, we measured pain and disability scores, generic health status, and back-specific patient satisfaction at baseline and at 1-, 4-, 7-, and 10-month intervals.
Patients in second and third groups experienced significantly lower pain and disability scores than first group at the end of 1-month period (P = 0.0027 and 0.0029, respectively). However, only the third group that was given spinal manipulations (SM) during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation. In the nonmaintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level.
SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.
Multicenter, prospective, consecutive clinical series.
To report on back pain and its association with patients' perceptions of appearance in a prospective cohort study of children before and after posterior spinal fusion for idiopathic scoliosis.
Back pain in idiopathic scoliosis has been noted to be reduced after surgery. However, uncertainty over its prevalence before and after operation persists. There is a paucity of data on correlations between patients' perceptions of their appearance and preoperative and postoperative pain.
We reviewed 1433 patients entered consecutively into the Prospective Pediatric Scoliosis Study, a database of children (8-22 years) undergoing operation for idiopathic scoliosis who have been followed for 1 and 2 years (n = 295) with the Scoliosis Research Society-22 and Spinal Appearance Questionnaire instruments.
Preoperative pain was reported by 77.9% of patients and 44% of surgeons. More preoperative pain correlated with older age (ρ = -.140, P = 0.000), greater body mass index (ρ = -0.168, P = 0.000), larger proximal thoracic curve ρ = -0.086, P = 0.019), and a higher score on the Spinal Appearance Questionnaire Appearance (greater perception of spinal deformity, ρ = -0.223, P = 0.000) and Appearance Desire scales (stronger desire to change the appearance of their spine, ρ = -0.153, P = 0.000).Pain was reduced at 1 and 2 years after operation (P = 0.0002). Patients who perceived themselves as less deformed (ρ = -0.284, P < 0.01) or had less desire to change their spinal appearance (ρ = -0.183, P < 0.01) experienced a greater reduction in pain 2 years after operation.Preoperative analgesic use for back pain was high (28.8%) and remained high at 2 years after operation (29.5%) (P > 0.05).
Back pain affects three-quarters of adolescents with idiopathic scoliosis and is reduced after posterior fusion. Patients who are overweight, older, and have larger proximal thoracic curve magnitudes report more preoperative pain. Patients who view themselves as more deformed tend to have more absolute pain, and less reduction in pain after operation.
Workers lose height during the day. Flexion-based exercises and body positions are commonly prescribed to unload the spine and prevent back pain. Lumbar extension positions have been researched and result in an increase in spine height. End-range lumbar extension postures increase spine height to a greater extent than mid-range lumbar extension postures, but these positions are not always tolerated by patients with lumbar conditions. No study to date has investigated the effect of end-range versus mid-range lumbar flexion postures on spine height changes. The purpose of this study was to investigate the effects of two techniques commonly used in clinical settings to unload the lumbar intervertebral disc (IVD) segments through increasing spine height in: (1) a sidelying mid-range lumbar flexion position; and (2) a sidelying end-range lumbar flexion position. A total of 20 asymptomatic women and 21 asymptomatic men with a mean age of 23.8 years (±2.5) participated in the study. Subjects were randomized systematically into 2 groups to determine the order of testing position. Measurements were taken with a stadiometer in the sitting position to detect change in spine height after each position. Results of the paired t-tests indicated that compared to the spine height in sitting, the sidelying end-range lumbar flexion position resulted in a statistically significant (p < .001) mean spine height gain of 4.78 mm (±4.01) while the sidelying mid-range lumbar flexion position resulted in a statistically significant (p < .001) mean spine height gain of 5.84 mm (±4.4). No significant difference between the height changes observed following the two sidelying positions was found (p = .22). Sidelying lumbar flexion positions offer valuable alternatives to lumbar extension positions to increase spine height, possibly through increasing hydration levels of the lumbar IVD and could be proposed as techniques to offset spinal shrinkage and the biomechanical consequences of sustained loads.
Prospective, randomized, controlled trial.
To investigate the effectiveness of home-based exercise on pain, dysfunction, and quality of life (QOL) in Japanese individuals with chronic low back pain (CLBP).
Exercise therapy is a widely used treatment for CLBP in many countries. The studies on its effectiveness have been performed only in Western industrialized countries. The existence of cross-cultural differences and heterogeneity of patients in each country may influence the outcome of interventions for CLBP. Data that would enable researchers to compare the effectiveness of interventions between widely different societies is lacking.
A total of 201 patients with nonspecific CLBP were randomly assigned to either the control or exercise therapy group: 89 men and 112 women with a mean age of 42.2 years. The control group was treated with nonsteroidal anti-inflammatory drugs (NSAIDs), and the exercise group performed trunk muscle strengthening and stretching exercises. The primary outcome measures were pain intensity (visual analogue scale) and dysfunction level (Japan Low back pain Evaluation Questionnaire [JLEQ] and Roland-Morris Disability Questionnaire [RDQ]) over 12 months. The secondary outcome measure was FFD (Finger-floor distance). Statistical analysis was performed using Wilcoxon signed-ranks and Mann-Whitney U tests, and estimation of the median with 95% CI was calculated.
In both groups, significant improvement was found at all points of follow-up assessment. However, JLEQ and RDQ were significantly more improved in the exercise group compared to the control group (P = 0.021 in JLEQ, P = 0.023 in RDQ). The 95% CI for the difference of medians of the change ratio between exercise and NSAID groups, [Exercise] - [NSAID], was -0.25 to -0.02 in JLEQ, -0.33 to 0.00 in RDQ, and -0.20 to 0.06 in visual analogue scale.
The home-based exercise prescribed and monitored by board-certified orthopedic surgeons was more effective than NSAIDs for Japanese patients with CLBP.
Single-group, prospective, repeated-measures design.
To determine differences in the changes of diffusion of water in the L5-S1 intervertebral disc between subjects with nonspecific low back pain (LBP) who reported an immediate reduction in pain intensity of 2 or greater on an 11-point (0-10) numeric rating scale after a 10-minute session of lumbar joint mobilization, followed by prone press-up exercises, compared to those who did not report an immediate reduction in pain intensity of 2 or greater on the pain scale.
Combining lumbar joint mobilization and prone press-up exercises is a common intervention for patients with LBP; however, there is conflicting evidence regarding the effectiveness and efficacy of this approach. Increased knowledge of the physiologic effects of the combined use of these treatments, and the relationship to pain reports, can lead to refinement of their clinical application.
Twenty adults, aged 22 to 54, participated in this study. All subjects reported LBP of at least 2 on an 11-point (0-10) verbally administered numeric rating scale at the time of enrollment in the study and were classified as being candidates for the combination of joint mobilization and prone press-ups. Subjects underwent T2- and diffusion-weighted lumbar magnetic resonance imaging scans before and immediately after receiving a 10-minute session of lumbar pressures in a posterior-to-anterior direction and prone press-up exercises. Subjects who reported a decrease in current pain intensity of 2 or greater immediately following treatment were classified as immediate responders, while the remainder were classified as not-immediate responders. The apparent diffusion coefficient, representing the diffusion of water in the nucleus pulposis, was calculated from the midsagittal diffusion-weighted images.
Following treatment, immediate responders (n = 10) had a mean increase in the apparent diffusion coefficient in the middle portion of the L5-S1 intervertebral disc of 4.2% compared to a mean decrease of 1.6% for the not-immediate responders (P<.005).
In a group of subjects with LBP, who were classified as being candidates for extension-based treatment, the report of an immediate reduction in pain intensity of 2/10 of greater after a treatment of posterior-to-anterior-directed pressures, followed by prone press-up exercises, was associated with an increase in diffusion of water in the nuclear region of the L5-S1 intervertebral disc. Subjects who did not report a pain reduction of at least 2/10 did not have a change in diffusion. J Orthop Sports Phys Ther 2010;40(5):256-264, Epub 12 March 2010. doi:10.2519/jospt.2010.3284.
Decreased intervertebral disc height can result in diminished load carrying capacity of the spinal segment. Clinical means of assessing postures able to rehydrate the discs were investigated.
The purposes of this study were 3-fold: (1) to determine if our test protocol using a commercially available stadiometer demonstrated findings consistent with prior laboratory-based protocols; (2) to determine if hyperextension in the prone position and trunk flexion in the supine position caused increased spine height after sustained loading; and (3) to compare the effects of hyperextension in the prone position and trunk flexion in the supine position on spine height changes after a period of sustained loading.
This study used a pretest, posttest crossover design. Ten women and 11 men (mean age, 24 +/- 2.6 years) participated. Subjects held either 10 minutes of hyperextension in the prone position or 10 minutes of trunk flexion in the supine position in the recovery phase. Spine height was measured using a commercially available stadiometer. Spinal height change was determined from measurements taken after loaded sitting and measurements taken after hyperextension in the prone position and trunk flexion in the supine position.
A 1-sample t test indicated no significant difference existed between our mean height change after 5 minutes of sitting and previously published validated findings. A paired t test indicated significant increase in height after both supine flexion and prone extension lying (P< .0001). The mean height gain was 3.11 mm using prone extension and 3.19 mm using the supine flexion protocol. A paired t test indicated no significant difference between these 2 recovery positions (P = .927).
The stadiometer measurement protocol demonstrated that hyperextension in the prone position and trunk flexion in the supine position were easily effective positions for the temporary recovery of spine height after sustained loading. These findings lay the foundation for future research into the viscoelastic creep properties of the intervertebral disk under loading and therapeutic conditions.
Chiropractic care is used by many older patients for low back pain (LBP), but there are no published results of randomized trials examining spinal manipulation (SM) for older adults. The purpose of this study was to compare the effects of 2 biomechanically distinct forms of SM and minimal conservative medical care (MCMC) for participants at least 55 years old with subacute or chronic nonradicular LBP.
Randomized controlled trial. The primary outcome variable was low back-related disability assessed with the 24-item Roland Morris Disability questionnaire at 3, 6, 12, and 24 weeks. Participants were randomly allocated to 6 weeks of care including 12 visits of either high-velocity, low-amplitude (HVLA)-SM, low-velocity, variable-amplitude (LVVA)-SM, or 3 visits of MCMC.
Two hundred forty participants (105 women and 135 men) ages 63.1 +/- 6.7 years without significant comorbidities. Adjusted mean Roland Morris Disability change scores (95% confidence intervals) from baseline to the end of active care were 2.9 (2.2, 3.6) and 2.7 (2.0, 3.3) in the LVVA-SM and HVLA-SM groups, respectively, and 1.6 (0.5, 2.8) in the MCMC group. There were no significant differences between LVVA-SM and HVLA-SM at any of the end points. The LVVA-SM group had significant improvements in mean functional status ranging from 1.3 to 2.2 points over the MCMC group. There were no serious adverse events associated with any of the interventions.
Biomechanically distinct forms of SM did not lead to different outcomes in older LBP patients and both SM procedures were associated with small yet clinically important changes in functional status by the end of treatment for this relatively healthy older population. Participants who received either form of SM had improvements on average in functional status ranging from 1 to 2.2 over those who received MCMC. From an evidence-based care perspective, patient preference and clinical experience should drive how clinicians and patients make the SM procedure decision for this patient population.
A new method for measuring spinal load is proposed, whereby changes in body height are used as a measure of disc compression. The rate and magnitude of disc compression are caused by the loading and its temporal pattern. A device is reported for measuring body height (SD less than 1 mm). Experiments showed the dinural shrinkage during a working day and the rapid recovery when lying down. Other experiments demonstrated how the rate of shrinkage is a function of the load on the spine. Further, shrinkage when sitting in different chairs has been compared, and the results are in agreement with disc pressure measurements, reported in the literature. Finally, examples are given of how the method can be used in ergonomic evaluations.
The visual analogue scale (VAS) is a simple and frequently used method for the assessment of variations in intensity of pain. In clinical practice the percentage of pain relief, assessed by VAS, is often considered as a measure of the efficacy of treatment. However, as illustrated in the present study, the validity of VAS estimates performed by patients with chronic pain may be unsatisfactory. Two types of VAS, an absolute and a comparative scale, were compared with respect to factors influencing the reliability and validity of pain estimates. As shown in this study the absolute type of VAS seems to be less sensitive to bias than the comparative one and is therefore preferable for general clinical use. Moreover, the patients appear to differ considerably in their ability to use the VAS reliably. When assessing efficacy of treatment attention should therefore be paid to several complementary indices of pain relief as well as to the individual's tendency to bias his estimates.
To report the clinical presentation and outcome of consecutive patients who received a course of nonoperative treatment, including manipulation, for low back and radiating leg pain. This review was conducted to generate hypotheses for a future clinical trial involving manipulation for the treatment of lumbar spine disk herniation.
A case series of consecutive patients presenting to a postgraduate teaching chiropractic clinic between 1990 and 1993 was evaluated. Three thousand, five hundred and fifty-three charts were reviewed; in 71 of the cases, the patient had low back pain (LBP) with radiating leg pain clinically diagnosed as lumbar spine disk herniation.
All outcome measures were extracted from the patients' charts. Subjective improvement reported by the patient, range of motion and nerve root tension signs were used to assess improvement.
Of the 59 patients who received a course of treatment, 90% reported improvement of their complaint. A subgroup analysis indicated that 75% of the patients that reported improvement of their conditions had an increase in straight leg raising (SLR) and lumbar range of motion. The maximum complication rate associated with this treatment approach was estimated to be 5% or less. A previous history of low back surgery was a statistically significant predictor of poor outcome.
Based on our results, we postulate that a course of nonoperative treatment including manipulation may be effective and safe for the treatment of back and radiating leg pain. This hypothesis remains to be tested in a prospective study.
The amount of lumbar and hip flexion and the relative contribution within movement during standing forward bending was recorded on a group of asymptomatic men and a group of men with a history of chronic low back pain.
To compare the relative contribution of the hip and lumbar spine to forward bending in the two groups.
The hips and lumbar spine both contribute to the forward bending motion, and an aberrant pattern of contribution in one or both regions could be related to the presence of chronic low back pain.
Thirty-two white men aged 18-36 years (15 with chronic low back pain and 17 asymptomatic) were assessed using a three-dimensional motion analysis system that allowed uninterrupted forward bending.
The men with chronic low back pain demonstrated a significant reduction in the mean total range and mean maximum lumbar flexion relative to the asymptomatic group. Mean hip flexion was not significantly different. Data analysis for 120 degrees of gross flexion revealed a subgroup of men with chronic low back pain with a significant decrease in hip flexion.
When assessing the relative motion of the lumbar spine and hips in standing forward flexion, there was measurable difference between asymptomatic men and a group of chronic low back pain patients. In particular, two subgroups of individuals with chronic low back pain appeared; one moved relatively similarly to the asymptomatic group, whereas the other sub-group demonstrated reduced hip mobility. These findings indicate the importance of assessing the lumbar and hip flexion motion in chronic low back pain patients to determine if a movement abnormality is present.
Objective:
To test the effect of two measurement techniques for repeated measures of spine height using stadiometry following five experimental activity conditions.DESIGN. Six subjects were repeatedly measured while they stepped in and out of the stadiometer for each pair of measures and again on another day when they remained in place in the stadiometer for all 10 measures.RESULTS. There was much greater variability in height measures with the "in-out" method while the "in place" method demonstrated a steady shrinkage over the 3-3.5 min required to obtain the repeated measures. RelevanceContrary to popular practice, leaving a subject in the stadiometer during repeated measures includes the shrinkage that occurs over the 3-3.5 min of measurement when standing and reduces random variation due to posture change.
This single-blind randomised clinical trial compared osteopathic manipulative treatment with chemonucleolysis (used as a control of known efficacy) for symptomatic lumbar disc herniation. Forty patients with sciatica due to this diagnosis (confirmed by imaging) were treated either by chemonucleolysis or manipulation. Outcomes (leg pain, back pain and self-reported disability) were measured at 2 weeks, 6 weeks and 12 months. The mean values for all outcomes improved in both groups. By 12 months, there was no statistically significant difference in outcome between the treatments, but manipulation produced a statistically significant greater improvement for back pain and disability in the first few weeks. A similar number from both groups required additional orthopaedic intervention; there were no serious complications. Crude cost analysis suggested an overall financial advantage from manipulation. Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis, it can be considered as an option for the treatment of symptomatic lumbar disc herniation, at least in the absence of clear indications for surgery. Further study into the value of manipulation at a more acute stage is warranted.
This study evaluated the effect of lumbosacral spinal manipulation with thrust and spinal mobilization without thrust on the excitability of the alpha motoneuronal pool in human subjects without low back pain.
To investigate the effect of high velocity, low amplitude thrust, or mobilization without thrust on the excitability of the alpha motoneuron pool, and to elucidate potential mechanisms in which manual procedures may affect back muscle activity.
The physiologic mechanisms of spinal manipulation are largely unknown. It has been proposed that spinal manipulation may reduce back muscle electromyographic activity in patients with low back pain. Although positive outcomes of spinal manipulation intervention for low back pain have been reported in clinical trials, the mechanisms involved in the amelioration of symptoms are unknown.
In this study, 17 nonpatient human subjects were used to investigate the effect of spinal manipulation and mobilization on the amplitude of the tibial nerve Hoffmann reflex recorded from the gastrocnemius muscle. Reflexes were recorded before and after manual spinal procedures.
Both spinal manipulation with thrust and mobilization without thrust significantly attenuated alpha motoneuronal activity, as measured by the amplitude of the gastrocnemius Hoffmann reflex. This suppression of motoneuronal activity was significant (P < 0.05) but transient, with a return to baseline values exhibited 30 seconds after intervention.
Both spinal manipulation with thrust and mobilization without thrust procedures produce a profound but transient attenuation of alpha motoneuronal excitability. These findings substantiate the theory that manual spinal therapy procedures may lead to short-term inhibitory effects on the human motor system.
The aim of this study was to determine the effect of sitting and standing postures on the repeatability of a stadiometer designed to detect small variations in spinal length. Two groups of ten healthy subjects, with no previous or known history of back problems, participated in this study. One group was measured in the standing posture, while the other group was measured in a sitting posture. All subjects gave informed consent to participate in this study. Subjects had a set of landmarks defining the spinal contour marked on their backs and then stood in the stadiometer for three series of ten measurements to be performed. At the end of each measurement, the subjects were requested to move away from and then be repositioned in the stadiometer. Subjects improved the repeatability across the measurement series. At the end of the second measurement series, all subjects presented mean standard deviations of 0.43 +/- 0.08 mm (range 0.30-0.50 mm) in the standing posture. In the sitting posture, deviations of less than 0.05 mm were obtained only at the end of the third measurement series (0.48 +/- 0.08 mm; range 0.34-0.62 mm), suggesting that this posture required three measurement series before repeatable measurements could be assured rather than two in the standing posture.
Objective:
To evaluate if chronic low back pain patients perform manual material handling tasks differently from control subjects.
Design:
Comparative study using a repeated measures design.
Background:
No study evaluated the lifting technique of back pain patients relative to control subjects during free style lifting and lowering tasks. Previous findings suggest that lowering would be more hazardous than lifting to the low back. It would be interesting to evaluate if chronic low back pain patients behave differently than controls when lifting and lowering.
Methods:
Thirty-three male subjects (18 controls, 15 suffering from non-specific chronic low back pain) participated. A 12-kg box was lifted (freestyle) from the floor to the hips (1) in front (symmetric task) or (2) to a shelf located at 90 degree on the right (asymmetric task) and was lowered back to the floor. A 3D biomechanical analysis involving the assessment of L5/S1 loading, posture of segments, inertial parameters, and EMG was performed.
Results:
There was no difference between the groups for postural (trunk and lower limb angles), inertial (trunk velocity and acceleration), and L5/S1 loading (moments and compression) variables. The patients showed abnormally low left lumbar erector spinae (symmetric task, lowering) or high left thoracic erector spinae (all tasks) EMG activation. Significant Group x Action (lifting vs. lowering) interactions were also observed for some inertial and L5/S1 loading variables suggesting that the biomechanical differences detected between lifting and lowering may have a differential influence on the technique used by back pain patients and control subjects.
Conclusions:
The gross lifting technique of back pain patients was unaltered relative to controls but the activation of paraspinal muscles differed, suggesting that a more detailed biomechanical analysis, such as the use of EMG driven models, might be required to reveal lumbar impairments during lifting.
Relevance:
To evaluate if chronic low back pain patients use naturally different lifting techniques to prevent pain exacerbation and damaged lumbar tissue overloading.
A systematic review.
This systematic review sought papers (January 1989-January 2000) on the passive straight leg raising test (PSLR) as a diagnostic component for low back pain (LBP) to identify, summarize, and assess developments in the test procedure, the factors influencing PSLR outcome, and the clinical significance of that outcome.
Previous studies suggested that the PSLR tractioned the sciatic nerve and that diminished leg elevation with reproduced pain indicated low lumbar intervertebral disc pathology.
Searches on six computerized bibliographic databases identified publications written about the PSLR. Papers were excluded if they were published before January 1989, were non-English language papers, or employed either an active SLR or a PSLR for purposes other than LBP diagnosis. The references of qualifying papers (and the references of references) were searched. Contact with primary authors, and others known to be active in this field, was attempted.
The PSLR procedure remains unchanged. The influence of hip rotation during the PSLR was discussed without consensus. Biomechanical devices improved intra- and interobserver reliability and so increased test reproducibility. Hamstrings were found to have a defensive role in protecting nerve roots by limiting PSLR range in cases of nerve root inflammation. A small diurnal variation in the PSLR may imply a poorer prognosis. A positive PSLR at 4 months after lumbar intervertebral disc surgery predicted poor reoperative outcome, and a negative 4-month PSLR predicted excellent outcome. The influence of psychosocial factors was not discussed, neither was the diagnostic significance of a negative PSLR outcome.
There remains no standard PSLR procedure, no consensus on interpretation of results, and little recognition that a negative PSLR test outcome may be of greater diagnostic value than a positive one. The causal link between LBP pathology and hamstring action remains unclear. There is a need for research into the clinical use of the PSLR; its intra- and interobserver reliability; the influences of age, gender, diurnal variation, and psychosocial factors; and its predictive value in lumbar intervertebral disc surgery.
To assess the loss of stature and its recovery in normal and pregnant women with and without low back pain (LBP) and to examine the relations between spinal shrinkage, recovery, and LBP.
Stature changes were measured before and after physical activity in each group and differences in response compared between groups.
A laboratory environment.
Thirty-one women (7 pregnant without LBP, 8 pregnant with LBP, 16 nonpregnant with no history of low back disorders) were recruited using convenience sampling. Controls were recruited from the general community; subjects in the pregnant groups were recruited from local primary care groups.
Not applicable.
Stature change was assessed as the main outcome measure. Changes in stature were interpreted with respect to the woman's stature at the start of the trial.
Stature loss induced by a moderate physical activity was similar (P>.05) in all groups (control, -3.99+/-1.13 mm; pregnant no back pain, -4.23+/-1.23 mm; pregnant with back pain, -4.57+/-1.53 mm). Differences were found after 20 minutes in a recovery position (P<.05): the controls were able to recover stature to a greater extent (111.2%+/-13.6%) than the other groups (P<.05). A negative correlation was found between regain in stature and LBP in pregnant subjects (r=-.81, P<.05).
The pregnant women with LBP were unable to recover stature to the same extent as the controls and pregnant women without LBP. Results suggest that LBP in pregnancy may be related to the woman's diminished ability to recover, rather than the magnitude of the spinal shrinkage imposed during the task.
A relationship between degenerative changes of the intervertebral disc and biomechanical functions of the lumbar spine has been suggested. However, the exact relationship between the grade of disc degeneration and the flexibility of the motion segment is not known.
To investigate the relationship between degenerative grades of the intervertebral disc and three-dimensional (3-D) biomechanical characteristics of the motion segment under multidirectional loading conditions.
A biomechanical and imaging study of human cadaveric spinal motion segments.
One hundred fourteen lumbar motion segments from T12-L1 to L5-S1 taken from 47 fresh cadaver spines (average age at death, 68 years; range, 39 to 87 years) were used in this study. The severity of degeneration (grades I to V according to Thomson's system) was determined using magnetic resonance (MR) images and cryomicrotome sections. Pure unconstrained moments with dead weights were applied to the motion segments in six load steps. The directions of loading included flexion, extension, right and left axial rotation, and right and left lateral bending.
When the MR images were graded, 2 segments had grade I disc degeneration; 45, grade II; 20, grade III; 26, grade IV; and 21, grade V. When the cryomicrotome sections were graded, 14 segments had grade I disc degeneration; 31, grade II; 22, grade III; 26, grade IV; and 21, grade V. Segments from the upper lumbar levels (T12-L1 to L3-4) tended to have greater rotational movement in flexion, extension, and axial rotation with disc degeneration up to grade IV, whereas the motion decreased when the disc degenerated to grade V. In the lower lumbar spine at L4-5 and L5-S1, motion in axial rotation and lateral bending was increased in grade III.
These results suggest that kinematic properties of the lumbar spine are related to disc degeneration. Greater motion generally was found with disc degeneration, particularly in grades III and IV, in which radial tears of the annulus fibrosus are found. Disc space collapse and osteophyte formation as found in grade V resulted in stabilization of the motion segments.
Despite clinical evidence for the benefits of spinal manipulation and the apparent wide usage of it, the biological mechanisms underlying the effects of spinal manipulation are not known. Although this does not negate the clinical effects of spinal manipulation, it hinders acceptance by the wider scientific and health-care communities and hinders rational strategies for improving the delivery of spinal manipulation.
The purpose of this review article is to examine the neurophysiological basis for the effects of spinal manipulation.
A review article discussing primarily basic science literature and clinically oriented basic science studies.
This review article draws primarily from the peer-reviewed literature available on Medline. Several textbook publications and reports are referenced. A theoretical model is presented describing the relationships between spinal manipulation, segmental biomechanics, the nervous system and end-organ physiology. Experimental data for these relationships are presented.
Biomechanical changes caused by spinal manipulation are thought to have physiological consequences by means of their effects on the inflow of sensory information to the central nervous system. Muscle spindle afferents and Golgi tendon organ afferents are stimulated by spinal manipulation. Smaller-diameter sensory nerve fibers are likely activated, although this has not been demonstrated directly. Mechanical and chemical changes in the intervertebral foramen caused by a herniated intervertebral disc can affect the dorsal roots and dorsal root ganglia, but it is not known if spinal manipulation directly affects these changes. Individuals with herniated lumbar discs have shown clinical improvement in response to spinal manipulation. The phenomenon of central facilitation is known to increase the receptive field of central neurons, enabling either subthreshold or innocuous stimuli access to central pain pathways. Numerous studies show that spinal manipulation increases pain tolerance or its threshold. One mechanism underlying the effects of spinal manipulation may, therefore, be the manipulation's ability to alter central sensory processing by removing subthreshold mechanical or chemical stimuli from paraspinal tissues. Spinal manipulation is also thought to affect reflex neural outputs to both muscle and visceral organs. Substantial evidence demonstrates that spinal manipulation evokes paraspinal muscle reflexes and alters motoneuron excitability. The effects of spinal manipulation on these somatosomatic reflexes may be quite complex, producing excitatory and inhibitory effects. Whereas substantial information also shows that sensory input, especially noxious input, from paraspinal tissues can reflexively elicit sympathetic nerve activity, knowledge about spinal manipulation's effects on these reflexes and on end-organ function is more limited.
A theoretical framework exists from which hypotheses about the neurophysiological effects of spinal manipulation can be developed. An experimental body of evidence exists indicating that spinal manipulation impacts primary afferent neurons from paraspinal tissues, the motor control system and pain processing. Experimental work in this area is warranted and should be encouraged to help better understand mechanisms underlying the therapeutic scope of spinal manipulation.
Secondary analysis of the 1998 Medical Expenditure Panel Survey.
To estimate total health care expenditures incurred by individuals with back pain in the United States, calculate the incremental expenditures attributable to back pain among these individuals, and describe health care expenditure patterns of individuals with back pain.
There is a lack of updated information on health care expenditures and expenditure patterns for individuals with back pain in the United States.
This study used data from the 1998 Medical Expenditure Panel Survey, a national survey on health care utilization and expenditures. Total health care expenditures and per-capita expenditures among individuals with back pain were calculated. Multivariate regression models were used to estimate the incremental expenditures attributable to back pain. The expenditure patterns were examined by stratifying individuals with back pain by sociodemographic characteristics and medical diagnosis, and calculating per-capita expenditures for each stratum.
In 1998, total health care expenditures incurred by individuals with back pain in the United States reached 90.7 billion dollars and total incremental expenditures attributable to back pain among these persons were approximately 26.3 billion dollars. On average, individuals with back pain incurred health care expenditures about 60% higher than individuals without back pain (3,498 dollars vs. 2,178 dollars). Among back pain individuals, at least 75% of service expenditures were attributed to those with top 25% expenditure, and per-capita expenditures were generally higher for those who were older, female, white, medically insured, or suffered from disc disorders.
Health care expenditures for back pain in the United States in 1998 were substantial. The expenditures demonstrated wide variations among individuals with different clinical, demographic, and socioeconomic characteristics.
The purpose of this study was to quantify in vivo vertebral motions and neurophysiological responses during spinal manipulation.
Nine patients undergoing lumbar decompression surgery participated in this study. Spinal manipulative thrusts (SMTs) ( approximately 5 ms; 30 N [Sham], 88 N, 117 N, and 150 N [max]) were administered to lumbar spine facet joints (FJs) and spinous processes (SPs) adjacent to an intraosseous pin with an attached triaxial accelerometer and bipolar electrodes cradled around the S1 spinal nerve roots. Peak baseline amplitude compound action potential (CAP) response and peak-peak amplitude axial (AX), posterior-anterior (PA), and medial-lateral (ML) acceleration time and displacement time responses were computed for each SMT. Within-subject statistical analyses of the effects of contact point and force magnitude on vertebral displacements and CAP responses were performed.
SMTs (>/= 88 N) resulted in significantly greater peak-to-peak ML, PA, and AX vertebral displacements compared with sham thrusts (P <.002). SMTs delivered to the FJs resulted in approximately 3-fold greater ML motions compared with SPs (P <.001). SMTs over the SPs resulted in significantly greater AX displacements compared with SMTs applied to the FJs (P <.05). Seventy-five percent of SMTs resulted in positive CAP responses with a mean latency of 12.0 ms. Collectively, the magnitude of the CAP responses was significantly greater for max setting SMTs compared with sham (P <.01).
Impulsive SMTs in human subjects were found to stimulate spinal nerve root responses that were temporally related to the onset of vertebral motion. Further work, including examination of the frequency and force duration dependency of SMT, is necessary to elucidate the clinical relevance of enhanced or absent CAP responses in patients.
Quebec Task Force Classification (QTFC) and pain pattern classification (PPC) procedures, including centralization and noncentralization, are common classification procedures. Classification was done to estimate validity of data obtained with QTFC and PPC procedures for differentiating patient subgroups at intake and for use in predicting rehabilitation outcomes at discharge and work status at 1 year after discharge from rehabilitation.
Patients (n=171, 54% male; mean age=37 years, SD=10, range=18-62) with acute work-related low back pain referred for physical therapy were analyzed.
Patients completed pain and psychosocial questionnaires at initial examination and discharge and pain diagrams throughout intervention. Physical therapists classified patients using QTFC and PPC data at intake. Patients were classified again at discharge by PPC (time-dependent PPC).
Analysis of variance of showed QTFC and PPC data could be used to differentiate patients by pain intensity or disability at intake. Analysis of covariance showed that intake PPC predicted pain intensity and disability at discharge, but QTFC did not. Logistic regression showed that PPC predicted work status at 1 year, but QTFC did not. Classifying patients over time using time-dependent PPC data reduced the false positive rate by 31% and increased percentage of change in pretest-posttest probability of return to work by 16% compared with classifying patients at intake.
Results support the discriminant validity of the QTFC data at intake and predictive validity of the PPC data at intake. Tracking PPC over time increases predictive validity for 1-year work status.