Spinal Manipulative Therapy Has an Immediate Effect on Thermal Pain Sensitivity in People With Low Back Pain: A Randomized Controlled Trial

Department of Physical Therapy, University of Florida, Gainesville, FL 32610-0154, USA.
Physical Therapy (Impact Factor: 2.53). 10/2009; 89(12):1292-303. DOI: 10.2522/ptj.20090058
Source: PubMed


Current evidence suggests that spinal manipulative therapy (SMT) is effective in the treatment of people with low back pain (LBP); however, the corresponding mechanisms are unknown. Hypoalgesia is associated with SMT and is suggestive of specific mechanisms.
The primary purpose of this study was to assess the immediate effects of SMT on thermal pain perception in people with LBP. A secondary purpose was to determine whether the resulting hypoalgesia was a local effect and whether psychological influences were associated with changes in pain perception.
This study was a randomized controlled trial.
A sample of convenience was recruited from community and outpatient clinics.
Thirty-six people (10 men, 26 women) currently experiencing LBP participated in the study. The average age of the participants was 32.39 (SD=12.63) years, and the average duration of LBP was 221.79 (SD=365.37) weeks.
Baseline demographic and psychological measurements were obtained, followed by quantitative sensory testing to assess temporal summation and Adelta fiber-mediated pain perception. Next, participants were randomly assigned to ride a stationary bicycle, perform low back extension exercises, or receive SMT. Finally, the same quantitative sensory testing protocol was reassessed to determine the immediate effects of each intervention on thermal pain sensitivity.
Hypoalgesia to Adelta fiber-mediated pain perception was not observed. Group-dependent hypoalgesia of temporal summation specific to the lumbar innervated region was observed. Pair-wise comparisons indicated significant hypoalgesia in participants who received SMT, but not in those who rode a stationary bicycle or performed low back extension exercises. Psychological factors did not significantly correlate with changes in temporal summation in participants who received SMT.
Only immediate effects of SMT were measured, so the authors are unable to comment on whether the inhibition of temporal summation is a lasting effect. Furthermore, the authors are unable to comment on the relationship between their findings and changes in clinical pain.
Inhibition of Adelta fiber-mediated pain perception was similar for all groups. However, inhibition of temporal summation was observed only in participants receiving SMT, suggesting a modulation of dorsal horn excitability that was observed primarily in the lumbar innervated area.

Download full-text


Available from: Giorgio Zeppieri, Oct 22, 2015
    • "Practitioners of Manual Medicine usually use High-Velocity Low-Amplitude (HVLA) thrust to manage different types of musculoskeletal disorders affecting the spine (Walser et al., 2009; Gross et al., 2010; Kuczynski et al., 2012). HVLA techniques produce different effects on the body system: mechanical effects (Triano and Schultz, 1997; Triano, 2001; Millan et al., 2012; Snodgrass et al., 2012) and neurophysiological effects (Pickar, 2002) on the axial muscles (Bicalho et al., 2010; Clark et al., 2011; Koppenhaver et al., 2011; Puentedura et al., 2011) as well as on the peripheral muscles (Herzog et al., 1999; Suter et al., 2000; Hillermann et al., 2006), and on sensitivity (Bialosky et al., 2009; Bishop et al., 2011; Sparks et al., 2013). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Very little is known about the kinematics of the upper cervical spine in particular during Manual Therapy techniques. In fact no data about displacement of the atlanto-axial joint during High-Velocity Low-Amplitude (HVLA) thrust are available. Knowing the precise kinematics of these vertebrae might allow a better comprehension of such important technique and possible vital structures involvement. A Zebris CMS20 ultrasound-based motion tracking system was adopted. Twenty fresh human cervical specimens were used in this study. Facet joint displacements of C1 relative to C2 were analysed during three consecutive HVLA thrusts into rotation. Displacement during the thrust and the maximum displacement reached with the manoeuvre were analysed. Descriptive statistics showed a mean Norm displacement during the thrust of 0.5 mm (SD ± 0.5). The maximum displacement, representing the overall facet movement from neutral to end-range position, indicated a Norm value of 6.0 mm (SD ± 3.4). Heterogeneous displacement directions were found during the thrust. Intra and inter-rater reliability reached an insufficient reproducibility level. Considering the amount of displacement induced, no statistical significant differences between the registrations were shown. Displacement during the execution of HVLA thrust is unintentional, unpredictable and not reproducible. On the other hand and in accordance with other studies, the displacement induced with the present technique seems not to be able to endanger vital structure on the Spinal Cord and the Vertebral Artery. This study also adds to a better comprehension of the kinematic of the atlanto-axial segment during the performance of HVLA manipulation. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Manual therapy 03/2015; DOI:10.1016/j.math.2015.03.006 · 1.71 Impact Factor
  • Source
    • "Another possibility is that SMT could have a regional effect, although still at the spinal level of the manipulative input. Some authors suggest an effect on the dorsal horn of the spinal cord [18] or on the periaqueductal grey area [19-21]. SMT is also thought to affect reflex neural outputs to both muscle and visceral organs by affecting both paraspinal muscle reflexes and motoneuron excitability [22]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Although there is evidence that spinal manipulative therapy (SMT) can reduce pain, the mechanisms involved are not well established. There is a need to review the scientific literature to establish the evidence-base for the reduction of pain following SMT. To determine if SMT can reduce experimentally induced pain, and if so, if the effect is i) only at the level of the treated spinal segment, ii) broader but in the same general region as SMT is performed, or iii) systemic. A systematic critical literature review. A systematic search was performed for experimental studies on healthy volunteers and people without chronic syndromes, in which the immediate effect of SMT was tested. Articles selected were reviewed blindly by two authors. A summary quality score was calculated to indicate level of manuscript quality. Outcome was considered positive if the pain-reducing effect was statistically significant. Separate evidence tables were constructed with information relevant to each research question. Results were interpreted taking into account their manuscript quality. Twenty-two articles were included, describing 43 experiments, primarily on pain produced by pressure (n = 27) or temperature (n = 9). Their quality was generally moderate. A hypoalgesic effect was shown in 19/27 experiments on pressure pain, produced by pressure in 3/9 on pain produced by temperature and in 6/7 tests on pain induced by other measures. Second pain provoked by temperature seems to respond to SMT but not first pain. Most studies revealed a local or regional hypoalgesic effect whereas a systematic effect was unclear. Manipulation of a “restricted motion segment” (“manipulable lesion”) seemed not to be essential to analgesia. In relation to outcome, there was no discernible difference between studies with higher vs. lower quality scores. These results indicate that SMT has a direct local/regional hypoalgesic effect on experimental pain for some types of stimuli. Further research is needed to determine i) if there is also a systemic effect, ii) the exact mechanisms by which SMT attenuates pain, and iii) whether this response is clinically significant.
    Chiropractic and Manual Therapies 08/2012; 20(1):26. DOI:10.1186/2045-709X-20-26
  • Source
    • "cardiovascular function) [15], and electromyographic activity of paraspinal muscles [16,17]. It has also been hypothesized to alter motoneuron excitability [18], increase muscle strength [19,20], alter sensorimotor integration [21], and affect pain regulation in the dorsal horn of the spinal cord [22] and the periaqueductal grey area [23-25]. However, it is unclear as to what this brings in terms of a biomechanical effect, such as an increased range of movement (ROM). "
    [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Spinal manipulative therapy (SMT) has been shown to have an effect on spine-related pain, both clinically and in experimentally induced pain. However, it is unclear if it has an immediate noticeable biomechanical effect on spinal motion that can be measured in terms of an increased range of motion (ROM). OBJECTIVE: To assess the quality of the literature and to determine whether or not SMT is associated with an immediate increase in ROM. DESIGN: A systematic critical literature review. METHOD: Systematic searches were performed in Pubmed, the Cochrane Library and EMBASE using terms relating to manipulation, movement and the spine. Selection of articles was made according to specific criteria by two independent reviewers. Two checklists were created based on the needs of the present review. Articles were independently reviewed by two reviewers. Articles were given quality scores and the data synthesized for each region treated in the literature. Findings were summarized in tables and reported in a narrative fashion. RESULTS: Fifteen articles were retained reporting on experiments on the neck, lumbar spine, hip and jaw. The mean quality score was 71/100 (ranges 33/100 - 92/100). A positive effect of SMT was reported in both studies where mouth opening was assessed after cervical manipulation. In five of the nine studies on cervical ROM a positive effect was reported, whereas the remaining four studies did not show improvement. None of the three studies of the lumbar spine showed an effect of SMT on lumbar ROMs and one study of sacroiliac manipulation reported no effect on the ROM of the hip joint. In relation to the quality score, the seven highest ranked studies, showed significant positive effects of SMT on ROM. Continuing down the list, the other studies reported no significant differences in the outcomes between groups. CONCLUSION: SMT seems sometimes to have a small effect on ROM, at least in the cervical spine. Further research should concentrate on areas of the spine that have the potential of actually improving to such a degree that a change can be easily uncovered.
    Chiropractic and Manual Therapies 08/2012; 20(1):23. DOI:10.1186/2045-709X-20-23
Show more