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The mechanism of back pain relief by spinal manipulation relies on decreased temporal summation of pain
Abstract
The aim of the present study was to determine whether thoracic spinal manipulation (SM) decreases temporal summation of back pain. The study comprised 2 controlled experiments including 16 and 15 healthy participants, respectively. Each study included 6 sessions during which painful or non-painful electrical stimulations were delivered in three conditions: 1) control 2) light mechanical stimulus (MS) or 3) SM. Electrical stimulation was applied on the thoracic spine (T4), in the area where SM and MS were performed. In Experiment 1, electrical stimulation consisted in a single 1-ms pulse while a single or repeated train of ten 1-ms pulses was used in Experiment 2. SM involved articular cavitation while MS was a calibrated force of 25 N applied manually for 2 seconds. For the single pulse, changes in pain or tactile sensation in the SM or MS sessions compared with the CTL session were not significantly different (all p’s >0.05). In contrast, temporal summation of pain was decreased in the SM session compared with the CTL session for both the single and repeated train (p’s < 0.05). Changes were not significant for the MS sessions (all p’s > 0.05) and no effect was observed for the tactile sensation (all p’s > 0.1). These results indicate that SM produces specific inhibitory effects on temporal summation of back pain, consistent with the involvement of a spinal anti-nociceptive mechanism in clinical pain relief by SM. This provides the first mechanistic evidence of back pain relief by spinal manipulation.
... Surgical and interventional procedures are available for a small subset of individuals who are unresponsive to conventional treatments [14]. Matrix rhythm therapy (MRT) is a dynamic external treatment that was developed by Randoll et al. [15]. It represents a novel approach to managing pain and mobility restrictions and is an electrotherapeutic modality stemming from Randoll's foundational research in Germany [15]. ...
... Matrix rhythm therapy (MRT) is a dynamic external treatment that was developed by Randoll et al. [15]. It represents a novel approach to managing pain and mobility restrictions and is an electrotherapeutic modality stemming from Randoll's foundational research in Germany [15]. The extracellular matrix is the primary medium through which cellular activities, preventive, therapeutic, regenerative, or destructive, impact the cellular environment. ...
... By gently and harmoniously pulsing, MRT helps restore extracellular matrix vibrations, allowing cells to re-establish their natural oscillations. This process enhances the delivery of oxygenated blood and nutrients through the extracellular matrix and facilitates the removal of waste products, acids, and gases [15,16]. This non-invasive therapy is often used to treat wound healing, pain, injuries, and musculoskeletal issues [17]. ...
Chronic low back pain (CLBP) is a widespread issue, and matrix rhythm therapy (MRT), a non-invasive therapy using low-frequency vibrations, is gaining interest for CLBP. However, evidence for its effectiveness and safety remains unclear. This scoping review aimed to systematically map and synthesise the existing literature on using MRT to manage CLBP. A comprehensive search of Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, Web of Science, Directory of Open Access Journals (DOAJ), and Scopus was conducted for randomised controlled trials (RCTs) published through March 2024. The methodological quality was systematically evaluated using the Physiotherapy Evidence Database Scale (PEDro). The initial search yielded a total of 47 articles. After screening the abstracts and full articles, two studies were included, with a mean score of 5/10 on the PEDro scale. A qualitative review was performed of the two selected RCTs. Meta-analysis was not possible because of the small number of articles in the study. While preliminary findings from the two studies suggest that MRT may be superior to Pilates and combined physical therapy for pain and disability in CLBP, these results require cautious interpretation because of limited research. Further high-quality investigations, particularly well-designed RCTs, are warranted to definitively assess the effectiveness of MRT in managing the pain, function, and other aspects of CLBP.
... SM has been shown to reduce both experimental and clinical pain (17,18) and recent clinical practice guidelines recommend the use of SM for the management of back pain (19)(20)(21)(22). Although several studies suggest that SM may decrease pain via segmental mechanisms involving the processing of C-nociceptor inputs in the spinal cord (23)(24)(25)(26), these mechanisms are not fully understood, and the effect of SM on primary hyperalgesia remains unclear. ...
... Two systematic reviews reported that SM decreases experimental pain in healthy volunteers (17,18). Accordingly, several experimental studies demonstrated that SM could decrease experimental cutaneous pain in healthy volunteers (23,24,(27)(28)(29)(30) and in patients with low back pain (25,26), when the nociceptive activity is amplified by centrally mediated mechanisms like temporal summation and central sensitization. In addition, a recent meta-analysis reported that physical therapy (including manual therapy such as SM) improves nociceptive processing influenced by or related to central sensitization in patients with chronic musculoskeletal pain (31). ...
... In line with this idea, it has been shown in patients with chronic back pain that brain activity related to spontaneous clinical pain differs from the brain activity related to experimental pain evoked in their back (73). However, it should be noted that findings from several studies suggest that SM affects the transmission of spinal nociceptive activity, regardless of the origin of the inputs (cutaneous or myofascial) (23)(24)(25)(26)(27)(28)(29)(30), although this remains to be confirmed with neurophysiological measures of spinal cord activity. Therefore, the lack of effect in the present study suggests that SM does not influence spinal nociceptive transmission when it is amplified by peripheral sensitization. ...
Musculoskeletal injuries lead to sensitization of nociceptors and primary hyperalgesia (hypersensitivity to painful stimuli). This
occurs with back injuries, which are associated with acute pain and increased pain sensitivity at the site of injury. In some cases,
back pain persists and leads to central sensitization and chronic pain. Thus, reducing primary hyperalgesia to prevent central
sensitization may limit the transition from acute to chronic back pain. It has been shown that spinal manipulation (SM) reduces
experimental and clinical pain, but the effect of SM on primary hyperalgesia and hypersensitivity to painful stimuli remains
unclear. The goal of the present study was to investigate the effect of SM on pain hypersensitivity using a capsaicin-heat pain
model. Laser stimulation was used to evoke heat pain and the associated brain activity, which were measured to assess their
modulation by SM. Eighty healthy participants were recruited and randomly assigned to one of the four experimental groups:
inert cream and no intervention; capsaicin cream and no intervention; capsaicin cream and SM at T7; capsaicin cream and placebo.
Inert or capsaicin cream (1%) was applied to the T9 area. SM or placebo were performed 25 minutes after cream application. A
series of laser stimuli were delivered on the area of cream application 1) before cream application, 2) after cream application but
before SM or placebo, and 3) after SM or placebo. Capsaicin cream induced a significant increase in laser pain (p<0.001) and laser�evoked potential amplitude (p<0.001). However, SM did not decrease the amplification of laser pain or laser-evoked potentials by
capsaicin. These results indicate that segmental SM does not reduce pain hypersensitivity and the associated pain-related brain
activity in a capsaicin-heat pain model.
... In turn, this initiates a cascade of neurophysiological effects that could be responsible for hypoalgesia and other clinical outcomes (38,43,44). It has been suggested that SM may inhibit pain through spinal segmental mechanisms, including the reduction of temporal summation during prolonged pain states (36,(45)(46)(47). Temporal summation can lead to synaptic plasticity in the spinal cord and to central sensitization (21,48). ...
... SM consisted of a short-duration, high-velocity, low-amplitude force applied to the spine to generate an audible release (cavitation). The spine was manipulated using a bilateral thenar or hypothenar contact over the transverse processes of the T5 or T9 vertebrae, depending on group allocation, after which a posterior to anterior thrust was applied to the spinal segment (47). These segments were chosen for SM to allow participants to lie prone in a stable position for the entire duration of the experiment, including the intervention period. ...
... This is necessary to allow artifact-free recording of EEG activity. A previous study showed a segmental reduction in temporal summation when SM was applied in the upper thoracic area (47). Therefore, T5 was chosen for segmental SM and T9 for heterosegmental SM. ...
Background and Aims: Spinal manipulation (SM) is currently recommended for the management of back pain. Experimental studies indicate that the hypoalgesic mechanisms of SM may rely on inhibition of segmental processes related to temporal summation of pain and, possibly, on central sensitization, although this remains unclear. The aim of this study was to determine whether experimental back pain, secondary hyperalgesia, and pain-related brain activity induced by capsaicin are decreased by segmental SM.
Methods: Seventy-three healthy volunteers were randomly allocated to one of four experimental groups: SM at T5 vertebral level (segmental), SM at T9 vertebral level (heterosegmental), placebo intervention at T5 vertebral level, or no intervention. Topical capsaicin was applied to the area of T5 vertebra for 40 min. After 20 min, the interventions were administered. Pressure pain thresholds (PPTs) were assessed outside the area of capsaicin application at 0 and 40 min to examine secondary hyperalgesia. Capsaicin pain intensity and unpleasantness were reported every 4 min. Frontal high-gamma oscillations were also measured with electroencephalography.
Results: Pain ratings and brain activity were not significantly different between groups over time ( p > 0.5). However, PPTs were significantly decreased in the placebo and control groups ( p < 0.01), indicative of secondary hyperalgesia, while no hyperalgesia was observed for groups receiving SM ( p = 1.0). This effect was independent of expectations and greater than placebo for segmental ( p < 0.01) but not heterosegmental SM ( p = 1.0).
Conclusions: These results indicate that segmental SM can prevent secondary hyperalgesia, independently of expectations. This has implications for the management of back pain, particularly when central sensitization is involved.
... However, procedures used in this study were different from previous studies so discrepancies may be explained by methodological differences. In line with the inhibition of C-fiber-related pain by SM, it was shown that TSP produced by repeated electrical stimulation in the back is inhibited by SM, while pain produced by a single electrical pulse is not [60]. ...
... In the present study, we selected this intervention as placebo intervention and skin contact was achieved with a hand-held dynamometer to standardize the applied force. This procedure is identical to that used in a previous study [60]. In addition to the placebo group, we included a control group to measure non-specific temporal effects, in which no intervention was applied. ...
... A previous study has shown that hypoalgesic effects can be produced by a SM at T4, where pain was applied (segmental SM) [60]. In the present study, T4 and T8 segments were selected for segmental and heterosegmental SM, for this reason and for practical reasons; with spinal manipulation at these segments, the participant can lie down comfortably without moving for the intervention. ...
The aim of this study was to examine the mechanisms underlying hypoalgesia induced by spinal manipulation (SM). Eighty-two healthy volunteers were assigned to one of the four intervention groups: no intervention, SM at T4 (homosegmental to pain), SM at T8 (heterosegmental to pain) or light mechanical stimulus at T4 (placebo). Eighty laser stimuli were applied on back skin at T4 to evoke pain and brain activity related to Aδ- and C-fibers activation. The intervention was performed after 40 stimuli. Laser pain was decreased by SM at T4 (p=0.028) but not T8 (p=0.13), compared with placebo. However, brain activity related to Aδ-fibers activation was not significantly modulated (all p>0.05), while C-fiber activity could not be measured reliably. This indicates that SM produces segmental hypoalgesia through inhibition of nociceptive processes that are independent of Aδ fibers. It remains to be clarified whether the effect is mediated by the inhibition of C-fiber activity.
... Similar studies in conscious horses demonstrated that repeated stimulations at subthreshold intensities, known as temporal summations (TS), are able to summate and facilitate the NWR (Spadavecchia et al. 2004). A repeated stimulus of constant intensity is simulating progressively increasing pain perception, which may be of value for the study of chronic pain (Price et al. 1994;Arendt-Nielsen & Petersen-Felix 1995;Randoll et al. 2017). ...
... Ambient temperature influences results for the thermal WTT2 model; detection of end points was clearer when tests were performed in a box stall with ambient temperatures >20 C rather than <10 C (Poller et al. 2013a). Details of the studies must be reported, for example, performed at constant ambient temperatures (Poller et al. 2013a,b;Echelmeyer et al. 2019), controlled room temperature (Moens et al. 2003;Figueiredo et al. 2012;Reed et al. 2019), or animals treated at the same time of the day (Figueiredo et al. 2012;Oliveira et al. 2014;Lopes et al. 2016;Gozalo-Marcilla et al. 2019a). Other aspects of the environment may influence results and should be specified, for example, performed in a quiet environment (Crosignani et al. 2017), in a 'familiar box' (Poller et al. 2013a,b) and animals acclimatized to the study environment and testing equipment (Moens et al. 2003;Love et al. 2012;Elfenbein et al. 2014;Gozalo-Marcilla et al. 2017a, 2019aEchelmeyer et al. 2019;Reed et al. 2019). ...
... Details of the studies must be reported, for example, performed at constant ambient temperatures (Poller et al. 2013a,b;Echelmeyer et al. 2019), controlled room temperature (Moens et al. 2003;Figueiredo et al. 2012;Reed et al. 2019), or animals treated at the same time of the day (Figueiredo et al. 2012;Oliveira et al. 2014;Lopes et al. 2016;Gozalo-Marcilla et al. 2019a). Other aspects of the environment may influence results and should be specified, for example, performed in a quiet environment (Crosignani et al. 2017), in a 'familiar box' (Poller et al. 2013a,b) and animals acclimatized to the study environment and testing equipment (Moens et al. 2003;Love et al. 2012;Elfenbein et al. 2014;Gozalo-Marcilla et al. 2017a, 2019aEchelmeyer et al. 2019;Reed et al. 2019). Fly repellent may diminish external stimuli (Gozalo-Marcilla et al. 2017a, 2019a. ...
Objective:
To perform a literature review of the thermal and mechanical antinociceptive devices used in pharmacological studies in standing horses published after 2011 (2012-2019). To complete a full literature review about electrical stimulation used for evaluation in similar studies.
Databases used:
PubMed, Google Scholar and Web of Science.
Conclusions:
A high level of standardization has been reached in antinociceptive studies in standing horses using thermal and mechanical stimuli in most recent years. Commercially available testing devices to deliver thermal, mechanical and electrical stimuli, with observation of aversive responses to these stimuli, are reliable, sensitive and specific. For electrical stimulus testing, there is evidence that the resistance between the electrodes should be measured and should not exceed 3 kΩ to guarantee consistent and reproducible stimuli. The specific analysis of electromyographic activity after an electrical stimulus provides more detailed information about the neurons stimulated.
... Most of the early theories proposed to explain the analgesic and hypoalgesic effects of spinal manipulation were heavily focused on the biomechanical changes following the intervention [1][2][3]. In recent years, however, there has been a paradigm shift toward a neurophysiological mechanism of spinal manipulation, as an increasing number of recent studies have reported various neural effects of spinal manipulation such as changes in somatosensory processing, muscle-reflexogenic responses, central motor excitability, motor neuron activity, neuroplastic brain changes, Hoffmann's reflex (H-reflex) responses, sympathetic activity and central sensitisation [5][6][7][8][9][10][11]. These studies have suggested a cascade of neurochemical responses in the central and peripheral nervous system following spinal manipulation. ...
... Biomechanical changes evoked as a result of spinal manipulation may induce neurophysiological responses by influencing the inflow of sensory input to the central nervous system (CNS) [5]. Moreover, the mechanical force applied during spinal manipulation could either stimulate or silence mechanosensitive and nociceptive afferent fibers in paraspinal tissues, including skin, muscles, disk, facet joints, tendons and ligaments [8,10]. These inputs are thought to stimulate pain-processing mechanisms and other physiological systems connected to the nervous system [4,5,11,12,18,20]. ...
... Over the past decades, a number of specific and nonspecific neural effects of spinal manipulation have been reported, including increased afferent discharge [33], central motor excitability [5], alterations in pain processing [7], reduction in temporal summation [10], stimulation of autonomic nervous system (ANS) [6], lessening of pain perception [36] and many more. These neural responses collectively implicate mechanisms mediated by the nervous system. ...
Spinal manipulation has been an effective intervention for the management of various musculoskeletal disorders. However, the mechanisms underlying the pain modulatory effects of spinal manipulation remain elusive. Although both biomechanical and neurophysiological phenomena have been thought to play a role in the observed clinical effects of spinal manipulation, a growing number of recent studies have indicated peripheral, spinal and supraspinal mechanisms of manipulation and suggested that the improved clinical outcomes are largely of neurophysiological origin. In this article, we reviewed the relevance of various neurophysiological theories with respect to the findings of mechanistic studies that demonstrated neural responses following spinal manipulation. This article also discussed whether these neural responses are associated with the possible neurophysiological mechanisms of spinal manipulation. The body of literature reviewed herein suggested some clear neurophysiological changes following spinal manipulation, which include neural plastic changes, alteration in motor neuron excitability, increase in cortical drive and many more. However, the clinical relevance of these changes in relation to the mechanisms that underlie the effectiveness of spinal manipulation is still unclear. In addition, there were some major methodological flaws in many of the reviewed studies. Future mechanistic studies should have an appropriate study design and methodology and should plan for a long-term follow-up in order to determine the clinical significance of the neural responses evoked following spinal manipulation.
... The study sample comprised of one hundred and twenty men (17)(18)(19)(20)(21)(22) yearsold) diagnosed with cervical and lumbar spine pain. The sample was selected from students who wanting to apply for sport and military faculties. ...
... The biomechanical approach suggests that SMT effect on a manipulable or functional spinal lesion; the treatment is designed to decrease internal mechanical stresses (Xia et al., 2017). The neurophysiological approach suggests that SMT acts on the primary afferent neurons from paraspinal tissues, the motor control system, and pain processing (Randoll et al., 2017). Pickar (2002) study results demonstrated that, the biomechanical changes caused by spinal manipulation have physiological consequences, through their effects on sensory information to the neuron. ...
... For example, segmentation inhibition produced by the manipulation increases the stimulation of non-nociceptive A-b fibers which decreases the pain experienced by an individual. Temporal summation, which evokes pain, is also shown to decrease through spinal manipulation [29,30]. ...
... Accordingly, dermatomal (lower limb) mechanical hyperalgesia remained unchanged. In previous studies, it was suggested that spinal manipulation produces immediate effects on secondary mechanical hyperalgesia 29 and on temporal summation of pain in the back, 95 or in the lower limb dermatome corresponding to the manipulated segment, both in healthy volunteers and in individuals with LBP. 85,96,97 Although these results contrast with the present findings, an important methodological difference should be noted. ...
Chronic primary low back pain (CPLBP) refers to low back pain that persists over three months, that cannot be explained by another chronic condition, and that is associated with emotional distress and disability. Previous studies have shown that spinal manipulative therapy (SMT) is effective to relieve CPLBP, but the underlying mechanisms remain elusive. This randomized placebo-controlled dual-blind mixed experimental trial (NCT05162924) aimed to investigate the efficacy of SMT to improve CPLBP and its underlying mechanisms. Ninety-eight individuals with CPLBP and 49 controls were recruited. Individuals with CPLBP received SMT (n=49) or a control intervention (n=49), twelve times over four weeks. The primary outcomes were CPLBP intensity (0-100 on a numerical rating scale) and disability (Oswestry Disability Index). Secondary outcomes included pressure pain thresholds in four body regions, pain catastrophizing, central sensitization inventory, depressive symptoms, and anxiety scores. Individuals with CPLBP showed widespread mechanical hyperalgesia (p<.001) and higher scores for all questionnaires (p<.001). SMT reduced pain intensity compared with the control intervention (mean difference: -11.7 [95% CI, -11.0 to -12.5], p=.01), but not disability (p=.5). Similar mild to moderate adverse events were reported in both groups. Mechanical hyperalgesia at the manipulated segment was reduced after SMT compared with the control intervention (p<.05). Pain catastrophizing was reduced after SMT compared with the control intervention (p<.05), but this effect was not significant after accounting for changes in clinical pain. Although the reduction of segmental mechanical hyperalgesia likely contributes to the clinical benefits of SMT, the role of pain catastrophizing remains to be clarified.
PERSPECTIVE
This randomized controlled trial found that twelve sessions of spinal manipulative therapy yield greater relief of chronic primary low back pain than a control intervention. These clinical effects were independent of expectations, and accompanied by an attenuation of hyperalgesia in the targeted segment and a modulation of pain catastrophizing.
... The swift, controlled thrusts might play a role in breaking adhesions or restoring the joint's natural movement, which could be the reason behind the immediate reduction in pain intensity post-treatment [28,29].The neurophysiological mechanism of thrust manipulation is conclusively explained by spinal cord mechanisms. Pain due to peripheral sensitization is caused by temporal summation of C-fibers, and it has been reported that thrust manipulation can interrupt this summation [30][31][32]. ...
... The hypothesis of how SM/M works can be roughly divided into biomechanical and neurophysiological hypotheses. The modes of action may be to reduce mechanical stress within the spine [13] or to affect major afferent neurons and motor control systems from paraspinal tissues [14]. Many recent guidelines that recommend SM/M emphasize the importance of targeting the appropriate individuals for treatment, particularly for patients with the more severe symptoms described above [15][16][17]. ...
Background
In this retrospective study, we aimed to develop a nomogram to predict recurrence during a 1-year period of spinal manipulation/mobilization (SM/M) in patients with low back pain (LBP) with greater pain intensity, more severe comorbid conditions, or a neuropathic component.
Methods
A total of 786 consecutive patients with LBP treated with SM/M as primary therapy were divided into training (n = 545) and validation (n = 241) sets. Cox regression analyses were used to assess the relative value of clinical factors and lumbar magnetic resonance imaging features associated with recurrence during the 1-year period. Predictors of recurrence with significant differences were used to construct a nomogram in the training set. We evaluated the performance of the model on the training and validation sets to determine its discriminative ability, calibration, and clinical utility. The prognostic value of the nomogram for predicting recurrence was assessed using Kaplan–Meier analysis and time-dependent receiver operating characteristic analyses.
Results
A nomogram comprising hospitalization time, previous history of LBP, disease duration, lumbar range of motion, lower extremity tendon reflex, muscle strength, ratio of herniation to uncompressed dural sac area, and Pfirrmann classification was established for recurrence during a 1-year period after SM/M in patients with LBP. Favorable calibration and discrimination were observed in the nomogram training and validation sets (C-index 0.753 and 0.779, respectively). Decision curve analysis confirmed the clinical utility of the nomogram. Over a 1-year period, the nomogram showed satisfactory performance in predicting recurrence in LBP after SM/M.
Conclusion
We established and validated a novel nomogram that can accurately predict a patient's risk of LBP recurrence following SM/M. This realistic prognostic model may aid doctors and therapists in their decision-making process and strategy optimization for non-surgical treatment of LBP using SM/M.
... Mechanisms of multimodal chiropractic care are not fully understood. However, current evidence suggests spinal manipulation can initiate neurophysiological changes resulting in reduced pain [15,16], disrupt intraand peri-articular joint adhesions, and improve joint or regional mobility in the spine [17][18][19]. Specific exercises are used to reduce abnormal mechanical loading of spinal structures from weak or poorly coordinated muscle groups [20]. ...
Background
Over 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial.
Methods
This single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10-week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables.
Results
We screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22–79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1–7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial.
Conclusions
We demonstrated the feasibility of participant recruitment, retention, and electronic data collection for conducting a pragmatic clinical trial of chiropractic care in a Veterans Health Administration facility. Using the pilot data and lessons learned, we modified and refined a protocol for a full-scale, multisite, pragmatic, National Institutes of Health-funded randomized trial of multimodal chiropractic care for veterans with chronic LBP that began recruitment in February 2021.
Trial registration
ClinicalTrials.gov NCT03254719
... Examples of other potential biomechanical effects are increased disc diffusion and decreased posterior-anterior stiffness 48 . Other systemic effects could include changes in the functioning of descending anti-nociceptive system 49 , a widespread effect on muscle spindle response 50 , and central mechanisms of pain modulation 51 . These examples are not an exhaustive list of potential mechanisms, as this topic is outside the scope of this systematic review. ...
The concept that spinal manipulation therapy (SMT) outcomes are optimized when the treatment is aimed at a clinically relevant joint is commonly assumed and central to teaching and clinical use (candidate sites). This systematic review investigated whether clinical effects are superior when this is the case compared to SMT applied elsewhere (non-candidate sites). Eligible study designs were randomized controlled trials that investigated the effect of spinal manipulation applied to candidate versus non-candidate sites for spinal pain. We obtained data from four different databases. Risk of bias was assessed using an adjusted Cochrane risk of bias tool, adding four items for study quality. We extracted between-group differences for any reported outcome or, when not reported, calculated effect sizes from the within-group changes. We compared outcomes for SMT applied at a ‘relevant’ site to SMT applied elsewhere. We prioritized methodologically robust studies when interpreting results. Ten studies, all of acceptable quality, were included that reported 33 between-group differences—five compared treatments within the same spinal region and five at different spinal regions. None of the nine studies with low or moderate risk of bias reported statistically significant between-group differences for any outcome. The tenth study reported a small effect on pain (1.2/10, 95%CI − 1.9 to − 0.5) but had a high risk of bias. None of the nine articles of low or moderate risk of bias and acceptable quality reported that “clinically-relevant” SMT has a superior outcome on any outcome compared to “not clinically-relevant” SMT. This finding contrasts with ideas held in educational programs and clinical practice that emphasize the importance of joint-specific application of SMT.
... Mechanical receptors on the intervertebral disks, facet joints, ligaments and muscles are related to neurophysiological model (Maigne and Vautravers, 2003;Pickar and Wheeler, 2001). Spinal manipulation generates afferent stimuli by a stretching of the joint capsule to mitigate spinal facilitation caused by the hypersensitivity of a dysfunctional segment (Bialosky et al., 2009;Boal and Gillette, 2004;George et al., 2006;Maigne and Vautravers, 2003;Pickar and Wheeler, 2001;Randoll et al., 2017;Vernon et al., 2012). This stretching of the joint capsule produced by the manipulation transmits sensory signals to the spinal cord through proprioceptors present within the capsule and muscles stimulating the periaqueductal grey matter (PAG) of the midbrain (Bialosky et al., 2009;Fryer et al., 2004;McLean et al., 2002;Pickar and Wheeler, 2001;Wright, 1995), which activates the descending serotoninergic and noradrenergic system, producing analgesia (Sluka and Wright, 2001). ...
Background
Joint manipulation is generally used to reduce musculoskeletal pain; however, evidence has emerged challenging the effects associated with the specificity of the manipulated vertebral segment. The aim of this study was to verify immediate hypoalgesic effects between specific and non-specific cervical manipulations in healthy subjects.
Method
Twenty-one healthy subjects (18–30 years old; 11 males, 10 females) were selected to receive specific cervical manipulation at the C6-7 segment (SCM) and non-specific cervical manipulation (NSCM) in aleatory order. A 48h interval between manipulations was considered. Pressure pain threshold (PPT) was measured pre- and post-manipulation with a digital algometer on the dominant forearm.
Results
The SCM produced a significant increase in the PPT (P < 0.001) however no difference was observed in the PPT after the NCSM (P = 0.476). The difference between the two manipulation techniques was 37.26 kPa (95% CI: 14.69 to 59.83, p = 0.002) in favor of the SCM group
Conclusion
Specific cervical manipulation at the C6-7 segment increases PPT on the forearm compared to non-specific cervical manipulation in healthy subjects.
... TTS was evaluated 5 min before CPM performance using a handheld pressure algometer (Model FDIX, Wagner InstrumentMark), with a 1 cm diameter flat rubber probe. TS was elicited with 10 pressure stimulation at pressure pain detection threshold intensity [23]. ...
Background:
It remains unclear as to whether verbal suggestions and expectancies can influence the perception of post-needling soreness. The aim of this study was to analyze the effects of verbal suggestions on post-needling soreness after dry needling of the trapezius muscle.
Methods:
This study is a randomized controlled trial including healthy subjects randomly assigned to one of three groups receiving different verbal suggestions about the effects of dry needling and the occurrence of post needling soreness (positive, negative, or neutral). Then, dry needling on a latent trigger point of the upper trapezius muscle was performed and the following outcomes were measured immediately after, 24, 48, and 72 h, and one week after the intervention: post-needling soreness intensity, pressure pain threshold (PPT), temporal summation (TS) and conditioned pain modulation (CPM).
Results:
Seventy-three consecutive participants were screened and 42 participants (12 men and 30 women, aged: 24 ± 8 years old) were eligible and finished the study protocol. The results showed that verbal suggestion did not influence the perception of post-needling soreness, since there were no differences between groups (p < 0.05) on the intensity of post-needling soreness or tenderness over a one-week follow-up. Moreover, verbal suggestion did not associate with changes in sensorimotor variables of TS and CPM.
Conclusions:
The induction of different types of expectations through verbal suggestion does not influence the perception of acute pain perceived during the performance of a deep dry needling technique and post-needling pain or soreness after deep dry needling on a latent upper trapezius myofascial trigger point (MTrP).
... For each pulse, the pressure was increased at a rate of approximately 2 kg/s up to the previously determined pain threshold [34]. Pulses were presented with an interstimulus interval of 1 s because this has previously been shown to be optimal for inducing TS with pressure pain [35]. Before the first pulse, subjects were instructed to orally rate the pain level of the first and tenth pulse with the NPRS. ...
Background: manual therapy (MT) has been shown to have positive effects in patients with osteoarthritis (OA)-related pain, and its use in clinical settings is recommended. However, the mechanisms of action for how these positive effects occur are not yet well understood. The aim of the present study was to investigate the influence of MT treatment on facilitatory nociception and endogenous pain modulation in patients with knee OA related pain. Methods: Twenty-eight patients with knee OA were included in this study. Pain intensity using the numerical pain rating scale (NPRS), temporal summation (TS), conditioned pain modulation (CPM), and local (knee) and distant (elbow) hyperalgesia through the pressure pain threshold (PPT), were assessed to evaluate the pain modulatory system. Patients underwent four sessions of MT treatments within 3 weeks and were evaluated at the baseline, after the first session and after the fourth session. Results: the MT treatment reduced knee pain after the first session (p = 0.03) and after the fourth session (p = 0.04). TS decreased significantly after the fourth session of MT (p = 0.02), while a significant increase in the CPM assessment was detected after the fourth session (p = 0.05). No significant changes in the PPT over the knee and elbow were found in the follow-ups. Conclusions: The results from our study suggest that MT might be an effective and safe method for improving pain and for decreasing temporal summation.
... Ultrasound-guided thoracic facet injection procedures have been well described in the literature and are commonly utilized in clinical practice [8,9]. In addition, manual therapy techniques including graded mobilizations and joint manipulation are commonly utilized by physical therapists, chiropractors, and osteopathic health care providers as a common intervention for treating facetogenic based thoracic back pain [10][11][12]. Varying treatment rationales exist in physical therapy immediately following facet injections such as whether to utilize high-velocity low amplitude thrust techniques days following the procedure. This in part can be due to patient presentation, referring provider guidelines based on clinical expertise, tissue healing time frames, or treating therapist preference to avoid interfering with the potential therapeutic benefits at the recently injected joint. ...
Facet injections and other pain management interventions are commonly performed in combination with conservative therapy to address spinal pain. Joint mobilizations are a highly utilized intervention for manual practitioners to treat patients with spinal pain. Clinical reasoning and decision making models have not been well described in the literature assessing if and when joint mobilizations are appropriate interventions immediately or shortly following facet injection procedures. It has not been well studied if joint mobilizations immediately following facet injections negatively impact the injected solution at the respective joint and thus influence therapeutic effect. More specifically, there is a paucity of evidence assessing this at the thoracic spine. The purpose of this study was to assess if thoracic joint high-velocity low amplitude thrust manipulations caused extravasation of injected radiolucent material at respective thoracic facet joints on a cadaver. This study included an expert physician performing ultrasound-guided facet injections, an experienced manual physical therapist performing joint mobilization techniques, and fluoroscopic assessment of radiolucent material pre- and post-manipulation by a board-certified radiologist with experience in this field of study. Imaging interpretation confirmed that extravasation at respective joints did not occur following manipulation. This basic research can help guide clinical reasoning for practitioners considering implementing manual therapy techniques following facet injections and help guide further research.
... These forces are complex three-dimensional (3-D) forces delivered to create forces and moments at the joint of interest to cause joint movements. This type of manipulation is known as High-Velocity Low-Amplitude SM (HVLA-SM) [6,7]. SM techniques have long been studied for their clinical effectiveness. ...
Background:
Spinal manipulation (SM) has been widely recognized and used with success in health care fields for spinal joint dysfunction and pain. SM is a procedure that involves small amplitude manipulative thrusts performed with speed. These forces are complex three-dimensional (3-D) forces delivered to create forces and moments at the joint of interest to cause joint movements. The aim of this study was to conduct a 3-dimensional analysis of the magnitude and direction of the forces transmitted in 2 techniques of thoracic spinal manipulation (TSM). Materials/Methods. Thirty-two healthy participants were recruited from the university community. The physical therapist performed TSM using anterior (A) to posterior (P) and P to A techniques once at each of T3, T7, and T12 spinal levels. The magnitude and direction of the forces transmitted during TSM were sensed by the force plates, and the camera system monitored vertebral motion by tracking motion markers.
Results:
There were no significant differences on the x-axis while there were significant differences on the y-axis between the measured spinal levels in the P to A technique. There were significant differences found at preload force maximum, preload force minimum, and peak force between T3 and T12 and between T7 and T12 and at peak base force between T7 and T12 on the z-axis. In the A to P technique, there were significant differences in the change of force in measured spinal levels at different axes.
Conclusion:
These study findings can help therapists better understand the mechanism of TSM and enhance the clinical usefulness of TSM.
... Interestingly, the result of being able to endure more pain is associated with decreased stiffness [20,37]. Therefore, a linkage may exist between a decrease in stiffness resulting in decreased activation of nociceptors as current evidence supports that manual therapy immediately increases the local pressure pain threshold [38] and induces other pain-related changes [39,40]. ...
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.
... After reading the title and abstract, 1,398 studies were eliminated because they did not meet the inclusion criteria, leaving only 29 articles for full-text analysis. Eleven studies were excluded for the following reasons: one for being performed in a population of healthy subjects [43], five for not measuring or not presenting the data of the TS or the CPM [44][45][46][47][48], one for not being an RCT [49], one for evaluation of CPM after surgery [50], one because it is a comparison between subjects with normal CPM, abnormal CPM, and healthy individuals [51], one [50] because it used the same data from another study already included [51], and one because it was an intervention by means of alternative therapies [52]. Finally, a total of 18 studies [51,[53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69] were included in the qualitative analysis and 17 [51,[54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69] in the quantitative analysis. ...
Introduction:
Chronic musculoskeletal pain is a major health, social, and economic problem. Most of the subjects who suffer from chronic musculoskeletal pain present processes of central sensitization. Temporal summation and conditioned pain modulation are the two most commonly used clinical measures of this. The objective of this review is to evaluate the effects of physical therapy on temporal summation (TS) and conditioned pain modulation (CPM) in patients with chronic musculoskeletal pain.
Methods:
This is a systematic review and meta-analysis. We searched the MEDLINE, EMBASE, CINAHL, EBSCO, PubMed, PEDro, Cochrane Collaboration Trials Register, Cochrane Database of Systematic Reviews, and SCOPUS databases. Different mesh terms and key words were combined for the search strategy, with the aim of encompassing all studies that have used any type of physical therapy treatment in patients with chronic musculoskeletal pain and have measured both TS and CPM.
Results:
Eighteen studies remained for qualitative analysis and 16 for quantitative analysis. Statistically significant differences with a 95% confidence interval (CI) were obtained for TS (-0.21, 95% CI = -0.39 to -0.03, Z = 2.50, P = 0.02, N = 721) and CPM (0.34, 95% CI = 0.12 to 0.56, Z = 2.99, P = 0.003, N = 680) in favor of physical therapy as compared with control. Manual therapy produces a slight improvement in TS, and physical therapy modalities in general improve CPM. No significant differences between the subgroups of the meta-analysis were found. The methodological quality of the studies was high.
Conclusions:
Physical therapy produces a slight improvement in central sensitization (CS)-related variables, with TS decreased and CPM increased when compared with a control group in patients with CMP. Only significant differences in TS were identified in the manual therapy subgroup.
... Based on our data, short-term changes in TS do not appear to differ based on responder status and thus symptomatic responses may not be tied to changes in the excitability of dorsal horn neurons after a brief manual therapy intervention. Others have speculated that SMT is capable of modulating central sensitisation processes, in part based on studies observing decreases in TS short-term after SMT (Randoll et al., 2017;Zafereo and Deschenes, 2015). This study offers preliminary evidence that short-term improvement in LBP is not related to short-term changes in TS. ...
Background
People with LBP who experience rapid improvement in symptoms after spinal manipulative therapy (SMT) are more likely to experience better longer-term outcomes compared to those who don't improve rapidly. It is unknown if short-term hypoalgesia after SMT could be a relevant finding in rapid responders.
Objectives
We aimed to explore whether rapid responders had different short-term pressure pain threshold (PPT) and temporal summation (TS) outcomes after SMT and sham compared to non-rapid responders.
Methods
This was a planned secondary analysis of a randomised controlled trial that recruited 80 adults with LBP (42 females, mean age 37 yrs). PPT at the calf, lumbar spine, and shoulder and TS at the hands and feet were measured before and three times over 30 min after a lumbar SMT or sham manipulation. Participants were classified as rapid responders or non-rapid responders based on self-reported change in LBP over the following 24 h.
Results
Shoulder PPT transiently increased more in the rapid responders than non-rapid responders immediately post-intervention only (between-group difference in change from baseline = 0.29 kg/cm², 95% CI 0.02–0.56, p = .0497). There were no differences in calf PPT, lumbar PPT, hand TS, or foot TS based on responder status.
Conclusions
Hypoalgesia in shoulder PPT occurred transiently in the rapid responders compared to the non-rapid responders. This may or may not contribute to symptomatic improvement after SMT or sham in adults with LBP, and may be a spurious finding. Short-term changes in TS do not appear to be related to changes in LBP.
... grade V mobilization) might affect the knee pain via descending inhibitory pathways. Hypoalgesia associated with spinal manipulation has been shown in many studies (Bialosky et al., 2008;Randoll et al., 2017), and is thought to be associated with decreased temporal summation vs. any local anatomical effects. In addition, decreased pain following LPM may be related to the activity of the neuroendocrine system. ...
Background
Patellofemoral pain(PFP) is a common musculoskeletal disorder. Quadriceps and core muscle neuromuscular control impairments are frequently associated with PFP. Lumbopelvic manipulation(LPM) has been shown to improve quadriceps and core muscle activation and decrease their inhibition, but changes in balance and knee joint position sense(JPS) after this intervention remain unknown.
Objective
To determine whether LPM decreases knee pain and JPS error and increases balance performance in patients with PFP.
Design
Randomized controlled trial.
Setting
Biomechanics laboratory at a rehabilitation science research center.
Methods
Forty-four patients with PFP participated in this study that randomly divided into two equal groups. One group received LPM and the other received sham LPM(positioning with no thrust) in a single session. At baseline and immediately after the intervention, outcomes were assessed in both groups, i.e.pain with a visual analog scale, balance with the modified star excursion balance test(mSEBT), and JPS at 20 degrees and 60 degrees of knee flexion with a Biodex dynamometer.
Results
There was a statistically significant improvement in pain, balance control(anterior direction) and JPS in the LPM group immediately after the intervention. In addition, we observed significant differences between groups in pain, balance control(anterior direction) and JPS at 60 degrees of knee flexion immediately after the intervention.
Conclusion
A single session of LPM immediately improved balance control,knee JPS and pain in patients diagnosed with PFP.
Clinical Rehabilitation Impact
Findings suggest that LPM may be used as a therapeutic tool for immediate improvement of symptoms of PFP. However,more research is needed to determine long term results.
... Central sensitization: increased responsiveness of nociceptive neurons to their normal input or recruitment of a response to normally subthreshold inputs 36 Interventions: Education about chronic pain mechanisms [53][54][55] Myofascial therapy to prevent and/or manage myofascial derangement from painful postures and/or movements 56 Spinal manipulation exhibits short-term influence on neural pain processes [57][58][59][60][61][62] Consider recommending graded exposure training 63 and mindfulness-based stress reduction 37 ...
Objective:
The purpose of this study was to develop a clinical decision aid for chiropractic management of common conditions causing low back pain (LBP) in veterans receiving treatment in US Veterans Affairs (VA) health care facilities.
Methods:
A consensus study using an online, modified Delphi technique and Research Electronic Data Capture web application was conducted among VA doctors of chiropractic. Investigators reviewed the scientific literature pertaining to diagnosis and treatment of nonsurgical, neuromusculoskeletal LBP. Thirty seed statements summarizing evidence for chiropractic management, a graphical stepped management tool outlining diagnosis-informed treatment approaches, and support materials were then reviewed by an expert advisory committee. Email notifications invited 113 VA chiropractic clinicians to participate as Delphi panelists. Panelists rated the appropriateness of the seed statements and the stepped process on a 1-to-9 scale using the RAND/University of California, Los Angeles methodology. Statements were accepted when both the median rating and 80% of all ratings occurred within the highly appropriate range.
Results:
Thirty-nine panelists (74% male) with a mean (standard deviation) age of 46 (11) years and clinical experience of 17 (11) years participated in the study. Accepted statements addressed included (1) essential components of chiropractic care, (2) treatments for conditions causing or contributing to LBP, (3) spinal manipulation mechanisms, (4) descriptions and mechanisms of commonly used chiropractic interventions, and (5) a graphical stepped clinical management tool.
Conclusion:
This study group produced a chiropractic clinical decision aid for LBP management, which can be used to support evidence-based care decisions for veterans with LBP.
... It has been suggested that reduction in pain sensitivity in response to SMT (manipulation-induced hypoalgesia) may be a mechanism contributing to the clinical pain relief some people report after SMT ( Randoll et al., 2017;Bialosky et al., 2009a;Zafereo and Deschenes, 2015). This area of research predominantly focuses on assessing quantitative sensory testing (QST) outcomes, in particular pressure pain threshold (PPT) and temporal summation (TS). ...
Background:
Changes in quantitative sensory tests have been observed after spinal manipulative therapy (SMT), particularly in pressure pain thresholds (PPT) and temporal summation (TS). However, a recent systematic review comparing SMT to sham found no significant difference in PPT in patients with musculoskeletal pain. The sham-controlled studies were generally low quality, and conclusions about other quantitative sensory tests could not be made.
Objectives:
We aimed to perform a sham-controlled study with the specific objective of investigating changes in PPT and TS short-term after lumbar SMT compared to sham manipulation in people with low back pain.
Methods:
This was a double-blind randomised controlled trial comparing high-velocity low-amplitude lumbar SMT against sham manipulation in participants with low back pain. Primary outcome measures were PPT at the calf, lumbar spine and shoulder, and TS at the hands and feet. These were measured at baseline, then immediately, 15 min and 30 min post-intervention.
Results:
Eighty participants (42 females) were included in the analyses (mean age 37 years), with 40 participants allocated to each intervention group. Significant between-group differences were only observed for calf PPT, which could be explained by a decrease in PPT (increased sensitivity) after SMT and an increase after sham. Feet TS decreased significantly over time after both SMT and sham, and any other changes over time were inconsistent.
Conclusions:
Our results suggest that lumbar SMT does not have a short-term hypoalgesic effect, as measured with PPT and TS, when compared to sham manipulation in people with low back pain.
... L'attività del midollo spinale è stata osservata essere influenzata dalla manipolazione spinale, determinando una riduzione di attività a livello delle corna dorsali del midollo spinale e influenzando l'attività neuromuscolare (24). A seguito di manipolazioni spinali, si sono osservate modifiche dei fenomeni di sommazione temporale e blocco selettivo dei neurotrasmettitori, in grado di indurre ipoalgesia nel paziente (33)(34)(35)(36)(37)(38)(39)(40)(41)(42). Anche altri parametri quali la scarica afferente (43)(44)(45)(46), l'attività del pool motoneuronale (47), l'attività muscolare (48)(49)(50) si sono dimostrati essere modulati a seguito dell'erogazione di manipolazioni spinali. ...
... 11 12 The neurophysiological approach suggests that SMT affects the primary afferent neurons from paraspinal tissues, the motor control system, and pain processing. [13][14][15][16][17][18] To resolve the issue of effectiveness, we conducted a systematic review and meta-analysis. This publication is an update of our earlier Cochrane review, which found high quality evidence suggesting no clinically relevant difference between SMT and effective interventions for reducing pain and improving function in patients with chronic low back pain. ...
Objective
To assess the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain.
Design
Systematic review and meta-analysis of randomised controlled trials.
Data sources
Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, and trial registries up to 4 May 2018, including reference lists of eligible trials and related reviews.
Eligibility criteria for selecting studies
Randomised controlled trials examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded, as was grey literature. No restrictions were applied to language or setting.
Review methods
Two reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence. The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months. Quality of evidence was assessed using GRADE. A random effects model was used and statistical heterogeneity explored.
Results
47 randomised controlled trials including a total of 9211 participants were identified, who were on average middle aged (35-60 years). Most trials compared SMT with recommended therapies. Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief (mean difference −3.17, 95% confidence interval −7.85 to 1.51) and a small, clinically better improvement in function (SMD −0.25, 95% confidence interval −0.41 to −0.09). High quality evidence suggested that compared with non-recommended therapies SMT results in small, not clinically better effects for short term pain relief (mean difference −7.48, −11.50 to −3.47) and small to moderate clinically better improvement in function (SMD −0.41, −0.67 to −0.15). In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. Statistical heterogeneity could not be explained. About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT.
Conclusion
SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.
... Dabei spielt die Geschwindigkeit der Ausführung eine wichtige Rolle: Auch ohne im Bereich der Gelenkblockade zu arbeiten, scheint es möglich, auf die Bewegungsfreiheit des Gelenks einzuwirken. Unter Umständen werden auch Wirkmechanismen stimuliert, die auf die Schmerzwahrnehmung wirken [26]. ...
Zusammenfassung
Impulstechniken an der Halswirbelsäule (HWS) treffen bei manualmedizinischen Therapeuten auf gemischte Gefühle: Die einen führen sie oft und auch mit Freude aus, andere empfinden sie als geradezu invasiv und hochgradig gefährlich. Worauf basieren die Sicherheit der einen und die Befürchtungen der anderen? Im Folgenden werden die anatomischen und biomechanischen Grundlagen der HWS kurz erläutert und dann auf 2 wichtige Probleme hingewiesen, die ein Risiko der Behandlung darstellen: Rheuma mit Instabilität und zervikale arterielle Dissektionen. Die Ergebnisse älterer und neuer Studien sollten Anhänger beider Gruppen zum Nachdenken anregen. Einerseits darf die Einschätzung des Risikos bei Impulstechniken nicht hauptsächlich auf Sicherheitstests basieren. Andererseits können z. B. Mobilisationen nicht als die generell bessere Alternative gelten. Weiterhin stellt die Instabilität der HWS insbesondere durch Rheuma ein Risiko dar, das sowohl die Mobilisation als auch die Impulstechnik klar kontraindiziert.
Introduction
Chronic low back pain (CLBP) is a highly prevalent and disabling condition. Identifying subgroups of patients afflicted with CLBP is a current research priority, for which a classification system based on pain mechanisms was proposed. Spinal manipulative therapy (SMT) is recommended for the management of CLBP. Yet, little data are available regarding its mechanisms of action, making it difficult to match this intervention to the patients who may benefit the most. It was suggested that SMT may influence mechanisms associated with central sensitisation. Therefore, classifying patients with CLBP according to central sensitisation mechanisms may help predict their response to SMT.
Methods and analysis
This protocol describes a randomised placebo-controlled trial aiming to examine which variables linked to central sensitisation may help predict the clinical response to SMT in a cohort of patients with CLBP. One hundred patients with chronic primary low back pain will be randomised to receive 12 sessions of SMT or placebo SMT over a 4-week period. Pain intensity and disability will be assessed as primary outcomes after completing the 4-week treatment (primary endpoint), and at 4-week and 12-week follow-ups. Baseline values of two pain questionnaires, lumbar pressure pain thresholds, concentrations of an inflammatory cytokine and expectations of pain relief will be entered as predictors of the response to SMT in a multiple regression model. Changes in these variables after treatment will be used in a second multiple regression model. The reference values of these predictors will be measured from 50 age and sex-matched healthy controls to allow interpretation of values in patients. Mixed analyses of variance will also be conducted to compare the primary outcomes and the predictors between groups (SMT vs placebo) over time (baseline vs post-treatment).
Ethics and dissemination
Ethical approval was granted by the Fundación Jiménez Díaz Clinical Research Ethics Committee.
Trial registration number
NCT05162924 .
Introduction
Joint mobilisation and manipulation often results in immediate pain relief in people with neck pain. However, the biological mechanisms behind pain relief are largely unknown. There is preliminary evidence that joint mobilisation and manipulation lessens the upregulated neuroimmune responses in people with persistent neck pain.
Methods and analysis
This study protocol describes a randomised placebo-controlled trial to investigate whether joint mobilisation and manipulation influence neuroimmune responses in people with persistent neck pain. People with persistent neck pain (N=100) will be allocated, in a randomised and concealed manner, to the experimental or control group (ratio 3:1). Short-term (ie, baseline, immediately after and 2 hours after the intervention) neuroimmune responses will be assessed, such as inflammatory marker concentration following in vitro stimulation of whole blood cells, systemic inflammatory marker concentrations directly from blood samples, phenotypic analysis of peripheral blood mononuclear cells and serum cortisol. Participants assigned to the experimental group (N=75) will receive cervical mobilisations targeting the painful and/or restricted cervical segments and a distraction manipulation of the cervicothoracic junction. Participants assigned to the control group (N=25) will receive a placebo mobilisation and placebo manipulation. Using linear mixed models, the short-term neuroimmune responses will be compared (1) between people in the experimental and control group and (2) within the experimental group, between people who experience a good outcome and those with a poor outcome. Furthermore, the association between the short-term neuroimmune responses and pain relief following joint mobilisation and manipulation will be tested in the experimental group.
Ethics and dissemination
This trial is approved by the Medical Ethics Committee of Amsterdam University Medical Centre, location VUmc (Approval number: 2018.181).
Trial registration number
NL6575 (trialregister.nl
Background:
Osteoarthritis (OA) is one of the most prevalent and disabling musculoskeletal diseases worldwide. There is preliminary evidence from experimental studies and consensus documents that chiropractic management may alleviate spine and/or extremity OA related pain in the short term.
Objective:
This research explores the potential relationship of a pragmatic course of care, including soft tissue therapy, spinal manipulation, and other treatments commonly delivered by chiropractors, to spine and extremity pain in patients with OA.
Methods:
A retrospective analysis of prospectively collected data from the chiropractic program at a publicly funded healthcare facility was conducted. The primary outcome measures for patients diagnosed with spine and/or extremity OA (n= 76) were numeric pain scores of each spinal and extremity region at baseline and discharge, and a change score was determined.
Results:
Statistically significant improvements that exceed a clinically meaningful difference in pain numeric rating scale scores were demonstrated by point change reductions from baseline to discharge visits. Change scores exceeding a minimally clinically important difference of "2-points" were present in the sacroiliac (-2.91), extremity (-2.84), cervical (-2.73), thoracic (-2.61), and lumbar (-2.59) regions.
Conclusion:
Patients diagnosed with OA in a socioeconomically disadvantaged community demonstrated reductions in mean pain scores in both a clinically meaningful and statistically significant manner concurrent with a course of chiropractic care.
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
Together, neck pain and back pain are the first cause of disability worldwide, accounting for more than 10% of the total years lived with disability. In this context, chiropractic care provides a safe and effective option for the management of a large proportion of these patients. Chiropractic is a healthcare profession mainly focused on the spine and the treatment of spinal disorders, including spine pain. Basic studies have examined the influence of chiropractic spinal manipulation (SM) on a variety of peripheral, spinal and supraspinal mechanisms involved in spine pain. While spinal cord mechanisms of pain inhibition contribute at least partly to the pain‐relieving effects of chiropractic treatments, the evidence is weaker regarding peripheral and supraspinal mechanisms, which are important components of acute and chronic pain. This narrative review highlights the most relevant mechanisms of pain relief by SM and provides a perspective for future research on SM and spine pain, including the validation of placebo interventions that control for placebo effects and other non‐specific effects that may be induced by SM.
Significance
Spinal manipulation inhibits back and neck pain partly through spinal segmental mechanisms and potentially through peripheral mechanisms regulating inflammatory responses. Other mechanisms remain to be clarified. Controls and placebo interventions need to be improved in order to clarify the contribution of specific and non‐specific effects to pain relief by spinal manipulative therapy.
Cracking sounds emitted from human synovial joints have been attributed historically to the sudden collapse of a cavitation bubble formed as articular surfaces are separated. Unfortunately, bubble collapse as the source of joint cracking is inconsistent with many physical phenomena that define the joint cracking phenomenon. Here we present direct evidence from real-time magnetic resonance imaging that the mechanism of joint cracking is related to cavity formation rather than bubble collapse. In this study, ten metacarpophalangeal joints were studied by inserting the finger of interest into a flexible tube tightened around a length of cable used to provide long-axis traction. Before and after traction, static 3D T1-weighted magnetic resonance images were acquired. During traction, rapid cine magnetic resonance images were obtained from the joint midline at a rate of 3.2 frames per second until the cracking event occurred. As traction forces increased, real-time cine magnetic resonance imaging demonstrated rapid cavity inception at the time of joint separation and sound production after which the resulting cavity remained visible. Our results offer direct experimental evidence that joint cracking is associated with cavity inception rather than collapse of a pre-existing bubble. These observations are consistent with tribonucleation, a known process where opposing surfaces resist separation until a critical point where they then separate rapidly creating sustained gas cavities. Observed previously in vitro, this is the first in-vivo macroscopic demonstration of tribonucleation and as such, provides a new theoretical framework to investigate health outcomes associated with joint cracking.
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.
In the past decade many countries around the world have produced clinical practice guidelines to assist practitioners in providing a care that is aligned with the best evidence. The aim of this study was to present and compare the most established evidence-based recommendations for the management of chronic nonspecific low back pain in primary care derived from current high-quality international guidelines.
Guidelines published or updated since 2002 were selected by searching PubMed, CINAHL, EMBASE, guidelines databases, and the World Wide Web. The methodological quality of the guidelines was assessed by three authors independently, using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. Guideline recommendations were synthesized into diagnostic and therapeutic approaches that were supported by strong, moderate or weak evidence.
Thirteen guidelines were included. In general, the quality was satisfactory. Guidelines had highest scores on clarity and presentation and scope and purpose domains, and lowest scores on applicability. There was a strong consensus among all the guidelines particularly regarding the use of diagnostic triage and the assessment of prognostic factors. Consistent therapeutic recommendations were information, exercise therapy, multidisciplinary treatment, and combined physical and psychological interventions.
Compared to previous assessments, the average quality of the guidelines dealing with chronic low back pain has improved. Furthermore, all guidelines are increasingly aligning in providing therapeutic recommendations that are clearly differentiated from those formulated for acute pain. However, there is still a need for improving quality and generating new evidence for this particular condition.
Spinal manipulative techniques (SMT) have shown clinical effectiveness in some patients with musculoskeletal pain.
We performed the current experiment to test whether regional pain modulation is to be expected from thoracic SMT.
Randomized experimental design performed in a university pain laboratory.
The primary outcome was experimental pain sensitivity in cervical and lumbar innervated area.
Ninety healthy volunteers were randomly assigned to receive one of three interventions (SMT, exercise, or rest) to the upper thoracic spine. Participants completed questionnaires about pain-related affect and expectations regarding each of the interventions. We collected experimental pain sensitivity measures of cervical and lumbar innervated areas before and immediately after randomly assigned intervention. Mixed model analysis of covariance was used to test changes in measures of experimental pain sensitivity.
No interactions or intervention (group) effects were noted for pressure or A-delta-mediated thermal pain responses. Participants receiving SMT had greater reductions in temporal sensory summation (TSS).
This present study indicates thoracic SMT that reduces TSS in healthy subjects. These findings extend our previous work in healthy and clinical subjects by indicating change in the nocioceptive afferent system occurred caudal to the region of SMT application. However, the duration of reduction in TSS is unknown, and more work needs to be completed in clinical populations to confirm the relevance of these findings.
Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.
High-velocity, low-amplitude (HVLA) manipulation is an effective treatment of low back pain (LBP); however, the corresponding mechanisms are undetermined. Hypoalgesia is associated with HVLA manipulation and suggests specific mechanisms of action. An audible pop (AP) is also associated with HVLA manipulation; however, the influence of the AP on the hypoalgesia associated with HVLA manipulation is not established. The purpose of the current study was to observe the influence of the AP on hypoalgesia associated with HVLA manipulation.
The current study represents a secondary analysis of 40 participants. All participants underwent thermal pain sensitivity testing to their leg and low back using protocols specific to A delta fiber-mediated pain and temporal summation. Next, participants received HVLA manipulation to their low back, and the examiner recorded whether an AP was perceived. Finally, participants underwent immediate follow-up thermal pain sensitivity testing using the same protocols. Separate repeated-measure analyses of variance (ANOVAs) were used to observe changes in pain sensitivity before and immediately after HVLA manipulation.
Hypoalgesia of A delta fiber-mediated pain was observed in the low back after HVLA (P < .05), and this was independent of whether an AP was perceived (P > .05). Hypoalgesia of temporal summation was observed in the lower extremity after HVLA (P < .05), and this was independent of whether an AP was perceived (P = .08). However, a moderate effect size for temporal summation was observed favoring participants in whom an AP was perceived.
The current study suggests hypoalgesia is associated with HVLA manipulation and occurs independently of a perceived AP. Inhibition of lower extremity temporal summation may be larger in individuals in whom an AP is perceived, but further study is necessary to confirm this finding.
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.
The underlying causes of spinal manipulation hypoalgesia are largely unknown. The beneficial clinical effects were originally theorized to be due to biomechanical changes, but recent research has suggested spinal manipulation may have a direct neurophysiological effect on pain perception through dorsal horn inhibition. This study added to this literature by investigating whether spinal manipulation hypoalgesia was: a) local to anatomical areas innervated by the lumbar spine; b) correlated with psychological variables; c) greater than hypoalgesia from physical activity; and d) different for A-delta and C-fiber mediated pain perception.
Asymptomatic subjects (n = 60) completed baseline psychological questionnaires and underwent thermal quantitative sensory testing for A-delta and C-fiber mediated pain perception. Subjects were then randomized to ride a stationary bicycle, perform lumbar extension exercise, or receive spinal manipulation. Quantitative sensory testing was repeated 5 minutes after the intervention period. Data were analyzed with repeated measures ANOVA and post-hoc testing was performed with Bonferroni correction, as appropriate.
Subjects in the three intervention groups did not differ on baseline characteristics. Hypoalgesia from spinal manipulation was observed in lumbar innervated areas, but not control (cervical innervated) areas. Hypoalgesic response was not strongly correlated with psychological variables. Spinal manipulation hypoalgesia for A-delta fiber mediated pain perception did not differ from stationary bicycle and lumbar extension (p > 0.05). Spinal manipulation hypoalgesia for C-fiber mediated pain perception was greater than stationary bicycle riding (p = 0.040), but not for lumbar extension (p = 0.105).
Local dorsal horn mediated inhibition of C-fiber input is a potential hypoalgesic mechanism of spinal manipulation for asymptomatic subjects, but further study is required to replicate this finding in subjects with low back pain.
The mechanisms thorough which spinal manipulative therapy (SMT) exerts clinical effects are not established. A prior study has suggested a dorsal horn modulated effect; however, the role of subject expectation was not considered. The purpose of the current study was to determine the effect of subject expectation on hypoalgesia associated with SMT.
Sixty healthy subjects agreed to participate and underwent quantitative sensory testing (QST) to their leg and low back. Next, participants were randomly assigned to receive a positive, negative, or neutral expectation instructional set regarding the effects of a specific SMT technique on pain perception. Following the instructional set, all subjects received SMT and underwent repeat QST.
No interaction (p = 0.38) between group assignment and pain response was present in the lower extremity following SMT; however, a main effect (p < 0.01) for hypoalgesia was present. A significant interaction was present between change in pain perception and group assignment in the low back (p = 0.01) with participants receiving a negative expectation instructional set demonstrating significant hyperalgesia (p < 0.01).
The current study replicates prior findings of c- fiber mediated hypoalgesia in the lower extremity following SMT and this occurred regardless of expectation. A significant increase in pain perception occurred following SMT in the low back of participants receiving negative expectation suggesting a potential influence of expectation on SMT induced hypoalgesia in the body area to which the expectation is directed.
Persistent pain interfering with daily activities is common. Chronic pain has been defined in many ways. Chronic pain syndrome is a separate entity from chronic pain. Chronic pain is defined as, “pain that persists 6 months after an injury and beyond the usual course of an acute disease or a reasonable time for a comparable injury to heal, that is associated with chronic pathologic processes that cause continuous or intermittent pain for months or years, that may continue in the presence or absence of demonstrable pathologies; may not be amenable to routine pain control methods; and healing may never occur.” In contrast, chronic pain syndrome has been defined as a complex condition with physical, psychological, emotional, and social components. The prevalence of chronic pain in the adult population ranges from 2% to 40%, with a median point prevalence of 15%. Among chronic pain disorders, pain arising from various structures of the spine constitutes the majority of the problems. The lifetime prevalence of spinal pain has been reported as 54% to 80%. Studies of the prevalence of low back pain and neck pain and its impact in general have shown 23% of patients reporting Grade II to IV low back pain (high pain intensity with disability) versus 15% with neck pain. Further, age related prevalence of persistent pain appears to be much more common in the elderly associated with functional limitations and difficulty in performing daily life activities. Chronic persistent low back and neck pain is seen in 25% to 60% of patients, one-year or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Estimates and patterns of productivity losses and direct health care expenditures among individuals with back and neck pain in the United States continue to escalate. Recent studies have shown significant increases in the prevalence of various pain problems including low back pain. Frequent use of opioids in managing chronic non-cancer pain has been a major issue for health care in the United States placing a significant strain on the economy with the majority of patients receiving opioids for chronic pain necessitating an increased production of opioids, and escalating costs of opioid use, even with normal intake. The additional costs of misuse, abuse, and addiction are enormous. Comorbidities including psychological and physical conditions and numerous other risk factors are common in spinal pain and add significant complexities to the interventionalist’s clinical task. This section of the American Society of Interventional Pain Physicians (ASIPP)/EvidenceBased Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of spinal pain and its relevance to health care interventions. Key words: Chronic pain, chronic spinal pain, chronic low back pain, chronic neck pain, chronic thoracic pain, prevalence, health care utilization, loss of productivity, interventional techniques, surgery, comorbid factors, socioeconomic effects, health care impact
The purpose of this review is to critically evaluate the research that has been published in the area of the biomechanics of spinal manipulation. The external forces applied by clinicians on patients during high-speed, low-amplitude treatments are assessed. Then, the corresponding evidence on the effects of these treatments is reviewed. These effects include the relative vertebral movements, the internal forces, the reflex responses and reflex inhibitions, and selected viscerosomatic responses. Finally, the efficacy of spinal manipulation is summarized from a clinical point of view. In summary, high-speed, low-amplitude spinal manipulative treatments are associated with peak forces in excess of the body weight of the treating clinician. These forces create relative vertebral movements in the paraphysiologic zone, but do not cause stresses or strains on the vertebral artery that are of mechanical concern. Spinal manipulative treatments typically produce facet joint cavitation, always result in wide-spread muscular reflex responses of multireceptor origin, cause decreases in muscle inhibition associated with back or joint pain and dysfunction, and have beneficial effects in alleviating pain.
Low back pain (LBP) is a leading cause of disability worldwide. In the absence of a classification system for pain syndromes, classification of LBP on the basis of the distribution of pain as axial (pain generally localized to the low back) or radicular neuropathic (pain radiating to the lower extremities) is relevant to clinical practice because the distribution of pain is often a corollary of frequently occurring disease processes involving the lumbar spine. Common sources of axial LBP include the intervertebral disc, facet joint, sacroiliac joint, and paraspinal musculature, whereas common sources of radicular pain include a herniated intervertebral disc and spinal stenosis. The accuracy of historical and physical examination findings has been established for sacroiliac joint pain, radiculopathy, and lumbar spinal stenosis. However, the accuracy of similar data, so-called red flags, for identifying the underlying medical sources of LBP has been overstated. Diagnostic imaging studies can be useful, and adherence to established guidelines can protect against overuse. Multiple pharmacological trials exist for the management of LBP; however, the long-term outcomes of commonly used drugs are mixed. For carefully selected patients with axial LBP, radiofrequency denervation techniques can provide sustained pain relief. In patients with radicular pain, transforaminal epidural steroid injections may provide short-term pain relief, but neurostimulation may confer more enduring benefits of refractory symptoms. Pain-related indications for commonly performed operations include spinal decompression for radicular symptoms as well as spinal fusion or disc prosthesis for discogenic LBP. Physical modalities and psychological treatments can improve pain and functioning, but patient preferences may influence treatment adherence.
The purpose of this study was to sample the stability of spinal manipulation performance in peak impulse force development over time and the ability of clinicians to adapt to arbitrary target levels with short-duration training.
A pre-post experimental design was used. Human analog mannequins provided standardized simulation for performance measures. A convenience sample was recruited consisting of 41 local doctors of chiropractic with 5 years of active clinical practice experience. Thoracic impulse force was measured among clinicians at baseline, after 4 months at pretraining, and again posttraining. Intraclass correlation coefficient values and within-subject variability defined consistency. Malleability was measured by reduction of error (paired t tests) in achieving arbitrary targeted levels of force development normalized to the individual's typical performance.
No difference was observed in subgroup vs baseline group characteristics. Good consistency was observed in force-time profiles (0.55 ≤ intraclass correlation coefficient ≤ 0.75) for force parameters over the 4-month interval. With short intervals of focused training, error rates in force delivery were reduced by 23% to 45%, depending on target. Within-subject variability was 1/3 to 1/2 that of between-subject variability. Load increases were directly related to rate of loading.
The findings of this study show that recalibration of spinal manipulation performance of experienced clinicians toward arbitrary target values in the thoracic spine is feasible. This study found that experienced clinicians are internally consistent in performance of procedures under standardized conditions and that focused training may help clinicians learn to modulate procedure characteristics.
Copyright © 2015. Published by Elsevier Inc.
This study examines the effect of normal aging on temporal summation (TS) of pain and the nociceptive flexion reflex (RIII). Two groups of healthy volunteers, young and elderly, received transcutaneous electrical stimulation applied to the right sural nerve to assess pain and the nociceptive flexion reflex (RIII-reflex). Stimulus intensity was adjusted individually to 120% of RIII-reflex threshold and shocks were delivered as single stimulus or as series of five stimuli to assess TS at 5 different frequencies (0.17Hz, 0.33Hz, 0.66Hz, 1Hz and 2 Hz). This study shows that robust TS of pain and RIII-reflex is observable in individuals aged between 18 and 75 years-old and indicates that these effects are comparable between young and elder individuals. These results contrast with some previous findings and imply that at least some pain regulatory processes, including temporal summation, may not be affected by normal aging, although this may vary depending on the methodology.
Spinal manipulative therapy (SMT) is effective for some individuals experiencing low back pain; however, the mechanisms are not established regarding the role of placebo. SMT is associated with changes in pain sensitivity suggesting related altered central nervous system response or processing of afferent nociceptive input. Placebo is also associated with changes in pain sensitivity, and the efficacy of SMT for changes in pain sensitivity beyond placebo has not been adequately considered. We randomly assigned 110 participants with low back pain to receive SMT, placebo SMT, placebo SMT with the instructional set "The manual therapy technique you will receive has been shown to significantly reduce low back pain in some people," or no intervention. Participants receiving the SMT and placebo SMT received their assigned intervention 6 times over 2 weeks. Pain sensitivity was assessed prior to and immediately following the assigned intervention during the first session. Clinical outcomes were assessed at baseline and following 2 weeks of participation in the study. Immediate attenuation of suprathreshold heat response was greatest following SMT (P = .05, partial η(2) = .07). Group-dependent differences were not observed for changes in pain intensity and disability at 2 weeks. Participant satisfaction was greatest following the enhanced placebo SMT. This study was registered at www.clinicaltrials.gov under the identifier NCT01168999.
The results of this study indicate attenuation of pain sensitivity is greater in response to SMT than the expectation of receiving an SMT. These findings suggest a potential mechanism of SMT related to lessening of central sensitization and may indicate a preclinical effect beyond the expectations of receiving SMT.
Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.
Heterotopic noxious counterstimulation (HNCS) by the application of a sustained noxious stimulus has been shown to inhibit nociceptive processes and decrease pain induced by a competing noxious stimulus. However, it is still not clear how attentional processes contribute to these effects. The main objective of this study was to compare the analgesic effects of HNCS in 2 sessions during which top-down attention was manipulated. Acute shock pain and the nociceptive flexion reflex were evoked by transcutaneous electrical stimulations of the right sural nerve in 4 blocks (15 stimuli/block): baseline, heterotopic innocuous counterstimulation (HICS), HNCS, and recovery. Counterstimulation was applied on the left upper limb with a thermode (HICS) or a cold pack (HNCS). Attention was manipulated between sessions by instructing participants to focus their attention on shock pain or counterstimulation. Shock pain ratings decreased significantly during counterstimulation (P<.001) with stronger effects of HNCS vs HICS in both sessions (P<.01). Furthermore, shock pain inhibition during HNCS relative to baseline was stronger with attention focusing on counterstimulation compared to attention focusing on shocks (P = .015). However, the relative decrease in pain ratings during HNCS vs HICS was not significantly affected by the direction of attention (P = .7). As for spinal nociceptive processes, nociceptive flexion reflex amplitude was significantly decreased during counterstimulation (P<.001) with larger reductions during HNCS compared to HICS (P = .03). However, these effects were not altered by attention (P = .35). Together, these results demonstrate that top-down attention and HNCS produce additive analgesic effects. However, attentional modulation of HNCS analgesia seems to depend on supraspinal processes.
Physical therapists internationally provide spinal manipulative therapy (SMT) to patients with musculoskeletal pain complaints. SMT has been a part of physical therapist practice since the profession's beginning. Early physical therapist clinical decision making for SMT was influenced by the approaches of osteopathic and orthopedic physicians at the time. Currently a segmental clinical decision making approach and a responder clinical decision making approach are two of the more common models through which physical therapist clinical use of SMT is directed. The focus of segmental clinical decision making is upon identifying a dysfunctional vertebral segment with the application of SMT to restore mobility and/or alleviate pain. The responder clinical decision making approach attempts to categorize individuals based on a pattern of signs and symptoms suggesting a likely positive response to SMT. The present manuscript provides an overview of common physical therapist clinical decision making approaches to SMT and presents areas requiring further study in order to optimize patient response.
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder involving abdominal pain and bowel dysfunction. IBS pain symptoms have been hypothesized to depend on peripheral and central mechanisms, but the pathophysiology is still unclear. The aim of the present study was to assess the contribution of cerebral and cerebrospinal processes to pain inhibition deficits in IBS. Fourteen female patients with diarrhea-predominant IBS (IBS-D) and 14 healthy female volunteers were recruited. Acute pain and the nociceptive withdrawal reflex (RIII reflex) were evoked by transcutaneous electrical stimulation of the right sural nerve with modulation by hetero-segmental counter-irritation produced by sustained cold pain applied on the left forearm. Psychological symptoms were assessed by questionnaires. Shock pain decreased significantly during counter-irritation in the controls (P<0.001) but not in IBS patients (P=0.52). Similarly, RIII-reflex amplitude declined during counter-irritation in the controls (P=0.009) but not in IBS patients (P=0.11). Furthermore, pain-related anxiety increased during counter-irritation in IBS patients (P=0.003) but not in the controls (P=0.74). Interestingly, across all subjects, counter-irritation analgesia was positively correlated with RIII-reflex inhibition (r=0.39, P=0.04) and negatively with pain-related anxiety (r=-0.61, P<0.001). In addition, individual differences in counter-irritation analgesia were predicted independently by the modulation of RIII responses (P=0.03) and by pain catastrophizing (P=0.01), with the latter mediating the effect of pain-related anxiety. In conclusion, these results demonstrate that pain inhibition deficits in female IBS-D patients depend on two potentially separable mechanisms reflecting: (1) altered descending modulation and (2) higher-order brain processes underlying regulation of pain and affect.
Biomechanics is the science that deals with the external and internal forces acting on biological systems and the effects produced by these forces. Here, we describe the forces exerted by chiropractors on patients during high-speed, low-amplitude manipulations of the spine and the physiological responses produced by the treatments. The external forces were found to vary greatly among clinicians and locations of treatment on the spine. Spinal manipulative treatments produced reflex responses far from the treatment site, caused movements of vertebral bodies in the "para-physiological" zone, and were associated with cavitation of facet joints. Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.
Persistent pain interfering with daily activities is common. Chronic pain has been defined in many ways. Chronic pain syndrome is a separate entity from chronic pain. Chronic pain is defined as, "pain that persists 6 months after an injury and beyond the usual course of an acute disease or a reasonable time for a comparable injury to heal, that is associated with chronic pathologic processes that cause continuous or intermittent pain for months or years, that may continue in the presence or absence of demonstrable pathologies; may not be amenable to routine pain control methods; and healing may never occur." In contrast, chronic pain syndrome has been defined as a complex condition with physical, psychological, emotional, and social components. The prevalence of chronic pain in the adult population ranges from 2% to 40%, with a median point prevalence of 15%. Among chronic pain disorders, pain arising from various structures of the spine constitutes the majority of the problems. The lifetime prevalence of spinal pain has been reported as 54% to 80%. Studies of the prevalence of low back pain and neck pain and its impact in general have shown 23% of patients reporting Grade II to IV low back pain (high pain intensity with disability) versus 15% with neck pain. Further, age related prevalence of persistent pain appears to be much more common in the elderly associated with functional limitations and difficulty in performing daily life activities. Chronic persistent low back and neck pain is seen in 25% to 60% of patients, one-year or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Estimates and patterns of productivity losses and direct health care expenditures among individuals with back and neck pain in the United States continue to escalate. Recent studies have shown significant increases in the prevalence of various pain problems including low back pain. Frequent use of opioids in managing chronic non-cancer pain has been a major issue for health care in the United States placing a significant strain on the economy with the majority of patients receiving opioids for chronic pain necessitating an increased production of opioids, and escalating costs of opioid use, even with normal intake. The additional costs of misuse, abuse, and addiction are enormous. Comorbidities including psychological and physical conditions and numerous other risk factors are common in spinal pain and add significant complexities to the interventionalist's clinical task. This section of the American Society of Interventional Pain Physicians (ASIPP)/Evidence-Based Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of spinal pain and its relevance to health care interventions.
The purpose of this study is to investigate the immediate effects of a single cervical spine manipulation and a manual contact intervention (MCI) on pressure pain thresholds (PPTs) and thermal pain thresholds over the elbow region and pain-free grip (PFG) force in patients with lateral epicondylalgia (LE).
A repeated measures, crossover, single-blinded randomized study was done. Ten patients with LE (5 female) aged from 30 to 49 years (mean, 42; SD, 6 years) participated in this study. Subjects attended 2 experimental sessions on 2 separate days at least 48 hours apart. At each session, participants received either a manipulative intervention or MCI assigned in a random fashion. Pressure pain threshold and hot and cold pain thresholds (HPT and CPT, respectively) over the lateral epicondyle of both elbows was assessed preintervention and 5 minutes postintervention by an examiner blinded to the treatment allocation of the patients. In addition, PFG on the affected arm and maximum grip force on the unaffected side were also assessed. A 3-way analysis of variance (ANOVA) with time (pre-post) and side (ipsilateral, contralateral to the intervention) as within-subjects variable and intervention (manipulation or MCI) as between-subjects variable was used to evaluate changes in PPT, HPT, CPT, or PFG.
The ANOVA detected a significant effect for time (F = 37.2, P < .001) and a significant interaction between intervention and time (F = 25.1, P < .001) for PPT levels. Post hoc revealed that the manipulative intervention produced a greater increase of PPT in both sides when compared with MCI (P < .001). The ANOVA did not detect significant effects for time (F = 2.7, P > .2), intervention (F = 2.8, P > .2), or side (F = 0.9, P > .4) for HPT. Again, no significant effects for time (F = 0.8, P > .4), side (F = 0.6, P > .4), or intervention (F = 0.8, P > .5) was found for CPT. Finally, a significant interaction between intervention and time (F = 9.4, P = .004) and between time * side * intervention (F = 18.2, P < .001) was found for grip force. Post hoc analysis revealed that the cervical manipulation produced an increase of PFG on the affected side as compared with the MCI (P < .001).
The application of a manipulation at the cervical spine produced an immediate bilateral increase in PPT in patients with LE. No significant changes for HPT and CPT were found. Finally, cervical manipulation increased PFG on the affected side, but not the maximum grip force on the unaffected arm. Future studies with larger sample sizes are required to examine the effects of thrust manipulation on PPT, HPT, CPT, or PFG.
Prior studies suggest manual therapy (MT) as effective in the treatment of musculoskeletal pain; however, the mechanisms through which MT exerts its effects are not established. In this paper we present a comprehensive model to direct future studies in MT. This model provides visualization of potential individual mechanisms of MT that the current literature suggests as pertinent and provides a framework for the consideration of the potential interaction between these individual mechanisms. Specifically, this model suggests that a mechanical force from MT initiates a cascade of neurophysiological responses from the peripheral and central nervous system which are then responsible for the clinical outcomes. This model provides clear direction so that future studies may provide appropriate methodology to account for multiple potential pertinent mechanisms.
Temporal summation of second pain and long-lasting tactile-evoked aftersensations are examples of sensory phenomenons that cannot be explained on the basis of responses of primary afferents. Two distinct classes of monkey spinothalamic tract neurons have responses to controlled natural stimuli that parallel and thus could account for the above phenomenons. One class, termed wide-dynamic-range, receives excitatory effects from sensitive mechanoreceptive afferents and from various nociceptive afferents including Adelta and C mechanothermal nociceptive afferents. Another class, termed nociceptive-specific, receives excitatory effects exclusively from primary nociceptive afferents. Both classes respond with an early and late response to a single noxious heat pulse (peak temperature = 51 C). The late response, unlike C nociceptive afferents but like second pain, summates in magnitude with each successive heat pulse. Gentle moving tactile stimuli evoke long-lasting (20-56 sec) after-discharges only in wide dynamic range neurons, and are similar in duration to the tactile after-sensation evoked by similar stimuli. Both the after-discharges and after-sensations can be abruptly terminated by rubbing the affected region. Temporal summation of second pain and cutaneous after-sensations are at least partly subserved by spinal cord mechanisms within the dorsal horn and are manifested in the output of spinothalamic tract neurons.
The response of paraspinal cutaneous pain tolerance levels to spinal manipulation has not been studied in an experimental model. This paper proposes such a model of pain tolerance measurement and describes the results of a controlled study of 50 assymptomatic subjects. The group receiving a spinal manipulation demonstrated a 140% increase in local cutaneous pain tolerance levels which was statistically significant (p less than 0.05). This is consistent with previous hypotheses regarding the mode of action of manipulation in the relief of spinal pain.
Evaluation and treatment of low back pain: a clinically focused review for primary care specialists
- Hooten