ArticlePDF Available

Spinal manipulation in the treatment of patients with MRI-confirmed lumbar disc herniation and sacroiliac joint hypomobility: A quasi-experimental study

Authors:

Abstract and Figures

Background To investigate the effect of lumbar and sacroiliac joint (SIJ) manipulation on pain and functional disability in patients with lumbar disc herniation (LDH) concomitant with SIJ hypomobility. Methods Twenty patients aged between 20 and 50 years with MRI-confirmed LDH who also had SIJ hypomobility participated in the trial in 2010. Patients who had sequestrated disc herniation were excluded. All patients received five sessions of spinal manipulative therapy (SMT) for the SIJ and lumbar spine during a 2-week period. Back and leg pain intensity and functional disability level were measured with a numerical rating scale (NRS) and the Oswestry Disability Index (ODI) at baseline, immediately after the 5th session, and 1 month after baseline. Results A significantly greater mean improvement in back and leg pain was observed in the 5th sessions and 1 month after SMT. Mean changes in ODI in the 5th session and 1 month after treatment also showed significant improvement. The MCIC for NRS and ODI scores in the present study were considered 20 and 6 points, respectively. Therefore, the mentioned improvements were not clinically significant in the 5th session or at 1-month follow-up. Conclusion Five sessions of lumbar and SIJ manipulation can potentially improve pain and functional disability in patients with MRI-confirmed LDH and concomitant SIJ hypomobility. Trial registration Irct.ir (Identifier: IRCT2017011924149N33), registered 19 February 2017 (retrospectively registered).
Content may be subject to copyright.
R E S E A R C H Open Access
Spinal manipulation in the treatment of
patients with MRI-confirmed lumbar disc
herniation and sacroiliac joint hypomobility:
a quasi-experimental study
Esmaeil Shokri
1
, Fahimeh Kamali
1,2,3*
, Ehsan Sinaei
2
and Farahnaz Ghafarinejad
1,2
Abstract
Background: To investigate the effect of lumbar and sacroiliac joint (SIJ) manipulation on pain and functional
disability in patients with lumbar disc herniation (LDH) concomitant with SIJ hypomobility.
Methods: Twenty patients aged between 20 and 50 years with MRI-confirmed LDH who also had SIJ hypomobility
participated in the trial in 2010. Patients who had sequestrated disc herniation were excluded. All patients received
five sessions of spinal manipulative therapy (SMT) for the SIJ and lumbar spine during a 2-week period. Back and
leg pain intensity and functional disability level were measured with a numerical rating scale (NRS) and the
Oswestry Disability Index (ODI) at baseline, immediately after the 5th session, and 1 month after baseline.
Results: A significantly greater mean improvement in back and leg pain was observed in the 5th sessions and
1 month after SMT. Mean changes in ODI in the 5th session and 1 month after treatment also showed significant
improvement. The MCIC for NRS and ODI scores in the present study were considered 20 and 6 points, respectively.
Therefore, the mentioned improvements were not clinically significant in the 5th session or at 1-month follow-up.
Conclusion: Five sessions of lumbar and SIJ manipulation can potentially improve pain and functional disability in
patients with MRI-confirmed LDH and concomitant SIJ hypomobility.
Trial registration: Irct.ir (Identifier: IRCT2017011924149N33), registered 19 February 2017 (retrospectively registered).
Keywords: Spinal manipulation, Lumbar disc herniation, Sacroiliac joint, Back pain
Background
Common low back problems include disc prolapse,
spinal stenosis and low back pain [1]. Disc herniation
can be categorized as protrusion (disc contained by the
annulus fibrosus), extrusion (disc materials migrated out
through the annulus fibrosus, but contained by the pos-
terior longitudinal ligament) and sequestration (disc ma-
terials released into the spinal canal) [1]. Disc prolapse
commonly presents with pain and numbness radiating
to the buttocks and legs due to spinal nerve or nerve
root compromise; however, it may be asymptomatic in
approximately 24% of all cases [1]. Symptomatic lumbar
disc disease (SLDD) is a term used to differentiate be-
tween structural abnormalities without clinical symp-
toms and abnormalities that induce clinical
presentations [2]. Approximately 95% of all instances of
lumbar disc herniation (LDH) occur at L4-L5 and L5-S1
levels [1].
Lumbar disc herniation commonly presents with low
back pain, and this problem is usually associated with
sacroiliac joint (SIJ) disorders. In fact, up to 30.7% of pa-
tients with LBP and sciatica also have SIJ dysfunction
[3]. A recent study reported the prevalence of SIJ dys-
function as 72.3% among patients with LDH [4]. Re-
searchers have claimed that depending on the type of SIJ
disorder, the lumbar spine (mostly L5) can also be
* Correspondence: fahimekamalii@gmail.com
1
Physical Therapy Department, School of Rehabilitation Sciences, Shiraz
University of Medical Sciences, Shiraz, Iran
2
Rehabilitation Sciences Research Center, Shiraz University of Medical
Sciences, Shiraz, Iran
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16
https://doi.org/10.1186/s12998-018-0185-z
involved [5]. The SIJ is part of the lumbarpelvichip
complex; since this complex works as a mechanical unit,
the involvement of any structure can affect the position
and movement of other sections [6].
Generally speaking, most patients with SLDD prefer
conservative treatments to surgical intervention. To
date, evidence has supported several conservative treat-
ments for SLDD including traction [7], McKenzie exten-
sion exercises [8] and rehabilitation [9].
The use of spinal manipulative therapy (SMT) for pa-
tients with SLDD has also been suggested; however, its
safety and indications have remained debatable, particu-
larly in individuals with disc disruption or instability [2].
In this regard, the risk of SMT causing clinically wors-
ened disc herniation or cauda equine syndrome in pa-
tients with LDH is estimated to be less than one in 3.7
million [2]. A systematic review in 2004 also confirmed
the safety and effectiveness of SMT for patients with
SLDD [2].
Some studies reported significant clinical improvements
in patients with SLDD after manipulation in comparison
to traction [10], heat [11] and sham manipulation [12],
but no significant differences when compared to exercise
therapy and medical corsets [11]. A recent study found
long-term improvement in pain and functional activity
after 1 year of follow-up [13], and another study in 2016
reported significant improvement in leg pain after 1 month
in patients with extrusion and sequestration of lumbar
discs, following manipulation [14].
Sacroiliac joint hypomobility has usually been over-
looked in the management of patients with LDH and low
back problems. However, there is no conclusive evidence
for the effectiveness of SMT in the treatment of patients
with LDH, and the evidence to date is contradictory.
Therefore, the present study aimed to investigate the ef-
fect of SMT applied to the lumbar spine and SIJ to treat
patients with SLDD who also had SIJ hypomobility.
Methods
Participants
Twenty patients (11 males, 9 females) aged 2050 years
old with MRI-proven unilateral LDH were included IN
2010 if they had SLDD in the L4-L5 or L5-S1 segment
concomitant with ipsilateral SIJ hypomobility (Table 1).
Leg pain during 1 to 10 months before the study was
their major complaint, and the mean level of leg pain
during the previous 24 h was 3070 out of 100 on a 0
100 numerical rating scale (NRS). The time interval
allowed between the MRI diagnosis and inclusion in the
study was 3 months. Exclusion criteria were sequestrated
LDH with neurological signs, spinal canal stenosis, spon-
dylolisthesis, previous lumbar surgery and gross instabil-
ity. Patients a with positive well straight leg raise (SLR)
test, indicating rather large disc herniation and poor
prognosis for conservative treatments [15,16], were also
excluded.
Study design
This was a prepost test quasi-experimental study. The
participants were selected among patients referred to
physical therapy clinics of Shiraz, Iran. Sample size was
calculated based on the NRS pain score reported in a
previous related study (mean [95% CI] = 22 [1530], α=
0.05, β= 0.02) [17]. Written informed consent was ob-
tained and ethical approval was granted by the Shiraz
University of Medical Sciences Ethics Committee (ap-
proval number CT-88-4614).
Demographic data, pain intensity, functional disability
and clinical diagnostic tests were recorded at baseline.
After that, the patients received five sessions of manipu-
lative therapy on alternate days, and the outcomes were
reassessed after the 1st and 5th sessions and at a 1-
month follow-up. All patients received both lumbar and
SIJ manipulations in each treatment session.
Interventions
Lumbar rotation manipulation
The neutral position of the spine was used for side-
posture lumbar manipulation. The patient lay on the
asymptomatic side (e.g. left) in the lateral recumbent
position, with his or her upper foot in the popliteal fossa
of the lower leg. Standing opposite to the patient, the
therapist grasped the patients lower shoulder and arm
and applied right rotation until motion was felt in the
desired segment of the lumbar spine. The patient was
rolled toward the therapist, with his or her arms posi-
tioned around the therapists right arm. The therapists
right forearm was in contact with the patients right ax-
illa and pectoral region to maintain appropriate rotation
from above. In this position, the therapist applied a
high-velocity low-amplitude thrust to the pelvis in an
anterior direction with his or her left forearm placed
Table 1 Participantsdemographic characteristics (N= 20)
Variable Value
a
Age 37.86 ± 9.62
BMI 25.10 ± 3.12
Side of LDH Right 11 (55)
Left 9 (45)
Side of SIJ hypomobility Right 8 (40)
Left 12 (60)
Segment of LDH L4 - L5 5 (25)
L5 - S1 15 (75)
Abbreviations:BMI body mass index, LDH lumbar disc herniation, SIJ
sacroiliac joint
a
Values are mean ± SD for continuous variables and number (percentage) for
categorical variables
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16 Page 2 of 7
behind the patients right hip. The therapist pressed the
spinous process of the upper vertebra downward with
his or her right thumb, while pulling the spinous process
of the lower vertebra upward with his or her left thumb.
The procedure was done in a way that avoided exacer-
bating the patients pain at the barrier point [18] (Fig. 1).
Sacroiliac joint manipulation
The patients lay supine on a treatment table, with their
fingers interlocked behind their head. The therapist
stood contralateral to the side to be manipulated and
moved the patient onto his or her side, then leaned to-
ward the dysfunction side, rotated the patient, and
exerted a quick thrust to the anterior superior iliac spine
in the posterior and inferior directions [18,19] (Fig. 2).
Outcome measures
The scores for back and leg pain were recorded separ-
ately on an NRS of 0 to 100, in which 0 indicated no
pain and 100 indicated the worst perceived pain [20].
The minimal clinically important change (MCIC) in
NRS score was 20 points [21,22].
The patientsfunctional disability level was determined
with the Oswestry Disability Index (ODI), a 10-item
questionnaire in which each item is scored from 0 to 5
[23]. The maximum score on the ODI is 50, and higher
scores indicate greater functional disability. However, in
the present study the maximum score was 45, since the
sex life item was omitted due to cultural issues. There-
fore relative values are reported here as the total score/
total possible score × 10. The MCIC for the ODI was re-
ported as 6 points in a sample of patients with LBP who
received physical therapy [24].
Participants were also assessed with the SLR and
slump tests to diagnose LDH, and standing flexion, sit-
ting flexion and Gillet tests were used to diagnose SIJ
hypomobility. Although the evidence is contradictory,
some studies have reported acceptable reliability for the
SIJ test. [2527] The results of five clinical tests were
recorded as positive or negative values at baseline, in the
5th session and 1 month after baseline.
Statistical analysis
The data were analyzed with the Statistical Package for
Social Sciences (SPSS), version 21.0 (IBM Corp.,
Armonk, NY, USA). The KolmogorovSmirnov test of
normality was conducted for all quantitative variables.
Repeated measure ANOVA was used to assess the
trends in changes in the NRS and ODI scores. Individual
time point differences were determined by the Bonfer-
roni post hoc test, and the results of the five clinical
tests were analyzed with the McNemar test.
Results
The NRS score for back pain showed statistically signifi-
cant improvement in the 5th session (P= 0.034) and at
1-month follow-up (P= 0.047) compared to the baseline
value. In addition, statistically significant improvement
in the leg NRS score was seen in the 5th session (P=0.
010) and at 1-month follow-up (P= 0.006). Because the
MCIC for NRS scores in the present study was 20
points, NRS score improvements in back and leg pain
were not clinically significant in the 5th session or at 1-
month follow-up (Figs. 3and 4) (Table 2).
The ODI scores indicated statistically significant im-
provement in the 5th session (P= 0.001) and at 1-month
follow-up (P = 0.001). Because the MCIC for ODI score
in the present study was 6 points, the improvements
were not considered clinically significant at the 5th ses-
sion or at 1-month follow-up (Fig. 5) (Table 2).
In 78.3% of our patients, the sides of SIJ hypomobility
and LDH were the same. After treatment, the patients
showed statistically significant improvements in Gillet,
standing flexion and sitting flexion tests in the 5th ses-
sion and at 1-month follow-up (P0.001). The findings
also indicated 95% improvement in the results of the SIJ
Fig. 1 Lumbar rotation manipulation
Fig. 2 Sacroiliac joint manipulation
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16 Page 3 of 7
hypomobility tests after SMT. We also observed a 20%
improvement in the SLR test results and a 15% improve-
ment in the slump test in the 5th session and at 1-
month follow-up after SMT, although these changes
were not statistically significant (Table 3).
Discussion
The aim of the present study was to investigate the ef-
fect of SMT on pain, functional disability and the results
of clinical tests of SIJ function and LDH in patients with
unilateral SLDD plus SIJ hypomobility. Our findings sug-
gest that five sessions of lumbar and SIJ manipulation
can lead to statistically significant improvement in pain
and functional disability, which in turn may restore nor-
mal SIJ mobility in these patients.
Compared to common treatments for LDH, SMT is
reported to be 37,000 to 148,000 times safer than non-
steroid antiinflammatory drugs and 55,500 to 444,000
times safer than surgery [28]. Neither worsening of
symptoms nor cauda equine syndrome were observed in
our participants after SMT. Epidemiologic data on the
rate of injuries caused by manipulation are limited. The
most common incidents are related to innocuous
physiologic reactions or short-term discomfort generated
at the treatment site. However, these are self-limiting
events that usually resolve within 24 h after SMT [28].
In rotational side-posture lumbar manipulation, the
impact of the facet joints limits axial rotation of the
lower lumbar vertebrae and consequently prevents an-
nulus fibrosus tearing [28]. In the present study, patients
with sequestrated LDH who had neurological signs were
excluded because these patients may have bowel and
bladder disorders, and many (but not all) of them are
thus candidates for surgery [29]. In the present study
manipulation was applied in the neutral flexionexten-
sion position to reduce the risk of injury.
The diagnosis and treatment of SIJ hypomobility in pa-
tients with SLDD are important issues that have not been
adequately addressed in the literature. In 78.3% of our
cases, the side of SIJ hypomobility was the same as the
side of LDH. After treatment, 95% improvement was ob-
tained in the results of SIJ hypomobility tests (Table 2).
The SIJ has been reported to be one of the main sources
of low back disorders [5]. A recent study also found that SIJ
dysfunction was a prevalent concomitant pathology in pa-
tients with LDH. Therefore, SIJ dysfunction should be con-
sidered in the treatment of these patients [4]. Pelvic
asymmetry as well as hypermobility or hypomobility of the
spinal or sacroiliac joints can cause low back pain [3,30].
Any involvement of the SIJ can induce muscle spasm in the
piriformis, which in turn can lead to sciatic irritation and a
wide range of symptoms mimicking radiculopathy [5]. In-
creased tension in the quadratus lumborum, iliopsoas or
hamstring muscles may also affect the SIJ mechanism of ac-
tion. Presumably, SIJ manipulation can decrease tension in
these muscles and consequently correct lumbar spine dys-
function [3,31].
Several mechanisms have been theorized for the mech-
anical and neurophysiological basis of SMT, including
stimulation or modulation of the somatosensory system to
evoke neuromuscular reflexes [32]. Forceful stretching of
the spinal muscles induces relaxation after SMT. Other
mechanisms are induced hypoalgesia [33], kinematic cor-
rection [34,35] and increased lumbar range of motion
[36]. A brief reduction in intradiscal pressure during SMT
in cadavers and return to baseline within less than 1 min
was reported in one earlier study [37]. Another study
showed reduced H-reflex amplitude in patients with uni-
lateral disc herniation, which improved after SMT [11].
The improved outcomes in our patients can be attributed
to two main factors. Firstly, SIJ manipulation may improve
normal functioning of the lumbar spine and related mus-
cles [38]. Secondly, lumbar side-posture rotational ma-
nipulation can induce spinal muscle relaxation [32],
Fig. 3 Trend in back pain intensity during the trial
Fig. 4 Trend in leg pain intensity during the trial
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16 Page 4 of 7
improve lumbar range of motion [36], and briefly decrease
intradiscal pressure [37].
The results of the SIJ hypomobility tests (including the
Gillet test, standing flexion and sitting flexion tests) im-
proved significantly in the 5th session and after 1-month
follow-up compared to baseline values, whereas no sta-
tistically significant improvement was observed in the
SLR and slump tests. Spinal manipulative therapy may
enhance mobility of the SIJ and lumbar vertebrae, and
affect the muscles in these regions, thus accounting for
the improvement in pain and functional ability. How-
ever, significant changes in the slump and SLR tests may
require additional interventions such as soft tissue ma-
nipulation and nerve mobilization, which were not
tested in this study.
In one controlled trial, SMT and sham manipulation
were compared in 102 participants with MRI-confirmed
LDH; the SMT group showed significantly greater im-
provement in back and leg pain after 6 months [12].
Nevertheless, the intervention in that study was a com-
bination of soft tissue manipulation and thrust manipu-
lation, and the diagnosis and treatment of SIJ
hypomobility were not considered.
In a prospective cohort study, Leemann et al., investi-
gated the effect of high-velocity, low-amplitude SMT in
patients with acute or chronic MRI-confirmed LDH, and
reported clinically significant improvement in back and
leg NRS and ODI scores in both short-term and long-
term assessments [13]. In a follow-up study, Ehrler et al.,
investigated the association of magnetic resonance im-
aging features, including axial location and type of her-
niation, with the outcomes of SMT in patients with
LDH [14]. This study reported greater improvements in
symptoms among patients with sequestrated SLDD who
received SMT to the level of herniation. These studies,
however, did not consider the treatment of the SIJ in pa-
tients with LDH.
Burton et al., also compared SMT with chemonucleo-
lysis in the treatment of patients with SLDD, and
reported greater improvements in back pain and disabil-
ity in the first few weeks in the SMT group [39]. Their
SMT, however, included a combination of thrust ma-
nipulation, mobilization and soft tissue stretching.
The results of previous studies have shown that SMT
is effective in the treatment of LDH [40]. The study
most similar to ours is the one by Galm et al., which in-
cluded 150 patients with LDH, 46 of whom had SIJ dys-
function. All participants received routine physiotherapy,
mobilization and SMT in the prone position. Significant
improvements were reported in lumbar and ischiatic
pain in the SIJ dysfunction group. These authors con-
cluded that in the presence of lumbar and ischiatic
symptoms, appropriate treatment for SIJ dysfunction
should be considered regardless of intervertebral disc
Table 2 Mean values of back pain, leg pain and functional disability during the trial
Outcomes Baseline
a
1st session 5th session 1 month Times with statistically significant differences (P-value)
Back NRS 44.95 ± 26.18 42.00 ± 25.30 30.50 ± 19.32 29.75 ± 16.42 Baseline - 5th session (0.034)
Baseline - 1 month (0.047)
Leg NRS 49.50 ± 23.94 47.25 ± 24.35 36.00 ± 16.90 33.75 ± 13.75 Baseline - 5th session (0.010)
Baseline - 1 month (0.006)
ODI 14.45 ± 4.40 n.d. 11.35 ± 4.54 10.95 ± 4.27 Baseline - 5th session (0.001)
Baseline - 1 month (0.001)
Abbreviations:NRS numerical rating scale, ODI Oswestry Disability Index, n.d. not determined
a
Values are mean ± SD
Fig. 5 Trend in functional disability level during the trial
Table 3 Distribution of improvements in diagnostic test results
in the 5th session and after 1-month follow-up
Test 5th session 1 month
(Positive/
Negative)
P-value (Positive/
Negative)
P-value
Gillet 1/19 < 0.001
*
1/19 < 0.001
*
Standing flexion 1/19 < 0.001
*
1/19 < 0.001
*
Sitting flexion 1/19 < 0.001
*
1/19 < 0.001
*
SLR 16/4 0.12 17/3 0.25
Slump 17/3 0.25 17/3 0.25
Abbreviations:SLR straight leg raising
*
Significant recovery compared to baseline
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16 Page 5 of 7
pathomorphology [3]. In this study, however, the num-
ber of treatment sessions and the results of SIJ and LDH
physical tests were not reported.
Our study had some limitations which should be
noted. The prepost test design did not include a con-
trol group; consequently, the results cannot be consid-
ered evidence in support of the clinical efficacy of SMT
for patients with LDH and SIJ hypomobility. A
controlled trial is advisable in which combined manipu-
lations are compared to lumbar or SIJ manipulation sep-
arately, to elucidate whether using both lumbar and SIJ
manipulation together yields better outcomes than using
a single type of manipulation. The small sample size and
lack of long-term follow-up are other limitations. In
addition, we are aware that measuring physiologic re-
sponses to SMT by recording electromyographic activity
of the spinal muscles, the myotomes and dermatomes of
the involved nerve roots, would strengthen the results of
future studies. Also, more reliable tests for SIJ dysfunc-
tion are available and should be used in future studies.
Despite these limitations, we addressed some shortcom-
ings of previous studies. The strengths of the present
study were matching of the physical examination find-
ings with imaging findings, considering SIJ hypomobility
in the treatment of patients with LDH, and the applica-
tion of spinal thrust manipulation alone rather than a
combination of therapeutic methods.
Conclusions
Spinal manipulative therapy can potentially improve
pain, functional disability and SIJ mobility in patients
with LDH concomitant with SIJ hypomobility; therefore,
it can be implemented in physical therapy programs for
these patients. However, further studies with larger sam-
ple sizes, longer follow-up periods and real control
groups should be done to provide more accurate results.
Abbreviations
LDH: Lumbar disc herniation; MCIC: Minimally clinically important change;
NRS: Numerical rating scale; ODI: Oswestry disability index; SIJ: Sacroiliac joint;
SLDD: Symptomatic lumbar disc disease; SMT: Spinal manipulative therapy
Acknowledgements
The authors would like to thank the Research Consultation Center (RCC) of
Shiraz University of Medical Sciences for their assistance with English-language
editing of this article, and K. Shashok (AuthorAID in the Eastern Mediterranean)
for improving the use of English in the revised manuscript.
Availability of data and materials
Please contact the corresponding author for raw data requests.
Authorscontributions
Concept development and design: ESh, FK, FG. Supervision: FK, FG. Data
collection/processing: ESh, FK, ES. Analysis/Interpretation: ESh, FK, ES. Writing
and critical review: ESh, ES. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Approval was granted by the Shiraz University of Medical Sciences Ethics
Committee (approval code: CT-88-4614).
Consent for publication
Written informed consent was obtained from the patients for publication of their
individual details and accompanying images in this manuscript. The consent form
is held by the authors and is available for review by the Editor-in-Chief.
Competing interests
The authors declare that they have no competing interests.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Physical Therapy Department, School of Rehabilitation Sciences, Shiraz
University of Medical Sciences, Shiraz, Iran.
2
Rehabilitation Sciences Research
Center, Shiraz University of Medical Sciences, Shiraz, Iran.
3
School of
Rehabilitation Sciences, Shiraz University of Medical Sciences, Abiverdi 1
St,Chamran Blvd., P.O. Box 71345-1733, Shiraz, Iran.
Received: 14 July 2017 Accepted: 4 April 2018
References
1. Adams MA, Bogduk N, Burton K, Dolan P. The Biomechanics of Back Pain,
2nd Ed. Edinburgh: Churchill Livingstone; 2006.
2. Lisi AJ, Holmes EJ, Ammendolia C. High-velocity low-amplitude spinal
manipulation for symptomatic lumbar disk disease: a systematic review of
the literature. J Manip Physiol Ther. 2005;28:42942.
3. Galm R, Fröhling M, Rittmeister M, Schmitt E. Sacroiliac joint dysfunction in
patients with imaging-proven lumbar disc herniation. Eur Spine J. 1998;7:4503.
4. Madani SP, Dadian M, Firouznia K, Alalawi S. Sacroiliac joint dysfunction in
patients with herniated lumbar disc: a cross-sectional study. J Back
Musculoskel Rehabil. 2013;26:2738.
5. Weksler N, Velan GJ, Semionov M, Gurevitch B, Klein M, Rozentsveig V,
Rudich T. The role of sacroiliac joint dysfunction in the genesis of low back
pain: the obvious is not always right. Arch Orthop Trauma Surg. 2007;127:
8858.
6. Hertling D, Kessler RM. Management of common musculoskeletal disorders :
physical therapy principles and methods. 4th ed. Philadelphia: Lippincott
Williams & Wilkins; 2006.
7. Harte AA, Baxter GD, Gracey JH. The efficacy of traction for back pain: a
systematic review of randomized controlled trials 1, 2. Arch Phys Med
Rehabil. 2003;84:154253.
8. Clare HA, Adams R, Maher CG. Construct validity of lumbar extension
measures in McKenzie's derangement syndrome. Man Ther. 2007;12:32834.
9. Marshall PW, Murphy BA. Evaluation of functional and neuromuscular
changes after exercise rehabilitation for low back pain using a Swiss ball: a
pilot study. J Manip Physiol Ther. 2006;29:55060.
10. Liu J, Zhang S. Treatment of protrusion of lumbar intervertebral disc by
pulling and turning manipulations. J Trad Chin Med. 2000;20:195.
11. Floman Y, Liram N, Gilai A. Spinal manipulation results in immediate H-reflex
changes in patients with unilateral disc herniation. Eur Spine J. 1997;6:398401.
12. Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of
acute back pain and sciatica with disc protrusion: a randomized double-
blind clinical trial of active and simulated spinal manipulations. Spine J.
2006;6:1317.
13. Leemann S, Peterson CK, Schmid C, Anklin B, Humphreys BK. Outcomes of
acute and chronic patients with magnetic resonance imagingconfirmed
symptomatic lumbar disc herniations receiving high-velocity, low-amplitude,
spinal manipulative therapy: a prospective observational cohort study with
one-year follow-up. J Manip Physiol Ther. 2014;37:15563.
14. Ehrler M, Peterson C, Leemann S, Schmid C, Anklin B, Humphreys BK.
Symptomatic, MRI confirmed, lumbar disc Herniations: a comparison of
outcomes depending on the type and anatomical axial location of the
hernia in patients treated with high-velocity, low-amplitude spinal
manipulation. J Manip Physiol Ther. 2016;39:1929.
15. Khuffash B, Porter R. Cross leg pain and trunk list. Spine. 1989;14:6023.
16. Kosteljanetz M, Bang F, Schmidt-olsen S. The clinical significance of straight-leg
raising (Lasegue's sign) in the diagnosis of prolapsed lumbar disc: Interobserver
variation and correlation with surgical finding. Spine. 1988;13:3935.
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16 Page 6 of 7
17. Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercise therapy in
patients with chronic low back pain: a randomized, controlled trial with
1-year follow-up. Spine. 2003;28:52531.
18. Cleland JA, Fritz JM, Childs JD, Kulig K. Comparison of the effectiveness of
three manual physical therapy techniques in a subgroup of patients with low
back pain who satisfy a clinical prediction rule: study protocol of a randomized
clinical trial [NCT00257998]. BMC Musculoskelet Disord. 2006;7:1.
19. Kamali F, Shokri E. The effect of two manipulative therapy techniques and
their outcome in patients with sacroiliac joint syndrome. J Bodyw Mov Ther.
2012;16:2935.
20. Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain rating scale
in patients with low back pain. Spine. 2005;30:13314.
21. Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically
important changes in chronic musculoskeletal pain intensity measured on a
numerical rating scale. Eur J Pain. 2004;8:28391.
22. Ostelo RW, de Vet HC. Clinically important outcomes in low back pain. Best
Pract Res Clin Rheumatol. 2005;19:593607.
23. Roland M, Fairbank J. The RolandMorris disability questionnaire and the
Oswestry disability questionnaire. Spine. 2000;25:311524.
24. Fritz JM, Irrgang JJ. A comparison of a modified Oswestry low back pain
disability questionnaire and the Quebec back pain disability scale. Phys
Ther. 2001;81:77688.
25. Carmichael JP. Inter-and intra-examiner reliability of palpation for sacroiliac
joint dysfunction. J Manip Physiol Ther. 1987;10:16471.
26. Herzog W, Read L, Conway P, Shaw L, McEwen M. Reliability of motion
palpation procedures to detect sacroiliac joint fixations. J Manip Physiol
Ther. 1989;12:8692.
27. Cibulka MT, Delitto A, Koldehoff RM. Changes in innominate tilt after
manipulation of the sacroiliac joint in patients with low back pain: an
experimental study. Phys Ther. 1988;68:135963.
28. Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk
herniations: a systematic review and risk assessment. J Manip Physiol Ther.
2004;27:197210.
29. Magee DJ. Orthopedic physical assessment, 6th ed. St. Lois: Elsevier; 2014.
30. Levangie PK. The association between static pelvic asymmetry and low back
pain. Spine. 1999;24:123442.
31. Cibulka MT, Rose SJ, Delitto A, Sinacore DR. Hamstring muscle strain treated
by mobilizing the sacroiliac joint. Phys Ther. 1986;66:12203.
32. Herzog W, Scheele D, Conway PJ. Electromyographic responses of back and
limb muscles associated with spinal manipulative therapy. Spine. 1999;24:
14652.
33. Vernon H. Qualitative review of studies of manipulation-induced
hypoalgesia. J Manip Physiol Ther. 2000;23:1348.
34. Lehman GJ, McGill SM. The influence of a chiropractic manipulation on lumbar
kinematics and electromyography during simple and complex tasks: a case
study. J Manip Physiol Ther. 1999;22:57681.
35. Cramer GD, Tuck NR, Knudsen JT, Fonda SD, Schliesser JS, Fournier JT, Patel P.
Effects of side-posture positioning and side-posture adjusting on the lumbar
zygapophysial joints as evaluated by magnetic resonance imaging: a before
and after study with randomization. J Manip Physiol Ther. 2000;23:38094.
36. Whittingham W, Nilsson N. Active range of motion in the cervical spine
increases after spinal manipulation (toggle recoil). J Manip Physiol Ther.
2001;24:5525.
37. Maigne J-Y, Guillon F. Highlighting of intervertebral movements and
variations of intradiskal pressure during lumbar spine manipulation: a
feasibility study. J Manip Physiol Ther. 2000;23:5315.
38. Isaacs ER, Bookhout MR. Bourdillons Spinal Manipulation. 6th ed. Boston:
Butterworth Heinemann; 2002.
39. Burton AK, Tillotson KM, Cleary J. Single-blind randomised controlled trial of
chemonucleolysis and manipulation in the treatment of symptomatic
lumbar disc herniation. Eur Spine J. 2000;9:2027.
40. Hahne AJ, Ford JJ, McMeeken JM. Conservative management of lumbar disc
herniation with associated radiculopathy: a systematic review. Spine. 2010;
35:E488504.
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16 Page 7 of 7
... No que diz respeito a dor, a maior parte dos estudos mostram uma melhora após a manipulação articular. No estudo de Shokri et al. [14], avaliaram 20 pacientes com lombalgia, proveniente de hérnia lombar, a qual aplicaram uma manipulação na articulação sacro-ilíaca, que apresentaram melhora da dor percebida, através da escala numérica da dor, a partir da quinta sessão, com um mês de tratamento. ...
... Quanto a ADM, todos as pesquisas que tiveram esse parâmetro avaliado, observaram um aumento. Esse resultado está relacionado a melhora da mobilidade articular, através do relaxamento muscular pós-manipulação [14,15]. Um estudo realizado anteriormente, mostrou que em duas sessões/semana durante 6 meses, em pacientes com lombalgia crônica não específica restaurou o movimento em todos os planos anatômicos da coluna lombar [7]. ...
... Interdependência regional é o termo que tem sido utilizado para descrever observações clínicas, relacionadas a diferentes regiões do corpo, principalmente com distúrbios musculoesqueléticos. Existe uma crescente base literária demonstrando que as intervenções aplicadas a uma determinada região anatômica podem influenciar o resultado e a função de outras regiões do corpo, que aparentemente poderiam não estar relacionadas [14]. ...
Article
O objetivo do presente estudo é revisar a literatura sobre a manipulação articular manual (MAM) e seus efeitos em indivíduos com lombalgia. Trata-se de uma revisão de literatura, realizada pela seleção de artigos nas bases de dados Periódico da CAPES, Scielo e PubMed Central, publicados nos últimos 5 anos (2015-2019). A pesquisa foi limitada à língua portuguesa e inglesa, com estudos realizados em humanos, foram excluídos resumos de dissertações ou teses acadêmicas, artigos de revisão e de opinião. Os desfechos considerados foram: efeito da manipulação na dor lombar aguda ou crônica, na qualidade de vida, na amplitude de movimento da coluna (ADM) e na incapacidade. A seleção dos artigos foi inicialmente através da apreciação dos títulos e em seguida dos resumos, que tinham potencial relevância, assim na sequência foi analisado cautelosamente em relação a elegibilidade através da leitura do artigo completo. E esta revisão foi realizada por meio de dois revisores independentes. Diante das buscas foram encontrados 102 artigos, desses, apenas 8 foram incluídos no estudo. Os resultados obtidos nesta revisão descrevem efeitos positivos da técnica MAM em sintomas de lombalgias, como dor, ADM e incapacidade, entretanto seus efeitos em QV permaneceram sem conclusões específicas neste caso.Palavras-chave: dor lombar, manipulação musculoesquelética, manipulação da coluna.
... For the imagistic diagnosis, at present, there is used simple X-ray for lumbar spine in two instances (front and profile), CT scan and magnetic resonance imaging (MRI). For now, MRI represents the selection imagistic method due to its advantage of not using ionizing radiations and its good visualization characteristics, especially for the soft tissues [25][26][27][28]. ...
Article
Full-text available
Lumbar herniated disc is the most frequent cause for lumbar pain. It is caused by degenerative, macroscopic and microscopic changes of the intervertebral discs. It is a chronic disease, with periods of exacerbation and remission under drug and physiotherapeutic treatment. When the disc lesions are large, with intense symptoms, reduced or impossible movements, with pain radiating to the sciatic nerve trajectory, a surgical treatment is required, to remove the herniated nucleus pulposus and decompress the nerve roots. Patients who present high inflammatory signs, high inflammatory serous markers, may have a longer postoperative recovery period, while the motor recovery may be late and incomplete. We analyzed a group of 24 patients with lumbar herniated disc that required discectomy, with clear inflammatory signs, together with histopathological and immunohistochemical changes present in the herniated disc.
... Besides, the concept of rapid rehabilitation is increasingly popularized in modern surgical treatment. PTED has the advantages of minimally invasiveness, short operation time, and fast recovery, which is in line with the concept of rapid rehabilitation [25,26]. Therefore, PTED has been widely used in the treatment of LDH [27]. ...
Article
Full-text available
Objective: This study sets out to investigate the role of magnetic resonance imaging (MRI) combined with magnetic resonance myelography (MRM) in patients after percutaneous transforaminal endoscopic discectomy (PTED) and to evaluate its value in postoperative rehabilitation. Methods: The clinical date of 96 patients with lumbar disc herniation (LDH) after PTED was retrospectively analyzed. The enrolled patients were divided into MRI group (n = 32) and MRI + MRM group (n = 64) according to whether MRM was performed. The nerve root sleeve (morphology, deformation) and dural indentation, intervertebral space height (ISH), intervertebral space angle (ISA), degree of pain (Visual Analogue Scale (VAS)), vertebral function (Japanese Orthopaedic Association (JOA)), and long-term recurrence were compared between the two groups. Results: Compared with the MRI group, the MRI + MRM group better displayed nerve root morphology, sheath sleeve deformation, and dural indentation. Both MRI and MRI + MRM showed ISH and ISA changes well. Compared with the MRI group, the MRI + MRM group had a significantly lower VAS score for lumbar and leg pain, a significantly higher JOA score, and a significantly lower 2-year recurrence rate. Conclusion: MRM combined with MRI is more beneficial to improve the prognosis of LDH patients after PTED.
... However, given the viscoelastic property of biological tissues and the high-velocity dynamic nature of SMT thrust, it is possible that other SMT characteristics (such as loading rate and thrust speed) could elicit different intradiscal pressure and loading of the intervertebral disc. Importantly, patients with lumbar disc herniation have been observed to significantly improve their pain level and disability following SMT (Leemann et al., 2014;Shokri et al., 2018). This suggests that, in addition to changes in intradiscal pressure, SMT may elicit other intervertebral disc responses, which may contribute to SMT's clinical effects. ...
Article
Background: Previous studies observed that the intervertebral disc experiences the greatest forces during spinal manipulative therapy (SMT) and that the distribution of forces among spinal tissues changes as a function of the SMT parameters. However, contextualized SMT forces, relative to the ones applied to and experienced by the whole functional spinal unit, is needed to understand SMT's underlying mechanisms. Aim: To describe the percentage force distribution between spinal tissues relative to the applied SMT forces and total force experienced by the functional unit. Methods: This secondary analysis combined data from 35 fresh porcine cadavers exposed to a simulated 300N SMT to the skin overlying the L3/L4 facet joint via servo-controlled linear motor actuator. Vertebral kinematics were tracked optically using indwelling bone pins. The functional spinal unit was then removed and mounted on a parallel robotic platform equipped with a 6-axis load cell. The kinematics of the spine during SMT were replayed by the robotic platform. By using serial dissection, peak and mean forces induced by the simulated SMT experienced by spinal structures in all three axes of motion were recorded. Forces experienced by spinal structures were analyzed descriptively and the resultant force magnitude was calculated. Results: During SMT, the functional spinal unit experienced a median peak resultant force of 36.4N (IQR: 14.1N) and a mean resultant force of 25.4N (IQR: 11.9N). Peak resultant force experienced by the spinal segment corresponded to 12.1% of the total applied SMT force (300N). When the resultant force experienced by the functional spinal unit was considered to be 100%, the supra and interspinous ligaments experienced 0.3% of the peak forces and 0.5% of the mean forces. Facet joints and ligamentum flavum experienced 0.7% of the peak forces and 3% of the mean forces. Intervertebral disc and longitudinal ligaments experienced 99% of the peak and 96.5% of the mean forces. Frontiers in Integrative Neuroscience | www.frontiersin.org 1 February 2022 | Volume 15 | Article 809372 Funabashi et al. Spinal Manipulative Therapy Force Distribution Conclusion: In this animal model, a small percentage of the forces applied during a posterior-to-anterior SMT reached spinal structures in the lumbar spine. Most SMT forces (over 96%) are experienced by the intervertebral disc. This study provides a novel perspective on SMT force distribution within spinal tissues.
... However, given the viscoelastic property of biological tissues and the high-velocity dynamic nature of SMT thrust, it is possible that other SMT characteristics (such as loading rate and thrust speed) could elicit different intradiscal pressure and loading of the intervertebral disc. Importantly, patients with lumbar disc herniation have been observed to significantly improve their pain level and disability following SMT (Leemann et al., 2014;Shokri et al., 2018). This suggests that, in addition to changes in intradiscal pressure, SMT may elicit other intervertebral disc responses, which may contribute to SMT's clinical effects. ...
Article
Full-text available
Background Previous studies observed that the intervertebral disc experiences the greatest forces during spinal manipulative therapy (SMT) and that the distribution of forces among spinal tissues changes as a function of the SMT parameters. However, contextualized SMT forces, relative to the ones applied to and experienced by the whole functional spinal unit, is needed to understand SMT’s underlying mechanisms. Aim To describe the percentage force distribution between spinal tissues relative to the applied SMT forces and total force experienced by the functional unit. Methods This secondary analysis combined data from 35 fresh porcine cadavers exposed to a simulated 300N SMT to the skin overlying the L3/L4 facet joint via servo-controlled linear motor actuator. Vertebral kinematics were tracked optically using indwelling bone pins. The functional spinal unit was then removed and mounted on a parallel robotic platform equipped with a 6-axis load cell. The kinematics of the spine during SMT were replayed by the robotic platform. By using serial dissection, peak and mean forces induced by the simulated SMT experienced by spinal structures in all three axes of motion were recorded. Forces experienced by spinal structures were analyzed descriptively and the resultant force magnitude was calculated. Results During SMT, the functional spinal unit experienced a median peak resultant force of 36.4N (IQR: 14.1N) and a mean resultant force of 25.4N (IQR: 11.9N). Peak resultant force experienced by the spinal segment corresponded to 12.1% of the total applied SMT force (300N). When the resultant force experienced by the functional spinal unit was considered to be 100%, the supra and interspinous ligaments experienced 0.3% of the peak forces and 0.5% of the mean forces. Facet joints and ligamentum flavum experienced 0.7% of the peak forces and 3% of the mean forces. Intervertebral disc and longitudinal ligaments experienced 99% of the peak and 96.5% of the mean forces. Conclusion In this animal model, a small percentage of the forces applied during a posterior-to-anterior SMT reached spinal structures in the lumbar spine. Most SMT forces (over 96%) are experienced by the intervertebral disc. This study provides a novel perspective on SMT force distribution within spinal tissues.
... The effectiveness and safety of manipulation analgesia have been clinically proven. 27 In recent years, the research of analgesic mechanism in manipulation has gradually shifted from the pathological structural changes 28,29 to the changes of pain neural pathway. 30 As far as the current studies are concerned, SMT works mainly through intervention of pain signal uploading, central pain signal processing, and feedback and suppression of pain signal to affect the pain neural pathway. ...
Article
Full-text available
Objective: To investigate the changes of regional homogeneity (Reho) values before and after spinal manipulative therapy (SMT) in patients with chronic low back pain (CLBP) through rest blood-oxygen-level-dependent functional magnetic resonance imaging (BOLD fMRI). Methods: Patients with CLBP (Group 1, n = 20) and healthy control subjects (Group 2, n = 20) were recruited. The fMRI was performed three times in Group 1 before SMT (time point 1, TP1), after the first SMT (time point 2, TP2), after the sixth SMT (time point 3, TP3), and for one time in Group 2, which received no intervention. The clinical scales were finished in Group 1 every time before fMRI was performed. The Reho values were compared among Group 1 at different time points, and between Group 1 and Group 2. The correlation between Reho values with the statistical differences and the clinical scale scores were calculated. Results: The bilateral precuneus and right mid-frontal gyrus in Group 1 had different Reho values compared with Group 2 at TP1. The Reho values were increased in the left precuneus and decreased in the left superior frontal gyrus in Group 1 at TP2 compared with TP1. The Reho values were increased in the left postcentral gyrus and decreased in the left posterior cingulate cortex and the superior frontal gyrus in Group 1 at TP3 compared with TP1. The ReHo values of the left precuneus in Group 1 at TP1 were negatively correlated with the pain degree at TP1 and TP2 (r = -0.549, -0.453; p = 0.012, 0.045). The Reho values of the middle temporal gyrus in Group 1 at TP3 were negatively correlated with the changes of clinical scale scores between TP3 and TP1 (r = 0.454, 0.559; p = 0.044, 0.01). Conclusion: Patients with CLBP showed abnormal brain function activity, which was altered after SMT. The Reho values of the left precuneus could predict the immediate analgesic effect of SMT.
... Lumbar disc herniation (LDH) refers to the nucleus pulposus tissue protruding or protruding into the posterior or spinal canal due to the rupture of the lumbar intervertebral disc fibrous annulus, resulting in compression of adjacent nerve roots. It produces lumbar pain, pain, and numbness of the lower limbs, and even incontinence, paralysis of both lower limbs [1][2][3]. LDH is a spinal degenerative disease, which generally includes four types: bulging, protruding, free, and Schmorl snodes. It will cause radiating pain in lower limbs clinically, and it is also one of the most common diseases that affect the quality of life of patients in real life [4]. ...
Article
Full-text available
The research aimed at discussing the analytic function of convolutional neural network (CNN) algorithm-based magnetic resonance images (MRI) in the correlation between lumbar disc herniation (LDH) and angle and irregular variation of joint (IVJ) of lumbar facet-joint (LFJ). First, CNN-based MRI (CNNM) algorithm was constructed, and Markov random field (MRF) and fuzzy C-means (FCM) algorithms were introduced for comparison. Meanwhile, all patients received MRI examination of lumbar, and CNNM algorithm was adopted in MRI images. The results showed that the sensitivity, specificity, accuracy, and precision (98.53%, 93.65%, 99.56%, and 98.74%, respectively) of the CNNM algorithm were all superior to those of MRF algorithm (90.41%, 81.11%, 91.18%, and 91.13%, respectively) and of FCM algorithm (93.14%, 82.86%, 93.23%, and 93.08%, respectively) (P<0.05). Besides, the lumbar spine angles of L3-L4, L4-L5, and L5-S1 (6.03 ± 1.34°, 7.14 ± 1.18°, and 8.96 ± 3.26°, respectively) in the experimental group was obviously less than those in the control group (6.84 ± 1.15°, 9.85 ± 1.25°, and 17.34 ± 4.79°, respectively) (P<0.05). In the experimental group, there was irregular mutation of LFJ in 78 cases, while 8 cases suffered from irregular mutation of LFJ in the control group. The proportions of protrusion in L3/4, L4/5, and L5/S1 segments (11 cases, 53 cases, and 14 cases, respectively) was higher than that in the control group (1 case, 5 cases, and 2 cases, respectively) (P<0.05). In short, the constructed CNNM algorithm had excellent performance in diagnosing lumbar MRI images and had clinical research and promotion value. Moreover, the IVJ of patients with LDH was notably increased, most of the physiological angle of the lumbar spine changed, and facet joint was correlated with the occurrence of LDH.
... In addition, the incidence of L4-L5 and L5-S1 is the highest of patients with LDH, accounting for about 95% of the whole symptoms, while the incidence of multiple intervertebral disc herniation only occupies about 15%. LDH tends to emerge in young adults aged 20-40 years old (more males suffer from this disease than females), and it is often common in information technology (IT) practitioners, teachers, civil servants, drivers, and other long-term office workers [4,5]. Excessive bending down should be avoided in life, and the back muscle should be exercised in order to improve lumbar muscle strength. ...
Article
Full-text available
In this paper, the application of 3-dimensional (3D) functional magnetic resonance imaging (FMRI) in the diagnosis of the 5th lumbar (L5) nerve root compression and brain functional areas in patients with lumbar disc herniation (LDH) was analyzed. The traditional fast independent component analysis (Fast ICA) algorithm was optimized based on the modified whitening matrix to establish a new type of Modified-Fast ICA (M-Fast ICA) algorithm that was compared with the introduced traditional Fast ICA and ICA. M-Fast ICA was applied to the 3D FMRI diffusion tensor imaging (DTI) evaluation of 65 patients with L5 nerve root pain due to LDH (group A) and 50 healthy volunteers (group B). The values of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) in the lumbar nerve roots (L3, L4, L5, and the 1st sacral vertebra (S1)) were recorded among subjects from the two groups. Besides, the score of edema degree in the lumbar nerve roots (L5 and S1) and activity of brain functional areas were also recorded among all subjects of the two groups. The results showed that the mean square error of M-Fast ICA was smaller than that of traditional Fast ICA and ICA, while its signal-to-noise ratio (SNR) was greater than that of Fast ICA and ICA (P
... [65][66][67] Osteopathic manipulation has few side effects in the general population 56 or in patients with herniated discs. [68][69][70] Current guidelines suggest manipulation is only contraindicated if there are progressive neurologic signs. 70 Manipulation at the segment of the herniation can be performed with greater safety using techniques that decrease IDP during the procedure. ...
Article
Full-text available
Introduction: Based on the osteopathic principle that “structure and function are interrelated,” a kidney that is not moving optimally with respiration might be limited in its physiologic functions as well. The objective of this study was to determine if osteopathic manipulative treatment (OMT) affects craniocaudal renal mobility and if there are any correlations between renal mobility and blood pressure measurements. Methods: 33 healthy female participants were recruited. 25 participants were in the treatment group, and 8 in the control group. All participants’ blood pressures were recorded initially. All participants were then evaluated for craniocaudal renal mobility via ultrasound measurements using Mindray Z6 technology. The treatment group then received an OMT protocol, while the control group rested for 20 minutes. The ultrasound evaluation for renal mobility was then repeated on the participants, and a final blood pressure reading obtained (Touro College HSIRB #1799). Results: OMT significantly increased the mobility of the right kidney (P<0.05), but not the left kidney. Although there was no direct correlation between changes in renal mobility and changes in blood pressure, both the systolic and diastolic blood pressure readings decreased significantly (P<0.05) after OMT. Conclusion: In this preliminary study, right kidney mobility increased and systolic and diastolic blood pressure measurements both decreased after OMT. Follow-up studies are warranted to further explore kidney mobility and its potential association with blood pressure measurements, as well as the effects of OMT on kidney mobility and blood pressure.
... Globally, scholars have achieved fruitful results in researching the MRI diagnosis of degenerative disc diseases, especially the MRI quantitative detection. [17] found that the intervertebral disc degeneration and multifidus amyotrophy were positively correlated at the L3-L4 intervertebral disc level, and the strengthening program of lumber intervertebral extensor muscle helped prevent amyotrophy and lumbar degeneration. [18] found that T2 and T1rho quantitative magnetic resonance imaging could detect the early degenerative changes of the intervertebral disc, and T1rho was more effective in the differential diagnosis of early degenerative diseases. ...
Article
Full-text available
Objective Based on the theoretical basis of Gabor wavelet transformation, the application effects of feature extraction algorithm in Magnetic Resonance Imaging (MRI) and the role of feature extraction algorithm in the diagnosis of lumbar vertebra degenerative diseases were explored. Method The structure of lumbar vertebra and degenerative changes were respectively introduced to clarify the onset mechanism and pathological changes of lumbar vertebra degenerative changes. Most importantly, the theoretical basis of Gabor wavelet transformation and the extraction effect of feature information in lumbar vertebra MRI images were introduced. The differentiation effects of feature information extraction algorithm on annulus fibrosus and nucleus pulposus were analyzed. In this study, the data of lumbar spine MRI was randomly selected from the Wenzhou Lumbar Spine Research Database as research objects. A total of 130 discs were successfully fitted, and 109 images were graded by a doctor after observation, which was compared with the results of the artificial diagnosis. Through the comparison with the results of observation and diagnosis by professional doctors, the accuracy of feature extraction algorithm based on Gabor wavelet transformation in the diagnosis of lumbar vertebra degenerative changes was analyzed. Results 1. Compared with the results of the manual diagnosis, the accuracy of the classification method was 88.3%. In addition, the specificity (SPE), accuracy (ACC), and sensitivity (SEN) of the classification method were respectively 89.5%, 92.4%, and 87.6%. 2. The mutual information method and the KLT algorithm were utilized for vertebral body tracking. The maximum mutual information method was more effective in the case of fewer image sequences; however, with the increase of image frames, the accumulation of errors would make the tracking effects of images get worse. Based on the KLT algorithm, the enhanced vertebral boundary information was selected; the soft tissues showed in the obtained images were smooth, the boundary information of vertebral body was enhanced, and the results were more accurate. Conclusion The feature extraction algorithm based on Gabor wavelet transformation could easily and quickly realize the localization of the lumbar intervertebral disc, and the accuracy of the results was ensured. In addition, from the aspect of vertebral body tracking, the tracking effects based on the KLT algorithm were better and faster than those based on the maximum mutual information method.
Article
Full-text available
Objective The purposes of this study were to evaluate patients with low-back pain (LBP) and leg pain due to magnetic resonance imaging–confirmed disc herniation who are treated with high-velocity, low-amplitude spinal manipulation in terms of their short-, medium-, and long-term outcomes of self-reported global impression of change and pain levels at various time points up to 1 year and to determine if outcomes differ between acute and chronic patients using a prospective, cohort design. Methods This prospective cohort outcomes study includes 148 patients (between ages of 18 and 65 years) with LBP, leg pain, and physical examination abnormalities with concordant lumbar disc herniations. Baseline numerical rating scale (NRS) data for LBP, leg pain, and the Oswestry questionnaire were obtained. The specific lumbar spinal manipulation was dependent upon whether the disc herniation was intraforaminal or paramedian as seen on the magnetic resonance images and was performed by a doctor of chiropractic. Outcomes included the patient’s global impression of change scale for overall improvement, the NRS for LBP, leg pain, and the Oswestry questionnaire at 2 weeks, 1, 3, and 6 months, and 1 year after the first treatment. The proportion of patients reporting “improvement” on the patient’s global impression of change scale was calculated for all patients and acute vs chronic patients. Pretreatment and posttreatment NRS scores were compared using the paired t test. Baseline and follow-up Oswestry scores were compared using the Wilcoxon test. Numerical rating scale and Oswestry scores for acute vs chronic patients were compared using the unpaired t test for NRS scores and the Mann-Whitney U test for Oswestry scores. Logistic regression analysis compared baseline variables with “improvement.” Results Significant improvement for all outcomes at all time points was reported (P < .0001). At 3 months, 90.5% of patients were “improved” with 88.0% “improved” at 1 year. Although acute patients improved faster by 3 months, 81.8% of chronic patients reported “improvement” with 89.2% “improved” at 1 year. There were no adverse events reported. Conclusions A large percentage of acute and importantly chronic lumbar disc herniation patients treated with chiropractic spinal manipulation reported clinically relevant improvement.
Article
Full-text available
To compare the effect of sacroiliac joint (SIJ) manipulation with SIJ and lumbar manipulation for the treatment of SIJ syndrome. Thirty-two women with SIJ syndrome were randomly divided into two groups of 16 subjects. One group received the high-velocity low-amplitude (HVLA) manipulation to the SIJ and the other group received both SIJ and lumbar HVLA manipulation to both the SIJ and lumbar spine in a single session. The outcomes were assessed using visual analogue scale (VAS) at baseline, immediately, 48 h and one month after the treatment for pain and also Oswestry Disability Index (ODI) questionnaire at baseline, 48 h and one month after the treatment. Analysis revealed a statistically significant improvement immediately, at 48 h and one month after treatment for pain and significant improvement at 48 h and one month after treatment for functional disability in the SIJ manipulated group. A significant improvement immediately, at 48 h and one month after treatment for pain and significant improvement at 48 h and one month after treatment for functional disability in the SIJ and lumbar manipulated group was also found. Furthermore, there were significant differences within groups in ODI and VAS when using Friedman test in both groups. By using Wilcoxon rank sum test no differences were observed in change scores between the two groups immediately, 48 h and one month after the treatment for VAS, or after 48 h and one month after the treatment for the ODI. A single session of SIJ and lumbar manipulation was more effective for improving functional disability than SIJ manipulation alone in patients with SIJ syndrome. Spinal HVLA manipulation may be a beneficial addition to treatment for patients with SIJ syndrome.
Article
Full-text available
A systematic review of randomized controlled trials. To determine the efficacy and adverse effects of conservative treatments for people who have lumbar disc herniation with associated radiculopathy (LDHR). Although conservative management is commonly used for people who have LDHR, the efficacy and adverse effects of conservative treatments for this condition are unclear. We searched 10 computer databases for trials published in English between 1971 and 2008. Trials focusing on people with referred leg symptoms and radiologic confirmation of a lumbar disc herniation were included if at least 1 group received a conservative and noninjection treatment. Eighteen trials involving 1671 participants were included. Seven (39%) trials were considered of high quality. Meta-analysis on 2 high-quality trials revealed that advice is less effective than microdiscectomy surgery at short-term follow-up, but equally effective at long-term follow-up. Individual high-quality trials provided moderate evidence that stabilization exercises are more effective than no treatment, that manipulation is more effective than sham manipulation for people with acute symptoms and an intact anulus, and that no difference exists among traction, laser, and ultrasound. One trial showed some additional benefit from adding mechanical traction to medication and electrotherapy methods. Adverse events were associated with traction (pain, anxiety, lower limb weakness, and fainting) and ibuprofen (gastrointestinal events). Advice is less effective than microdiscectomy in the short term but equally effective in the long term for people who have LDHR. Moderate evidence favors stabilization exercises over no treatment, manipulation over sham manipulation, and the addition of mechanical traction to medication and electrotherapy. There was no difference among traction, laser, and ultrasound. Adverse events were associated with traction and ibuprofen. Additional high-quality trials would allow firmer conclusions regarding adverse effects and efficacy.
Article
Objective: The purpose of this study was to evaluate whether specific MRI features, such as axial location and type of herniation, are associated with outcomes of symptomatic lumbar disc herniation patients treated with spinal manipulation therapy (SMT). Methods: MRI and treatment outcome data from 68 patients were included in this prospective outcomes study. Pain numerical rating scale (NRS) and Oswestry physical disability questionnaire (OPDQ) levels were measured at baseline. The Patients Global Impression of Change scale, the NRS and the OPDQ were collected at 2 weeks, 1, 3, 6 months and 1 year. One radiologist and 2 chiropractic medicine master's degree students analyzed the MRI scans blinded to treatment outcomes. κ statistics assessed inter-rater reliability of MRI diagnosis. The proportion of patients reporting relevant improvement at each time point was compared based on MRI findings using the chi-square test. The t test and ANOVA compared the NRS and OPDQ change scores between patients with various MRI abnormalities. Results: A higher proportion of patients with disc sequestration reported relevant improvement at each time point but this did not quite reach statistical significance. Patients with disc sequestration had significantly higher reduction in leg pain at 1 month compared to those with extrusion (P = .02). Reliability of MRI diagnosis ranged from substantial to perfect (K = .733-1.0). Conclusions: Patients with sequestered herniations treated with SMT to the level of herniation reported significantly higher levels of leg pain reduction at 1 month and a higher proportion reported improvement at all data collection time points but this did not reach statistical significance.
Article
Study Design. A multicenter, randomized, controlled trial with 1-year follow-up. Objectives. To compare the effect of manual therapy to exercise therapy in sick-listed patients with chronic low back pain ( > 8 wks). Summary and Background Data. The effect of exercise therapy and manual therapy on chronic low back pain with respect to pain, function, and sick leave have been investigated in a number of studies. The results are, however, conflicting. Methods. Patients with chronic low back pain or radicular pain sick-listed for more than 8 weeks and less than 6 months were included. A total of 49 patients were randomized to either manual therapy (n = 27) or to exercise therapy ( n = 22). Sixteen treatments were given over the course of 2 months. Pain intensity, functional disability (Oswestry disability index), general health ( Dartmouth COOP function charts), and return to work were recorded before, immediately after, at 4 weeks, 6 months, and 12 months after the treatment period. Spinal range of motion (Schober test) was measured before and immediately after the treatment period only. Results. Although significant improvements were observed in both groups, the manual therapy group showed significantly larger improvements than the exercise therapy group on all outcome variables throughout the entire experimental period. Immediately after the 2-month treatment period, 67% in the manual therapy and 27% in the exercise therapy group had returned to work ( P < 0.01), a relative difference that was maintained throughout the follow-up period. Conclusions. Improvements were found in both intervention groups, but manual therapy showed significantly greater improvement than exercise therapy in patients with chronic low back pain. The effects were reflected on all outcome measures, both on short and long-term follow-up.
Article
Objective: To investigate whether a more sophisticated and detailed analysis of both simple and complex tasks may yield more information regarding the short-term influence of an adjustment on spine biomechanics. Methods: The study used a single-subject, before-after design. Three-dimensional spine kinematics and trunk muscle electromyography were assessed during a variety of tasks performed by a professional golfer exhibiting nonspecific, chronic, low back pain. The patient received a right-to-left and left-to-right spinous pull adjustment. Results: After the adjustment, changes were seen in all 3 axes of motion during a golf swing, with concomitant muscle responses. In addition, changes in the off axes of motion were seen during simple movement tasks. Conclusions: A more detailed spine kinematic analysis, specifically analysis of motion in the nonprincipled axes, yielded more information regarding the short-term influence of an adjustment on lumbar spine motion and muscle function.
Article
To determine the relative frequency of sacroiliac joint dysfunction in a sample of patients with image proven lumbar disc herniation. A single group cross-sectional study was conducted in a three year period from 2007 in an outpatient clinic at a university hospital. Overall, 202 patients aged more than or equal to 18 years with image proven herniated lumbar disc and with physical findings suggestive of lumbosacral root irritation were included. Overall, 146 (72.3%) participants had sacroiliac joint dysfunction. The dysfunction was significantly more prevalent in females (p< 0.001, adjusted OR=2.46, 95% CI=1.00 to 6.03), patients with recurrent pain (p< 0.005, adjusted OR=2.33 with 95% CI=1.10 to 4.89) and patients with positive straight leg raising provocative test (p< 0.0001, adjusted OR=5.07, 95% CI=2.37 to 10.85). There was no significant relationship between the prevalence of SIJD, and working hours, duration of low back pain, or body mass index. Sacroiliac joint dysfunction is a significant pathogenic factor with high possibility of occurrence in low back pain. Thus, regardless of intervertebral disc pathology, sacroiliac joint dysfunction must be considered in clinical decision making.
Article
Part I: Basic Concepts and Techniques Chapter 1: Properties of Dense Connective Tissue Chapter 2: Wound Healing: Injury and Repair of Dense Connective Tissue Chapter 3: Arthrology Chapter 4: Chronic Pain Management in the Adult Chapter 5: Assessment of Musculoskeletal Disorders and Concepts of Management Chapter 6: Introduction to Manual Therapy Chapter 7: Myofascial Considerations and Evaluation in Somatic Dysfunction Chapter 8: Soft Tissue Manipulations Chapter 9: Relaxation and Related Techniques Chapter 10: Functional Exercise Part II: Clinical Applications-Peripheral Joints Chapter 11: The Shoulder and Shoulder Girdle Chapter 12: The Elbow and Forearm Chapter 13: The Wrist and Hand Complex Chapter 14: The Hip Chapter 15: The Knee Chapter 16: The Lower Leg, Ankle and Foot Chapter 17: The Temporomandibular Joint Part III: Clinical-The Spine Chapter 18: The Spine-General Structure and Biomechanical Considerations Chapter 19: The Cervical Spine Chapter 20: The Thoracic Spine Chapter 21: The Cervicothoracic-Upper Limb Scan Examination Chapter 22: The Lumbar Spine Chapter 23: The Sacroiliac Joint and the Lumbar-Pelvic-Hip-Complex Chapter 24: The Lumbosacral Joint and the Lumbar-Pelvic-Hip-Complex Chapter 25: Case Studies Appendix
Article
The purpose of this study was to assess the inter- and intraexaminer reliability of the Gillet-motion palpation procedure using 10 qualified chiropractors and 11 patients with a sacroiliac joint problem. Intraexaminer reliability was found to be statistically significant for all agreement scores investigated. Interexaminer reliability was found to be statistically significant for some of the agreement scores investigated but not for others. Severity of the low back problems did not seem to influence intra- or interexaminer agreement scores; however, chiropractor expertise did. High expertise was associated with lower intraexaminer agreement scores than low expertise. This finding is in contradiction with traditional beliefs and reported findings. The gait of the patient group was found to be significantly different from that of normal subjects as noted in an earlier report.
Article
The prognostic significance of gravity-induced trunk list and cross leg pain was investigated in 113 patients who had root tension signs from a lumbar disc lesion. Cross leg pain, (a positive contralateral straight leg raising sign) and list was associated with poor prognosis for conservative management. There was a high incidence of disc sequestration and extrusion in the operated patients with cross leg pain. It was concluded that cross leg pain is probably a contraindication to chymopapain injections, and the surgeon should be aware of the possibility of a migrated disc fragment during operation on patients with cross leg pain.