A randomized control trial to determine the effectiveness and physiological effects of spinal manipulation and spinal mobilization compared to each other and a sham condition in patients with chronic low back pain: Study protocol for The RELIEF Study

Comparison of Feng spinal mobilization with Maitland mobilization in management of chronic nonspecific low back pain: A cohort study

Feng spinal mobilization (FSM) is one of the most widely practiced techniques in traditional Chinese osteopathy, especially in China. However, whether this FSM technique is more effective than the Maitland posteroanterior mobilization (MM), which is widely used all over the world, is still unknown. The purpose of this study was to retrospectively analyze and compare the efficacy of these 2 treatments in patients with chronic nonspecific low back pain (CNLBP) as to provide a basis for the clinical treatment of chronic low back pain. A total of 83 patients, including 43 patients in the FSM group and 40 in the MM group, were enrolled in this cohort study. FSM or MM was performed on patients 3 times during a period of 2 weeks. Changes in the subjective and objective measurements were measured before and after the third treatment. The subjective symptoms recorded included the visual analogue scale (VAS), Oswestry disability index, and Patient Health Questionnaire-9. The objective symptoms, including the lumbar range of motion (ROM), and straight leg raise (SLR) height were also checked for any changes. The VAS scores were reassessed at the 1-year follow-up visit. The results showed that 2 weeks of FSM treatment significantly improved CNLBP patients modified Schober test (P < .05), extension ROM (P < .01), and SLR height (P < .05) while MM treatment did not. Both treatments significantly decreased the values of VAS, Oswestry disability index, and Patient Health Questionnaire-9 (P < .01). Compared to the MM treatment, the FSM treatment showed a much more significant improvement in VAS score (P < .01), range of motion of extension (P < .01), and SLR of both sides (P < .05). At the 1-year follow-up, VAS scores in both groups decreased significantly compared to pretreatments; however, there was no significant difference between the 2 groups. Our data suggested that the FSM treatment can provide better efficacy than MM in CNLBP patients, improving the VAS scores, lumbar extension ROM, and SLR height in a shorter time.

Comparison of yoga and dynamic neuromuscular stabilization exercise in chronic low back pain on magnetic resonance imaging of lumbar multifidus- protocol for a randomized controlled trial

Background

Degeneration of Lumbar muscle in chronic low back pain (CLBP) is characterized by an increase in fat infiltration of paraspinal muscle, decrease in the cross-sectional area (CSA) of lumbar multifidus muscle (LMM) and increased thickness of Thoracolumbar fascia (TLF) by 25%. The study objective is to compare the effects of yoga and dynamic neuromuscular stabilization (DNS) exercise on CSA, fat infiltration of LMM with magnetic resonance imaging (MRI), and TLF thickness using musculoskeletal ultrasound imaging (MSK-USI) in CLBP.

Methods

One hundred and forty-four participants with CLBP, which persisted longer than three months, will be recruited for this trial. Both group interventions focused on LMM. The experimental group will receive structured yoga sessions, and the Control Group will receive exercise based on DNS. In each group, exercises will be performed for 3–5 days/week and progressed for 12 weeks. Baseline data will be collected, followed by the recording of primary outcome measure (MRI) and secondary outcome measures (MSK-USI, Oswestry disability index, visual analogue score, optimism, self-efficacy, mood, physical activity, fear of movement, pain catastrophizing, and coping) at baseline and the end of 12th weeks. The normality of data will be verified. Based on the data distribution, within-group analysis and between-group analysis will be performed.

Discussion

This will be the first RCT to compare the effect of yoga and DNS exercise among chronic low back pain participants. This will provide evidence of these interventions' impact on CSA, fat infiltration of LMM, and thickness of TLF in CLBP.

Registration number

CTRI/2021/08/035984 (This trial was registered prospectively).

The Changes of Motor Control Strategies in Non-specific Chronic Low Back Pain During Spinal Manipulation and Muscle Energy Techniques: A Beta-band Intermuscular Pair-Wise Coherence Analysis

Background: Until now, a variety of techniques have been introduced to address the adverse effects of NS-CLBP, including spinal manipulation technique (SMT) and muscle energy technique (MET). However, most of these techniques have focused on pain assessment and disability. In other words, the intermuscular synchronization between the co-contracting muscles was not considered, and hence, the effectiveness of these techniques on the corticospinal tract function was not studied. Objectives: This study aimed to compare the effects of SMT and MET on corticospinal tract function during four phases of standing, flexion, relaxation, and extension in flexion-extension task (F-ET) in NS-CLBP using pair-wise coherence of Beta-band intermuscular coherence (Bb-IMC). Methods: Twenty volunteer healthy male subjects and twenty-four male subjects with NS-CLBP (20 - 45 years of age) participated in this work. The patients had continuous or recurrent symptoms for three months or more without any referral pain to the lower extremities. The patients were randomly assigned to two equal intervention groups (SMT and MET), and the techniques were applied as described by Greenman. Surface electromyography (sEMGs) from lumbopelvic muscles was recorded for all participants (i.e., healthy group and the patient groups), while they performed three trials of F-ET, and the pair-wise coherence for all muscles was calculated using Bb-IMC analysis. Besides, in the patient's groups, sEMGs from the muscles were recorded before and after the interventional techniques (i.e., SMT and MET), while they performed three trials of F-ET, and the pair-wise coherence was calculated. Multivariate analysis of variance test was used to compare the healthy subjects and patient groups before the interventions in A and B muscle cross at different phases of F-ET task. Furthermore, in the NS-CLBP patients, comparisons were made before and after the interventions in each group (i.e., SMT and MET groups) as well as between the two groups in A and B muscle cross at different phases of the F-ET task. Results: In the standing phase of F-ET, there were no significant differences in the SMT and MET group before and after the intervention in PWC of A muscle cross and B muscle cross (P < 0.05). Considering the flexion phase, there were significant differences in the SMT group in all pair muscles as PWC (M1-M4), PWE (M1-M6), PWC (M4-M6) (P < 0.05), whereas there was one significantly in PWC (M4-M6) in the MET group (P < 0.05). In the relaxation phase, the SMT had significantly in PWC (M2-M5), whereas there was one significantly in PWC (M4-M6) in MET group (P < 0.05). In the extension phase, although the SMT was not significant (P < 0.05) in the MET intervention group, there were significant differences in the PWC (M2-M3) and PWC muscles (M2-M5). Conclusions: This study provided some pieces of evidence about the effects of one of the common manual therapy techniques on the primary motor cortex and corticospinal drive in the NS-CLBP patients. The results showed that, by increasing the pair-wise coherence in all phases of FE-T, SMT intervention was more effective than MET intervention. Therefore, the pair-wise coherence of Bb-IMC can be considered an approach for clinicians when designing the rehabilitation protocol to ensure optimal treatment.

Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain

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.

Comparison of the Beta-Band Intermuscular Pool Coherence Between Chronic Non-specific Low Back Pain and Healthy Subjects

Objectives: The current study aimed to compare between the chronic non-specific low back pain (CNSLBP) and healthy subjects during four phases of the trunk flexion-extension task (standing, flexion, relaxation, and extension phases) by using pool coherence as well as pairwise coherence of Beta band Intermuscular coherence (Bb-IMC) and flexion relaxation phenomena. Methods: Twenty-four men with CNSLBP and 20 healthy men voluntarily participated in this study. All subjects performed three tests of Flexion-extension task (F-ET) while the surface electromyography (sEMGs) were recorded from the right erector spinal muscle of the lumbar region “1”, left erector spinal muscle of the lumbar region “2”, right gluteus maximus muscle”3”, left gluteus maximus muscle”4”, right hamstring muscle”5” and left hamstring muscle”6”. Accordingly, group A contains muscles 1, 4, and 6 and group B consists of muscles 2, 3, and 5. The pool coherence (PC) and the pairwise coherence (PWC) for all the above-mentioned muscles were calculated using Beta-band intermuscular coherence analysis. Thereafter, the mean pool coherence (mPC) was considered for group A and group B for four phases of F-ET in three groups as following: CNSLBP patients group, healthy subjects group and the third group included all subjects that participated in this study, whether patients or healthy and it was called the general group. Moreover, the mean pairwise coherence (mPWC) among each pair of group A and B muscles was calculated for four phases of F-ET using Bb-IMC in CNSLBP patients and healthy subjects. Results: These results indicated a high value of A mPC in the general group and healthy subjects in the flexion phase, whereas the same A mPC in CNSLBP patients was high in all phases of F-ET. On the other hand, while B mPC was high in the general group and healthy subjects in the extension phase; it was high in all phases of F-ET in CNSLBP patients; B mPC in CNSLBP patients was high in extension, standing, and flexion phases. A mPWC and B mPWC were not significantly different between CNSLBP patients and healthy subjects in all phases of F-ET. However, only A mPWC “1 - 4” and the A mPWC “4 - 6” were significantly smaller in CNSLBP patients compared to the healthy subjects in the relaxation and flexion phases, respectively. Hence, we suggest pool coherence of Bb-IMC, not pairwise coherence of Bb-IMC, to compare CNSLBP patients and healthy subjects. Conclusions: According to the present findings, we suggest using the pool coherence of Bb-IMC in the clinical examination for CNSLBP patients and studying the probable cortical effects and the effectiveness of various treatments on corticospinal tract function in CNSLBP.

Spinal Manipulation for Subacute and Chronic Lumbar Radiculopathy: A Randomized Controlled Trial

OBJECTIVE

We evaluated the efficacy of spinal manipulation for the management of nonacute lumbar radiculopathy.

METHODS

In a university hospital we performed a randomized controlled trial with 2 parallel arms. Patients (n = 44) with unilateral radicular low back pain lasting more than 4 weeks were randomly allocated to manipulation and control groups. The primary outcome was the intensity of the low back pain on a visual analog scale. The secondary outcome was the Oswestry Disability Questionnaire score. We also measured spinal ranges of motion. The assessments were carried out at the baseline, immediately after intervention, and at 3 months' follow-up. All patients underwent physiotherapy. The manipulation group received three sessions of manipulation therapy 1 week apart. For manipulation, we used Robert Maigne's technique.

RESULTS

Both groups experienced a decrease in back and leg pain significantly (all P ≤ 0.003). However, only the manipulation group showed significantly favorable results in the Oswestry scores (P < 0.001), and the straight leg raise test (P = 0.001). All ranges of motion increased significantly with manipulation (all P < 0.001), but the control group showed favorable results only in right and left rotations and in extension (all P < 0.001). Between-group analyses showed significantly better outcomes for manipulation in all measurements (all P ≤ 0.009) with large effect sizes.

CONCLUSION

Spinal manipulation improves the results of physiotherapy over a period of 3 months for patients with subacute or chronic lumbar radiculopathy.

Effect of Spinal Manipulative and Mobilization Therapies in Young Adults With Mild to Moderate Chronic Low Back Pain: A Randomized Clinical Trial

IMPORTANCE

Low back pain (LBP) is one of the most common reasons for seeking medical care. Manual therapy is a common treatment of LBP, yet few studies have directly compared the effectiveness of thrust (spinal manipulation) vs nonthrust (spinal mobilization) techniques.

OBJECTIVE

To evaluate the comparative effectiveness of spinal manipulation and spinal mobilization at reducing pain and disability compared with a placebo control group (sham cold laser) in a cohort of young adults with chronic LBP.

DESIGN, SETTING, AND PARTICIPANTS

This single-blinded (investigator-blinded), placebo-controlled randomized clinical trial with 3 treatment groups was conducted at the Ohio Musculoskeletal and Neurological Institute at Ohio University from June 1, 2013, to August 31, 2017. Of 4903 adult patients assessed for eligibility, 4741 did not meet inclusion criteria, and 162 patients with chronic LBP qualified for randomization to 1 of 3 treatment groups. Recruitment began on June 1, 2013, and the primary completion date was August 31, 2017. Data were analyzed from September 1, 2017, to January 20, 2020.

INTERVENTIONS

Participants received 6 treatment sessions of (1) spinal manipulation, (2) spinal mobilization, or (3) sham cold laser therapy (placebo) during a 3-week period.

MAIN OUTCOMES AND MEASURES

Coprimary outcome measures were the change from baseline in Numerical Pain Rating Scale (NPRS) score over the last 7 days and the change in disability assessed with the Roland-Morris Disability Questionnaire (scores range from 0 to 24, with higher scores indicating greater disability) 48 to 72 hours after completion of the 6 treatments.

RESULTS

A total of 162 participants (mean [SD] age, 25.0 [6.2] years; 92 women [57%]) with chronic LBP (mean [SD] NPRS score, 4.3 [2.6] on a 1-10 scale, with higher scores indicating greater pain) were randomized. Fifty-four participants were randomized to the spinal manipulation group, 54 to the spinal mobilization group, and 54 to the placebo group. There were no significant group differences for sex, age, body mass index, duration of LBP symptoms, depression, fear avoidance, current pain, average pain over the last 7 days, and self-reported disability. At the primary end point, there was no significant difference in change in pain scores between spinal manipulation and spinal mobilization (0.24 [95% CI, -0.38 to 0.86]; P = .45), spinal manipulation and placebo (-0.03 [95% CI, -0.65 to 0.59]; P = .92), or spinal mobilization and placebo (-0.26 [95% CI, -0.38 to 0.85]; P = .39). There was no significant difference in change in self-reported disability scores between spinal manipulation and spinal mobilization (-1.00 [95% CI, -2.27 to 0.36]; P = .14), spinal manipulation and placebo (-0.07 [95% CI, -1.43 to 1.29]; P = .92) or spinal mobilization and placebo (0.93 [95% CI, -0.41 to 2.29]; P = .17).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, neither spinal manipulation nor spinal mobilization appeared to be effective treatments for mild to moderate chronic LBP.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01854892.

Effectiveness of a theory-based back care intervention on spine-related behavior among pupils: a school-based randomised controlled trial (T-Bak study)

Background

Children’s health and welfare have a special place in research and policy in many countries. One of the most important concerns is the increasing rate of backache in children due to many of behavioral risk factors. The aim of this study was to evaluate the effectiveness of an educational program on promoting back-related behavior as well as knowledge, skills, beliefs, and self-efficacy among fifth grade girls.

Methods

The theory-based back care (T-Bak) study was a school-based randomised controlled trial (RCT) that assessed the effectiveness of developing a back care training program based on the social cognitive theory (SCT). A total of 104 schoolchildren aged 11 ± 1.0 years were assigned to intervention (n = 52) and control (n = 52) groups. The intervention group received six sessions training on proper lifting and carrying techniques, having proper posture during daily activities, and correct backpack wearing techniques with a 1-week interval while the control group received nothing. Then, the two groups were assessed for knowledge, skills, self-efficacy, beliefs, and behavior at four points in time: baseline, immediate, three and six-months post-intervention. The changes of the outcomes investigated using univariate repeated measures analysis of variance. Partial eta squared measure (η_p²) was used to calculate effect sizes.

Results

A positive change was found for the intervention group back-related behavior from baseline to immediate post-intervention and follow-ups (F = 78.865, p < 0.001, η_p² = 0.22). Overall there were 36.4% improvement for knowledge (η_p² = 0.21), 53.2% for the skills (η_p² = 0.25), 19.5% for the self-efficacy (η_p² = 0.11), and 25.6% for the beliefs (η_p² = 0.14) scores from baseline to 6 months’ follow-up assessments among the intervention group (p < 0.001). The results also showed a significant interaction effect between group and time.

Conclusion

The T-Bak intervention was effective in improving back-related behavior in pupils. It is now available and could be evaluated further in back-care related studies.

Trial registration

Current Controlled Trials IRCT20180528039885N1, 30th Oct 2018, ‘Prospectively registered’. https://www.irct.ir/trial/31534

Comparative study of muscle energy technique, craniosacral therapy, and sensorimotor training effects on postural control in patients with nonspecific chronic low back pain

Background:

Malalignment in the pelvic and spinal column disturbs the balance and decreases the postural control ability. Malalignment is known as one of the main causes of back pain particularly the nonspecific chronic low back pain (NSCLBP). The aim of the study is to compare the effect of muscle energy technique (MET), craniosacral therapy (CST), and sensorimotor training (SMT) on postural control in patients with NSCLBP.

Materials and Methods:

In this randomized clinical trial study, 45 NSCLBP patients were accidentally allocated in three groups including CST (n = 15), MET (n = 15), and SMT (n = 15). Clinical interventions including CST, MET, and SMT were performed in 10 sessions in 5 weeks (2 sessions per week). The parameters of center of pressure (COP) were assessed in 8 positions such as standing position on double or single leg with open or closed eyes or half squat position on double or single leg with open or closed eyes.

Results:

The results of this study showed that all three methods of CST, MET, and SMT are effective in postural control in patients with NSCLBP, although it seems that CST is effective on more balance factors. CST has a greater effect on balance in standing position on a single leg with closed eye. It was also found that the effect of CST was continuous after follow-up.

Conclusion:

Moreover, MET and SMT methods were effective in balance control in NSCLBP patients and postural control was more affected by CST.

Agreement Analysis between Vive and Vicon Systems to Monitor Lumbar Postural Changes

Immersive virtual reality has recently developed into a readily available system that allows for full-body tracking. Can this affordable system be used for component tracking to advance or replace expensive kinematic systems for motion analysis in the clinic? The aim of this study was to assess the accuracy of position and orientation measures from Vive wireless body trackers when compared to Vicon optoelectronic tracked markers attached to (1) a robot simulating trunk flexion and rotation by repeatedly moving to know locations, and (2) healthy adults playing virtual reality games necessitating significant trunk displacements. The comparison of both systems showed component tracking with Vive trackers is accurate within 0.68 ± 0.32 cm translationally and 1.64 ± 0.18° rotationally when compared with a three-dimensional motion capture system. No significant differences between Vive trackers and Vicon systems were found suggesting the Vive wireless sensors can be used to accurately track joint motion for clinical and research data.