Association between history and physical examination factors and change in lumbar multifidus muscle thickness after spinal manipulation in patients with low back pain

The Effect of Combining Spinal Manipulation and Dry Needling in Individuals With Nonspecific Low Back Pain

Low back pain (LBP) is one of the most common and costly musculoskeletal conditions impacting health care in the United States. The development of multimodal strategies of treatment is imperative in order to curb the growing incidence and prevalence of LBP. Spinal manipulative therapy (SMT), dry needling (DN), and exercise are common nonpharmacological treatments for LBP. This study is a 3-armed parallel-group design randomized clinical trial. We enrolled and randomized 96 participants with LBP into a multimodal strategy of treatment consisting of a combination of DN and SMT, DN only, and SMT only, followed by an at-home exercise program. All participants received 4 treatment sessions in the first 2 weeks followed by a 2-week home exercise program. Outcomes included clinical (Oswestry Disability Index, numeric pain intensity rating) and mechanistic (lumbar multifidus, erector spinae, and gluteus medius muscle activation) measures at baseline, 2, and 4 weeks. Participants in the DN and SMT groups showed larger effects and statistically significant improvement in pain and disability scores, and muscle percent thickness change at 2 weeks and 4 weeks of treatment when compared to the other groups. This study was registered prior to participant enrollment. PERSPECTIVE: This article presents the process of developing an optimized multimodal treatment plan utilizing SMT, DN, and exercise to address the burden of LBP for impacted individuals and the health care system. This method could potentially help clinicians who treat LBP to lower initial pain and increase exercise compliance. (clinicaltrials.gov NCT05802901).

Treatment and Response Factors in Muscle Activation during Spinal Manipulation

The forces applied during a spinal manipulation produce a neuromuscular response in the paraspinal muscles. A systematic evaluation of the factors involved in producing this muscle activity provides a clinical insight. The purpose of this study is to quantify the effect of treatment factors (manipulation sequence and manipulation site) and response factors (muscle layer, muscle location, and muscle side) on the neuromuscular response to spinal manipulation. The surface and indwelling electromyographies of 8 muscle sites were recorded during lumbar side-lying manipulations in 20 asymptomatic participants. The effects of the factors on the number of muscle responses and the muscle activity onset delays were compared using mixed-model linear regressions, effect sizes, and equivalence testing. The treatment factors did not reveal statistical differences between the manipulation sequences (first or second) or manipulation sites (L3 or SI) in the number of muscle responses (p = 0.11, p = 0.28, respectively), or in muscle activity onset delays (p = 0.35 p = 0.35, respectively). There were significantly shorter muscle activity onset delays in the multifidi compared to the superficial muscles (p = 0.02). A small effect size of side (d = 0.44) was observed with significantly greater number of responses (p = 0.02) and shorter muscle activity onset delays (p < 0.001) in the muscles on the left side compared to the right. The location, layer, and side of the neuromuscular responses revealed trends of decreasing muscle response rates and increasing muscle activity onset delays as the distance from the manipulation site increased. These results build on the body of work suggesting that the specificity of manipulation site may not play a role in the neuromuscular response to spinal manipulation-at least within the lumbar spine. In addition, these results demonstrate that multiple manipulations performed in similar areas (L3 and S1) do not change the response significantly, as well as contribute to the clinical understanding that the muscle response rate is higher and with a shorter delay, the closer it is to the manipulation.

Effects of lumbar joint mobilization on trunk function, postural balance, and gait in patients with chronic stroke: A randomized pilot study

BACKGROUND

Patients with stroke have hypomobility in the facet joint of affected side. Lumbar joint mobilization could be used to maintain function and mobility of the joints.

OBJECTIVE

This study aimed to investigate the effects of lumbar joint mobilization on trunk function, postural balance, and gait in patients with stroke.

METHODS

Thirty patients with stroke were randomly assigned to two groups. Lumbar joint mobilization was provided for 15 min, 5 times a week for 6 weeks to patients who were allocated into the experimental group. Patients who were allocated into the control group received a sham intervention. Trunk function (trunk impairment scale), postural balance (weight distribution, Berg balance scale, and timed up and go test), and walking (10 m walk test, functional gait assessment, step length, and stride length) were evaluated before and after the experiment for all the patients.

RESULTS

Lumbar joint mobilization significantly improved trunk function, postural balance, and gait compared with pre-test values in the experimental group (P< 0.05). Significant differences were seen in trunk function, postural balance, and walking between the two groups (P< 0.05).

CONCLUSION

Lumbar joint mobilization might be an effective intervention for trunk function, postural balance, and walking in patients with stroke.

The morphological characteristics of paraspinal muscles in young patients with unilateral neurological symptoms of lumbar disc herniation

Objective

The objective of this study was to explore the morphological characteristics of paraspinal muscles in young patients with unilateral neurological symptoms of lumbar disc herniation.

Methods

This study retrospectively analyzed young patients aged 18–40 years who were hospitalized for lumbar disc herniation in our hospital from June 2017 to June 2020. Data on sex, age, body mass index (BMI), subcutaneous fat tissue thickness (SFTT) at the L1-L2 level, duration of symptoms, degree of lumbar disc herniation, visual analog scale (VAS) for the lower back, Mo-fi-disc score, relative cross-sectional area (RCAS) of the paravertebral muscles (psoas major [PM], multifidus [MF], and erector spinae [ES]), and degree of fat infiltration (DFF) of the paravertebral muscles were collected. The VAS was used to evaluate the intensity of low back pain. Patients with VAS-back >4 points were defined as the low back pain group, and patients with ≤4 points were defined as the control group. The demographic characteristics, as well as the bilateral and ipsilateral paravertebral muscles, of the two groups were compared and analyzed.

Result

A total of 129 patients were included in this study (52 patients in the LBP group and 77 patients in the control group). There were no significant differences in sex, BMI, or Pfirrmann grade of lumbar disc herniation between the two groups (P > 0.05). The age of the LBP group (33.58 ± 2.98 years) was greater than that of the control group (24.13 ± 2.15 years) (P = 0.002), and the SFTT at the L1-L2 level (13.5 ± 7.14 mm) was higher than that of the control group (7.75 ± 6.31 mm) (P < 0.05). Moreover, the duration of symptoms (9.15 ± 0.31 months) was longer than that of the control group (3.72 ± 0.48 months) (P < 0.05), and the Mo-fi-disc score (8.41 ± 3.16) was higher than that of the control group (5.53 ± 2.85) (P < 0.05). At L3/4 and L5/S1, there was no significant difference in the RCSA and DFF of the bilateral and ipsilateral paraspinal muscles between the LBP group and the control group. At L4/5, there was no significant difference in the RCSA and DFF of the paraspinal muscles on either side in the LBP group (P > 0.05). In the control group, the RCSA of the MF muscle on the diseased side was smaller than that on the normal side (P < 0.05), and the DFF of the MF muscle on the diseased side was larger than that on the normal side (P < 0.05). In addition, there was no significant difference in the ES and PM muscles on both sides (P > 0.05). At L4/5, the RCSA of the MF muscle on the normal side was significantly smaller in the LBP group than in the control group (P < 0.05), and the DFF of the MF muscle on the normal side was significantly larger in the LBP group than in the control group (P < 0.05). There was no significant difference in the ES and PM muscles on the same side between the two groups (P > 0.05).

Conclusion

In young patients with unilateral neurological symptoms of lumbar disc herniation, symmetrical atrophy of the bilateral MF muscle is more prone to causing low back pain. Older age, higher SFTT at the L1-L2 levels, longer symptom duration, higher Mo-fi-di score, and greater muscle atrophy on the normal side of the MF increased the incidence of low back pain in young patients with unilateral lumbar disc herniation.

Neuromuscular Consequences of Lumbopelvic Dysfunction: Research and Clinical Perspectives

Injuries involving the lumbopelvic region (ie, lumbar spine, pelvis, hip) are common across the lifespan and include pathologies such as low back pain, femoroacetabular impingement syndrome, labrum tear, and osteoarthritis. Joint injury is known to result in an arthrogenic muscle response which contributes to muscle weakness and altered movement patterns. The purpose of this manuscript is to summarize the arthrogenic muscle response that occurs across lumbopelvic region pathologies, identify methods to quantify muscle function, and propose suggestions for future research. While each lumbopelvic region pathology is unique, there are a few common impairments and a relative consistent arthrogenic muscle response that occurs across the region. Hip muscle weakness and hip joint range of motion limitations occur with both lumbar spine and hip pathologies, and individuals with low back pain are known to demonstrate inhibition of the transversus abdominis and multifidus. Assessment of muscle inhibition is often limited to research laboratory settings, but dynamometers, ultrasound imaging, and electromyography offer clinical capacity to quantify muscle function and inform treatment pathways. Future studies should systematically determine the arthrogenic muscle response across multiple muscle groups and the timeline for changes in muscle function and determine whether disinhibitory modalities improve functional outcomes beyond traditional treatment approaches.

Optimization of Spinal Manipulative Therapy Protocols: A Factorial Randomized Trial Within a Multiphase Optimization Framework

Spinal manipulative therapy (SMT) is a common nonpharmacological treatment for low back pain (LBP). Although generally supported by systematic reviews and practice guidelines, clinical trials evaluating SMT have been characterized by small effect sizes. This study adopts a Multiphase Optimization Strategy framework to examine individual components of an SMT delivery protocol using a single-blind trial with the goal of identifying and optimizing a multicomponent SMT protocol. We enrolled 241 participants with LBP. All participants received 2 SMT treatment sessions in the first week then were randomly assigned additional treatment based on a fully factorial design. The 3 randomized treatment components provided in twice weekly sessions over 3 weeks were multifidus activating exercise, spinal mobilizing exercise, and additional SMT dose. Primary outcomes included clinical (Oswestry Disability Index, numeric pain intensity rating) and mechanistic (spinal stiffness, multifidus muscle activation) measures assessed at baseline, 1, 4, and 12 weeks. Significant differences were found for the Oswestry index after 12 weeks for participants receiving multifidus activating exercise (mean difference = -3.62, 97.5% CI: -6.89, -0.35; P= .01). There were no additional significant main or interaction effects for other treatment components or different outcome measures. The optimized SMT protocol identified in this study included SMT sessions followed by multifidus activating exercises. PERSPECTIVE: Optimizing the effects of nonpharmacological treatments such as SMT for LBP is challenging due to uncertainty regarding mechanisms and the complexity of multicomponent protocols. This factorial randomized trial examined SMT protocols provided with differing co-interventions with mechanistic and patient-centered outcomes. Patient-centered outcomes were optimized by inclusion of lumbar multifidus strengthening exercises.

How Does the Measurement of Disability in Low Back Pain Map Unto the International Classification of Functioning, Disability and Health?: A Scoping Review of the Manual Medicine Literature

ABSTRACT

The objective of this study was to catalog items from instruments used to measure functioning, disability, and contextual factors in patients with low back pain treated with manual medicine (manipulation and mobilization) according to the International Classification of Functioning, Disability and Health. This catalog will be used to inform the development of an International Classification of Functioning, Disability and Health-based assessment schedule for low back pain patients treated with manual medicine. In this scoping review, we systematically searched MEDLINE, Embase, PsycINFO, and CINAHL. We identified instruments (questionnaires, clinical tests, single questions) used to measure functioning, disability, and contextual factors, extracted the relevant items, and then linked these items to the International Classification of Functioning, Disability and Health. We included 95 articles and identified 1510 meaningful concepts. All but 70 items were linked to the International Classification of Functioning, Disability and Health. Of the concepts linked to the International Classification of Functioning, Disability and Health, body functions accounted for 34.7%, body structures accounted for 0%, activities and participation accounted for 41%, environmental factors accounted for 3.6%, and personal factors accounted for 16%. Most items used to measure functioning and disability in low back pain patient treated with manual medicine focus on body functions, as well as activities and participation. The lack of measures that address environmental factors warrants further investigation.

Does Plantar Pressure Distribution Influence the Lumbar Multifidus Muscle Thickness in Asymptomatic Individuals? A Preliminary Study

BACKGROUND

Atrophy can occur in the lumbar multifidus (LM) muscle quickly as a result of various musculoskeletal problems. Knowing factors influencing muscle thickness of the LM will provide important clues about lumbopelvic stability.

OBJECTIVES

Although there are several studies in the literature investigating the adverse effects of foot-ankle postural disorders on the lumbopelvic region, to our knowledge there has been no investigation of plantar pressure distribution (PPD) as a factor influencing muscle thickness of the LM. The aim of this study was to determine whether PPD could affect LM muscle thickness.

METHODS

This observational study consisted of 25 asymptomatic individuals. Ultrasonographic imaging was used to determine the thickness of the LM. All participants were subjected to PPD analysis using the Digital Biometry Scanning System and Milletrix software in 9 different plantar pressure zones. The Pearson product-moment correlation coefficients were used to examine the correlations between the LM muscle thickness and other variables. Stepwise multiple linear regression analysis was used to determine the variables with the greatest influence on LM muscle thickness.

RESULTS

Peak pressures of medial and lateral zones of the heel were the significant and independent factors influencing static LM thickness, with 39.5% of the variance; moreover, the peak pressures of heel medial and fourth metatarsal bone were the significant and independent factors influencing dynamic LM thickness, with 38.7% of the variance.

CONCLUSIONS

Plantar pressure distribution could be an important factor influencing LM thickness, although further research is required. Examining foot-ankle biomechanics may provide information about the stability of the LM.

Inconsistent descriptions of lumbar multifidus morphology: A scoping review

Background

Lumbar multifidus (LM) is regarded as the major stabilizing muscle of the spine. The effects of exercise therapy in low back pain (LBP) are attributed to this muscle. A current literature review is warranted, however, given the complexity of LM morphology and the inconsistency of anatomical descriptions in the literature.

Methods

Scoping review of studies on LM morphology including major anatomy atlases. All relevant studies were searched in PubMed (Medline) and EMBASE until June 2019. Anatomy atlases were retrieved from multiple university libraries and online. All studies and atlases were screened for the following LM parameters: location, imaging methods, spine levels, muscle trajectory, muscle thickness, cross-sectional area, and diameter. The quality of the studies and atlases was also assessed using a five-item evaluation system.

Results

In all, 303 studies and 19 anatomy atlases were included in this review. In most studies, LM morphology was determined by MRI, ultrasound imaging, or drawings – particularly for levels L4–S1. In 153 studies, LM is described as a superficial muscle only, in 72 studies as a deep muscle only, and in 35 studies as both superficial and deep. Anatomy atlases predominantly depict LM as a deep muscle covered by the erector spinae and thoracolumbar fascia. About 42% of the studies had high quality scores, with 39% having moderate scores and 19% having low scores. The quality of figures in anatomy atlases was ranked as high in one atlas, moderate in 15 atlases, and low in 3 atlases.

Discussion

Anatomical studies of LM exhibit inconsistent findings, describing its location as superficial (50%), deep (25%), or both (12%). This is in sharp contrast to anatomy atlases, which depict LM predominantly as deep muscle. Within the limitations of the self-developed quality-assessment tool, high-quality scores were identified in a majority of studies (42%), but in only one anatomy atlas.

Conclusions

We identified a lack of standardization in the depiction and description of LM morphology. This could affect the precise understanding of its role in background and therapy in LBP patients. Standardization of research methodology on LM morphology is recommended. Anatomy atlases should be updated on LM morphology.

The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial

BACKGROUND

Chiropractic maintenance care is effective as secondary/tertiary prevention of non-specific low back pain (LBP), but the potential effect moderation by psychological characteristics is unknown. The objective was to investigate whether patients in specific psychological sub-groups had different responses to MC with regard to the total number of days with bothersome pain and the number of treatments.

METHOD

Data from a two-arm randomized pragmatic multicenter trial with a 12-month follow up, designed to investigate the effectiveness of maintenance care, was used. Consecutive patients, 18-65 years of age, with recurrent and persistent LBP seeking chiropractic care with a good effect of the initial treatment were included. Eligible subjects were randomized to either maintenance care (prescheduled care) or to the control intervention, symptom-guided care. The primary outcome of the trial was the total number of days with bothersome LBP collected weekly for 12 months using an automated SMS system. Data used to classify patients according to psychological subgroups defined by the West Haven-Yale Multidimensional Pain Inventory (adaptive copers, interpersonally distressed and dysfunctional) were collected at the screening visit.

RESULTS

A total of 252 subjects were analyzed using a generalized estimating equations linear regression framework. Patients in the dysfunctional subgroup who received maintenance care reported fewer days with pain (-30.0; 95% CI: -36.6, -23.4) and equal number of treatments compared to the control intervention. In the adaptive coper subgroup, patients who received maintenance care reported more days with pain (10.7; 95% CI: 4.0, 17.5) and more treatments (3.9; 95% CI: 3.5, 4.2). Patients in the interpersonally distressed subgroup reported equal number of days with pain (-0.3; 95% CI: -8.7, 8.1) and more treatments (1.5; 95% CI: 0.9, 2.1) on maintenance care.

CONCLUSIONS

Psychological and behavioral characteristics modify the effect of MC and should be considered when recommending long-term preventive management of patients with recurrent and persistent LBP.

Imaging with ultrasound in physical therapy: What is the PT's scope of practice? A competency-based educational model and training recommendations

Physical therapists employ ultrasound (US) imaging technology for a broad range of clinical and research purposes. Despite this, few physical therapy regulatory bodies guide the use of US imaging, and there are limited continuing education opportunities for physical therapists to become proficient in using US within their professional scope of practice. Here, we (i) outline the current status of US use by physical therapists; (ii) define and describe four broad categories of physical therapy US applications (ie, rehabilitation, diagnostic, intervention and research US); (iii) discuss how US use relates to the scope of high value physical therapy practice and (iv) propose a broad framework for a competency-based education model for training physical therapists in US. This paper only discusses US imaging—not ‘therapeutic’ US. Thus, ‘imaging’ is implicit anywhere the term ‘ultrasound’ is used.

Rehabilitative Ultrasound Imaging Evaluation in Physiotherapy: Piloting a Systematic Review

Background: Research of ultrasound use in physiotherapy and daily practice has led to its use as an everyday tool. Methods: The aims were: (1) Checking the proposed systematic review protocol methodology; (2) evaluating the evidence from the last five years; and (3) coordinating the work of the team of reviewers in performing a complete systematic review. Thus, this is a pilot study prior to a full systematic review. The findings in databases related to health sciences with the meta-search engine Discovery EBSCO, Covidence, and Revman were used. Inclusion and exclusion criteria were described for eligibility. Results: Search provided 1029 references regarding the lumbar region on ultrasound scans. Of these, 33 were duplicates. After Covidence, 996 studies were left for screening. A full-text reading brought one randomized clinical trial (RCT). Conclusions: Validity and reliability references were found. The most suitable points were novice versus expert, and ultrasound versus electromyography (EMG) with just one RCT cohort, and observational and case reports. The lines of investigation increasingly endorsed the validity of using ultrasound in physiotherapy. Post-acquisition image analysis could also be a future line of research.

Assessment of chiropractic care on strength, balance, and endurance in active-duty U.S. military personnel with low back pain: a protocol for a randomized controlled trial

BACKGROUND

Low back pain (LBP) is a common cause of disability among U.S. military personnel. Approximately 20% of all diagnoses resulting in disability discharges are linked to back-related conditions. Because LBP can negatively influence trunk muscle strength, balance, and endurance, the military readiness of active-duty military personnel with LBP is potentially compromised. Chiropractic care may facilitate the strengthening of trunk muscles, the alteration of sensory and motor signaling, and a reduction in pain sensitivity, which may contribute to improving strength, balance, and endurance for individuals with LBP. This trial will assess the effects of chiropractic care on strength, balance, and endurance for active-duty military personnel with LBP.

METHODS/DESIGN

This randomized controlled trial will allocate 110 active-duty military service members aged 18-40 with non-surgical acute, subacute, or chronic LBP with pain severity of ≥2/10 within the past 24 h. All study procedures are conducted at a single military treatment facility within the continental United States. Participants are recruited through recruitment materials approved by the institutional review board, such as posters and flyers, as well as through provider referrals. Group assignment occurs through computer-generated random allocation to either the study intervention (chiropractic care) or the control group (waiting list) for a 4-week period. Chiropractic care consists primarily of spinal manipulation at a frequency and duration determined by a chiropractic practitioner. Strength, balance, and endurance outcomes are obtained at baseline and after 4 weeks. The primary outcome is a change between baseline and 4 weeks of peak isometric strength, which is measured by pulling on a bimanual handle in a semi-squat position. Secondary outcomes include balance time during a single-leg standing test and trunk muscle endurance with the Biering-Sorensen test. Patient-reported outcomes include pain severity, disability measured with the Roland Morris Disability Questionnaire, symptom bothersomeness, PROMIS-29, Fear Avoidance Beliefs Questionnaire, expectations of care, physical activity, and global improvement.

DISCUSSION

This trial may help inform further research on biological mechanisms related to manual therapies employed by chiropractic practitioners.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02670148 Registered on 1 February 2016.

The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain-A pragmatic randomized controlled trial

Background

For individuals with recurrent or persistent non-specific low back pain (LBP), exercise and exercise combined with education have been shown to be effective in preventing new episodes or in reducing the impact of the condition. Chiropractors have traditionally used Maintenance Care (MC), as secondary and tertiary prevention strategies. The aim of this trial was to investigate the effectiveness of MC on pain trajectories for patients with recurrent or persistent LBP.

Method

This pragmatic, investigator-blinded, two arm randomized controlled trial included consecutive patients (18–65 years old) with non-specific LBP, who had an early favorable response to chiropractic care. After an initial course of treatment, eligible subjects were randomized to either MC or control (symptom-guided treatment). The primary outcome was total number of days with bothersome LBP during 52 weeks collected weekly with text-messages (SMS) and estimated by a GEE model.

Results

Three hundred and twenty-eight subjects were randomly allocated to one of the two treatment groups. MC resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment. During the 12 month study period, the MC group (n = 163, 3 dropouts) reported 12.8 (95% CI = 10.1, 15.5; p = <0.001) fewer days in total with bothersome LBP compared to the control group (n = 158, 4 dropouts) and received 1.7 (95% CI = 1.8, 2.1; p = <0.001) more treatments. Numbers presented are means. No serious adverse events were recorded.

Conclusion

MC was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific LBP but it resulted in a higher number of treatments. For selected patients with recurrent or persistent non-specific LBP who respond well to an initial course of chiropractic care, MC should be considered an option for tertiary prevention.

Optimizing treatment protocols for spinal manipulative therapy: study protocol for a randomized trial

BACKGROUND

Low back pain is a common and costly condition. Spinal manipulative therapy (SMT) is a treatment supported in some guidelines, although most clinical trials examining SMT report small effect sizes. Enhancing the effects of SMT requires an understanding of underlying mechanisms and a systematic approach to leverage understanding of mechanisms to create more effective treatment protocols that are scalable in clinical practice. Prior work has identified effects on spinal stiffness and lumbar multifidus activation as possible mechanisms. This project represents a refinement phase study within the context of a multi-phase optimization strategy (MOST) framework. Our goal is to identify an optimized SMT treatment protocol by examining the impact of using co-intervention exercise strategies that are proposed to accentuate SMT mechanisms. The optimized protocol can then be evaluated in confirmation phase clinical trials and implementation studies.

METHODS

A phased, factorial randomized trial design will be used to evaluate the effects of three intervention components provided in eight combinations on mechanistic (spinal stiffness and multifidus muscle activation) and patient-reported outcomes (pain and disability). All participants will receive two sessions then will be randomly assigned to receive six additional sessions (or no additional treatment) over the next three weeks with factorial combinations of additional SMT and exercise co-interventions (spine mobilizing and multifidus activating). Outcome assessments occur at baseline, and one week, four weeks, and three months after enrollment. Pre-specified analyses will evaluate main effects for treatment components as well as interaction effects.

DISCUSSION

Building on preliminary findings identifying possible mechanisms of effects for SMT, this trial represents the next phase in a multiphase strategy towards the ultimate goal of developing an optimized protocol for providing SMT to patients with LBP. If successful, the results of this trial can be tested in future clinical trials in an effort to produce larger treatment benefits and improve patient-centered outcomes for individuals with LBP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02868034 . Registered on 16 August 2016.

Muscle Control and Non-specific Chronic Low Back Pain

Objectives

Chronic low back pain (CLBP) is the most prevalent of the painful musculoskeletal conditions. CLBP is a heterogeneous condition with many causes and diagnoses, but there are few established therapies with strong evidence of effectiveness (or cost effectiveness). CLBP for which it is not possible to identify any specific cause is often referred to as non‐specific chronic LBP (NSCLBP). One type of NSCLBP is continuing and recurrent primarily nociceptive CLBP due to vertebral joint overload subsequent to functional instability of the lumbar spine. This condition may occur due to disruption of the motor control system to the key stabilizing muscles in the lumbar spine, particularly the lumbar multifidus muscle (MF).

Methods

This review presents the evidence for MF involvement in CLBP, mechanisms of action of disruption of control of the MF, and options for restoring control of the MF as a treatment for NSCLBP.

Results

Imaging assessment of motor control dysfunction of the MF in individual patients is fraught with difficulty. MRI or ultrasound imaging techniques, while reliable, have limited diagnostic or predictive utility. For some patients, restoration of motor control to the MF with specific exercises can be effective, but population results are not persuasive since most patients are unable to voluntarily contract the MF and may be inhibited from doing so due to arthrogenic muscle inhibition.

Conclusions

Targeting MF control with restorative neurostimulation promises a new treatment option.

Essential literature for the chiropractic profession: Results and implementation challenges from a survey of international chiropractic faculty

OBJECTIVE

Scientific literature applicable to chiropractic practice proliferates in quantity, quality, and source. Chiropractic is a worldwide profession and varies in scope between states or provinces and from country to country. It is logical to consider that the focus and emphasis of chiropractic education varies between programs as well. This original research study endeavored to determine "essential literature" recommended by chiropractic faculty. The purpose of this article is (1) to share our results and (2) to promote discussion and explore means for future collaboration of chiropractic faculty through a worldwide platform.

METHODS

A 2-phase recruitment occurred initially at the institutional level and subsequently at the faculty level. A Web-based survey used qualitative data collection methods to gather bibliographic citations. Descriptive statistics were calculated for demographics, and citation responses were ranked per number of recommendations, grouped into categories, and tabulated per journal source and publication date.

RESULTS

Forty-one chiropractic programs were contacted, resulting in 30 participating chiropractic programs (16 US and 14 international). Forty-five faculty members completed the entire survey, submitting 126 peer-reviewed publications and 25 additional citations. Readings emphasized clinical management of spine pain, the science of spinal manipulation, effectiveness of manual therapies, teaching of chiropractic techniques, outcomes assessments, and professional issues.

CONCLUSION

A systematic approach to surveying educators in international chiropractic institutions was accomplished. The results of the survey provide a list of essential literature for the chiropractic profession. We recommend establishing a chiropractic faculty registry for improved communication and collaboration.

The effects of pelvic diagonal movements and resistance on the lumbar multifidus

[Purpose] The purpose of this study was to compare the effects of pelvic diagonal movements, made with and without resistance, on the thickness of lumbar multifidus muscles. [Subjects and Methods] Participants in this study were healthy subjects who had no musculoskeletal disorders or lumbar-related pain. Participants were positioned on their side and instructed to lie with their hip flexor at 40 degrees. Ultrasonography was used for measurement, and the values of two calculations were averaged. [Results] The thickness of ipsilateral lumbar multifidus muscles showed a significant difference following the exercise of pelvic diagonal movements. The results of anterior elevation movements and posterior depression movements also demonstrated significant difference. There was no significant difference in lumbar multifidus muscles thickness between movements made with and without resistance. [Conclusion] These findings suggest that pelvic diagonal movements can be an effective method to promote muscular activation of the ipsilateral multifidus. Furthermore, researchers have concluded that resistance is not required during pelvic diagonal movements to selectively activate the core muscles.

Changes in deep lumbar stabilizing muscle thickness by transcutaneous neuromuscular electrical stimulation in patients with low back pain

BACKGROUND

Transcutaneous neuromuscular electrical stimulation (NMES) is known to stimulate contraction of deep lumbar stabilizing muscles.

OBJECTIVE

The purpose of this study was to investigate changes in deep lumbar stabilizing muscle thickness during transcutaneous NMES on specific abdominal wall and paraspinal regions.

METHODS

Thirty patients with low back pain (LBP) were recruited. Three sessions were preformed: Session 1: NMES on abdominal wall, Session 2: NMES on lumbar paraspinal area, and Session 3: concurrent NMES on abdominal wall and lumbar paraspinal area. Real time ultrasound imaging (RUSI) of three abdominal stabilizing muscles; transverse abdominis (TrA), obliquus internus (OI), obliquus externus (OE) muscles and one posterior stabilizer, the lumbar multifidus muscles (LM) was captured.

RESULTS

All studied muscles of TrA, OI, OE, and LM were found to have significant thickness increases during all three sessions compared to resting state (p < 0.05). Thicknesses changes of TrA, OI, and LM were significant during simultaneous NMES of both abdominal wall and lumbar paraspinal regions (Session 3) (p < 0.05).

CONCLUSIONS

Our results indicate that concurrent NMES on abdominal wall and lumbar paraspinal area is most effective to maximally activate deep lumbar stabilizers. Rehabilitative efforts for patients with LBP may benefit from simultaneous transcutaneous NMES of abdominal and lumbar regions.

The Influence of Centralization and Directional Preference on Spinal Control in Patients With Nonspecific Low Back Pain

STUDY DESIGN

Prospective cohort, test-retest design.

BACKGROUND

Directional preference (DP) with centralization (CEN) and DP without CEN are common pain-pattern responses assessed by Mechanical Diagnosis and Therapy (MDT). Although there is evidence that MDT can reduce pain and disability in the short term by treating the patient with direction-specific exercises concordant with the patient's DP, the mechanism responsible for this is unclear.

OBJECTIVE

To determine whether clinical signs of impaired spinal control improve immediately after eliciting a DP-with-CEN response or a DP-without-CEN response in patients with nonspecific low back pain.

METHODS

Participants underwent a standardized MDT assessment and were classified into the following pain-pattern subgroups: DP with CEN, DP without CEN, or no DP. Clinical signs of impaired spinal control were assessed pre-MDT assessment and post-MDT assessment by an independent examiner. Four spinal control tests were conducted: aberrant lumbar movements while bending forward, the active straight leg raise (ASLR) test, the Trendelenburg test, and the prone instability test. Differences in spinal control pre-MDT assessment and post-MDT assessment were calculated for the 3 pain-pattern subgroups and compared with chi-square tests. We hypothesized that a larger proportion of patients in the DP-with-CEN subgroup would exhibit improved spinal control than patients categorized as DP without CEN or no DP.

RESULTS

Of 114 patients recruited, 51 patients (44.7%) were categorized as DP with CEN, 23 (20.2%) as DP without CEN, and 40 (35.1%) as no DP. Before MDT assessment, between 28.9% (Trendelenburg test) and 63.7% (ASLR test) of patients showed impaired spinal control. After MDT assessment, a larger proportion of patients in the DP-with-CEN subgroup (43%) showed improvement than those in the no-DP subgroup (7%) on aberrant lumbar movements (P = .02). Likewise, more patients in the DP-with-CEN subgroup (50%) improved on the ASLR test than those in the no-DP subgroup (8%, P<.01) or the DP-without-CEN subgroup (7%, P = .01). Changes in Trendelenburg test and prone instability test outcomes did not reach statistical significance.

CONCLUSION

Immediately following MDT assessment, a larger proportion of patients with a DP-with-CEN pain pattern showed improvement in clinical signs of spinal control compared to patients with a DP-without-CEN or no-DP pain pattern. The current study was registered in the Dutch trial registry at http://www.trialregister.nl/trialreg/index.asp (NTR4246).

LEVEL OF EVIDENCE

Therapy, level 2b.

The effects of transcutaneous neuromuscular electrical stimulation on the activation of deep lumbar stabilizing muscles of patients with lumbar degenerative kyphosis

[Purpose] To investigate the effectiveness of three different neuromuscular electrical stimulation (NMES) protocols for the deep lumbar stabilizing muscles of patients with lumbar degenerative kyphosis (LDK). [Subjects and Methods] Twenty patients with LDK were recruited. Three stimulation protocols were investigated: stimulation of the abdominal muscles (protocol A); stimulation of the lumbar muscles (protocol B); and simultaneous stimulation of the abdominal and lumbar muscles (protocol A+B). Images of the obliquus externus (OE), obliquus internus (OI), transversus abdominis (TrA), and lumbar multifidus (LM) muscles were captured by real-time ultrasound imaging (RUSI). [Results] The thickness of LM was significantly greater during stimulation than at rest for all three protocols. Thicknesses of the abdominal muscles (TrA, OI, and OE) were significantly greater during stimulation than at rest for protocols A and A+B. Thickness increases in LM were significantly greater during protocols B and A+B, but not during protocol A. Thickness increases in the abdominal muscles (TrA, OI, and OE) were significantly greater during protocols A and A+B, but not during protocol B. [Conclusion] NMES can significantly activate the deep lumbar stabilizing muscles of patients with LDK. Protocol A+B of NMES is recommended to aid postural correction and low back pain (LBP) in patients with LDK.

The evaluation of lumbar multifidus muscle function via palpation: reliability and validity of a new clinical test

BACKGROUND CONTEXT

The lumbar multifidus muscle provides an important contribution to lumbar spine stability, and the restoration of lumbar multifidus function is a frequent goal of rehabilitation. Currently, there are no reliable and valid physical examination procedures available to assess lumbar multifidus function among patients with low back pain.

PURPOSE

To examine the inter-rater reliability and concurrent validity of the multifidus lift test (MLT) to identify lumbar multifidus dysfunction among patients with low back pain.

STUDY DESIGN/SETTING

A cross-sectional analysis of reliability and concurrent validity performed in a university outpatient research facility.

PATIENT SAMPLE

Thirty-two persons aged 18 to 60 years with current low back pain and a minimum modified Oswestry disability score of 20%. Study participants were excluded if they reported a history of lumbar spine surgery, lumbar radiculopathy, medical red flags, osteoporosis, or had recently been treated with spinal manipulation or trunk stabilization exercises.

OUTCOME MEASURES

Concurrent measures of lumbar multifidus muscle function at the L4-L5 and L5-S1 levels were obtained with the MLT (index test) and real-time ultrasound imaging (reference standard).

METHODS

The inter-rater reliability of the MLT was examined by measuring the level of agreement between two blinded examiners. Concurrent validity of the MLT was investigated by comparing clinicians' judgments with real-time ultrasound imaging measures of lumbar multifidus function.

RESULTS

Inter-rater reliability of the MLT was substantial to excellent (κ=0.75 to 0.81, p≤.01) and free from errors of bias and prevalence. When performed at L4-L5 or L5-S1, the MLT demonstrated evidence of concurrent validity through its relationship with the reference standard results at L4-L5 (rbis=0.59-0.73, p≤.01). The MLT generally failed to demonstrate a relationship with the reference standard results from the L5-S1 level.

CONCLUSIONS

Our results provide preliminary evidence supporting the reliability and validity of the MLT to assess lumbar multifidus function at the L4-L5 spinal level. Additional research examining the measurement properties and utility of this test should be undertaken before confident implementation with patients.

Verification of an optimized stimulation point on the abdominal wall for transcutaneous neuromuscular electrical stimulation for activation of deep lumbar stabilizing muscles

BACKGROUND CONTEXT

Transcutaneous neuromuscular electrical stimulation (NMES) can stimulate contractions in deep lumbar stabilizing muscles. An optimal protocol has not been devised for the activation of these muscles by NMES, and information is lacking regarding an optimal stimulation point on the abdominal wall.

PURPOSE

The goal was to determine a single optimized stimulation point on the abdominal wall for transcutaneous NMES for the activation of deep lumbar stabilizing muscles.

STUDY DESIGN

Ultrasound images of the spinal stabilizing muscles were captured during NMES at three sites on the lateral abdominal wall. After an optimal location for the placement of the electrodes was determined, changes in the thickness of the lumbar multifidus (LM) were measured during NMES.

METHODS

Three stimulation points were investigated using 20 healthy physically active male volunteers. A reference point R, 1 cm superior to the iliac crest along the midaxillary line, was used. Three study points were used: stimulation point S1 was located 2 cm superior and 2 cm medial to the anterior superior iliac spine, stimulation point S3 was 2 cm below the lowest rib along the same sagittal plane as S1, and stimulation point S2 was midway between S1 and S3. Sessions were conducted stimulating at S1, S2, or S3 using R for reference. Real-time ultrasound imaging (RUSI) of the abdominal muscles was captured during each stimulation session. In addition, RUSI images were captured of the LM during stimulation at S1.

RESULTS

Thickness, as measured by RUSI, of the transverse abdominis (TrA), obliquus internus, and obliquus externus was greater during NMES than at rest for all three study points (p<.05). Transverse abdominis was significantly stimulated more by NMES at S1 than at the other points (p<.05). The LM thickness was also significantly greater during NMES at S1 than at rest (p<.05).

CONCLUSIONS

Neuromuscular electrical stimulation at S1 optimally activated deep spinal stabilizing muscles, TrA and LM, as evidenced by RUSI. The authors recommend this optimal stimulation point be used for NMES in the course of lumbar spine stabilization training in patients having difficulty initiating contraction of these muscles.

Activations of deep lumbar stabilizing muscles by transcutaneous neuromuscular electrical stimulation of lumbar paraspinal regions

Objective

To investigate changes in lumbar multifidus (LM) and deep lumbar stabilizing abdominal muscles (transverse abdominis [TrA] and obliquus internus [OI]) during transcutaneous neuromuscular electrical stimulation (NMES) of lumbar paraspinal L4-L5 regions using real-time ultrasound imaging (RUSI).

Methods

Lumbar paraspinal regions of 20 healthy physically active male volunteers were stimulated at 20, 50, and 80 Hz. Ultrasound images of the LM, TrA, OI, and obliquus externus (OE) were captured during stimulation at each frequency.

Results

The thicknesses of superficial LM and deep LM as measured by RUSI were greater during NMES than at rest for all three frequencies (p<0.05). The thicknesses in TrA, OI, and OE were also significantly greater during NMES of lumbar paraspinal regions than at rest (p<0.05).

Conclusion

The studied transcutaneous NMES of the lumbar paraspinal region significantly activated deep spinal stabilizing muscle (LM) and the abdominal lumbar stabilizing muscles TrA and OI as evidenced by RUSI. The findings of this study suggested that transcutaneous NMES might be useful for improving spinal stability and strength in patients having difficulty initiating contraction of these muscles.

Long-term lumbar multifidus muscle atrophy changes documented with magnetic resonance imaging: a case series

A retrospective case series of three patients with chronic low back pain who received baseline MRI scans revealing multifidus muscle atrophy with fatty replacement is provided. Each patient received spinal manipulative therapy, and two were compliant with low back exercises targeting the multifidus. A follow-up scan performed >1 year later was compared to the baseline scan revealing a decrease in atrophy with fatty replacement in the two patients who performed multifidus-focused low back exercises (15% and 39% on the left and 7% and 32% on the right respectively), and an increase in the patient who underwent spinal manipulation alone (41% and 53%). Interestingly, the decrease in atrophy in the two patients that performed the exercises correlated to functional improvements. Though limited, these results highlight the utility of MRI in quantifying positive and negative long-term changes in multifidus atrophy, which may be an indicator of recovery in chronic low back pain patients.

A clinical prediction rule to identify patients with low back pain who are likely to experience short-term success following lumbar stabilization exercises: a randomized controlled validation study

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

To determine the validity of a previously suggested clinical prediction rule (CPR) for identifying patients most likely to experience short-term success following lumbar stabilization exercise (LSE). Background Although LSE is commonly used by physical therapists in the management of low back pain, it does not seem to be more effective than other interventions. A 4-item CPR for identifying patients most likely to benefit from LSE has been previously suggested but has yet to be validated.

METHODS

One hundred five patients with low back pain underwent a baseline examination to determine their status on the CPR (positive or negative). Patients were stratified by CPR status and then randomized to receive an LSE program or an intervention consisting of manual therapy (MT) and range-of-motion/flexibility exercises. Both interventions included 11 treatment sessions delivered over 8 weeks. Low back pain-related disability was measured by the modified version of the Oswestry Disability Index at baseline and upon completion of treatment.

RESULTS

The statistical significance for the 2-way interaction between treatment group and CPR status for the level of disability at the end of the intervention was P = .17. However, among patients receiving LSE, those with a positive CPR status experienced less disability by the end of treatment compared with those with a negative CPR status (P = .02). Also, among patients with a positive CPR status, those receiving LSE experienced less disability by the end of treatment compared with those receiving MT (P = .03). In addition, there were main effects for treatment and CPR status. Patients receiving LSE experienced less disability by the end of treatment compared to patients receiving MT (P = .05), and patients with a positive CPR status experienced less disability by the end of treatment compared to patients with a negative CPR status, regardless of the treatment received (P = .04). When a modified version of the CPR (mCPR) containing only the presence of aberrant movement and a positive prone instability test was used, a significant interaction with treatment was found for final disability (P = .02). Of the patients who received LSE, those with a positive mCPR status experienced less disability by the end of treatment compared to those with a negative mCPR status (P = .02), and among patients with a positive mCPR status, those who received LSE experienced less disability by the end of treatment compared to those who received MT (P = .005).

CONCLUSION

The previously suggested CPR for identifying patients likely to benefit from LSE could not be validated in this study. However, due to its relatively low level of power, this study could not invalidate the CPR, either. A modified version of the CPR that contains only 2 items may possess a better predictive validity to identify those most likely to succeed with an LSE program. Because this modified version was established through post hoc testing, an additional study is recommended to prospectively test its predictive validity.

LEVEL OF EVIDENCE

Prognosis, level 1b-.

Review of methods used by chiropractors to determine the site for applying manipulation

Background

With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation.

Methods

Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation.

Results

A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement.

Conclusions

A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care– methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine–such as skin conductance or thermography–tend not to be supported by the available evidence.

Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases

OBJECTIVE

The purpose of this study was to systematically search the literature for studies reporting serious adverse events following lumbopelvic spinal manipulative therapy (SMT) and to describe the case details.

METHODS

A systematic search was conducted in PubMed including MEDLINE, EMBASE, CINAHL, and The Cochrane Library up to January 12, 2012, by an experienced reference librarian. Study selection was performed by 2 independent reviewers using predefined criteria. We included cases involving individuals 18 years or older who experienced a serious adverse event following SMT applied to the lumbar spine or pelvis by any type of provider (eg, chiropractic, medical, physical therapy, osteopathic, layperson). A serious adverse event was defined as an untoward occurrence that results in death or is life threatening, requires hospital admission, or results in significant or permanent disability. We included studies published in English, German, Dutch, and Swedish.

RESULTS

A total of 2046 studies were screened, and 41 studies reporting on 77 cases were included. Important case details were frequently unreported, such as descriptions of SMT technique, the pre-SMT presentation of the patient, the specific details of the adverse event, time from SMT to the adverse event, factors contributing to the adverse event, and clinical outcome. Adverse events consisted of cauda equina syndrome (29 cases, 38% of total); lumbar disk herniation (23 cases, 30%); fracture (7 cases, 9%); hematoma or hemorrhagic cyst (6 cases, 8%); or other serious adverse events (12 cases, 16%) such as neurologic or vascular compromise, soft tissue trauma, muscle abscess formation, disrupted fracture healing, and esophageal rupture.

CONCLUSIONS

This systematic review describes case details from published articles that describe serious adverse events that have been reported to occur following SMT of the lumbopelvic region. The anecdotal nature of these cases does not allow for causal inferences between SMT and the events identified in this review. Recommendations regarding future case reporting and research aimed at furthering the understanding of the safety profile of SMT are discussed.