Manual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: a randomized controlled trial

Immediate efficacy of auricular acupuncture combined with active exercise in the treatment of acute lumbar sprains in 10 minutes: Protocol of a randomized controlled trial

BACKGROUND

Acute lumbar sprain (ALS) is common musculoskeletal disorder characterized by severe low back pain and activity limitation, which significantly impacts the patient's work and life. Immediate relief of pain and restoration of mobility in a short period of time are the main needs of patients when they visit the clinic. This study aims to evaluate the immediate efficacy of this combined treatment for ALS within 10 minutes.

METHODS

This is a single-center, prospective, randomized clinical trial. 128 eligible patients with ALS will be randomly allocated in a 1:1 ratio to either the auricular acupuncture (AA) group or the sham auricular acupuncture (SAA) group. All patients will receive a single 10-minute treatment. The primary outcome will be the change in pain intensity after 10 minutes of treatment. The secondary outcomes include changes in pain intensity at other time points (2, 5 minutes), changes in lumbar range of motion (ROM) at different time points, blinded assessment, treatment effect expectancy scale evaluation, and treatment satisfaction scale evaluation. All participants will be included in the analysis according to the intention-to-treat principle.

DISCUSSION

This is the first randomized controlled trial to assess the immediate efficacy of AA combined with active exercise for ALS. The findings of this study are expected to provide a simple and rapid treatment for ALS in clinical.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2400083740. Registered 30 April 2024.

Physiotherapeutic and non-conventional approaches in patients with chronic low-back pain: a level I Bayesian network meta-analysis

Chronic low back pain (cLBP) is a major cause of disability and healthcare expenditure worldwide. Its prevalence is increasing globally from somatic and psychosocial factors. While non-pharmacological management, and in particular physiotherapy, has been recommended as a first-line treatment for cLBP, it is not clear what type of physiotherapeutic approach is the most effective in terms of pain reduction and function improvement. This analysis is rendered more difficult by the vast number of available therapies and a lack of a widely accepted classification that can effectively highlight the differences in the outcomes of different management options. This study was conducted according to the PRISMA guidelines. In January 2024, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. All the randomised controlled trials (RCTs) which compared the efficacy of physiotherapy programs in patients with cLBP were accessed. Studies reporting on non-specific or mechanical cLPB were included. Data concerning the Visual Analogic Scale (VAS) or numeric rating scale (NRS), Roland Morris Disability Questionnaire (RMQ) and Oswestry Disability Index (ODI). Data from 12,773 patients were collected. The mean symptom duration was 61.2 ± 51.0 months and the mean follow-up was 4.3 ± 5.9 months. The mean age was 44.5 ± 9.4 years. The mean BMI was 25.8 ± 2.9 kg/m2. The Adapted Physical Exercise group evidenced the lowest pain score, followed by Multidisciplinary and Adapted Training Exercise/Complementary Medicine. The Adapted Physical Exercise group evidenced the lowest RMQ score followed by Therapeutic Exercises and Multidisciplinary. The Multidisciplinary group evidenced the lowest ODI score, followed by Adapted Physical Exercise and Physical Agent modalities. Within the considered physiotherapeutic and non-conventional approaches to manage nonspecific and/or mechanic cLBP, adapted physical exercise, physical agent modalities, and a multidisciplinary approach might represent the most effective strategy to reduce pain and disability.

Evolving Spinal Treatment Modalities: A Review of the Literature on Non-surgical Interferential Differential Dynamics (IDD) Therapy

Low back pain is one of the most common ailments encountered by physicians and orthopedic surgeons. There are various modalities used to treat low back pain, including conservative management, and a few of them involve rest, medications, massage, bracing, acupuncture, and physical therapy. Though most of the patients improve with conservative management, the burden of this disease has been very high and caused a significant amount of economic loss. Therefore, in-depth knowledge of all conservative methods is essential for physicians managing low back pain. Furthermore, there can be many causes of low back pain. Some of the more common ones are mechanical back pain due to paraspinal muscles or facetal in origin, discogenic back pain, and sacroiliac joint dysfunction. Many patients, especially the older population, have the discogenic origin as the more common cause of back pain, and traction therapy has been used for its treatment for ages. In this review, we discuss non-surgical spinal decompression/traction therapy popularly known as interferential differential dynamics (IDD) therapy with its current standing and recent advancement.

Rehabilitation following ulnar collateral ligament injury of the elbow in a female acrobatic athlete: A case report

BACKGROUND

The mechanism of injury and the conservative rehabilitation of the ulnar collateral ligament of the elbow (UCL) are well studied and reported in overhead athletes, while research on gymnastic athletes is sparse. Evidence suggests exercise as the mainstay in UCL injury rehabilitation. With this report, we aimed to provide a complete rehabilitation protocol following a partial UCL tear of an acrobatic athlete, where exercise and adjunct treatments, such as manual therapy, were used in a progressive staged rehabilitation.

CASE DESCRIPTION

A 16-year-old female acrobatic athlete was diagnosed with partial tear of the anterior band of UCL. The rehabilitation included progressive exercise loading in conjunction with manual therapy for 10 sessions in 8 weeks. Pain, UCL special tests, the Disabilities of Arm, Shoulder and Hand Score Questionnaire (DASH), and the Upper Limb Functional Index (ULFI) were assessed and administered at baseline and at 3, 6, 10 weeks, and 3 months.

RESULTS

Improvement in all outcome measures was noted at the 3-month follow-up indicating a substantial reduction in pain and disability, and an increase in stability of the elbow joint. Return to training was achieved at 8 weeks from the initial visit, while return to sport at the pre-injury level was achieved at 3 months.

CONCLUSION

Progressive exercise loading along with the addition of manual therapy is an effective intervention for the rehabilitation and return to sport following a partial UCL tear. A progressive staged rehabilitation guideline for acrobatic athletes with UCL injuries has been provided to be used and guide clinical practice.

LEVEL OF EVIDENCE

Level IV.

Management of low back pain and lumbosacral radicular syndrome: the Guideline of the Royal Dutch Society for Physical Therapy (KNGF)

BACKGROUND

Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines.

AIM

To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists.

DESIGN

Clinical practice guideline.

SETTING

Inpatient and outpatient.

POPULATION

Adults with LBP and/or LRS.

METHODS

Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase.

RESULTS

The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment.

CONCLUSIONS

An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises.

CLINICAL REHABILITATION IMPACT

This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.

Effectiveness of exercise therapy on pain relief and jaw mobility in patients with pain-related temporomandibular disorders: a systematic review

Background

Orofacial pain conditions are complex disorders that involve biological, social, and psychological factors. Temporomandibular Disorders (TMDs) are one of the most common orofacial pain conditions, and our previous literature review indicated that exercise therapy has shown promise in reducing TMD-related pain. However, more evidence is needed to firmly establish its effectiveness.

Objectives

This systematic review aims to investigate the effectiveness of exercise therapy on pain relief and jaw mobility in patients with pain-related TMDs.

Methods

To include randomized controlled trials (RCTs) written in English, a literature search was performed using PubMed, Scopus, Web of Science, Cochrane Library, Ovid, EBM reviews, and Academic Search Complete initially from 4th November 2020 until March 2022. A PICOS for this review was as follows; P: Patients with TMD myalgia or arthralgia, I: Excursion exercise, Stretch exercises, Resistance exercise, or Coordination exercise, C: No treatment or education only. O: Pain intensity and Range of Motion (ROM), S: RCTs. After title screening, a full-text assessment was done to extract data. According to Risk of Bias (RoB) 2.0, risk of bias was assessed in each included paper by 2 reviewers independently.

Results

A total of 3,388 titles were identified from the electronic database search. After the screening and full-text evaluation, only 5 studies (145 participants) were eligible to be included. Among the exercise modalities, coordination exercise showed a significant effect on pain relief and improvement of joint mobility.

Discussion

Due to the heterogeneity and small sample size of the included studies, a meta-analysis was not feasible. However, this systematic review suggested that exercise therapy, especially coordinate exercise, can be effective in managing painful TMD conditions. Further research is needed to establish optimal parameters for this patient population, as well as standardization and consistency in terminology and treatment structure.

Home Exercise Programs Are Infrequently Prescribed in Trials of Supervised Exercise for Individuals With Low Back Pain: A Scoping Review of 292 Randomized Controlled Trials

OBJECTIVES: To (1) determine how often home exercise programs (HEPs) are prescribed in supervised exercise trials for low back pain (LBP) and (2) describe characteristics of the HEP programs (design, purpose, dose, and adherence). DESIGN: Scoping review. LITERATURE SEARCH: PubMed, CINAHL, and Ovid MEDLINE were searched from January 1, 2010, to August 17, 2021. STUDY SELECTION CRITERIA: Randomized controlled trials that included adults with LBP who received exercise interventions. DATA SYNTHESIS: The presence or absence of a prescribed HEP and any details of the HEP including design, dose, and adherence were extracted and summarized. RESULTS: Of 2689 potentially relevant trials, 292 were eligible for inclusion. Ninety-four trials (32%) included a HEP. The most commonly prescribed home exercises were core stability, trunk strengthening, and motor control exercises. There was great variation in the frequency and duration with which HEPs were prescribed. Adherence to HEPs was measured in fewer than half of the trials, and the methods for measuring adherence were inconsistent. Adherence to HEPs ranged from 29% to 82% in the 21 trials that reported adherence. CONCLUSION: Home exercise programs are not regularly prescribed in supervised exercise trials for LBP. There was considerable variation in prescribing HEPs and monitoring exercise adherence in trials of exercise-based treatments for adults with LBP. There is no consistent method used to measure participants' adherence to HEPs, and adherence percentages vary widely. J Orthop Sports Phys Ther 2023;53(3):120-142. Epub: 16 January 2023. doi:10.2519/jospt.2023.11448.

Over Half of Clinical Trials of Mobilization and Manipulation for Patients With Low Back Pain May Have Limited Real-World Applicability: A Systematic Review of 132 Clinical Trials

OBJECTIVE

To evaluate the existing body of trials assessing manual therapy for low back pain (LBP) to determine where it falls on the efficacyeffectiveness continuum.

DESIGN

Methodology systematic review.

LITERATURE SEARCH

PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and PEDro (Physiotherapy Evidence Database) were searched for trials published between January 1, 2000, and April 30, 2021.

STUDY SELECTION CRITERIA

We included randomized clinical trials investigating joint mobilization and manipulation for adults with nonspecific LBP that were available in English.

DATA SYNTHESIS

We used the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool to score included trials across 4 domains: participant characteristics, trial setting, flexibility of intervention(s), and clinical relevance of experimental and comparison intervention(s). Proportions of trials with greater emphasis on efficacy or effectiveness were calculated for each domain.

RESULTS

Of the 132 included trials, a greater proportion emphasized efficacy than effectiveness for domains participant characteristics (50% vs 38%), trial setting (71% vs 20%), and flexibility of intervention(s) (61% vs 25%). The domain clinical relevance of experimental and comparison intervention(s) had lower emphasis on efficacy (41% vs 50%).

CONCLUSION

Most trials investigating manual therapy for LBP lack pragmatism across the RITES domains (ie, they emphasize efficacy). To improve real-world implementation, more research emphasizing effectiveness is needed. This could be accomplished by recruiting from more diverse participant pools, involving multiple centers that reflect common clinical practice settings, involving clinicians with a variety of backgrounds/experience, and allowing flexibility in how interventions are delivered. J Orthop Sports Phys Ther 2022;52(8):532-545. Epub: 19 June 2022. doi:10.2519/jospt.2022.10962.

Well-described exercises for chronic low back pain in Life Science Literature: A systematic review

BACKGROUND

Therapeutic exercise (TE) is recommended in multimodal treatment for patients with non-specific chronic back pain (cLBP).

OBJECTIVE

The aim of this study is to identify an exercise or a spectrum of exercises, well described and reproducible by the clinician, for cLBP patients.

METHODS

Systematic review by researching in the databases MEDLINE, EMBASE, PEDro, CINAHL, and Scopus. Evidence from Randomized Controlled Trials (RCTs) supported the TE in patients with non-specific cLBP, provided that it was well described and could be repeated by another therapist. Methodological evaluation was performed using the PEDro scale and only studies with a score of ⩾ 6 were included. The assessment of the intervention description was carried out with the TIDieR checklist. The risk of bias was examined.

RESULTS

Twenty-one articles were included in this systematic review. The defective description and the poorly reporting of the intervention makes it more difficult for the clinician to include the TE into clinical practice.

CONCLUSIONS

The findings of this study showed that the reporting of the intervention in high quality RCT on chronic low back pain is low, threatening the external validity of the results.

Efficacy of the cognitive functional therapy (CFT) in patients with chronic nonspecific low back pain: a study protocol for a randomized sham-controlled trial

Background

Chronic low back pain is a public health problem, and there is strong evidence that it is associated with a complex interaction of biopsychosocial factors. Cognitive functional therapy (CFT) is a promising new intervention that deals with potentially modifiable multidimensional aspects of pain (e.g., provocative cognitive, movement, and lifestyle behaviors).

Methods

To investigate the efficacy of CFT compared with a sham intervention for pain intensity and disability post-intervention (immediately after the last session) in patients with non-specific chronic low back pain (CLBP). This study is a randomized controlled trial in which 152 (18–60 years old) patients with CLBP will be enrolled. The patients will be randomly allocated to receive (1) CFT intervention or (2) sham intervention. The experimental group will receive individualized CFT in a pragmatic manner (5 to 7 sessions) based on the clinical progression of the participants. The sham group will attend six sessions: consisting of 30 min of photobiomodulation using a detuned device and more than 15 min of talking about neutral topics. Patients from both groups also will receive an educational booklet (for ethical reasons). Participants will be assessed pre and post-intervention, 3 months, and 6 months after randomization. The primary outcomes will be pain intensity and disability post-intervention. The secondary outcomes will be: pain intensity and disability at 3- and 6-month follow-up, as well as self-efficacy, global perceived effect of improvement, and functioning post-intervention, 3-, and 6-month follow-up. The patients and the assessor will be blinded to the treatment administered (active vs. sham).

Statistical analysis

The between-group differences (effects of treatment), as well as the treatment effect for the primary and secondary outcomes, and their respective 95% confidence intervals will be calculated by constructing linear mixed models.

Discussion

To the best of our knowledge, the current study will be the first to compare CFT vs. sham intervention. Sham-controlled RCTs may help to understand the influence of non-specific factors on treatment outcomes. Considering complex interventions as CFT, it is imperative to understand the impact of contextual factors on outcomes.

Trial registration

ClinicalTrials.gov NCT04518891. First Posted: August 19, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06466-8.

Comparison of an Iranian Traditional Massage (Fateh Method) with Physiotherapy and Acupuncture for Patients with Chronic Low Back Pain: a Randomized Controlled Trial

Background

Low back pain (LBP) is currently a major reason for disability worldwide. Therapeutic massage is one of the most popular non-pharmacological methods for managing chronic LBP (CLBP), and the Fateh method is a massage technique based on Iranian Traditional Medicine.

Objectives

The current study aimed to compare the effects of Fateh massage with those of acupuncture and physiotherapy on relieving pain and disability in CLBP.

Methods

Eighty-four patients with CLBP were categorized into groups that received Fateh massage, acupuncture, or physiotherapy. Each group included 28 randomly assigned patients who completed 10 sessions of therapy. Visual analogue scale (VAS) scores and Roland-Morris disability scores were evaluated at baseline, after intervention, and four weeks later. The findings were analyzed with SPSS software.

Results

The baseline VAS and Roland-Morris scores of the three study groups did not indicate significant differences (p > 0.05). All three groups showed significant pre-post improvements in both scores (p < 0.05). At the end of the treatment sessions, the three groups showed no significant difference in the reductions in pain intensity and disability score (p > 0.05). Improvements in disability and pain between the first and third time points were significant in all three groups (p < 0.05 for each group). In addition, the results of massage, physiotherapy, and acupuncture groups were not significantly different (p > 0.05). No adverse events occurred in the patients.

Conclusion

The effects of Fateh massage were comparable to those of acupuncture and physiotherapy in reducing pain and disability in patients with CLBP.

Segmental spine mobility differences between lumbar flexion- and extension-based movement syndromes in patients with low back pain

BACKGROUND

The Movement System Impairment (MSI) model is useful for identifying spine-hip mobility and motor control deficits that may contribute to low back pain (LBP). While previous studies have found differences in global spine-hip movement impairments between lumbar MSI subgroups, no studies have compared segmental spine movement impairments between these subgroups. Therefore, the purpose of this study is to analyze segmental lumbar mobility in participants with LBP and a lumbar flexion- or extension-based MSI.

METHODS

Forty participants with subacute-chronic LBP were placed into one of three age groups (< 35, 35-54, or > 54 years-old) and then classified into a flexion- or extension-based MSI sub-group. Segmental lumbar range of motion (ROM) was measured in degrees using a skin-surface device. Total lumbar and segmental flexion and extension ROM of L1-L2 to L5-S1 was compared between MSI sub-groups for each age group using separate two-way ANOVAs.

RESULTS

Significant main effects were found for the independent variables of MSI subgroup and age. Participants in all three age groups with a flexion-based MSI displayed significantly less lumbar extension (-0.6∘) at L4-5 as compared to participants with an extension-based MSI (-2.1∘), p= 0.03. In addition, lumbar total and segmental ROM was significantly less for older individuals in both subgroups.

CONCLUSIONS

Individuals with LBP may demonstrate a pattern of lumbar segmental hypomobility in the opposite direction of their MSI. Future studies may investigate the added value of direction-specific spinal mobilization to a program of MSI-based exercise.

Effects of non-surgical decompression therapy in addition to routine physical therapy on pain, range of motion, endurance, functional disability and quality of life versus routine physical therapy alone in patients with lumbar radiculopathy; a randomized controlled trial

BACKGROUND

Lumbar radiculopathy is an extensively common complaint reported by patients of low back pain (LBP), resulting in several impairments. A comparatively novel technique, non-surgical spinal decompression (NSD), is introduced, which uses a sensitive computerized feedback mechanism and decompresses the spinal nerve roots through segmental distraction. The objective of this study was to determine the effects of NSD therapy in addition to routine physical therapy on pain, lumbar range of motion (ROM), functional disability, back muscle endurance (BME), and quality of life (QOL) in patients with lumbar radiculopathy.

METHODS

A total of sixty patients with lumbar radiculopathy were randomly allocated into two groups, an experimental (n = 30) and a control (n = 30) group, through a computer-generated random number table. Baseline values were recorded before providing any treatment by using a visual analogue scale (VAS), Urdu version of Oswestry disability index (ODI-U), modified-modified Schober's test (MMST), prone isometric chest raise test, and Short Form 36-Item Survey (SF-36) for measuring the pain at rest, functional disability, lumbar ROM, BME, and QOL, respectively. All patients received twelve treatment sessions over 4 weeks, and then all outcome measures were again recorded.

RESULTS

By using the ANCOVA test, a statistically significant (p < 0.05) between-group improvement was observed in VAS, ODI-U, BME, lumbar ROM, role physical (RP), and bodily pain (BP) domains of SF-36, which was in favour of NSD therapy group. The between-group difference was 1.07 ± 0.32 cm (p < .001) for VAS, 5.65 ± 1.48 points (p < .001) for ODI-U, 13.93 ± 5.85 s (p = 0.002) for BME, 2.62 ± 0.27 cm (p < .001) for lumbar flexion, 0.96 ± 0.28 (p < .001) for lumbar extension, 5.77 ± 2.39 (p = 0.019) for RP and 6.33 ± 2.52 (p = 0.016) for BP domain of SF-36. For these outcomes, a medium to large effect size (d = 0.61-2.47, 95% CI: 0.09-3.14) was observed.

CONCLUSION

It was concluded that a combination of non-surgical spinal decompression therapy with routine physical therapy is more effective, statistically and clinically, than routine physical therapy alone in terms of improving pain, lumbar range of motion, back muscle endurance, functional disability, and physical role domain of quality of life, in patients with lumbar radiculopathy, following 4 weeks of treatment.

TRIAL REGISTRATION

WHO Iranian registry of clinical trials ( IRCT20190717044238N1 ) Dated: 23.12.2019.

Sustained acoustic medicine for the treatment of musculoskeletal injuries: a systematic review and meta-analysis

BACKGROUND

Musculoskeletal injuries account for 10 million work-limited days per year and often lead to both acute and/or chronic pain, and increased chances of re-injury or permanent disability. Conservative treatment options include various modalities, nonsteroidal anti-inflammatory drugs, and physical rehabilitation programs. Sustained Acoustic Medicine is an emerging prescription home-use mechanotransductive device to stimulate cellular proliferation, increase microstreaming and cavitation in situ, and to increase tissue profusion and permeability. This research aims to summarize the clinical evidence on Sustained Acoustic Medicine and measurable outcomes in the literature.

METHODS

A systematic literature review was conducted using PubMed, EBSCOhost, Academic Search Complete, Google Scholar and ClinicalTrials.gov to identify studies evaluating the effects of Sustained Acoustic Medicine on the musculoskeletal system of humans. Articles identified were selected based on inclusion criteria and scored on the Downs and Black checklist. Study design, clinical outcomes and primary findings were extracted from included studies for synthesis and meta-analysis statistics.

RESULTS

A total of three hundred and seventy-two participants (372) were included in the thirteen clinical research studies reviewed including five (5) level I, four (4) level II and four (4) level IV studies. Sixty-seven (67) participants with neck and back myofascial pain and injury, one hundred and fifty-six (156) participants with moderate to severe knee pain and radiographically confirmed knee osteoarthritis (Kellgren-Lawrence grade II/III), and one hundred forty-nine (149) participants with generalized soft-tissue injury of the elbow, shoulder, back and ankle with limited function. Primary outcomes included daily change in pain intensity, change in Western Ontario McMaster Osteoarthritis Questionnaire, change in Global Rate of Change, and functional outcome measures including dynamometry, grip strength, range-of-motion, and diathermic heating (temperature measurement).

CONCLUSION

Sustained Acoustic Medicine treatment provides tissue heating and tissue recovery, improved patient function and reduction of pain. When patients failed to respond to physical therapy, Sustained Acoustic Medicine proved to be a useful adjunct to facilitate healing and return to work. As a non-invasive and non-narcotic treatment option with an excellent safety profile, Sustained Acoustic Medicine may be considered a good therapeutic option for practitioners.

Effects of dynamic stabilization exercises and muscle energy technique on selected biopsychosocial outcomes for patients with chronic non-specific low back pain: a double-blind randomized controlled trial

OBJECTIVES

Low back pain is the most prevalent musculoskeletal condition, and causes activity limitations which result in reduced work productivity and high medical expenditure. The management of this condition has been challenging to both clinicians and researchers. While the use of Muscle Energy Technique (MET) as a potentially effective treatment strategy seems promising, studies examining MET combined with exercise therapy are scarce and studies with strong methodology are lacking. Therefore, this study aims to determine the effects of a combination of Dynamic Stabilization Exercises (DSE) and MET on selected biopsychosocial outcomes compared to DSE alone or conventional physiotherapy in the management of chronic non-specific low back pain (NSLBP).

METHODS

A total of 125 (80 male and 45 female) patients with chronic NSLBP were involved in this study, they were recruited from Rasheed Shekoni Teaching hospital and Federal Medical centre Birnin-Kudu, Jigawa State, Nigeria. A random number generator method was used to allocate patients to either DSE + MET (n=41), DSE alone (n=39) or conventional physiotherapy (n=45). Interventions were administered twice a week over 12 weeks. Outcome measures included pain intensity, lumbar (flexion and extension) range of motion, functional-disability, self-perceived health status, limitations in activities and participation restrictions. These were assessed at baseline, mid-intervention at six weeks, post-intervention at 12 weeks and long term follow-up at 24 weeks. Data was analyzed using repeated-measures ANOVA to determine significance difference within groups and between groups.

RESULTS

All intervention groups showed within-groups changes of the study outcomes over time (p<0.001). However, between-group comparisons showed greater improvements in pain intensity (F=7.91, p<0.001), lumbar ROM (flexion F=1.51, p<0.001; extension F=3.25, p<0.001), activity limitations/participation restrictions (F=3.7, p<0.001) and health status (F=10.9, p<0.001) for the intervention in which MET and DSE were combined. The MET plus DSE interventions were superior to DSE and convention physiotherapy for all outcome measures, except for functional disability (F=0.53, p=0.590).

CONCLUSIONS

The data from this study showed MET combined with DSE had greater therapeutic benefits compared to DSE or conventional physiotherapy on selected biopsychosocial outcomes in patients with chronic NSLBP. The findings from the study show that the combination of MET with DSE is safe and has beneficial effects in the management of patients with chronic NSLBP.

CLINICAL TRIAL REGISTRATION

The study protocol has been registered with www.ClinicalTrial.gov with the registration number NCT3449810.

The effect of muscles energy technique in the management of chronic mechanical low back pain: A scoping review

BACKGROUND

The Muscle Energy Technique (MET) is one of the treatments of choice for the management of chronic mechanical low back pain (MLBP); however, there is a paucity of evidence to justify its effectiveness.

OBJECTIVES

The objectives of this review are to explore, analyze and summarize the available evidence related to the effectiveness of MET in the management of chronic MLBP.

METHOD

The scoping review methodology was adopted based on a recommendation from the work of Arksey and O'Malley, to systematically appraise literature and map the existing evidence on the effectiveness of MET in the management of chronic MLBP. A systematic search was performed comprising of an electronic search of online databases using key search terms and subsided by a hand search to identify the existing literature on the topic which was summarized and discussed.

RESULT

Initially 25,195 hits were identified which were screened to examine their eligibility based on predetermined inclusion criteria after removing duplicate articles. Eleven articles met the inclusion criteria and were discussed.

CONCLUSIONS

Generally there exists a scarcity of published articles on the effect of MET in chronic MLBP. However, the analysis of the retrieved articles showed that the MET procedure is a favourable intervention that is safe (i.e. no adverse effects) and can be effective as a standalone treatment or in combination with other treatment strategies for patients with chronic MLBP with the potential to provide numerous physical and psychosocial benefits.

Progressive Resistance Exercises plus Manual Therapy Is Effective in Improving Isometric Strength in Overhead Athletes with Shoulder Impingement Syndrome: A Randomized Controlled Trial

Reduction in isometric strength of the scapulohumeral muscles is a commonly seen impairment in overhead athletes afflicted with shoulder impingement syndrome (SIS). The purpose of this study was to compare the effects of two different treatment programs: progressive resistance exercises plus manual therapy (PRE plus MT) and motor control exercises (MCE), on isometric strength of upper trapezius (UT), middle trapezius (MTr), lower trapezius (LT), serratus anterior (SA), supraspinatus (Supr.), anterior deltoid (A.D), and latissimus dorsi (LD). 80 male university-level overhead athletes clinically diagnosed with SIS were randomly allocated into either of the two groups: PRE plus MT and MCE group. Athletes in the PRE plus MT group underwent graduated exercises with resistance elastic band, stretching exercises, and mobilization of the thoracic and shoulder joints. MCE group was submitted to motor control exercises in varied planar positions. Athletes in both groups underwent management 3 times a week for 8 weeks. Isometric strength of UT, MTr, LT, Supr, A.D, SA, and LD was measured at three-time points: baseline, 4th week, and 8th week. Relative to baseline, both interventions were found to be effective in increasing and optimizing the isometric strength of muscles (p < 0.05) except for supraspinatus in the MCE group (p > 0.05). However, athletes in PRE plus MT group presented a more pronounced increase in isometric strength than those in the MCE group. Between groups analysis found the largest isometric strength improvement in PRE plus MT group for A.D, followed by Supr. and UT muscles (p < 0.05; effect size: 0.39 to 0.40). The study concluded that compared to MCE, PRE plus MT provides greater improvement in the isometric strength of scapulohumeral muscles.

Moderators of the Effect of Spinal Manipulative Therapy on Pain Relief and Function in Patients with Chronic Low Back Pain: An Individual Participant Data Meta-analysis

STUDY DESIGN

Individual participant data (IPD) meta-analysis.

OBJECTIVE

The aim of this study was to identify which participant characteristics moderate the effect of spinal manipulative therapy (SMT) on pain and functioning in chronic LBP.

SUMMARY OF BACKGROUND

The effects of SMT are comparable to other interventions recommended in guidelines for chronic low back pain (LBP); however, it is unclear which patients are more likely to benefit from SMT compared to other therapies.

METHODS

IPD were requested from randomized controlled trials (RCTs) examining the effect of SMT in adults with chronic LBP for pain and function compared to various other therapies (stratified by comparison). Potential patient moderators (n = 23) were a priori based on their clinical relevance. We investigated each moderator using a one-stage approach with IPD and investigated this interaction with the intervention for each time point (1, 3, 6, and 12 months).

RESULTS

We received IPD from 21 of 46 RCTs (n = 4223). The majority (12 RCTs, n = 2249) compared SMT to recommended interventions. The duration of LBP, baseline pain (confirmatory), smoking, and previous exposure to SMT (exploratory) had a small moderating effect across outcomes and follow-up points; these estimates did not represent minimally relevant differences in effects; for example, patients with <1 year of LBP demonstrated more positive point estimates for SMT versus recommended therapy for the outcome pain (mean differences ranged from 4.97 (95% confidence interval, CI: -3.20 to 13.13) at 3 months, 10.76 (95% CI: 1.06 to 20.47) at 6 months to 5.26 (95% CI: -2.92 to 13.44) at 12 months in patients with over a year LBP. No other moderators demonstrated a consistent pattern across time and outcomes. Few moderator analyses were conducted for the other comparisons because of too few data.

CONCLUSION

We did not identify any moderators that enable clinicians to identify which patients are likely to benefit more from SMT compared to other treatments.Level of Evidence: 2.

The effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain: an individual participant data meta-analysis

BACKGROUND

A 2019 review concluded that spinal manipulative therapy (SMT) results in similar benefit compared to other interventions for chronic low back pain (LBP). Compared to traditional aggregate analyses individual participant data (IPD) meta-analyses allows for a more precise estimate of the treatment effect.

PURPOSE

To assess the effect of SMT on pain and function for chronic LBP in a IPD meta-analysis.

DATA SOURCES

Electronic databases from 2000 until April 2016, and reference lists of eligible trials and related reviews.

STUDY SELECTION

Randomized controlled trials (RCT) examining the effect of SMT in adults with chronic LBP compared to any comparator.

DATA EXTRACTION AND DATA SYNTHESIS

We contacted authors from eligible trials. Two review authors independently conducted the study selection and risk of bias. We used GRADE to assess the quality of the evidence. A one-stage mixed model analysis was conducted. Negative point estimates of the mean difference (MD) or standardized mean difference (SMD) favors SMT.

RESULTS

Of the 42 RCTs fulfilling the inclusion criteria, we obtained IPD from 21 (n=4223). Most trials (s=12, n=2249) compared SMT to recommended interventions. There is moderate quality evidence that SMT vs recommended interventions resulted in similar outcomes on pain (MD -3.0, 95%CI: -6.9 to 0.9, 10 trials, 1922 participants) and functional status at one month (SMD: -0.2, 95% CI -0.4 to 0.0, 10 trials, 1939 participants). Effects at other follow-up measurements were similar. Results for other comparisons (SMT vs non-recommended interventions; SMT as adjuvant therapy; mobilization vs manipulation) showed similar findings. SMT vs sham SMT analysis was not performed, because we only had data from one study. Sensitivity analyses confirmed these findings.

LIMITATIONS

Only 50% of the eligible trials were included.

CONCLUSIONS

Sufficient evidence suggest that SMT provides similar outcomes to recommended interventions, for pain relief and improvement of functional status. SMT would appear to be a good option for the treatment of chronic LBP. Systematic Review Registration Number PROSPERO CRD42015025714.

Effects of manual therapy on fear avoidance, kinesiophobia and pain catastrophizing in individuals with chronic musculoskeletal pain: Systematic review and meta-analysis

OBJECTIVE

To systematically review the effectiveness of manual therapy on fear-avoidance, kinesiophobia, and pain catastrophizing in patients with chronic musculoskeletal pain.

LITERATURE SEARCH

Databases (Medline, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and SCOPUS) were searched from inception up to March 2020.

STUDY SELECTION CRITERIA

Two reviewers independently selected randomized controlled trials that investigated the effects of manual therapy associated or not with other interventions on fear-avoidance, kinesiophobia and pain catastrophizing in patients with chronic musculoskeletal pain.

DATA SYNTHESIS

Standardized Mean Differences (SMD) and 95% confidence interval (CI) were calculated using a random-effects inverse variance model for meta-analysis according to the outcome of interest, comparison group and follow-up period. The level of evidence was synthesized using GRADE.

RESULTS

Eleven studies were included with a total sample of 717 individuals. Manual therapy was not superior to no treatment on reducing fear-avoidance at short-term (low quality of evidence; SMD = -0.45, 95% CI -0.99 to 0.09), and intermediate-term (low quality of evidence; SMD = -0.48, 95% CI -1.0 to 0.04). Based on very-low quality of evidence, manual therapy was not better than other treatments (SMD = 0.10, 95% CI -0.56 to 0.77) on reducing fear-avoidance, kinesiophobia (SMD = -0.12, 95% CI -0.87 to 0.63) and pain catastrophizing (SMD = -0.16, 95% CI -0.48 to 0.17) at short-term.

CONCLUSION

Manual therapy may not be superior to no treatment or other treatments on improving fear-avoidance, kinesiophobia and pain catastrophizing, based on very low or low quality of evidence. More studies are necessary to strengthen the evidence of effects of manual therapy on pain-related fear outcomes.

Lumbar lordotic change and its fulcrum in low back pain disorders: Radiographic evaluation

Background

Globally, low back pain (LBP) is now the leading cause of disability. Patients often have lumbar spine motion dysfunction (motion decrease/increase), and this may affect the lumbar lordosis (LL). Though the relationship between LL and LBP is controversial, it has immense clinical significance, because it serves as the basis of therapeutic exercises for treating and preventing LBP. An angular measure of LL that consistently detects even a small lordotic change (LC) would be considered reliable.

Aims and Objectives

The consistency of some radiographic angles in detecting LC in a potential LBP disorder was evaluated, and LC fulcrum deducted.

Materials and Methods

In both normal (control) and spondylotic (test) lateral lumbosacral radiographs of both genders, LL was retrospectively measured using the following angular measures and sample sizes: Lumbosacral angle (LSA, 125), Lumbosacral joint angle (LSJA, 115), Cobb angle (118), and Tangential radiologic assessment of lumbar lordosis (TRALL) angle (101). The angles' consistency in detecting intra-gender LC between control versus test was evaluated. The intervertebral disc (IVD) that sub-tended the most consistent angle represents the LC fulcrum. All cases were ≥17 years of age. Data was analyzed with IBM SPSS Statistics 23.0 (NY, USA); P < 0.05 was considered statistically significant.

Results

LSJA detected slight intra-gender LC in both genders, LSA in males only, Cobb and TRALL angles in none. The IVD of L5/S1 sub-tended the LSJA and therefore represents the LC fulcrum.

Conclusion

LSJA is a reliable measure of lumbar LC in physical therapy of LBP, especially, the non-specific LBP disorders.

Comparison between high-velocity low-amplitude manipulation and muscle energy technique on pain and trunk neuromuscular postural control in male workers with chronic low back pain: A randomised crossover trial

BACKGROUND

A therapeutic recommendation for restoring function in individuals with chronic low back pain (CLBP) is manual therapy through manipulative spinal or muscle energy techniques.

OBJECTIVES

To compare the effectiveness of two osteopathic manipulative techniques on clinical low back symptoms and trunk neuromuscular postural control in male workers with CLBP.

METHOD

Ten male workers with CLBP were randomly allocated to two groups: high-velocity low-amplitude (HVLA) manipulation or muscle energy techniques (MET). Each group received one therapy per week for both techniques during 7 weeks of treatment. Pain and function were measured by using the Numeric Pain-Rating Scale, the McGill Pain Questionnaire and the Roland Morris Disability Questionnaire. The lumbar flexibility was assessed by Modified Schober Test. Electromyography (EMG) and force platform measurements were used for evaluation of trunk muscular activation and postural balance, respectively at three different times: baseline, post intervention, and 15 days later.

RESULTS

Both techniques were effective (p < 0.01) in reducing pain with large clinical differences (-1.8 to -2.8) across immediate and after 15 days. However, no significant effect between groups and times was found for other variables, namely neuromuscular activation and postural balance measures.

CONCLUSION

Both techniques (HVLA thrust manipulation and MET) were effective in reducing back pain immediately and 15 days later. Neither technique changed the trunk neuromuscular activation patterns nor postural balance in male workers with LBP.

CLINICAL IMPLICATIONS

These results may facilitate clinical decision-making for CLBP management in physiotherapy programs.

Comparison of Physiotherapy Approaches in Low Back Pain: A Randomized Controlled Trial

BACKGROUND

The purpose of this study was to compare the effectiveness of rehabilitation approaches in individuals with low back pain (LBP) on pain, spinal mobility, disability, and muscular strength.

METHODS

Ninety volunteers were included and divided into four groups depending on the rehabilitation approach: group 1, soft tissue mobilization techniques and stabilization exercises (n=24; 11 females [F], 13 males [M]); group 2, Kinesio Taping and stabilization exercises (n=24; 12F, 12M); group 3, stabilization exercises (n=22; 11F, 11M); and group 4, reflex therapy and stabilization exercises (n=20; 10F, 10M). Visual Analog Scale for pain intensity, an isokinetic evaluation for strength at 60°/s and a side-plank position test for trunk stabilization were measured before and assessed at the beginning, after a 4-week treatment and during 4 weeks of follow-up. The functional status was evaluated with the Oswestry Disability Index.

RESULTS

Individuals in all groups showed similar decrease in pain after the treatment and at 1-month follow-up, but there were no significant differences in pain levels between the groups (P<0.05).

CONCLUSION

All therapeutic approaches were found to be effective in diminishing pain and thus helpful in increasing strength and stabilization in patients with LBP.

A Meta-Analysis of the Reliability of Four Field-Based Trunk Extension Endurance Tests

This meta-analysis aimed to estimate the inter- and intra-tester reliability of endurance measures obtained through trunk extension field-based tests and to explore the influence of the moderators on the reliability estimates. The reliability induction rate of trunk extension endurance measures was also calculated. A systematic search was conducted using various databases, and subsequently 28 studies were selected that reported intraclass correlation coefficients for trunk extension endurance measures. Separate meta-analyses were conducted using a random-effects model. When possible, analyses of potential moderator variables were carried out. The inter-tester average reliability of the endurance measure obtained from the Biering-Sorensen test was intraclass correlation coefficient (ICC) = 0.94. The intra-session reliability estimates of the endurance measures recorded using the Biering-Sorensen test, the prone isometric chest raise test, and the prone double straight-leg test were ICC = 0.88, 0.90, and 0.86, respectively. The inter-session average reliability of the endurance measures from the Biering-Sorensen test, the prone isometric chest raise test, and the dynamic extensor endurance test were ICC = 0.88, 0.95, and 0.99, respectively. However, due to the limited evidence available, the reliability estimates of the measures obtained through the prone isometric chest raise, prone double straight-leg, and dynamic extensor endurance tests should be considered with a degree of caution. Position control instruments, tools, and familiarization session demonstrated a statistical association with the inter-session reliability of the Biering-Sorensen test. The reliability induction rate was 72.8%. Only the trunk extension endurance measure obtained through the Biering-Sorensen test presented sufficient scientific evidence in terms of reliability to justify its use for research and practical purposes.

Short- or Long-Term Treatment of Spinal Disability in Older Adults With Manipulation and Exercise

OBJECTIVE

Back and neck pain are associated with disability and loss of independence in older adults. Whether long-term management using commonly recommended treatments is superior to shorter-term treatment is unknown. This randomized clinical trial compared short-term treatment (12 weeks) versus long-term management (36 weeks) of back- and neck-related disability in older adults using spinal manipulative therapy (SMT) combined with supervised rehabilitative exercises (SRE).

METHODS

Eligible participants were ages ≥65 years with back and neck disability for ≥12 weeks. Coprimary outcomes were changes in Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores after 36 weeks. An intent-to-treat approach used linear mixed-model analysis to detect between-group differences. Secondary analyses included other self-reported outcomes, adverse events, and objective functional measures.

RESULTS

A total of 182 participants were randomized. The short-term and long-term groups demonstrated significant improvements in back disability (ODI score -3.9 [95% confidence interval (95% CI) -5.8, -2.0] versus ODI score -6.3 [95% CI -8.2, -4.4]) and neck disability (NDI score -7.3 [95% CI -9.1, -5.5] versus NDI score -9.0 [95% CI -10.8, -7.2]) after 36 weeks, with no difference between groups (back ODI score 2.4 [95% CI -0.3, 5.1]; neck NDI score 1.7 [95% CI 0.8, 4.2]). The long-term management group experienced greater improvement in neck pain at week 36, in self-efficacy at weeks 36 and 52, and in functional ability, and balance.

CONCLUSION

For older adults with chronic back and neck disability, extending management with SMT and SRE from 12 to 36 weeks did not result in any additional important reduction in disability.

Pain Outcomes with an Elliptical Regimen (POWER) Study: Identifying the Proper Dosage of Exercise for Therapeutic Effect in Persons with Chronic Back Pain

BACKGROUND CONTEXT

Exercise therapy for low back pain has long been prescribed as one of the initial remedies for back pain. Traditional therapy is completed under a therapist's supervision and consists of lumbar stabilization, aerobic exercise and stretching exercises. Recent studies have explored treating back pain with aerobic exercise such as walking which can be done anywhere and without supervision which is lower cost and easily administered.

PURPOSE

To assess a therapeutic dosage of aerobic exercise that is associated with pain reduction in persons experiencing low back pain.

STUDY DESIGN

Case series.

PARTICIPANT DESCRIPTION

Sixteen patients entered the study and twelve patients completed the study (mean ± SD: age 51 ± 11 years; weight 89.2 ± 16 kg). Subjects were included if they were ages 18-65, had chronic back pain lasting for more than 3 months and a score of greater than 30% on the Oswestry Low Back Disability Questionnaire.

METHODS

Subjects underwent a six-week exercise program using the elliptical trainer three times each week. Exercise duration was steadily increased each week for the length of the study. The total cumulative amount of work that coincided with significant reductions in chronic low back pain was then identified.

RESULTS

At 4 weeks, pain scores were significantly reduced from baseline (3.2 vs 4.7, p<0.0001). This significant pain reduction corresponded to an average of 30.8 Kcal/kg of body mass in cumulative work performed. Pain was significantly reduced by 21% and 32% on the Oswestry Questionnaire and the PROMIS 29 respectively.

CONCLUSIONS

These pilot findings suggest that approximately 30.8 kcal/Kg of accumulated physiological work is a therapeutic "dosage" of exercise needed for significant reduction in chronic back pain. Clinicians can begin to use this benchmark for their oversight of rehabilitation programs to determine if an exercise program has been sufficiently intense and long enough in duration for managing their patients with chronic low back pain.

Effectiveness of spinal manipulation and myofascial release compared with spinal manipulation alone on health-related outcomes in individuals with non-specific low back pain: randomized controlled trial

OBJECTIVE

To investigate the effectiveness of spinal manipulation combined with myofascial release compared with spinal manipulation alone, in individuals with chronic non-specific low back pain (CNLBP).

DESIGN

Randomized controlled trial with three months follow-up.

SETTING

Rehabilitation clinic.

PARTICIPANTS

Seventy-two individuals (between 18 and 50 years of age; CNLBP ≥12 consecutive weeks) were enrolled and randomly allocated to one of two groups: (1) Spinal manipulation and myofascial release - SMMRG; n=36) or (2) Spinal manipulation alone (SMG; n=36).

INTERVENTIONS

Combined spinal manipulation (characterized by high velocity/low amplitude thrusts) of the sacroiliac and lumbar spine and myofascial release of lumbar and sacroiliac muscles vs manipulation of the sacroiliac and lumbar spine alone, twice a week, for three weeks.

MAIN OUTCOME MEASURES

Assessments were performed at baseline, three weeks post intervention and three months follow-up. Primary outcomes were pain intensity and disability. Secondary outcomes were quality of life, pressure pain-threshold and dynamic balance.

RESULTS

No significant differences were found between SMMRG vs SMG in pain intensity and disability post intervention and at follow-up. We found an overall significant difference between-groups for CNLBP disability (SMG-SMMRG: mean difference of 5.0; 95% confidence interval of difference 9.9; -0.1), though this effect was not clinically important and was not sustained at follow-up.

CONCLUSIONS

We demonstrated that spinal manipulation combined with myofascial release was not more effective compared to spinal manipulation alone for patients with CNLBP.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03113292.

Somatosensory and Motor Differences between Physically Active Patients with Chronic Low Back Pain and Asymptomatic Individuals

Background and Objectives: Chronic low back pain (CLBP) is the most common occupational disorder due to its associated disability and high risk of recurrence and chronicity. However, the mechanisms underlying physical and psychological variables in patients with CLBP remain unclear. The main objective of this study was to assess whether there were differences between physically active patients with nonspecific CLBP compared with asymptomatic individuals in sensorimotor and psychological variables. Materials and Methods: This was an observational cross-sectional design with a nonprobabilistic sample. The sample was divided into two groups: individuals with nonspecific CLBP (n = 30) and asymptomatic individuals as a control (n = 30). The psychological variables assessed were low back disability, fear of movement, pain catastrophizing, and self-efficacy. The sensorimotor variables assessed were two-point discrimination, pressure pain threshold, lumbopelvic stability, lumbar flexion active range of motion, and isometric leg and back strength. Results: Statistically significant differences between the groups in terms of catastrophizing levels (p = 0.026) and fear of movement (p = 0.001) were found, but no statistically significant differences between groups were found in self-efficacy (p > 0.05). No statistically significant differences between the groups in any of the sensorimotor variables were found (p > 0.05). Conclusion: No sensorimotor differences were found between patients with asymptomatic and chronic low back pain, but differences were found in the psychological variables of catastrophizing and fear of movement.

Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To assess the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, and trial registries up to 4 May 2018, including reference lists of eligible trials and related reviews.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded, as was grey literature. No restrictions were applied to language or setting.

REVIEW METHODS

Two reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence. The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months. Quality of evidence was assessed using GRADE. A random effects model was used and statistical heterogeneity explored.

RESULTS

47 randomised controlled trials including a total of 9211 participants were identified, who were on average middle aged (35-60 years). Most trials compared SMT with recommended therapies. Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief (mean difference -3.17, 95% confidence interval -7.85 to 1.51) and a small, clinically better improvement in function (SMD -0.25, 95% confidence interval -0.41 to -0.09). High quality evidence suggested that compared with non-recommended therapies SMT results in small, not clinically better effects for short term pain relief (mean difference -7.48, -11.50 to -3.47) and small to moderate clinically better improvement in function (SMD -0.41, -0.67 to -0.15). In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. Statistical heterogeneity could not be explained. About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT.

CONCLUSION

SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.

Effect of subgroup-specific multimodal therapy on chronic spinal back pain and function-a prospective inpatient multicentre clinical trial in Germany

Treatment modalities of spinal pain patients are discussed diversely, and different multimodal therapy programs have been developed. Purpose of the present study was to evaluate therapy outcome and effectiveness of an inpatient interdisciplinary and multimodal treatment program.This prospective multicentre clinical trial has been performed with patients from orthopedic hospitals receiving a functional musculoskeletal therapy pathway. Outcome measures were pain intensity and back-specific function (Oswestry Disability Index) before (T1) and after the intervention (T2) as well as after 6 and 12 months (T3, T4). Statistical approach included parametric (t test) and nonparametric (Wilcoxon-test) tests and the calculation of effect sizes. Additionally, a statistical subgroup analysis based on selected parameters (degree of pain chronicity, gender, and age) was performed using linear mixed models.In total, 249 patients (42.6% men, 57.4% women) with spinal pain were included, 133 patients were accessible for follow-up at T3 and 106 patients at T4.Average pain (AP) reduced significantly (P <.001) from T1 to T4 with an effect size of 0.99. Back-specific function also improved (P <.001) over all measuring time points (TP) (effect size: 0.63). Furthermore, the statistical subgroup analysis demonstrated the efficacy of the treatment concept within the subgroup parameters chronicity degree and age.A functional musculoskeletal therapy pathway including treatment of musculoskeletal dysfunctions appears to be beneficial in terms of treating pain and function. Pain chronicity and age seems to be factors influencing therapy outcome. Further studies are needed to examine the superiority of these inpatient programs for back pain including control groups.

Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis

BACKGROUND CONTEXT

Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain. However, questions remain about their efficacy, dosing, safety, and how these approaches compare with other therapies.

PURPOSE

The present study aims to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain.

STUDY DESIGN/SETTING

This is a systematic literature review and meta-analysis.

OUTCOME MEASURES

The present study measures self-reported pain, function, health-related quality of life, and adverse events.

METHODS

We identified studies by searching multiple electronic databases from January 2000 to March 2017, examining reference lists, and communicating with experts. We selected randomized controlled trials comparing manipulation or mobilization therapies with sham, no treatment, other active therapies, and multimodal therapeutic approaches. We assessed risk of bias using Scottish Intercollegiate Guidelines Network criteria. Where possible, we pooled data using random-effects meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to determine the confidence in effect estimates. This project is funded by the National Center for Complementary and Integrative Health under Award Number U19AT007912.

RESULTS

Fifty-one trials were included in the systematic review. Nine trials (1,176 patients) provided sufficient data and were judged similar enough to be pooled for meta-analysis. The standardized mean difference for a reduction of pain was SMD=-0.28, 95% confidence interval (CI) -0.47 to -0.09, p=.004; I2=57% after treatment; within seven trials (923 patients), the reduction in disability was SMD=-0.33, 95% CI -0.63 to -0.03, p=.03; I2=78% for manipulation or mobilization compared with other active therapies. Subgroup analyses showed that manipulation significantly reduced pain and disability, compared with other active comparators including exercise and physical therapy (SMD=-0.43, 95% CI -0.86 to 0.00; p=.05, I2=79%; SMD=-0.86, 95% CI -1.27 to -0.45; p<.0001, I2=46%). Mobilization interventions, compared with other active comparators including exercise regimens, significantly reduced pain (SMD=-0.20, 95% CI -0.35 to -0.04; p=.01; I2=0%) but not disability (SMD=-0.10, 95% CI -0.28 to 0.07; p=.25; I2=21%). Studies comparing manipulation or mobilization with sham or no treatment were too few or too heterogeneous to allow for pooling as were studies examining relationships between dose and outcomes. Few studies assessed health-related quality of life. Twenty-six of 51 trials were multimodal studies and narratively described.

CONCLUSION

There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe. Multimodal programs may be a promising option.

Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative

OBJECTIVE

The objective of this study was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments.

METHODS

The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a nonpharmacological intervention. The panel updated the search strategies in Medline. We assessed admissible systematic reviews and randomized controlled trials for each question using A Measurement Tool to Assess Systematic Reviews and Cochrane Back Review Group criteria. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee.

RESULTS

For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).

CONCLUSIONS

A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

Effects of photobiomodulation therapy in patients with chronic non-specific low back pain: protocol for a randomised placebo-controlled trial

INTRODUCTION

Low back pain (LBP) is one of the largest and most frequent public health problems worldwide. Photobiomodulation therapy (PBMT) is a frequently used non-pharmacological therapy for the treatment of musculoskeletal disorders. However, there is little high-quality scientific evidence that demonstrates the effectiveness of PBMT in the treatment of patients with chronic LBP in the short, medium and long term. Therefore, the objective of this clinical trial is to evaluate the effects of PBMT in patients with chronic non-specific LBP in the short, medium and long term.

METHODS AND ANALYSES

This is a prospectively registered, two-arm randomised placebo-controlled trial with blinded patients, assessors and treatment providers. One hundred and forty-eight patients with chronic non-specific LBP will be recruited. Treatment sessions will be provided three times a week for 4 weeks (totaling 12 sessions) with patients receiving either placebo or active PBMT. For ethical reasons, all patients, regardless of treatment allocation, will also receive an information booklet based on 'The Back Book'. Clinical outcomes will be measured at baseline, at the end of treatment, as well as 3, 6 and 12 months after randomisation. The primary outcomes will be pain intensity and disability measured after 12 sessions of treatment. The secondary outcomes will be pain intensity and disability measured at 3, 6 and 12 months after randomisation, in addition to specific disability and global perceived effect in all time points.

ETHICS AND DISSEMINATION

The study was approved by the Research Ethics Committee of Universidade Cidade de São Paulo. The results will be disseminated through scientific publications and presentations at national and international scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03089424.

Predictive factors for reporting adverse events following spinal manipulation in randomized clinical trials - secondary analysis of a systematic review

While spinal manipulative therapy (SMT) is recommended for the treatment of spinal disorders, concerns exist about adverse events associated with the intervention. Adequate reporting of adverse events in clinical trials would allow for more accurate estimations of incidence statistics through meta-analysis. However, it is not currently known if there are factors influencing adverse events reporting following SMT in randomized clinical trials (RCTs). Thus our objective was to investigate predictive factors for the reporting of adverse events in published RCTs involving SMT. The Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs involving SMT. Domains of interest included: sample size; publication date relative to the 2010 CONSORT statement; risk of bias; the region treated; and number of intervention sessions. 7398 records were identified, of which 368 articles were eligible for inclusion. A total of 140 (38.0%) articles reported on adverse events. Articles were more likely to report on adverse events if they possessed larger sample sizes, were published after the 2010 CONSORT statement, had a low risk of bias and involved multiple intervention sessions. The region treated was not a significant predictor for reporting on adverse events. Predictors for reporting on adverse events included larger sample size, publication after the 2010 CONSORT statement, low risk of bias and trials involving multiple intervention sessions. We recommend that researchers focus on developing robust methodologies and participant follow-up regimens for RCTs involving SMT.

McKenzie Method of Mechanical Diagnosis and Therapy was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific low back pain: a randomised placebo controlled trial with short and longer term follow-up

Background

The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is one of the exercise approaches recommended by low back pain (LBP) guidelines. We investigated the efficacy of MDT compared with placebo in patients with chronic LBP.

Methods

This was a prospectively registered, two-arm randomised placebo controlled trial, with a blinded assessor. A total of 148 patients seeking care for chronic LBP were randomly allocated to either MDT (n=74) or placebo (n=74). Patients from both groups received 10 treatment sessions over 5 weeks. Patients from both groups also received an educational booklet. Clinical outcomes were obtained at the end of treatment (5 weeks) and 3, 6 and 12 months after randomisation. Primary outcomes were pain intensity and disability at the end of treatment (5 weeks). We also conducted a subgroup analysis to identify potential treatment effect modifiers that could predict a better response to MDT treatment.

Results

The MDT group had greater improvements in pain intensity at the end of treatment (mean difference (MD) −1.00, 95% CI −2.09 to −0.01) but not for disability (MD −0.84, 95% CI −2.62 to 0.93). We did not detect between-group differences for any secondary outcomes, nor were any treatment effect modifiers identified. Patients did not report any adverse events.

Conclusion

We found a small and likely not clinically relevant difference in pain intensity favouring the MDT method immediately at the end of 5 weeks of treatment but not for disability. No other difference was found for any of the primary or secondary outcomes at any follow-up times.

Trial registration number

ClinicalTrials.gov (NCT02123394)

Physical activity and the mediating effect of fear, depression, anxiety, and catastrophizing on pain related disability in people with chronic low back pain

BACKGROUND

Chronic low back pain is a worldwide burden that is not being abated with our current knowledge and treatment of the condition. The fear-avoidance model is used to explain the relationship between pain and disability in patients with chronic low back pain. However there are gaps in empirical support for pathways proposed within this model, and no evidence exists as to whether physical activity moderates these pathways.

METHODS

This was a cross-sectional study of 218 people with chronic low back pain. Multiple mediation analyses were conducted to determine the role of fear, catastrophizing, depression, and anxiety in the relationship between pain and disability. Separate analyses were performed with physical activity as the moderator. Individuals were classified as performing regular structured physical activity if they described on average once per week for > 30-minutes an activity classified at least moderate intensity (≥ 4-6 METs), activity prescribed by an allied health professional for their back pain, leisure time sport or recreation, or self-directed physical activity such as resistance exercise.

RESULTS

Fear, catastrophizing, and depression significantly mediated the relationship between pain and disability (p<0.001). However the mediating effect of catastrophizing was conditional upon weekly physical activity. That is, the indirect effect for catastrophizing mediating the relationship between pain and disability was only significant for individuals reporting weekly physical activity (B = 1.31, 95% CI 0.44 to 2.23), compared to individuals reporting no weekly physical activity (B = 0.21, 95% CI -0.50 to 0.97). Catastrophizing also mediated the relationship between pain and fear (B = 0.37, 95% CI 0.15 to 0.62), with higher scores explaining 53% of the total effect of pain on fear.

CONCLUSIONS

These results support previous findings about the importance of fear and depression as factors that should be targeted in low back pain patients to reduce back pain related disability. We have also extended understanding for the mediating effect of catastrophizing on back pain related disability. Back pain patients engaged with regular physical activity may require counselling with regards to negative pain perceptions.

Effects of Myofascial Release in Nonspecific Chronic Low Back Pain: A Randomized Clinical Trial

STUDY DESIGN

Double-blind, randomized parallel sham-controlled trial with concealed allocation and intention-to treat analysis.

OBJECTIVE

To investigate the effects of an isolate myofascial release (MFR) protocol on pain, disability, and fear-avoidance beliefs in patients with chronic low back pain (CLBP).

SUMMARY OF BACKGROUND DATA

MFR is a form of manual medicine widely used by physiotherapists in the management of different musculoskeletal pathologies. Up to this moment, no previous studies have reported the effects of an isolated MFR treatment in patients with CLBP.

METHODS

Fifty-four participants, with nonspecific CLBP, were randomized to MFR group (n = 27) receiving four sessions of myofascial treatment, each lasting 40 minutes, and to control group (n = 27) receiving a sham MFR. Variables studied were pain measured by means Short Form McGill Pain Questionnaire (SF-MPQ) and visual analog scale (VAS), disability measured with Roland Morris Questionnaire, and fear-avoidance beliefs measured with Fear-Avoidance Beliefs Questionnaire.

RESULTS

Subjects receiving MFR displayed significant improvements in pain (SF-MPQ) (mean difference -7.8; 95% confidence interval [CI]: -14.5 to -1.1, P = 0.023) and sensory SF-MPQ subscale (mean difference -6.1; 95% CI: -10.8 to -1.5, P = 0.011) compared to the sham group, but no differences were found in VAS between groups. Disability and the Fear-Avoidance Beliefs Questionnaire score also displayed a significant decrease in the MFR group (P < 0.05) as compared to sham MFR.

CONCLUSION

MFR therapy produced a significant improvement in both pain and disability. Because the minimal clinically important differences in pain and disability are, however, included in the 95% CI, we cannot know whether this improvement is clinically relevant.

LEVEL OF EVIDENCE

2.

Does the inclusion of spinal manipulative therapy in multimodal treatment regimens result in better outcomes in chronic low back pain? A systematic review

Low back pain (LBP) is the most common musculoskeletal disorder. It is costly, both health wise and socioeconomically. Spinal manipulative therapy (SMT) is a popular and well researched conservative management of chronic LBP. However, little is known about its role cum effectiveness as part of multimodal treatment regimens. The aim of this systematic review is to examine the evidence of the effectiveness of SMT as part of a multimodal regimen in the management of chronic LBP. Eligible studies were identified by searching Medline, Embase, PEDro, CINAHL, AMED, and the Cochrane Central Register of controlled trials. Randomized controlled trials (RCTs) on patients with chronic mechanical LBP were considered. Data from four RCTs (430 participants) were included in this review. All four had a low risk of bias. Three studies found a statistically significant improvement in pain and function at both short term and long term in the group that received SMT as part of a multimodal treatment regimen. Heterogeneity in the nature of the interventions that made up the treatment regimen, comparison interventions, duration of treatment and follow-up periods were identified. There is moderate quality evidence that the addition of SMT to multimodal treatment regimens for chronic LBP results in better outcomes in terms of pain and function as compared to other conservative interventions.

Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial

OBJECTIVES

The aim of the study was to examine the efficacy of spinal mobilization in subjects with low back pain (LBP) and associated spinal disk degeneration.

METHODS

Seventy-five subjects suffering from chronic LBP (>3 months) were randomly allocated into 3 groups of 25 subjects each. Each group received five treatment sessions with the first group receiving manual therapy (MT) (spinal mobilization), the second a sham treatment, and the third conventional physiotherapy (CP) (stretching exercises, transcutaneous electrical nerve stimulation, and massage). Subjects were assessed for their pain intensity using the numerical pain rating scale and for their self-reported disability using the Oswestry and Roland-Morris Questionnaire at baseline and after the completion of the five treatment sessions.

RESULTS

Paired t-tests showed a significant improvement for all outcome measures in the MT and CP group (p < 0.05). Analysis of covariance revealed that the MT group had significant improvement in all outcome measures in comparison with the sham and CP group (p < 0.05), whereas no significant difference was observed between the sham and CP group (p > 0.05).

DISCUSSION

MT is preferable to CP in order to reduce the pain intensity and disability in subjects with chronic LBP and associated disk degeneration. The findings of this study may lead to the establishment of spinal mobilization as one of the most preferable approaches for the management of LBP due to disk degeneration.

LEVEL OF EVIDENCE

1b.

Comparison of a Stratified Group Intervention (STarT Back) With Usual Group Care in Patients With Low Back Pain: A Nonrandomized Controlled Trial

STUDY DESIGN

A nonrandomized controlled trial.

OBJECTIVE

This study aims to explore the effectiveness of group-based stratified care in primary care.

SUMMARY OF BACKGROUND DATA

Stratified care based on psychosocial screening (STarT Back) has demonstrated greater clinical and cost-effectiveness in patients with low back pain. However, low back pain interventions are often delivered in groups and evaluating this system of care in a group setting is important.

METHODS

Patients were recruited from 60 general practices and linked physiotherapy services. A new group stratified intervention was compared with a historical nonstratified control group. Patients stratified as low, medium and high risk were offered risk-matched group care. Consenting participants completed self-report measures of functional disability (primary outcome measure), pain, psychological distress, and beliefs. The historical control received a generic group intervention. Analysis was by intention to treat.

RESULTS

In total, 251 patients in the new stratified intervention and 332 in the historical control were included in the primary analysis at 12 weeks. The mean age of patients was 43 ± 10.98 years. Overall adjusted mean changes in the RMDQ scores were higher in the stratified intervention than in the control arm at 12-week follow-up (P = 0.028). Exploring the risk groups, individually the high-risk stratified group, demonstrated better outcome over the controls (P = 0.031). The medium-risk stratified intervention demonstrated equally good outcomes (P = 0.125), and low-risk stratified patients, despite less intervention, did as well as the historical controls (P = 0.993).

CONCLUSION

Stratified care delivered in a group setting demonstrated superior outcomes in the high-risk patients, and equally good outcomes for the medium and low-risk groups. This model, embedded in primary care, provides an early and effective model of chronic disease management and adds another dimension to the utility of the STarT Back system of care.

LEVEL OF EVIDENCE

2.

Fascial Manipulation® for chronic aspecific low back pain: a single blinded randomized controlled trial

BACKGROUND

The therapeutic approach to chronic aspecific low back pain (CALBP) has to consider the multifactorial aetiology of the disorder. International guidelines do not agree on unequivocal treatment indications. Recommendations for fascial therapy are few and of low level evidence but several studies indicate strong correlations between fascial thickness and low back pain. This study aims at comparing the effectiveness of Fascial Manipulation® associated with a physiotherapy program following guidelines for CALBP compared to a physiotherapy program alone.

METHODS

24 subjects were randomized into two groups, both received eight treatments over 4 weeks. Outcomes were measured at baseline, at the end of therapy and at a 1 month and a 3 months follow-up. Pain was measured with the visual analogue scale (VAS) and the brief pain inventory (BPI), function with the Rolland-Morris disability questionnaire (RMDQ), state of well-being with the short-form 36 health-survey (SF-36). The mean clinical important difference (MCID) was also measured.

RESULTS

Patients receiving Fascial Manipulation® showed statistically and clinically significant improvements at the end of care for all outcomes, in the short (RMDQ, VAS, BPI) and medium term for VAS and BPI compared to manual therapy. The MCID show significant improvements in the means and percentage of subjects in groups in all outcomes post-treatment, in the short and medium term.

CONCLUSION

Fascial tissues were implicated in the aetiology of CALBP and treatment led to decreased symptomatic, improved functional and perceived well-being outcomes that were of greater amplitude compared to manual therapy alone.

Fascial Manipulation® for chronic aspecific low back pain: a single blinded randomized controlled trial

BACKGROUND

The therapeutic approach to chronic aspecific low back pain (CALBP) has to consider the multifactorial aetiology of the disorder. International guidelines do not agree on unequivocal treatment indications. Recommendations for fascial therapy are few and of low level evidence but several studies indicate strong correlations between fascial thickness and low back pain. This study aims at comparing the effectiveness of Fascial Manipulation® associated with a physiotherapy program following guidelines for CALBP compared to a physiotherapy program alone.

METHODS

24 subjects were randomized into two groups, both received eight treatments over 4 weeks. Outcomes were measured at baseline, at the end of therapy and at a 1 month and a 3 months follow-up. Pain was measured with the visual analogue scale (VAS) and the brief pain inventory (BPI), function with the Rolland-Morris disability questionnaire (RMDQ), state of well-being with the short-form 36 health-survey (SF-36). The mean clinical important difference (MCID) was also measured.

RESULTS

Patients receiving Fascial Manipulation® showed statistically and clinically significant improvements at the end of care for all outcomes, in the short (RMDQ, VAS, BPI) and medium term for VAS and BPI compared to manual therapy. The MCID show significant improvements in the means and percentage of subjects in groups in all outcomes post-treatment, in the short and medium term.

CONCLUSION

Fascial tissues were implicated in the aetiology of CALBP and treatment led to decreased symptomatic, improved functional and perceived well-being outcomes that were of greater amplitude compared to manual therapy alone.