The within-session change in low back pain intensity following spinal manipulative therapy is related to differences in diffusion of water in the intervertebral discs of the upper lumbar spine and L5-S1

Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial

BACKGROUND CONTEXT

Nonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS.

PURPOSE

This study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS.

STUDY DESIGN/SETTING

Randomized, single-blinded, multi-center, parallel-group clinical trial.

PATIENT SAMPLE

One hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period.

OUTCOME MEASURES

The primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months.

METHODS

Patients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63).

RESULTS

At 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group.

CONCLUSION

Patients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up.

A randomized controlled trial comparing different sites of high-velocity low amplitude thrust on sensorimotor integration parameters

Increasing evidence suggests that a high-velocity, low-amplitude (HVLA) thrust directed at a dysfunctional vertebral segment in people with subclinical spinal pain alters various neurophysiological measures, including somatosensory evoked potentials (SEPs). We hypothesized that an HVLA thrust applied to a clinician chosen vertebral segment based on clinical indicators of vertebral dysfunction, in short, segment considered as "relevant" would significantly reduce the N30 amplitude compared to an HVLA thrust applied to a predetermined vertebral segment not based on clinical indicators of vertebral dysfunction or segment considered as "non-relevant". In this double-blinded, active-controlled, parallel-design study, 96 adults with recurrent mild neck pain, ache, or stiffness were randomly allocated to receiving a single thrust directed at either a segment considered as "relevant" or a segment considered as "non-relevant" in their upper cervical spine. SEPs of median nerve stimulation were recorded before and immediately after a single HVLA application delivered using an adjusting instrument (Activator). A linear mixed model was used to assess changes in the N30 amplitude. A significant interaction between the site of thrust delivery and session was found (F1,840 = 9.89, p < 0.002). Pairwise comparisons showed a significant immediate decrease in the N30 complex amplitude after the application of HVLA thrust to a segment considered "relevant" (- 16.76 ± 28.32%, p = 0.005). In contrast, no significant change was observed in the group that received HVLA thrust over a segment considered "non-relevant" (p = 0.757). Cervical HVLA thrust applied to the segment considered as "relevant" altered sensorimotor parameters, while cervical HVLA thrust over the segment considered as "non-relevant" did not. This finding supports the hypothesis that spinal site targeting of HVLA interventions is important when measuring neurophysiological responses. Further studies are needed to explore the potential clinical relevance of these findings.

Myofascial and discogenic origins of lumbar pain: A critical review

The purpose of this three-part narrative review is to examine the anatomy of, and the research which supports, either the lumbar myofascia or intervertebral disc (IVD) as principal sources of our patient's low back pain. A comprehensive understanding of anatomical lumbar pain generators in combination with the current treatment-based classification system will further improve and enhance clinical decision-making skills. Section I reviews the anatomy of the spinal myofascia, myofascial sources of lumbar pain, and imaging of myofascial tissues. Part II reviews the anatomy of the IVD, examines the IVD as a potential lumbar pain generator, and includes detailed discussion on Nerve Growth Factor, Inflammatory Cytokines, Vertebral End Plates and Modic change, Annular tears, and Discogenic instability. Part III looks at the history of myofascial pain, lab-based research and myofascial pain, and various levels of discogenic pain provocation research including animal, laboratory and human subjects. Our review concludes with author recommendations on developing a comprehensive understanding of altered stress concentrations affecting the posterior annulus fibrosis, neo-innervation of the IVD, inflammatory cytokines, discogenic instability, and how this knowledge can complement use of the Treatment-Based Classification System.

Variability of Intradiscal Pressure During Cervical Spine Posterior-Anterior Mobilization: A Cadaveric Investigation

OBJECTIVES

The purpose of this study was to investigate in cadaveric specimens the reliability of measuring cervical intradiscal pressure (CIDP) and if posterior-anterior (PA) mobilizations targeting the cervical spine were associated with CIDP changes.

METHODS

Cervical PA mobilizations were performed on the spinous processes of 7 (3 men, 4 women) cadaveric specimens using a servo-controlled linear actuator to provide 25N and 45N forces. CIDP measurements were performed at C4-5, C5-6, C6-7, and C7-T1 intervertebral discs (IVDs) using a fiberoptic catheter system that recorded CIDP for each IVD cervical segment. To assess CIDP measurement reliability, the intraclass correlation coefficient (ICC [3,k]) was calculated. Repeated measures Friedman analysis of variance assessed effect of cervical mobilizations on CIDP for before, during, and immediately after mobilization at 25N and 45N forces for each cervical IVD segment.

RESULTS

All CIDP measurements demonstrated excellent reliability (ICC >0.98). During the 25N mobilizations, the median CIDP varied from -0.12 to 0.91 (interquartile range, 5.22-5.36), while for 45N mobilizations the median ranged from -0.94 to 1.21 (interquartile range, -7.74 to 43.49). These changes were not statistically significant (P > .40) during 25N and 45N PA mobilizations, with the exception of C5-6 CIDP at 25N and 45N (P = .05 and .018, respectively).

CONCLUSION

There was high CIDP variability between cadavers during and after mobilization. Mobilizations of 1 cervical vertebra resulted in both CIDP increase or decrease at adjacent and remote cervical IVD segments that were not consistent. Cervical PA mobilizations produced variable CIDP changes at adjacent and remote cervical segments in cadavers.

Force Distribution Within Spinal Tissues During Posterior to Anterior Spinal Manipulative Therapy: A Secondary Analysis

Background

Previous studies observed that the intervertebral disc experiences the greatest forces during spinal manipulative therapy (SMT) and that the distribution of forces among spinal tissues changes as a function of the SMT parameters. However, contextualized SMT forces, relative to the ones applied to and experienced by the whole functional spinal unit, is needed to understand SMT’s underlying mechanisms.

Aim

To describe the percentage force distribution between spinal tissues relative to the applied SMT forces and total force experienced by the functional unit.

Methods

This secondary analysis combined data from 35 fresh porcine cadavers exposed to a simulated 300N SMT to the skin overlying the L3/L4 facet joint via servo-controlled linear motor actuator. Vertebral kinematics were tracked optically using indwelling bone pins. The functional spinal unit was then removed and mounted on a parallel robotic platform equipped with a 6-axis load cell. The kinematics of the spine during SMT were replayed by the robotic platform. By using serial dissection, peak and mean forces induced by the simulated SMT experienced by spinal structures in all three axes of motion were recorded. Forces experienced by spinal structures were analyzed descriptively and the resultant force magnitude was calculated.

Results

During SMT, the functional spinal unit experienced a median peak resultant force of 36.4N (IQR: 14.1N) and a mean resultant force of 25.4N (IQR: 11.9N). Peak resultant force experienced by the spinal segment corresponded to 12.1% of the total applied SMT force (300N). When the resultant force experienced by the functional spinal unit was considered to be 100%, the supra and interspinous ligaments experienced 0.3% of the peak forces and 0.5% of the mean forces. Facet joints and ligamentum flavum experienced 0.7% of the peak forces and 3% of the mean forces. Intervertebral disc and longitudinal ligaments experienced 99% of the peak and 96.5% of the mean forces.

Conclusion

In this animal model, a small percentage of the forces applied during a posterior-to-anterior SMT reached spinal structures in the lumbar spine. Most SMT forces (over 96%) are experienced by the intervertebral disc. This study provides a novel perspective on SMT force distribution within spinal tissues.

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.

Assessing the contribution of lower limb mobilization, in the supine position, on shoulder-pelvis girdles dissociation

BACKGROUND

Several articular, muscular and neurological diseases generate mobility loss in the shoulder and pelvis girdles. Joint mobilization contributes to improving shoulder-pelvis girdles dissociation, but current mobilization techniques are not always successful and standardized. A robotic medical device, DPA Med®, by inducing trunk mobilization through lower limb oscillation has been developed for producing such a shoulder-pelvis girdles dissociation and is already used worldwide in rehabilitation hospitals.

RESEARCH QUESTION

To determine the optimal lower limb oscillation frequency that generated the best shoulder-pelvis girdles dissociation using the DPA Med® device.

METHODS

Thirty healthy adult volunteers (mean age: 38.6 [SD 15.2] years, mean height: 174 [SD 11.9] cm, mean body mass: 70.3 [SD 14.7] kg) participated in this prospective study. A kinematic analysis quantified pelvic and shoulder girdle mobility (rotation and lateral tilt) at different DPA Med® frequencies, from 0.5 Hz to 1 Hz. A visual analysis of the lower limb movement was also performed, using video sensors, to better understand the kinematics involved.

RESULTS

All DPA Med® frequencies have shown significant shoulder-pelvis girdles dissociation (p < 0.05). This study established an optimal oscillation frequency with the minimal interindividual variability at 0.808 Hz. It induced pelvic mobility similar to that of normal gait, in the transverse and frontal planes (10.3°, SD 2.9°, and 12.0°, SD 2.2°, respectively). This trunk mobility was achieved by producing a lemniscate-shaped motion in the lower limbs (an eight-shaped motion in the transverse plane).

SIGNIFICANCE

This study has shown that the DPA Med® device is able to induce shoulder-pelvis girdles dissociation similar to that of normal gait and allowed to establish the existence of an optimal DPA Med® oscillation frequency for lower limb mobility at 0.808 Hz. Further studies are required to evaluate its potentially benefits on gait disorders.

Three-Dimensional Spinal Position With and Without Manual Distraction Load Increases Spinal Height

OBJECTIVE

The purpose of this study was to investigate if spinal height increases using 3-dimensional (3-D) spinal position with and without manual distraction load and to assess the correlation between spine height changes and degrees of trunk rotation.

METHODS

Fifty-six participants were randomly placed in one of two groups: (1) 3-D spinal position with manual distraction load, and (2) without manual distraction load. Spinal height was measured before and after the interventions using a stadiometer. For the statistical analysis, we used a 2 (Loading status: pre- versus post-intervention height) X 2 (3-D spinal position: with versus without manual distraction load) repeated measures Analysis of Variance (ANOVA) was used to identify significant interaction and main effects. Paired t-tests were used to calculate differences in spinal height changes between the two interventions. Pearson correlation coefficient was used to measure correlations between changes in spinal heights and degrees of trunk rotation.

RESULTS

Mean spinal height increase with 3-D spinal position with and without manual distraction load was 6.30 mm (±6.22) and 5.69 mm (±4.13), respectively. No significant interaction effect was present between loading status and 3-D spinal position but a significant main effect in loading status was. Paired t-tests revealed significant differences in spinal heights between pre-and post-3-D spinal position with and without manual distraction load. No significant correlation was measured between trunk rotation and spinal height changes.

CONCLUSION

3-D spinal position with or without distraction load increased spinal height. This suggests that 3-D spinal positioning without manual distraction could be used in home settings to help maintain intervertebral disc (IVD) health.

Immediate effects of cervical mobilisations on neck muscle activity during active neck movements in patients with non-specific neck pain. A double blind placebo controlled trial

BACKGROUND

Cervical mobilisations are used to treat people with neck pain but their mechanisms of action are unclear. One theorised reason for induced analgesia is effect on neck muscle activity.

OBJECTIVES

To assess the effects of cervical mobilisations on muscle activity during active neck movements and whether changes in muscle activity are associated with changes in symptoms.

DESIGN

Double-blind randomised placebo controlled trial.

SETTING

Primary care.

PARTICIPANTS

40 patients (aged 19 to 80 years, 24 female) with non-specific neck pain.

INTERVENTIONS

One session of cervical mobilisations or motionless manual contact (placebo).

MAIN OUTCOME MEASURES

sternocleidomastoid (SCM), scalene (SCA), upper trapezius (UT) and erector spinae (ES) surface electromyography (SEMG) during active neck flexion, extension, side flexion and rotation was measured immediately before and after the intervention. Patients were classified as responders according to change in symptoms assessed using the Global Rating of Change Scale (GROC).

RESULTS

Compared with placebo, patients receiving mobilisation showed an increase in contralateral UT and ES SEMG during rotation and contralateral and ipsilateral SCM, SCA and UT during side flexion (P<0.05), however changes were mostly associated with an increase in range and speed of movement. The only association with GROC was increased (5%) SEMG in the contralateral SCM during side flexion in the mobilisation group (P=0.013).

CONCLUSION

Cervical mobilisations caused increased neck SEMG, mostly due to increased movement range and speed. Change in muscle activity is unlikely to be a major mechanism of action of cervical mobilisations in symptomatic improvement with physiological neck movements. (ClinicalTrials.gov record number: 2016/066).

CLINICAL TRIALS REGISTRY

ClinicalTrials.gov record number: 2016/066.

Differences in neck surface electromyography, kinematics and pain occurrence during physiological neck movements between neck pain and asymptomatic participants. A cross-sectional study

BACKGROUND

Neck pain has been associated with altered muscle activity and impaired kinematics. Patients frequently report pain during physiological neck movements. Previously, the average muscle activity during these movements has been measured. However, muscle activity is modulated by the position in the range of movement, hence the study of neck muscle activity in discrete sections of the range of movement is warranted. Evidence is conflicting regarding range of movement restriction in neck pain. No study has assessed the point in the range of movement at which pain occurs. This study aimed to investigate neck kinematics, muscle activity and pain during physiological neck movements in participants with and without neck pain.

METHODS

Neck kinematics and surface electromyography were recorded continuously and analysed in 10° increments during forward and side flexion, extension and rotation of the neck in 20 neck pain and 20 asymptomatic participants. Point of pain occurrence in the range of movement was recorded.

FINDINGS

Neck pain participants demonstrated significantly lower activity of scalene during flexion and extension, and a non-significant higher activity in sternocleidomastoids during rotation. No differences in neck kinematics were observed. 65% of neck pain participants reported pain during at least one neck movement. Pain was reported in the last ≈20-40% of the range of movement.

INTERPRETATION

Exercises used in current practice to minimise scalene activity may not be appropriate for all neck pain patients. Restricted range of movement is not a consistent feature of neck pain. Movement associated neck pain is present at the end of range of movement, which has implications for the study of neck pain and rehabilitation.

Short-term increase in discs' apparent diffusion is associated with pain and mobility improvements after spinal mobilization for low back pain

Pain perception, trunk mobility and apparent diffusion coefficient (ADC) within all lumbar intervertebral discs (IVDs) were collected before and shortly after posterior-to-anterior (PA) mobilizations in 16 adults with acute low back pain. Using a pragmatic approach, a trained orthopaedic manual physical therapist applied PA mobilizations to the participants' spine, in accordance with his examination findings. ADC _all was computed from diffusion maps as the mean of anterior (ADC _ant ), middle (ADC _mid ), and posterior (ADC _post ) portions of the IVD. After mobilization, pain ratings and trunk mobility were significantly improved and a significant increase in ADC _all values was observed. The greatest ADC _all changes were observed at the L₃-L₄ and L₄-L₅ levels and were mainly explained by changes in ADC _ant and ADC _post , respectively. No significant changes in ADC were observed at L₅-S₁ level. The reduction in pain and largest changes in ADC observed at the periphery of the hyperintense IVD region suggest that increased peripheral random motion of water molecules is implicated in the IVD nociceptive response modulation. Additionally, ADC changes were observed at remote IVD anatomical levels that did not coincide with the PA spinal mobilization application level.

Age-related differences in the response of the L5-S1 intervertebral disc to spinal traction

BACKGROUND

Lumbar traction is a common treatment for low back pain; however its mechanisms of action are poorly understood. It has been hypothesized that a key effect of lumbar traction is its capacity to influence fluid movement within the intervertebral disc (IVD).

OBJECTIVES

To determine differences in the apparent diffusion coefficient (ADC) obtained with lumbar diffusion-weighted imaging (DWI) of the L5-S1 IVD before, and during, the application of lumbar traction.

DESIGN

Case series, repeated measures.

METHODS

A static traction load of ∼50% of body-weight was applied to the low back using a novel "MRI-safe" apparatus. DWI of the lumbar spine was performed prior to, and during the application of the traction load.

RESULTS

Participants were currently asymptomatic and included a young adult group (n = 18) and a middle-aged group (n = 15). The young adult group had a non-significant 2.2% increase in ADC (mean change = 0.03 × 10^-3 mm²/s, SD = 0.24, 95% CI = -0.09, 0.15). The ADC for the middle-aged group significantly increased by 20% (mean change of 0.18 × 10^-3 mm²/s, SD = 0.19; 95% CI = 0.07, 0.28; p = 0.003; effect size = 0.95). There was an inverse relationship between the ADC obtained before traction and the percent increase in ADC that was measured during traction.

CONCLUSION

Static traction was associated with an increase in diffusion of water within the L5-S1 IVDs of middle-age individuals, but not in young adults, suggesting age-related differences in the diffusion response. Further study is needed to assess the relationship between these findings and the symptoms of back pain.

LEVEL OF EVIDENCE

4.

Physiological effects of physical therapy interventions on lumbar intervertebral discs: A systematic review

BACKGROUND CONTEXT

The use of physical therapy has been recommended in the treatment of low back pain based on primarily mechanical and neurophysiological effects. Recent studies have measured the physiological effects of physical therapy interventions, including manual therapy and traction, on the intervertebral discs (IVD), and these findings may have implications for the long-term management or even prevention of low back pain.

PURPOSE

The objective of this systematic review is to investigate the literature regarding possible physiological effects of physical therapy interventions on the intervertebral disc (IVD).

STUDY DESIGN

Systematic Review.

METHODS

A literature search of published articles through December 2014 resulted in the retrieval of 8 clinical studies assessing the influence of physical therapy interventions on the physiology of the IVD.

RESULTS

Three studies, including two using animal models, investigated the effects of 30-minute intermittent traction on disc height. One in vivo animal study and two studies using human subjects assessed changes of disc height associated with static traction. Three studies investigated the effects of lumbar spine manipulation and mobilization on changes in water diffusion within the IVD. All studies confirmed, either directly or indirectly, that their respective intervention influenced disc physiology primarily through water flow.

CONCLUSION

Physical therapy interventions may have an effect on the physiology of the IVD, primarily through water diffusion and molecular transport, which are important for the health of the IVD.

Tissue loading created during spinal manipulation in comparison to loading created by passive spinal movements

Spinal manipulative therapy (SMT) creates health benefits for some while for others, no benefit or even adverse events. Understanding these differential responses is important to optimize patient care and safety. Toward this, characterizing how loads created by SMT relate to those created by typical motions is fundamental. Using robotic testing, it is now possible to make these comparisons to determine if SMT generates unique loading scenarios. In 12 porcine cadavers, SMT and passive motions were applied to the L3/L4 segment and the resulting kinematics tracked. The L3/L4 segment was removed, mounted in a parallel robot and kinematics of SMT and passive movements replayed robotically. The resulting forces experienced by L3/L4 were collected. Overall, SMT created both significantly greater and smaller loads compared to passive motions, with SMT generating greater anterioposterior peak force (the direction of force application) compared to all passive motions. In some comparisons, SMT did not create significantly different loads in the intact specimen, but did so in specific spinal tissues. Despite methodological differences between studies, SMT forces and loading rates fell below published injury values. Future studies are warranted to understand if loading scenarios unique to SMT confer its differential therapeutic effects.

Spinal manipulation does not affect pressure pain thresholds in the absence of neuromodulators: a randomized controlled trial

BACKGROUND

Measurement of pressure pain threshold (PPT) is a way to determine one of the many potential treatment effects of spinal manipulative therapy.

OBJECTIVE

To determine how multiple spinal manipulations administered in a single-session affected PPTs at local and distal sites in asymptomatic individuals.

METHODS

Participants were randomly assigned into one of three groups: Group one (n = 18) received a lumbar manipulation followed by a cervical manipulation. Group two (n = 17) received a cervical manipulation followed by a lumbar manipulation. The control group (n = 19) received two bouts of five minutes of rest. At baseline and after each intervention or rest period, each participant's PPTs were obtained using a handheld algometer. The PPTs were tested bilaterally over the lateral epicondyles of the humerus and over the mid-bellies of the upper trapezius, lumbar paraspinal, and the tibialis anterior muscles. This study was registered with ClinicalTrials.gov, and its Identifier is NCT02828501.

RESULTS

Repeated-measures ANOVAs and Kruskal-Wallis tests showed no significant within- or between-group differences in PPT. Within-group effect sizes in the changes of PPT ranged from -.48 at the left paraspinal muscles to .24 at the left lateral humeral epicondyle. Statistical power to detect significant differences at α of 0.05 was calculated to be 0.94.

CONCLUSIONS

This study suggests that in young adults who do not have current or recent symptoms of spinal pain, multiple within-session treatments of cervical and lumbar spinal manipulation fail to influence PPTs. Changes in PPT that are observed in symptomatic individuals are likely to be primarily influenced by pain-related neuromodulators rather than by an isolated, mechanical effect of spinal manipulation.

The evolving role of physical therapists in the long-term management of chronic low back pain: longitudinal care using assisted self-management strategies

Background

Longitudinal studies have shown that the symptoms of chronic low back pain (CLBP) will follow an episodic trajectory characterized by periods of high and low pain intensity that can persist for many years. There is a growing belief that the contemporary approach of limiting physical therapy to short, but intense courses of treatment for (CLBP) may be sub-optimal because these limited “windows” of clinical care are not congruent with the natural history of this condition. Recent research has suggested that people with CLBP undergo substantial, and individualized long-term variations in the neural processing of nociception over time. This has led to the concept of a “unique biosignature of pain” that may explain much of the variation in a person’s clinical picture. These and other findings have led to the reconceptualization of CLBP as an individualized, and continually evolving condition that may be more suitably managed by empowering the patient toward self-management strategies that can be modified as needed over time by the PT.

Objectives

The purpose of this Master Class Paper is to describe an emerging approach for the treatment of CLBP that emphasizes the formation of a long-term therapeutic alliance between the patient and the PT with an emphasis on individualized, patient-preferred approaches for activity-based self-management as an alternative to the contemporary approach of short, intense episodes of care directed toward pain reduction.

Conclusion

Longitudinal care using assisted self-management strategies is more congruent with the natural history of CLBP than are traditional approaches for PT intervention. This approach may empower patients to undergo lifestyle changes that will favorably influence long-term outcomes; however additional research is needed.

Do participants with low back pain who respond to spinal manipulative therapy differ biomechanically from nonresponders, untreated controls or asymptomatic controls?

STUDY DESIGN

Nonrandomized controlled study.

OBJECTIVE

To determine whether patients with low back pain (LBP) who respond to spinal manipulative therapy (SMT) differ biomechanically from nonresponders, untreated controls or asymptomatic controls.

SUMMARY OF BACKGROUND DATA

Some but not all patients with LBP report improvement in function after SMT. When compared with nonresponders, studies suggest that SMT responders demonstrate significant changes in spinal stiffness, muscle contraction, and disc diffusion. Unfortunately, the significance of these observations remains uncertain given methodological differences between studies including a lack of controls.

METHODS

Participants with LBP and asymptomatic controls attended 3 sessions for 7 days. On sessions 1 and 2, participants with LBP received SMT (+LBP/+SMT, n = 32) whereas asymptomatic controls did not (-LBP/-SMT, n = 57). In these sessions, spinal stiffness and multifidus thickness ratios were obtained before and after SMT and on day 7. Apparent diffusion coefficients from lumbar discs were obtained from +LBP/+SMT participants before and after SMT on session 1 and from an LBP control group that did not receive SMT (+LBP/-SMT, n = 16). +LBP/+SMT participants were dichotomized as responders/nonresponders on the basis of self-reported disability on day 7. A repeated measures analysis of covariance was used to compare apparent diffusion coefficients among responders, nonresponders, and +LBP/-SMT subjects, as well as spinal stiffness or multifidus thickness ratio among responders, nonresponders, and -LBP/-SMT subjects.

RESULTS

After the first SMT, SMT responders displayed statistically significant decreases in spinal stiffness and increases in multifidus thickness ratio sustained for more than 7 days; these findings were not observed in other groups. Similarly, only SMT responders displayed significant post-SMT improvement in apparent diffusion coefficients.

CONCLUSION

Those reporting post-SMT improvement in disability demonstrated simultaneous changes between self-reported and objective measures of spinal function. This coherence did not exist for asymptomatic controls or no-treatment controls. These data imply that SMT impacts biomechanical characteristics within SMT responders not present in all patients with LBP. This work provides a foundation to investigate the heterogeneous nature of LBP, mechanisms underlying differential therapeutic response, and the biomechanical and imaging characteristics defining responders at baseline.

LEVEL OF EVIDENCE

3.

Improving long-term outcomes for chronic low back pain: time for a new paradigm?

These are exciting times for physical therapists who treat people with chronic low back pain (CLBP). Many of the mysteries of this condition are starting to be revealed, and it appears that major breakthroughs are on the way. Advances in neuroimaging, coupled with increased understanding of the molecular and submolecular events associated with the symptoms of back pain, are helping us reconceptualize the etiologies and mechanisms of this condition. The result of these advances is that physical therapists now have a wide range of potential "treatment packages" that can include patient education, manual therapy, and a wide variety of exercise options for people with CLBP. The question is, "How can long-term, self-management programs become more effective?"