Comparing targeted thrust manipulation with general thrust manipulation in patients with low back pain. A general approach is as effective as a specific one. A randomised controlled trial

Effect of exercise and manual therapy or kinesiotaping on sEMG and pain perception in chronic low back pain: a randomized trial

The importance of incorporating lumbo-pelvic stability core and controlling motor exercises in patients with chronic low back pain (CLBP) reinforces the use of strategies to improve biopsychosocial beliefs by reducing biomedical postulations. However, clinical practice guidelines recommend multimodal approaches incorporating exercise and manual therapy (MT), and instead reject the application of kinesiotape (KT) in isolation. Therefore, the objectives of this study were to analyze the effects of 12 weeks of exercises combined with MT or KT on perceived low back pain using the visual analog scale (VAS) and muscle electric activity measured with electromyography (EMG) of the rectus abdominis and multifidus in CLBP (mild disability) and to explore the relationship between the rectus abdominis and multifidus ratios and pain perception after intervention. A blinded, 12-week randomized controlled trial (RCT) was carried out, involving three parallel groups of patients with CLBP. The study was registered at Clinicaltrial.gov and assigned the identification number NCT05544890 (19/09/22). The trial underwent an intention-to-treat analysis. The primary outcome revealed a multimodal treatment program supplemented by additional therapies such as MT and KT, resulting in significant reductions in perceived low back pain. The subjective assessment of individuals with CLBP indicated no discernible distinction between exclusive core stability exercises and control-motor training when combined with MT or KT. Notably, our findings demonstrated positive alterations in both the mean and peak EMG values of the right rectus abdominis in the exercise group, suggesting a beneficial impact on muscle activation. This study focused on assessing the activation levels of the trunk musculature, specifically the rectus abdominis (RA) and multifidus (MF), in individuals with CLBP exhibiting mild disability according to the Oswestry Disability Index. Importantly, improvements in the VAS values were observed independently of changes in muscle electrical activity.

Clinical relevance of combined treatment with exercise in patients with chronic low back pain: a randomized controlled trial

Low back pain is a widespread public health concern owing to its high prevalence rates according to the Global Burden of Diseases. This study aimed to investigate the effect of exercise alone or in combination with manual therapy and kinesiotherapy on pain sensitivity, disability, kinesiophobia, self-efficacy, and catastrophizing in patients with chronic low back pain (CLBP). A total of 55 participants were enrolled and randomly allocated to one of three groups: (1) exercise alone group (ET; n = 19), (2) exercise + manual therapy group (ETManual therapy; n = 18), and (3) exercise + kinesio tape group (ETkinesiotape; n = 18). The interventions consisted of core stabilization exercises (ET group), prior spinal manipulation with core exercises (ETManual therapy group), and combined application of kinesiotape plus core stabilization exercises (ETkinesiotape group). The primary outcome was disability. The secondary outcomes were pain sensitization, kinesiophobia, catastrophizing, and self-efficacy. Assessments were performed at baseline and at weeks 3, 6, and 12. All therapies applied achieved significant improvements over time after 12 weeks in all parameters analyzed. ETmanualtherapy showed the greatest changes in all variables, with significant differences from the rest of the interventions in Oswestry (ODI) (3 and 6 weeks, respectively). A clinically significant cutoff point was achieved for the ETmanualtherapy group in the ODI parameter (-54.71%, -63.16% and -87.70% at 3, 6, and 12 weeks, respectively). Manual therapy prior to the core exercise technique was the most effective approach to improve health-related functionality compared with exercise alone or exercise combined with kinesiotape in patients with CLBP.Clinical Trial Registration Number: NCT05544890.

A modern way to teach and practice manual therapy

BACKGROUND

Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment, patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care.

PURPOSE

The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety, comfort, and efficiency. These practical elements are contextualised by positive communication, a collaborative context, and person-centred care. The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies.

METHODS

A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements.

CONCLUSIONS

Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Spinal Manipulative Therapy for Nonspecific Low Back Pain: Does Targeting a Specific Vertebral Level Make a Difference?: A Systematic Review With Meta-analysis

OBJECTIVE: We aimed to examine whether targeting spinal manipulative therapy (SMT), by applying the intervention to a specific vertebral level, produces superior clinical outcomes than a nontargeted approach in patients with nonspecific low back pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, Scopus, PEDro, and Index to Chiropractic Literature were searched up to May 31, 2023. STUDY SELECTION CRITERIA: Randomized controlled trials comparing targeted SMT (mobilization or manipulation) to a nontargeted approach in patients with nonspecific low back pain, and measuring the effects on pain intensity and patient-reported disability. DATA SYNTHESIS: Data extraction, risk of bias, and evaluation of the overall certainty of evidence using the GRADE approach were performed by 2 authors independently. Meta-analyses were performed using the restricted maximum likelihood method. RESULTS: Ten randomized controlled trials (n = 931 patients) were included. There was moderate-certainty evidence of no difference between targeted SMT and a nontargeted approach for pain intensity at postintervention (weighted mean difference = -0.20 [95% CI: -0.51, 0.10]) and at follow-up (weighted mean difference = 0.05 [95% CI: -0.26, 0.36]). For patient-reported disability, there was moderate-certainty evidence of no difference at postintervention (standardized mean difference = -0.04 [95% CI: -0.36, 0.29]) and at follow-up (standardized mean difference = -0.05 [95% CI: -0.24, 0.13]). Adverse events were reported in 4 trials, and were minor and evenly distributed between groups. CONCLUSION: Targeting a specific vertebral level when administering SMT for patients with nonspecific low back pain did not result in improved outcomes on pain intensity and patient-reported disability compared to a nontargeted approach. J Orthop Sports Phys Ther 2023;53(9):1-11. Epub: 28 July 2023. doi:10.2519/jospt.2023.11962.

Manual Therapy versus Localisation (Tactile, Sensory Training) in Patients with Non-Specific Neck Pain: A Randomised Clinical Pilot Trial

Manual therapy (MT) techniques typically incorporate localised touch on the skin with the application of specific kinetic forces. The contribution of localised touch to the effectiveness of MT techniques has not been evaluated. This study investigated the immediate effects of MT versus localisation training (LT) on pain intensity and range of movement (ROM) for neck pain. In this single-blind randomised controlled trial thirty eligible neck pain volunteers (23 females and 7 males), aged 28.63 ± 12.49 years, were randomly allocated to MT or to a motionless (LT) group. A single three-minute treatment session was delivered to each group's cervico-thoracic area. The LT involved tactile sensory stimulation applied randomly to one out of a nine-block grid. Subjects were asked to identify the number of the square being touched, reflecting a different location on the region of skin. MT involved three-minute anteroposterior (AP) glides and sustained natural apophyseal glides (SNAG) techniques. Pre- and post-intervention pain intensity were assessed using a pressure pain threshold (PPT) algometer and the numeric pain rating scale (NPRS). Neck ROM was recorded with a bubble inclinometer. Improvements in ROM and self-reported pain were recorded in both groups (p < 0.001) without differences in NPRS, ROM or PPT scores between groups (p > 0.05). Tactile sensory training (localisation) was as effective as MT in reducing neck pain, suggesting a component of MT's analgesic effect to be related with the element of localised touch rather than the forces induced during passive movements.

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.

The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: Myth or reality? A systematic review

The concept that spinal manipulation therapy (SMT) outcomes are optimized when the treatment is aimed at a clinically relevant joint is commonly assumed and central to teaching and clinical use (candidate sites). This systematic review investigated whether clinical effects are superior when this is the case compared to SMT applied elsewhere (non-candidate sites). Eligible study designs were randomized controlled trials that investigated the effect of spinal manipulation applied to candidate versus non-candidate sites for spinal pain. We obtained data from four different databases. Risk of bias was assessed using an adjusted Cochrane risk of bias tool, adding four items for study quality. We extracted between-group differences for any reported outcome or, when not reported, calculated effect sizes from the within-group changes. We compared outcomes for SMT applied at a 'relevant' site to SMT applied elsewhere. We prioritized methodologically robust studies when interpreting results. Ten studies, all of acceptable quality, were included that reported 33 between-group differences-five compared treatments within the same spinal region and five at different spinal regions. None of the nine studies with low or moderate risk of bias reported statistically significant between-group differences for any outcome. The tenth study reported a small effect on pain (1.2/10, 95%CI - 1.9 to - 0.5) but had a high risk of bias. None of the nine articles of low or moderate risk of bias and acceptable quality reported that "clinically-relevant" SMT has a superior outcome on any outcome compared to "not clinically-relevant" SMT. This finding contrasts with ideas held in educational programs and clinical practice that emphasize the importance of joint-specific application of SMT.

Effects of biomechanical parameters of spinal manipulation: A critical literature review

Spinal manipulation is a manual treatment technique that delivers a thrust, using specific biomechanical parameters to exert its therapeutic effects. These parameters have been shown to have a unique dose-response relationship with the physiological responses of the therapy. So far, however, there has not been a unified approach to standardize these biomechanical characteristics. In fact, it is still undetermined how they affect the observed clinical outcomes of spinal manipulation. This study, therefore, reviewed the current body of literature to explore these dosage parameters and evaluate their significance, with respect to physiological and clinical outcomes. From the experimental studies reviewed herein, it is evident that the modulation of manipulation's biomechanical parameters elicits transient physiological responses, including changes in neuronal activity, electromyographic responses, spinal stiffness, muscle spindle responses, paraspinal muscle activity, vertebral displacement, and segmental and intersegmental acceleration responses. However, to date, there have been few clinical trials that tested the therapeutic relevance of these changes. In addition, there were some inherent limitations in both human and animal models due to the use of mechanical devices to apply the thrust. Future studies evaluating the effects of varying biomechanical parameters of spinal manipulation should include clinicians to deliver the therapy in order to explore the true clinical significance of the dose-response relationship.

The effect of lumbar spine manipulation on pain and disability in Achilles tendinopathy. A case report

BACKGROUND/PURPOSE

Cervical and thoracic spine manipulation has been found to reduce tendon pain and disability in lateral epicondylalgia and rotator cuff tendinopathy. Based on these findings, the application of lumbar spine manipulation may also provide similar improvements in Achilles tendinopathy (AT). Therefore, the purpose of this study was to evaluate the effect of lumbar spine manipulation on pain and disability in a patient experiencing AT.

CASE DESCRIPTION

A 44 years old male ex-football player presented with a 20-year history of persistent Achilles tendon pain (ATP) consistent with AT diagnosis. The patient attended 12 treatment sessions receiving a high-velocity, low amplitude lumbar spine manipulation. Outcome measures were collected at baseline, 2 weeks, 4 weeks, 3 months and 6 months and included pain in visual analogue scale, the American Orthopedic Foot and Ankle Score, the 36-Item Short Form Health Survey and the Victorian Institute of Sport Assessment-Achilles questionnaire. Pressure pain threshold was also assessed using an electronic pressure algometer.

OUTCOMES

Improvement in all outcome measures was noted 6-months post intervention. Outcome measures indicated substantial improvements in both the patient's pain and disability. The patient was able to perform activities of daily living without difficulties, suggesting higher level of function and quality of life at 6-months post initial evaluation.

CONCLUSION

These findings have demonstrated the positive effects of lumbar spine manipulation on ATP and disability. Further studies, specifically clinical trials investigating the effect of lumbar spine manipulation or combining this technique with exercises and functional activities are suggested.