Benjamin Hidalgo

The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews

Abstract Objective: to review and update the evidence for different forms of manual therapy (MT) for patients with different stages of non-specific low back pain (LBP). Data sources: MEDLINE, Cochrane-Register-of-Controlled-Trials, PEDro, EMBASE. Method: A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent reviewers according to Cochrane and PRISMA guidelines. A total of 360 studies were evaluated using qualitative criteria. Two stages of LBP were categorized; combined acute–subacute and chronic. Further sub-classification was made according to MT intervention: MT1 (manipulation); MT2 (mobilization and soft-tissue-techniques); and MT3 (MT1 combined with MT2). In each sub-category, MT could be combined or not with exercise or usual medical care (UMC). Consequently, quantitative evaluation criteria were applied to 56 eligible randomized controlled trials (RCTs), and hence 23 low-risk of bias RCTs were identified for review. Only studies providing new updated information (11/23 RCTs) are presented here. Results: Acute–subacute LBP: STRONG-evidence in favour of MT1 when compared to sham for pain, function and health improvements in the short-term (1–3 months). MODERATE-evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain, function and health improvements in the short-term. Chronic LBP: MODERATE to STRONG-evidence in favour of MT1 in comparison to sham for pain, function and overall-health in the short-term. MODERATE-evidence in favour of MT3 combined with exercise or UMC in comparison to exercise and back-school was established for pain, function and quality-of-life in the short and long-term. LIMITED-evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term. LIMITED-evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term. Conclusion: This systematic review updates the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies.

Reliability and validity of a kinematic spine model during active trunk movement in healthy subjects and patients with chronic non-specific low back pain.

OBJECTIVE To develop a standardized, reliable, valid spine model of active trunk movements that accurately discriminates kinematic patterns of patients with chronic non-specific low back pain from those of healthy subjects. DESIGN Comparative cohort study. SUBJECTS Healthy subjects (n = 25) and patients with chronic non-specific low back pain (n = 25) aged 30-65 years. METHODS Subjects performed 7 trunk movements from a seated position at non-imposed speed during 2 sessions. Nine markers on bony landmarks measured range of motion and speed of 5 spinal segments, recorded by 8 optoelectronic cameras. RESULTS Both groups showed good-excellent reliability in all movements for range of motion and speed of all spinal segments (intraclass correlation (ICC), 0.70-0.96; standard error of measurement, expressed as a percentage, 19.4-3.3%). The minimal detectable change in the patient group was 16.7-53.7%. Range of motion and speed in all spinal segments for trunk flexion, rotation, and flexion with rotation differed significantly between groups (p < 0.001), with large/very large effect sizes (Cohens d = 1.2-2). Binary logistic regression yielded sensitivities/specificities of 92%/84% for range of motion and 92%/80% for speed. CONCLUSION Kinematic variables are valid, reliable measures and can be used clinically to diagnose chronic non-specific low back pain, manage treatment, and as quantitative outcome measures for clinical trial interventions.

Effects of proprioceptive disruption on lumbar spine repositioning error in a trunk forward bending task.

BACKGROUND Various inputs of proprioception have been identified and shown to influence low back proprioception sense. OBJECTIVE To investigate the effect of disrupting proprioception on lumbar spine repositioning error during forward bending. METHOD Healthy-subjects (n=28) and patients with non-specific chronic low-back pain (n=10) aged between 20-50 years. Subjects performed 5 repetitions of a lumbar repositioning task targeting 30° of trunk-forward-bending from a seated-position with different proprioceptive disturbances administered to the low back. Video analysis of skin reflective markers measured lumbar spine range-of-motion. A control-task was performed without any proprioceptive disturbance, while the remaining 4 tasks were electro-stimulation, vibration, taping and sitting on an unstable surface. RESULTS The healthy group showed significantly altered repositioning error when compared with the control task (p=0.004): control-task vs. taping-task, vibration-task and unstable-sitting. In the NS-CLBP group, one motor-task showed significant difference in control-task vs. taping-task (p=0.004). Comparison between the NS-CLBP and matched-healthy groups revealed that the NS-CLBP subjects had larger repositioning-error (p=0.009) for control, taping and vibration tasks. CONCLUSIONS Proprioceptive disturbances had the most significant effect in increasing repositioning-error among healthy subjects. The between-groups analysis confirmed evidence consistent with the literature of greater repositioning-error in people with NS-CLBP than healthy subjects.

Intertester Agreement and Validity of Identifying Lumbar Pain Provocative Movement Patterns Using Active and Passive Accessory Movement Tests

OBJECTIVE The purpose of this study was to evaluate the interexaminer agreement and validity of active and passive pain provocation tests in the lumbar spine. METHODS Two blinded raters examined 36 participants, 18 of whom were asymptomatic and 18 reported subacute nonspecific low back pain (LBP). Two types of pain provocation tests were performed: (1) physiological movements in single (flexion/extension) and, when necessary, combined planes and (2) passive accessory intervertebral movement tests of each lumbar vertebra in prone with the lumbar spine in neutral, flexion, and extension position. RESULTS The interobserver agreement in both groups was good to excellent for the identification of flexion (κ = 0.87-1) or extension (κ = 0.65-0.74) as the most painful pattern of spinal movement. In healthy participants, 0% was identified as having a flexion provocative pattern and 8.8% were identified as having an extension provocative pattern. In the LBP group, 20% were identified as having a flexion provocative pattern vs 60% with an extension provocative pattern. The average interexaminer agreement for passive accessory intervertebral movement tests in both groups was moderate to excellent (κ = 0.42-0.83). The examiners showed good sensitivity (0.67-0.87) and specificity (0.82-0.85) to distinguish participants with LBP using this combined examination procedure. CONCLUSION The use of a combination of pain provocative tests was found to have acceptable interexaminer reliability and good validity in identifying the main pain provocative movement pattern and the lumbar segmental level of involvement. These pain provocation tests were able to distinguish participants with LBP from asymptomatic participants and may help clinicians in directing manual therapy treatment.

Short-Term Effects of Mulligan Mobilization With Movement on Pain, Disability, and Kinematic Spinal Movements in Patients With Nonspecific Low Back Pain: A Randomized Placebo-Controlled Trial

OBJECTIVE The purpose of this clinical study was to compare the immediate- and short-term effects of lumbar Mulligan sustained natural apophyseal glides (SNAGs) on patients with nonspecific low back pain with respect to 2 new kinematic algorithms (KA) for range of motion and speed as well as pain, functional disability, and kinesiophobia. METHODS This was a 2-armed randomized placebo-controlled trial. Subjects, blinded to allocation, were randomized to either a real-SNAG group (n = 16) or a sham-SNAG group (n = 16). All patients were treated during a single session of real/sham SNAG (3 × 6 repetitions) to the lumbar spine from a sitting position in a flexion direction. Two new KA from a validated kinematic spine model were used and recorded with an optoelectronic device. Pain at rest and during flexion as well as functional disability and kinesiophobia was recorded by self-reported measures. These outcomes were blindly evaluated before, after treatment, and at 2-week follow-up in both groups. RESULTS Of 6 variables, 4 demonstrated significant improvement with moderate-to-large effect sizes (ES) in favor of the real-SNAG group: KA-R (P = .014, between-groups ES Cliff δ = -.52), pain at rest and during flexion (visual analog scale, P < .001; ES = -.73/-.75), and functional-disability (Oswestry Disability Index, P = .003 and ES = -.61). Kinesiophobia was not considered to be significant (Tampa scale, P = .03) but presented moderate ES = -.46. Kinematic algorithms for speed was not significantly different between groups (P = .118) with a small ES = -.33. All 6 outcome measures were significantly different (P ≤ .008) during within-group analysis (before and after treatment) only in the real-SNAG group. No serious or moderate adverse events were reported. CONCLUSION This study showed evidence that lumbar spine SNAGs had a short-term favorable effect on KA-R, pain, and function in patients with nonspecific low back pain.

Use of kinematic algorithms to distinguish people with chronic non-specific low back pain from asymptomatic subjects: a validation study.

OBJECTIVE To determine whether kinematic algorithms can distinguish subjects with chronic non-specific low back pain from asymptomatic subjects and subjects simulating low back pain, during trunk motion tasks. DESIGN Comparative cohort study. SUBJECTS A total of 90 subjects composed 3 groups; 45 chronic non-specific low back pain patients in the CLBP group; 45 asymptomatic controls people in the asymptomatic controls group. 20/45 subjects from the asymptomatic controls group composed the CLBP simulators group as well. METHOD During performance of 7 standardized trunk motion tasks 6 spinal segments from the kinematic spine model were recorded by 8 infrared cameras. Two logit scores, for range of motion and speed, were used to investigate differences between the groups. Group allocation based on logit scores was also calculated, allowing the assessment of sensitivity and specificity of the algorithms. RESULTS For the 90 subjects (pooled data), the logit scores for range of motion and speed demonstrated highly significant differences between groups (p < 0.001). The logit score means and standard deviation (SD) values in the asymptomatic group (n = 45) and chronic non-specific low back pain group (n = 45), respectively, were -1.6 (SD 2.6) and 2.8 (SD 2.8) for range of motion and -2.6 (SD 2.5) and 1.2 (SD 1.9) for speed. The sensitivity and specificity (n = 90) for logit score for range of motion were 0.80/0.82 and for logit score for speed were 0.80/0.87, respectively. CONCLUSION These results support the validity of using 2 movement algorithms, range of motion and speed, to discriminate asymptomatic subjects from those with low back pain. However, people simulating low back pain cannot be distinguished from those with real low back pain using this method.

The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review

OBJECTIVE: To review and update the evidence for different forms of manual therapy (MT) and exercise for patients with different stages of non-specific neck pain (NP). Data sources: MEDLINE, Cochrane-Register-of-Controlled-Trials, PEDro, EMBASE. METHOD: A qualitative systematic review covering a period from January 2000 to December 2015 was conducted according to updated-guidelines. Specific inclusion criteria only on RCTs were used; including differentiation according to stages of NP (acute – subacute [ASNP] or chronic [CNP]), as well as sub-classification based on type of MT interventions: MT1 (HVLA manipulation); MT2 (mobilization and/or soft-tissue-techniques); MT3 (MT1 + MT2); and MT4 (Mobilization-with-Movement). In each sub-category, MT could be combined or not with exercise and/or usual medical care. RESULTS: Initially 121 studies were identified for potential inclusion. Based on qualitative and quantitative evaluation criteria, 23 RCTs were identified for review. Evidence for ASNP: MODERATE-evidence: In favour of (i) MT1 to the cervical spine (Cx) combined with exercises when compared to MT1 to the thoracic spine (Tx) combined with exercises; (ii) MT3 to the Cx and Tx combined with exercise compared to MT2 to the Cx with exercise or compared to usual medical care for pain and satisfaction with care from short to long-term. Evidence for CNP: STRONG-evidence: Of no difference of efficacy between MT2 at the symptomatic Cx level(s) in comparison to MT2 on asymptomatic Cx level(s) for pain and function. MODERATE to STRONG-evidence: In favour of MT1 and MT3 on Cx and Tx with exercise in comparison to exercise or MT alone for pain, function, satisfaction with care and general-health from short to moderate-terms. MODERATE-evidence: In favour (i) of MT1 as compared to MT2 and MT4, all applied to the Cx, for neck mobility, and pain in the very short term; (ii) of MT2 using sof-tissue-techniques to the Cx and Tx or MT3 to the Cx and Tx in comparison to no-treatment in the short-term for pain and disability. CONCLUSION: This systematic review updates the evidence for MT combined or not with exercise and/or usual medical care for different stages of NP and provides recommendations for future studies. Two majors points could be highlighted, the first one is that combining different forms of MT with exercise is better than MT or exercise alone, and the second one is that mobilization need not be applied at the symptomatic level(s) for improvements of NP patients. These both points may have clinical implications for reducing the risk involved with some MT techniques applied to the cervical spine.

Effects of ankle dorsiflexion limitation on lower limb kinematic patterns during a forward step-down test

BACKGROUND Altered lower limb movement patterns (LLMP) during the forward step down (FSD) test have been studied in people suffering from knee instability. However, ankle dorsiflexion range of motion (ADROM) seems to be related to LLMP but no causal inference has been defined between those variables. OBJECTIVE Our goals were to evaluate (1) psychometric quality of the FSD test in healthy people and (2) the influence of experimental restricted ADROM on LLMP. METHODS Kinematics were measured by a motion capture system. Angular displacement and speed were calculated as well as center of mass (COM) and knee linear displacement. Forty-two healthy participants; firstly, performed the test three times to assess reliability, and secondly the same test in an experimental condition limiting the ADROM. RESULTS Reliability was excellent for all parameters (ICC: 0.75-0.99, SEM%: 2.0-34.0%). ADROM limitation significantly decreased Knee flexion range of motion (ROM) (-3.8∘), increased Hip flexion ROM (6∘), Hip adduction ROM (6.1∘), Pelvis drop ROM (3.5∘), Pelvic rotation ROM (3.1∘). No significant effect was found for Hip rotation ROM. CONCLUSIONS LLMP was affected by this experimental ADROM limitation in healthy people. As this limitation is often encountered in post-traumatic ankle sprain patients, clinicians should consider this point during FSD assessment test.

Effet de l'étirement sur les patterns cinématiques de la colonne lombaire

Les etirements sont un moyen habituellement utilises par les kinesitherapeutes pour traiter les lombalgiques. Une etude preliminaire est en cours.