- Role of Manipulation in Mechanical Back Pain

Carpenter, Nelson. Low back strengthening for the prevention and treatment of low back pain. Medical Science Sports Exercise 1999; 31(1): 18-24. Because of the association of physical activity with increased pain, chronic low back pain patients often avoid using their backs. Their decreased joint mobilization is associated with wasting of trunk muscles, a decreased in muscular strength and endurance and cardiovascular fitness, as well as, stiffness of ligaments and joints, reduced metabolic activity, and an increased susceptibility to sprains, strains, and muscle spasms. These deleterious effects of muscle / joint disuse provoke symptoms, causing greater avoidance of activity. This cyclical pattern of pain / avoidance of activity / de-conditioning / more pain, referred to as the “De-conditioning Syndrome” is defining characteristic of the chronic low back pain patient studies show that chronic low back pain patients have significant lower trunk strength compared with controls. Also, weak trunk muscles are an important risk factor for low-back problems.

Fear Avoidance Behavior leads to inactivity, immobilization and disuse. This may result in tissue impairment, reduced strength and ROM, stiffness and weakness. As a result there are reduced motor skills, proprioception, balance, stability, and increased risk of injury leading to more fear / avoidance.

Fritz, George, et al. The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain; 2001 94(1): 7-15 Waddell et al (1993) developed the fear-avoidance beliefs questionnaire and showed that fear-avoidance beliefs (FABs) are an important psychosocial variable in patients with chronic disability due to low back pain. The importance of FABs in acute low back pain patients has not been explored. In 78 subjects with work-related low back pain less than three weeks, measures of pain intensity, physical impairment, disability, nonorganic signs and symptoms, and depression were initially evaluated, as were FABs. Disability and work status were re-assessed after four weeks of physical therapy. FABs were significant predictors of four-week disability and work status after controlling for all other variables. FABs are present in acute low back pain patients and may be the most important factor in determining the transition from acute to chronic low back pain. Higher FABs are established early in the course of low back pain and are related to more persistent disability and difficulty returning to full work status. Screening for FABs may be useful for identifying patients at risk of prolonged disability and work absence.

- Articular Neurology and Chiropractic Adjustments

Herzog, PhD. Clinical Biomechanics of Spinal Manipulation. Churchill Livingston 2000. Before treatment muscle shows high EMG activity and was found to be stiff based on motion palpation. During treatment EMG activity increased presumable because of reflex activation produced as a result of the treatment. Following treatment, EMG was silent, and the muscle was found to be relaxed and soft based on motion palpation. The EMG hypertonicity was largely abolished immediately after the spinal manipulation induced EMG response, supporting the idea that spinal manipulation reduces hyperactivation of muscles in areas of back pain.

- Manipulation and Exercise

Morton, PT, M Hth Sc. Manipulation in the treatment of acute low back pain. J Manual and Manipulation Ther 1999; 7(4): 182-189. Prospective study of 29 patients with ALBP (four weeks or less) randomized to two treatment groups: group 1) Fifteen subjects receive spinal manipulation and stabilization exercises (to contract multifidi and improve co-contractions between multifidi and abdominal muscles); 2) Fourteen subjects receive stabilization exercise program alone. Patients got spinal manipulation two times a week for a total of eight treatments. Post treatment assessment performed weekly for four weeks, then without further spinal manipulation but continuing exercise program at two months then three months. Outcomes: ROM, Roland, VAS taken at initial visit, at the end of each week, and at two and three months. Results: Significant differences between groups appeared at one week for pain and ROM and at four weeks for disability. All three outcomes increased further with time. Acute low back pain patients, who received spinal manipulation and exercise program improved to a greater extent than patients who receive the exercise program alone. At three months, group one (spinal manipulation and exercise group) had mean disability score on the Roland 90.3% less than exercise alone group. Eleven out of 15 patients in group one had no disability at three months versus only one in 14 in group two (exercise alone). At three months, group one had a mean pain score 100% less than group two. None of the 15 patients in group one had pain at the end of three months, versus 13 of 14 in group still had pain. At three months, group one had mean ROM 46.44% more than group two. Conclusions: patients who received spinal manipulation plus exercise for acute low back pain will improve more and faster than patients who receive exercises alone. The difference between the groups appears early. Spinal manipulation also appears to be cost-effective.

Bronfort DC, PhD et al. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine 2001; 26: 788-99. After a one-week baseline, 191 patients with chronic mechanical neck pain were randomized to 11 weeks of treatment with follow up at five weeks, 11 weeks, three, six, and 12 months to compare efficacy of 20 to one hour sessions of spinal manipulation alone, spinal manipulation plus low tech exercise, or MedX (high-tech exercise). Patients randomized to receive: 1) spinal manipulation only: by one of nine DCs, high velocity low amplitude to cervical and thoracic spine and light soft tissue massage and then 45 minutes of detuned micro-current after spinal manipulation to control for similar time per visit. 2) Spinal manipulation plus exercise: spinal manipulation by one of nine DCs to cervical and thoracic spine plus light soft tissue massage and low tech exercise: 45 minutes supervised sessions of progressive strengthening for neck and upper body proceeded by short aerobic warm up and light stretch. Upper body strengthening includes push-ups, dumbbell weights of two to 10 pounds. Cervical strengthening exercises with weight attachments to headgear (1.25 – 10 pounds). 3) MedX exercise: one-on-one supervision by physical therapist. Sessions begin with stretching, upper body strengthening, and 15-20 minutes aerobic stationary bike. Dynamic progressive resistance exercises on MedX cervical extension and rotation machines to isolate C-rotators and extensors. All patients in all groups were instructed to use a home exercise program of resistive extension, flexion and rotation exercises with rubber tubing device. Outcomes: patient rated neck pain, disability, functional health status (SF-36), global improvement, satisfaction with care, and medication use. ROM, muscle strength, and endurance assessed by examiners blinded to patients’ treatment assignment. Results: After 11 weeks: patient rated outcomes: all three groups improved. No significant differences between groups in terms of pain, neck disability, general health, improvement, except for satisfaction with care, which was significant higher for spinal manipulation plus exercise than for spinal manipulation alone. In terms of neck performance at least twice as much improvement in spinal manipulation / exercise as in spinal manipulation on all measures including ROM. Spinal manipulation / exercise showed greater improvement in flex endurance and flex strength than MedX. MedX showed higher gains than spinal manipulation in most measures with flex the exception. Long term outcomes: Tendency in short term for the two exercise groups to perform better continued thru-out one follow up year and resulted in significant group differences of medium effect size and are clinically important, especially between the spinal manipulation exercise versus spinal manipulation group. Spinal manipulation / exercise patient satisfaction was superior to both MedX and spinal manipulation. Spinal manipulation /exercise was superior to spinal manipulation alone in terms of pain, satisfaction and improvement and MedX was superior to spinal manipulation in terms of pain. Conclusion: with exception of patient satisfaction for which spinal manipulation / exercise was superior to spinal manipulation alone, no clinically important group differences were observed at 11 weeks. During the follow up year, there was a cumulative advantage for both spinal manipulation / exercise and MedX exercise compared to spinal manipulation. Both exercise groups showed very similar improvements in all outcomes, but spinal manipulation / exercise reported greater satisfaction with care. The use of strengthening exercise whether in combination with spinal manipulation or in the form of high-tech MedX program appears to be more beneficial to patients with chronic neck pain than spinal manipulation alone in terms of pain, satisfaction and overall improvement and MedX was superior to spinal manipulation in terms of pain.

- Strengthening Multifidi and Reducing Future Back Pain

Nourbaksh, PT, PhD, Arab, PT MSc. Relationship between mechanical factors and the incidence of low back pain. JOSPT 2002; 32(9): 447-460. Study investigates the association among mechanical factors and occurrence of low back pain. Six hundred subjects categorized in four groups: 1) Asymp men. 2) Asymp women. 3) Men with low back pain. 4) Women with low back pain. (Each: #150, 43 years). Measured 17 physical characteristics and the association with low back pain: back extensor endurance and length; length of ilioposas, abdominal muscle, hip adductor, hip flexor, hamstrings, gastrosoleus; strength of hip flexor, extensor, abductor, adductor, abdominal muscle; pelvic tilt, foot arch. Results: endurance of back extensor muscles had the highest association with low back pain of all factors; length of back extensor muscles, strength of hip flexors, hip adductors, and abdominal muscles with low back pain. Other studies also show a decrease in back extensor muscle endurance in chronic low back pain patients. Factors including size of lumbar lordosis, pelvic tilt, leg length discrepancy, and length of abdominal, hamstrings, and iliopsoas muscles are not associated with low back pain. EMG studies indicate paraspinal muscles in low back pain patients have a faster fatigue rate. Fatigued muscles have longer response time sand decreased ability to tolerate sudden loads. Excessive, uncontrolled loads may induce strain on the facet joints and other passive structures resulting in low back pain. Studies show that improvement of erector spinae endurance is important in preventing and treating low back pain. Improved symptoms may be due to enhanced muscle endurance and coordination between the trunk flexor and extensor muscles.

- Multifidi, Back Stabilizers and Chronic Low Back Pain

Lee, J-H, MD et al. Spine 1999; 24(1): 54-57. Study investigates trunk muscles weakness as a risk factor of low back pain in asymp subjects. Sixty-seven subjects (men age 17) with no history or treatment for low back pain were observed. Trunk muscle strength was measured isokinetically for trunk extension and flexion and torso rotation. Peak torques and agonist / antagonist ratios were calculated. Symptoms were followed for five years to determine the incidence of low back pain (defined as back pain leading to work absence and / or requiring medical attention). Results: 18 subjects developed low back pain during the five years. There were no differences between non-low back pain and low back pain groups regarding age, height, weight, peak torque values, or left rotation / right rotation ratio. However, the extension / flexion ration of the low back pain demonstrated significantly lower values than that of the non-low back pain group. Conclusion: the imbalance of trunk muscle strength – lower extensor muscle strength than flexor muscle strength, is a risk factor of low back pain incidence.

- Negative Effects of Bed-rest and Inactivity

Waddell, M.D. Spine 1987; 12(7): 632-644. Protracted rest leads to a catabolic state with general malaise. There is demineralization of bone and a 3% loss of muscle strength per day. Rest, particularly prolonged bed rest may be the most harmful treatment ever devised and a potent cause of iatrogenic disability.

Waddell, M.D. Annals of Rheumatic Diseases 1993; 52: 317-319. Prolonged bed rest is the most effective method known for producing a severe disuse syndrome.