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

BioMed Central (BMC) Musculoskeletal Disorders2012 13:162 Pierre Balthazard, Pierre de Goumoens, Gilles Rivier, Philippe Demeulenaere,Pierluigi Ballabeni, Olivier Dériaz KEY POINTS FROM THIS ARTICLE: The aim of this study was to assess whether manual therapy (MT) has animmediate analgesic effect, and to compare the lasting effect on functional disabilityof MT plus AE to sham therapy (ST) plus AE. This is the first controlled study toassess the efficacy of spinal manipulation/mobilization followed by specific activeexercises. 1) Recent clinical recommendations still propose active exercises (AE) for chronicnon-specific low back pain (CNSLBP). 2) Current evidences suggest that manual therapy (MT) induces an immediateanalgesic effect through neurophysiologic mechanisms at peripheral, spinal andcortical levels. [Key Point] 3) Randomization: Patients in this study selection were aged 20 to 65 years with non-specific low backpain with or without leg symptoms, for a period between 12 and 26 weeks. Theyhad no radiologic abnormalities other than degenerative disease.22 patients were assigned to manual therapy plus active exercise.20 patients were assigned to sham therapy (dysfunctional ultrasound) plus activeexercise. Active exercise was started in the clinical setting and was eventually performed at home.Eight therapeutic sessions were delivered over 4 to 8 weeks.Patients were evaluated at each session, before and after treatment, at week 8 andagain at 3 and 6 months using standard measurement outcomes, which included: * Visual Analogue Scale (VAS) for pain intensity * Oswestry Disability Index (ODI) for disability 4) MT intervention induced a better immediate analgesic effect. 5) MT + AE induced lower disability (-7.1, ODI) and lower pain (-1.2, VAS). 6) This study confirmed the immediate analgesic effect of MT over ST. Followedby specific active exercises, it reduces significantly functional disability and tends toinduce a larger decrease in pain intensity, compared to a control group. 7) These results confirm the clinical relevance of MT as an appropriatetreatment for CNSLBP. 8) These authors propose that CNSLBP and its clinical presentations andmanifestations may be linked to alterations in neuro-cortical function. Theneurophysiologic mechanisms at cortical level should be investigated morethoroughly for MT. [Key Point] 9) Randomized controlled trials reported that manual therapy is more effectiveon physical function, mental health, physical disability and/or pain than nointervention, sham manipulation, light exercises or general active exercises. 10) Manual therapy may interfere with the neuromuscular, autonomic andendocrine responses, produce a placebo effect and/or alter the patientspsychological state. [Key Point] 11) The manual therapy consisted of: A)) Passive intervertebral movements with postero-anterior pressure applied onpainful or stiffed vertebral segment(s) with the patient lying prone. AND/OR B)) A muscle-energy technique using a hold-relaxed technique on an iliumdysfunction with the patient side lying. AND/OR C)) High velocity, low amplitude rotational-lateral flexion dynamic thrust(manipulation) performed on a stiffed vertebral segment(s) with the patient sidelying. 12) The active exercise consisted of: A)) Educational information on low back anatomy and biomechanics and ways toprotect the spine during activities of daily. B)) 2 home mobility exercises (supine pelvic tilt and low back lateral flexion), tobe performed twice a day, 2 sets of 10 repetitions. C)) After the 3rd or 4th session, the recommendation of home exercises changesto stretching and motor control exercises. D)) Mobility exercises during the 8 therapeutic sessions to improve patientsspinal range of motion. E)) Passive stretching exercises for the spine, hamstring, iliopsoas, rectusfemoris, and piriformis. F)) Strengthening exercises for weak superficial trunk muscles. 13) For MT/ST intervention, the immediate effect of intervention was in favor ofmanual therapy over detuned ultrasound, with a greater decrease in pain level. 14) The main original result of this study is that manual therapy, immediatelyfollowed by active exercise, accelerates reduced disability in CNSLBP patients. 15) The analgesic effect of MT combined with exercises can be efficient todecrease pain for CNSLBP. The analgesic effect of manual therapy (i.e., theimmediate effect) may allow the patient to perform better/more accurate activeexercises. 16) The present study confirms the immediate analgesic effect of manual therapyfor CNSLBP. Followed by specific active exercises, it significantly reduces functionaldisability and tends to induce a larger decrease in pain intensity, compared to acontrol group. 17) CNSLBP is largely characterized by structural, functional and neurochemicalcortical modifications. [Key Point] 18) Improving the knowledge of the precise neurophysiologic mechanisms ofmanual therapy at cortical level seems essential in order to validate the choice ofthis therapy for CNSLBP. 19) For CNSLBP, the use of spinal manipulation/mobilization is favorablyrecommended. COMMENTS FROM DAN MURPHY Since both manual therapy and sham therapy (dysfunctional ultrasound) were bothfollowed with active exercise, the clear conclusion for CNSLBP treatment is: 1) Manual therapy is a lot better than sham therapy. 2) Manual therapy is a lot better than exercise (since the same exercises wereperformed by the sham dysfunctional ultrasound group). Importantly, these authors contend that CNSLBP involves alterations in neurocorticalfunction, and that manual therapy can improve this neuro-cortical function. Importantly, these authors acknowledge that manual therapy affects autonomicand endocrine responses, a key point for chiropractors.