Article Review Summary by Tyler Tice, PT, DPT, MS, ATC

ARTICLE REVIEW: Regional Manual Therapy and Motor Control exercise for Chronic low back pain: A Randomized Clinical Trial

Chronic low back pain is a common complaint among many individuals and can negatively impact their routine activities. The most up to date evidence suggests treatment for chronic low back pain should consist of a combination of manual therapy, motor control exercises, and a general exercise program. Recent questions have developed on the benefits of performing manual therapy techniques to other areas of the body which may contribute to low back pain (such as the hips or the thoracic spine). This concept is termed regional interdependence, which means impairments in a remote anatomical region can cause primary pain complaints in a different region. There is limited evidence to support or refute this idea when it comes to treatment of low back pain. This study looks at the additive effects of manual therapy to the thoracic, pelvic, and hip regions when combined with standard physical therapy (PT) to the lumbar spine.

Participants: Forty (40) participants were used for this study that were between 18-65 years old, had active low back pain for at least the past 3 months, had at least one hypomobile thoracic or lumbar segment (back stiffness), demonstrated hip mobility deficits, and had at least one hypermobile lumbar segment or weak pelvic/ trunk muscle strength. Also, these participants did not have any red flags, systemic inflammatory conditions, nerve related signs/ symptoms, no spinal injections within past 2 weeks, and would be safe to tolerate manual therapy. Each participant underwent a 2-week, 4-week, and 12-week follow up.

Outcome Measures: The main outcome measure was disability level of each patient measured by the Modified Oswestry Low Back Disability Questionnaire (ODQ). This is a patient reported questionnaire that has shown to be reliable, valid, and responsive to measure disability. Other outcome measures include pain intensity, pain catastrophizing, fear avoidance beliefs, and perceived effect of treatment. Each of these were measured using different patient reported questionnaires as well.

Regional Manual Therapy group : 10 minutes of manual therapy consisting of non-thrust and thrust manipulation to the lumbar spine, thoracic spine, pelvis or hips; or soft tissue gliding over these areas. 20 minutes of motor control exercises that were progressively advanced.
Standard Lumbar PT: 10 minutes of manual therapy consisting of non-thrust mobilizations to the lumbar spine or soft tissue gliding between L1-L5 vertebrae. 20 minutes of motor control exercises that were progressively advanced.
Each group received 30 minutes of treatment 2x/ week for 4 weeks. Both groups were given a home exercise program to work on motor control and self-mobilizations. After the 4 weeks of treatment, they were to perform their HEP 3x/ week for the next 8 weeks without coming to PT sessions.

Significant differences were found for both groups for improvements in disability level, pain levels, pain catastrophizing scales, and fear avoidance beliefs across time. At the 2-week and 4-week follow up, the regional manual therapy group was more likely to report a >50% improvement in their disability level and had a higher rating of perceived effect; but neither showed a significant difference at the 12-week mark.

Both groups had significant improvements across multiple domains over the 12-week period indicating the combination of manual therapy with exercise is beneficial for the treatment of chronic low back pain. The group receiving regional manual therapy in addition to exercises had a greater decrease in reported disability during the 4 weeks of receiving treatment suggesting interventions to areas other than the lumbar spine may improve patient outcomes in a quicker manner. This improves efficiency of physical therapists and may allow the patient to return their prior functional levels in a shorter amount of time.

Some limitations of this study include: small sample size, different forms of manipulation were used based on therapist discretion (however, other studies suggest no difference in thrust vs non-thrust manipulations for outcomes of chronic low back pain), patients allowed to use pain medications. Also, results of this study should only be applied to patients with chronic low back pain and associated hip stiffness with spinal hyper or hypomobility.

Manual therapy with a progressive motor control exercise program is beneficial for chronic low back pain. Assessing associated joints at the thoracic spine, pelvis, and hips should be performed by therapists as deficits at these joints can contribute to pain in the low back. For these other deficits found, performing manual therapy techniques in addition to standard physical therapy treatment may provide additional short-term benefits and allow patients to more quickly return to their routine activities with less pain.

It is standard practice for us at Physical Therapy First to assess adjacent joints and determine any other anatomical factors that can be contributing to someone’s pain. We provide thorough examinations and will utilize manual therapy techniques accordingly to treat all parts of the body. In addition, we understand the benefits of proper exercise programs to make them progressive and functional so our patients can meet their individualized goals. Back pain can be debilitating and the PTs at Physical Therapy First are here to help!

Jason Zafereo, Sharon Wang-Price, Toni Roddey & Kelli Brizzolara (2018) Regional manual therapy and motor control exercise for chronic low back pain: a randomized clinical trial, Journal of Manual & Manipulative Therapy, 26:4, 193-202, DOI: 10.1080/10669817.2018.1433283