Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial Article in The Journal of manual & manipulative therapy · June 2016  DOI: 10.1080/10669817.2016.1184435

Randomised control trial : Level 1b

Summary:

Curious about the effects of a 5-week, once a week session of 10-minute spinal mobilisation to the levels of the spine with disc degeneration as shown on MRI for patients with chronic low back pain?

This RCT study compared the effectiveness of spinal mobilisation/manual therapy (MT) vs. conventional physiotherapy (CP) vs. sham treatment (ST) in subjects with low back pain and associated spinal disc degeneration.

Method:

The 75-subject selected with low back pain sufferers who were referred for physiotherapy after orthopaedic consultation.  

Inclusion criteria: Pain in the lumbar region > 3 months  accompanied by MRI scan within 12 months.

Exclusion criteria : Any history of spinal surgery, autoimmune disease, spondylolysis/listhesis, fractures, pregnancy, cardio-respiratory pathology, stroke, CE syndrome, continuous use of pain medications, spinal inflammation, spinal tumor, subjects receiving immunosuppressant medication, corticosteroid medication use in the last month and osteoporosis.

These subjects were divided into 3 groups to receive either MT, CP or ST.  The MT group received once a weekly treatment with  10-minute spinal mobilisation to the levels of the spine which shown with disc degeneration changes. The CP group received once a weekly, 5 minutes of static stretch to the lower limbs, 20 minutes of TENS in the lumbar area and 15 minutes of massage to the lower back region. The ST group received once a weekly, 10-minute gentle touch to the skin overlying the lumbar spine.

Results:

Numerical pain rating scale (NPRS) and two questionnaires (Oswesrtry and Roland-Morris) the trial showed significant differences between MT and ST group and between the MT and CP group. No significant difference was observed between the ST and CP group.

A 6-month follow up was conducted on the basis of asking question  whether they sought for professional help regarding their low back pain. This trial was able to show positive results of manual therapy perhaps by their utilisation of the comprehensive exclusion criteria.

limitation of the study :

Lack of a home exercise or education programme. one year- old lumbar MRI scan to assess disk degeneration. spinal mobilization was applied to the segment/s that showed disk degeneration. Perhaps, a future study could compare the efficacy of mobilizing the degenerated segments with mobilizing the symptomatic level as this is more commonly used.

Why this study is relevant:

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The articular mobilization activates the dorsal periaqueductal gray area (dPAG) of the brain which  influencing pain perception.
There are several studies shown an immediate reduction in pain and/or increased activity of the sympathetic nervous system, suggesting indirect association with the dPAG. There is also hypothesis that joint mobilization initiates the descending pain inhibitory mechanisms.

If the pain is  articular origin then Spinal mobilization have an effect of reduction in pain because it involves contact with the skin. Moreover, it is possible that there may be  increased volume of nerve impulses from the skin. It  can result in pain reduction  which can potentially influence the nociceptor activity.

Clinical implementation:

This study shows the effectiveness of segmental mobilization of the affected joint. Manual therapy is an effective treatment in order to reduce pain intensity and disability in subjects with chronic LBP and associated disk degeneration. The establishment of spinal mobilization as one of the most preferable approaches for the management of LBP due to disk degeneration.

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