Brain Connectomic Mechanisms of Spinal Manipulative Therapy on LDH Analgesia Based on Multimodal MRI

Low back and leg pain caused by lumbar disc herniation (LDH) is common. Lever positioning manipulation (LPM) is a spinal manual therapy used to relieve this pain, but how it affects the brain is unclear. This study will compare active LPM with a sham procedure and use multimodal magnetic resonance imaging (MRI) to investigate changes in brain networks associated with pain relief.

A total of 84 adults with LDH will be randomly assigned in a 1:1 ratio to active LPM or sham LPM, with three sessions per week for 12 weeks. An additional 42 age- and sex-matched healthy adults will undergo baseline assessments without treatment. Participants with LDH will be assessed before treatment, immediately after the first session, at week 6, and at week 12. Outcomes include pain intensity, lumbar function, disability, adverse events, and MRI measures of functional and structural brain connectivity. The study aims to identify brain connectomic mechanisms associated with LPM-induced analgesia.

Study Overview

• Status: Not yet recruiting
• Conditions: Lumbar Disc Herniation
• Intervention / Treatment: Procedure: Active Lever Positioning Manipulation; Procedure: Sham Lever Positioning Manipulation

Detailed Description

This is a single-center, prospective, randomized, participant- and outcome-assessor-masked, sham-controlled study with a matched healthy control cohort. Eighty-four participants with lumbar disc herniation will be randomly allocated 1:1 to active lever positioning manipulation or sham lever positioning manipulation using a computer-generated block randomization sequence prepared by an independent statistician. Allocation will be concealed in sequentially numbered, opaque, sealed envelopes. Forty-two age- and sex-matched healthy controls will complete baseline clinical and MRI assessments only.

Active and sham treatments will be delivered three times weekly for 12 weeks, with approximately 20 minutes per session. The sham procedure will reproduce the treatment setting, participant position, preparatory procedures, and practitioner contact but will omit the rapid lever-pulling maneuver. Analgesics, neurotrophic drugs, sedatives, spinal manipulation, acupuncture, traction, and other therapies that could affect pain or MRI outcomes will be prohibited during the treatment period.

Participants with LDH will be assessed at baseline before randomization, immediately after the first treatment session, at week 6, and at week 12. The primary outcome is change in pain intensity measured by the Visual Analog Scale from baseline to week 12. Secondary clinical outcomes include lumbar function measured by the Japanese Orthopaedic Association score and disability measured by the Oswestry Disability Index. Multimodal MRI will be used to evaluate longitudinal changes in functional network topology, white-matter structural connectivity, and structure-function coupling. Exploratory analyses will examine gray-matter covariance and associations between clinical improvement and imaging changes. Safety will be assessed through adverse-event monitoring and vital-sign checks at each treatment session.

• Study Type: Interventional
• Enrollment (Estimated): 126
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Lijiang Lv; Phone Number: +86-18958107858; Email: lvlijiang0288@163.com

Study Locations

• China
  • Zhejiang
    • Hangzhou, Zhejiang, China, 310053
      • The Third Affiliated Hospital of Zhejiang Chinese Medical University
      • Contact: Lijiang Lv; Phone Number: +86-18958107858; Email: lvlijiang0288@163.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

Patients with lumbar disc herniation (LDH):

• Diagnosis of LDH based on clinical symptoms, physical examination findings, and lumbar imaging consistent with neurological localization; central, paracentral, far-lateral, foraminal, or subarticular lumbar disc protrusion.
• Aged 18-65 years, of either sex, and right-handed.
• In the non-acute phase of LDH, with symptom duration of more than 2 weeks.
• Visual Analog Scale (VAS) score greater than 4 and Japanese Orthopaedic Association (JOA) score less than 15.
• No use of analgesics, neurotrophic drugs, or sedatives within 1 month before enrollment.
• No systematic treatment, spinal manipulation, or other physical therapies within 1 month before enrollment.
• Able to understand the study procedures and complete clinical assessments and MRI scans.
• Provides written informed consent.

Healthy controls:

• Aged 18-65 years, of either sex, and right-handed.
• No history of LDH or chronic low back pain.
• No current pain condition requiring treatment.
• No neurological or psychiatric disorders.
• No known structural brain abnormalities.
• No MRI contraindications.
• Able to complete clinical assessments and MRI scans.
• Provides written informed consent.

Exclusion Criteria:

Patients with LDH:

• Low back pain or sciatica caused by conditions other than LDH.
• Lumbar spondylolisthesis, lumbar tumor, spinal tuberculosis, severe osteoporosis, or localized lumbar skin lesions that may interfere with treatment.
• Severe cardiovascular, cerebrovascular, hepatic, renal, hematopoietic, neurological, or psychiatric disease.
• History of severe head trauma, loss of consciousness, or known structural brain abnormality.
• Impaired consciousness, severe visual or hearing impairment, speech disorder, or inability to complete clinical assessments.
• Non-MRI-compatible metal implants, implanted electronic devices, cardiac pacemakers, severe claustrophobia, or inability to tolerate MRI scanning.
• Asymptomatic LDH.
• Pregnancy, lactation, or planned pregnancy during the study period.
• Participation in another clinical trial within the previous 3 months.
• Any condition judged by the investigators to make the patient unsuitable for participation.

Healthy controls:

• Any condition that may affect eligibility, MRI safety, or data quality.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Active Lever Positioning Manipulation; Participants with lumbar disc herniation receive active lever positioning manipulation three times per week for 12 weeks, approximately 20 minutes per session. The procedure includes segment localization, stabilization, positioning to the pre-thrust point, and a rapid lever-pulling maneuver during exhalation.	Procedure: Active Lever Positioning Manipulation; Delivered three times weekly for 12 weeks, approximately 20 minutes per session, by an experienced rehabilitation practitioner. With the participant's hips and knees flexed and legs crossed, the practitioner identifies the target lumbar segment, stabilizes it with the elbow, holds the ankles, and lifts and pulls the legs upward and inward to the pre-thrust position. A rapid lever-pulling maneuver is then performed while the participant exhales.
Sham Comparator: Sham Lever Positioning Manipulation; Participants with lumbar disc herniation receive sham lever positioning manipulation three times per week for 12 weeks, approximately 20 minutes per session. The sham procedure reproduces the treatment setting, position, preparatory procedures, and practitioner contact but omits the rapid lever-pulling maneuver.	Procedure: Sham Lever Positioning Manipulation; Delivered three times weekly for 12 weeks, approximately 20 minutes per session, in the same setting and position as the active procedure. Preparatory positioning and practitioner contact are reproduced, but no rapid lever-pulling maneuver is performed. The position is held for 30 seconds with a 15-cm elastic lumbar belt placed around the lower abdomen and pelvis at L4-S1, light hand contact on the ankles, and gradual release.
No Intervention: Matched Healthy Controls; Age- and sex-matched healthy adults undergo baseline clinical assessment and multimodal MRI only. They receive no study intervention and provide a reference for baseline brain connectivity measures.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Pain Intensity Measured by the Visual Analog Scale (VAS)	Pain intensity will be assessed using the Visual Analog Scale (VAS). The prespecified primary endpoint is the between-group difference between active LPM and sham LPM in change from baseline to week 12. VAS will also be collected immediately after the first treatment session and at week 6.	Baseline, immediately after the first treatment session, week 6, and week 12; primary endpoint at week 12

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Lumbar Function Measured by the Japanese Orthopaedic Association (JOA) Score	Lumbar neurological and functional status will be assessed using the Japanese Orthopaedic Association (JOA) score. Change from baseline will be compared between the active LPM and sham LPM groups.	Baseline, immediately after the first treatment session, week 6, and week 12
Change in Disability Measured by the Oswestry Disability Index (ODI)	Disability related to low back pain will be assessed using the Oswestry Disability Index (ODI), a patient-reported measure of limitations in daily activities. Change from baseline will be compared between the active LPM and sham LPM groups.	Baseline, immediately after the first treatment session, week 6, and week 12
Change in Resting-State Functional Brain Network Topology	Resting-state functional MRI will be parcellated using the 116-region Automated Anatomical Labeling atlas. Pearson correlation matrices and graph-theoretical metrics reflecting network integration, segregation, and nodal importance will quantify functional topology. Longitudinal change will be compared between active LPM and sham LPM.	Baseline, immediately after the first treatment session, week 6, and week 12; main longitudinal comparison from baseline to week 12
Change in White-Matter Structural Connectivity	Diffusion tensor imaging will be parcellated with the 116-region Automated Anatomical Labeling atlas. Whole-brain deterministic streamline tractography will generate structural networks. Edges will be weighted by mean fractional anisotropy along streamlines connecting region pairs, with absent connections coded as zero. Longitudinal change will be compared between active LPM and sham LPM.	Baseline, immediately after the first treatment session, week 6, and week 12; main longitudinal comparison from baseline to week 12
Change in Brain Structure-Function Coupling	Functional and white-matter structural connectivity matrices will use the same 116-region Automated Anatomical Labeling parcellation. For each participant, structure-function coupling will be quantified by the correspondence between functional and structural edge weights across the connectome. Longitudinal change will be compared between active LPM and sham LPM.	Baseline, immediately after the first treatment session, week 6, and week 12; main longitudinal comparison from baseline to week 12

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Group-Level Gray-Matter Structural Covariance Networks	High-resolution T1-weighted images will be segmented, and gray-matter volume will be extracted for each Automated Anatomical Labeling region. Group-level structural covariance networks will be constructed from interregional covariance in gray-matter volume after adjustment for relevant demographic and anatomical covariates. This exploratory measure will be interpreted at the group level rather than as an individual biomarker.	Baseline, immediately after the first treatment session, week 6, and week 12; exploratory longitudinal comparison from baseline to week 12
Association Between Changes in Connectome Metrics and Clinical Outcomes	Exploratory Spearman rank correlation analyses will assess whether changes in individual-level functional network topology, white-matter structural connectivity, and structure-function coupling are associated with changes in Visual Analog Scale, Japanese Orthopaedic Association, and Oswestry Disability Index scores. The Benjamini-Hochberg false discovery rate procedure will control for multiple comparisons.	Baseline through week 12; change scores for the main exploratory association calculated from baseline to week 12
Incidence of Adverse Events	The number and proportion of participants experiencing adverse events will be recorded. Any undesirable medical occurrence will be documented regardless of causal relationship, and severity and relationship to the intervention will be assessed. Vital signs and treatment-related discomfort or safety concerns will be checked at each treatment session; serious adverse events will be reported according to institutional requirements.	From the first treatment session through the end of the 12-week intervention

Collaborators and Investigators

• Sponsor: The Third Affiliated hospital of Zhejiang Chinese Medical University

Study record dates

Study Major Dates

• Study Start (Estimated): July 1, 2026
• Primary Completion (Estimated): September 1, 2027
• Study Completion (Estimated): September 1, 2027

Study Registration Dates

• First Submitted: July 22, 2026
• First Submitted That Met QC Criteria: July 22, 2026
• First Posted (Actual): July 27, 2026

Study Record Updates

• Last Update Posted (Actual): July 27, 2026
• Last Update Submitted That Met QC Criteria: July 22, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: Brain Connectome; Multimodal MRI; Lever Positioning Manipulation
• Additional Relevant MeSH Terms: Bone Diseases; Musculoskeletal Diseases; Pathological Conditions, Anatomical; Spinal Diseases; Hernia; Pathological Conditions, Signs and Symptoms; Intervertebral Disc Displacement
• Other Study ID Numbers: ZSLL-KY-20222-049-02

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No