Effect of spinal manipulation on sensorimotor functions in back pain patients: study protocol for a randomised controlled trial

David G Wilder, Robert D Vining, Katherine A Pohlman, William C Meeker, Ting Xia, James W Devocht, R Maruti Gudavalli, Cynthia R Long, Edward F Owens, Christine M Goertz, David G Wilder, Robert D Vining, Katherine A Pohlman, William C Meeker, Ting Xia, James W Devocht, R Maruti Gudavalli, Cynthia R Long, Edward F Owens, Christine M Goertz

Abstract

Background: Low back pain (LBP) is a recognized public health problem, impacting up to 80% of US adults at some point in their lives. Patients with LBP are utilizing integrative health care such as spinal manipulation (SM). SM is the therapeutic application of a load to specific body tissues or structures and can be divided into two broad categories: SM with a high-velocity low-amplitude load, or an impulse "thrust", (HVLA-SM) and SM with a low-velocity variable-amplitude load (LVVA-SM). There is evidence that sensorimotor function in people with LBP is altered. This study evaluates the sensorimotor function in the lumbopelvic region, as measured by postural sway, response to sudden load and repositioning accuracy, following SM to the lumbar and pelvic region when compared to a sham treatment.

Methods/design: A total of 219 participants with acute, subacute or chronic low back pain are being recruited from the Quad Cities area located in Iowa and Illinois. They are allocated through a minimization algorithm in a 1:1:1 ratio to receive either 13 HVLA-SM treatments over 6 weeks, 13 LVVA-SM treatments over 6 weeks or 2 weeks of a sham treatment followed by 4 weeks of full spine "doctor's choice" SM. Sensorimotor function tests are performed before and immediately after treatment at baseline, week 2 and week 6. Self-report outcome assessments are also collected. The primary aims of this study are to 1) determine immediate pre to post changes in sensorimotor function as measured by postural sway following delivery of a single HVLA-SM or LVVA-SM treatment when compared to a sham treatment and 2) to determine changes from baseline to 2 weeks (4 treatments) of HVLA-SM or LVVA-SM compared to a sham treatment. Secondary aims include changes in response to sudden loads and lumbar repositioning accuracy at these endpoints, estimating sensorimotor function in the SM groups after 6 weeks of treatment, and exploring if changes in sensorimotor function are associated with changes in self-report outcome assessments.

Discussion: This study may provide clues to the sensorimotor mechanisms that explain observed functional deficits associated with LBP, as well as the mechanism of action of SM.

Trial registration: This trial is registered in ClinicalTrials.gov, with the ID number of NCT00830596, registered on January 27, 2009. The first participant was allocated on 30 January 2009 and the final participant was allocated on 17 March 2011.

Figures

Figure 1
Figure 1
Participant flow chart.
Figure 2
Figure 2
Detailed order of the sensorimotor function procedures.

References

    1. Nachemson AL, Jonsson E. Neck and Back Pain: The scientific evidence of causes, diagnosis and treatment. Philadelphia: Lippincott Williams & Wilkins; 2000.
    1. Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord. 2000;13(3):205–217. doi: 10.1097/00002517-200006000-00003.
    1. Carey TS, Freburger JK, Holmes GM, Castel L, Darter J, Agans R, Kalsbeek W, Jackman A. A long way to go: practice patterns and evidence in chronic low back pain care. Spine. 2009;34(7):718–724. doi: 10.1097/BRS.0b013e31819792b0.
    1. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008. pp. 1–23.
    1. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3. doi: 10.1186/1746-1340-18-3.
    1. Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR, Haas M, Haneline M, Micozzi M, Updyke W, Mootz R, Triano JJ, Hawk C. Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. J Manipulative Physiol Ther. 2008;31(9):659–674. doi: 10.1016/j.jmpt.2008.10.007.
    1. Triano JJ. In: Clinical Biomechanics of Spinal Manipulation. Herzog W, editor. New York: Churchill Livingstone; 2000. The Mechanics of Spinal Manipulation; pp. 92–190.
    1. Herzog W. In: Clinical Biomechanics of Spinal Manipulation. Herzong W, editor. New York: Churchill Livingstone; 2000. The Mechanical Neuromuscular, and Physiologic Effects Produced by Spinal Manipulation; pp. 191–207.
    1. Haldeman S, Chapman-Smith D, Petersen DM, editor. Guidelines for Chiropractic Quality Assurance and Practice Parameters. Maryland: Aspen Publishers; 1993.
    1. Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories. J Manipulative Physiol Ther. 2002;25(4):251–262. doi: 10.1067/mmt.2002.123166.
    1. Tsung BY, Evans J, Tong P, Lee RY. Measurement of lumbar spine loads and motions during rotational mobilization. J Manipulative Physiol Ther. 2005;28(4):238–244. doi: 10.1016/j.jmpt.2005.03.014.
    1. Snodgrass SJ, Rivett DA, Robertson VJ. Manual forces applied during cervical mobilization. J Manipulative Physiol Ther. 2007;30(1):17–25. doi: 10.1016/j.jmpt.2006.11.008.
    1. Evans DW, Lucas N. What is 'manipulation'? A reappraisal. Man Ther. 2010;15(3):286–291. doi: 10.1016/j.math.2009.12.009.
    1. Graham BA, Clausen P, Bolton PS. A descriptive study of the force and displacement profiles of the toggle-recoil spinal manipulative procedure (adjustment) as performed by chiropractors. Man Ther. 2010;15(1):74–79. doi: 10.1016/j.math.2009.07.003.
    1. Wilder DG, Pope MH, Frymoyer JW. The biomechanics of lumbar disc herniation and the effect of overload and instability. J Spinal Disord. 1988;1(1):16–32.
    1. Wilder DG, Pope MH, Seroussi RE, Dimnet J, Krag MH. The balance point of the intervertebral motion segment: an experimental study. Bull Hosp Jt Dis Orthop Inst. 1989;49(2):155–169.
    1. Crisco JJ III, Panjabi MM. The intersegmental and multisegmental muscles of the lumbar spine. A biomechanical model comparing lateral stabilizing potential. Spine. 1991;16(7):793–799. doi: 10.1097/00007632-199107000-00018.
    1. Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992;5(4):383–389. doi: 10.1097/00002517-199212000-00001.
    1. Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord. 1992;5(4):390–396. doi: 10.1097/00002517-199212000-00002.
    1. Panjabi M, Abumi K, Duranceau J, Oxland T. Spinal stability and intersegmental muscle forces. A biomechanical model. Spine. 1989;14(2):194–200. doi: 10.1097/00007632-198902000-00008.
    1. Moorhouse KM, Granata KP. Role of reflex dynamics in spinal stability: intrinsic muscle stiffness alone is insufficient for stability. J Biomech. 2007;40(5):1058–1065. doi: 10.1016/j.jbiomech.2006.04.018.
    1. Borghuis J, Hof AL, Lemmink KA. The importance of sensory-motor control in providing core stability: implications for measurement and training. Sports Med. 2008;38(11):893–916. doi: 10.2165/00007256-200838110-00002.
    1. Cholewicki J, Panjabi MM, Khachatryan A. Stabilizing function of trunk flexor-extensor muscles around a neutral spine posture. Spine. 1997;22(19):2207–2212. doi: 10.1097/00007632-199710010-00003.
    1. Cholewicki J, McGill SM. Mechanical stability of the in vivo lumbar spine: implications for injury and chronic low back pain. Clin Biomech. 1996;11(1):1–15. doi: 10.1016/0268-0033(95)00035-6.
    1. Bjerkefors A, Carpenter MG, Thorstensson A. Dynamic trunk stability is improved in paraplegics following kayak ergometer training. Scand J Med Sci Sports. 2007;17(6):672–679. doi: 10.1111/j.1600-0838.2006.00621.x.
    1. Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil. 2004;85(3 Suppl 1):S86–S92.
    1. Brumagne S, Cordo P, Verschueren S. Proprioceptive weighting changes in persons with low back pain and elderly persons during upright standing. Neurosci Lett. 2004;366(1):63–66. doi: 10.1016/j.neulet.2004.05.013.
    1. Cholewicki J, Silfies SP, Shah RA, Greene HS, Reeves NP, Alvi K, Goldberg B. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 2005;30(23):2614–2620. doi: 10.1097/01.brs.0000188273.27463.bc.
    1. Hodges P, van den Hoorn W, Dawson A, Cholewicki J. Changes in the mechanical properties of the trunk in low back pain may be associated with recurrence. J Biomech. 2009;42(1):61–66. doi: 10.1016/j.jbiomech.2008.10.001.
    1. Hamberg-van Reenen HH, Ariens GA, Blatter BM, van Mechelen W, Bongers PM. A systematic review of the relation between physical capacity and future low back and neck/shoulder pain. Pain. 2007;130(1-2):93–107. doi: 10.1016/j.pain.2006.11.004.
    1. Chen CL, Yeung KT, Bih LI, Wang CH, Chen MI, Chien JC. The relationship between sitting stability and functional performance in patients with paraplegia. Arch Phys Med Rehabil. 2003;84(9):1276–1281. doi: 10.1016/S0003-9993(03)00200-4.
    1. Horak FB, Dimitrova D, Nutt JG. Direction-specific postural instability in subjects with Parkinson's disease. Exp Neurol. 2005;193(2):504–521. doi: 10.1016/j.expneurol.2004.12.008.
    1. van Dieen JH, Cholewicki J, Radebold A. Trunk muscle recruitment patterns in patients with low back pain enhance the stability of the lumbar spine. Spine. 2003;28(8):834–841.
    1. Panjabi MM. A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. Eur Spine J. 2006;15(5):668–676. doi: 10.1007/s00586-005-0925-3.
    1. Holm S, Indahl A, Solomonow M. Sensorimotor control of the spine. J Electromyogr Kinesiol. 2002;12(3):219–234. doi: 10.1016/S1050-6411(02)00028-7.
    1. Bouche K, Stevens V, Cambier D, Caemaert J, Danneels L. Comparison of postural control in unilateral stance between healthy controls and lumbar discectomy patients with and without pain. Eur Spine J. 2006;15(4):423–432. doi: 10.1007/s00586-005-1013-4.
    1. Sung PS, Kang YM, Pickar JG. Effect of spinal manipulation duration on low threshold mechanoreceptors in lumbar paraspinal muscles: a preliminary report. Spine. 2005;30(1):115–122.
    1. Pickar JG, Wheeler JD. Response of muscle proprioceptors to spinal manipulative-like loads in the anesthetized cat. J Manipulative Physiol Ther. 2001;24(1):2–11. doi: 10.1067/mmt.2001.112017.
    1. Mergner T, Rosemeier T. Interaction of vestibular, somatosensory and visual signals for postural control and motion perception under terrestrial and microgravity conditions--a conceptual model. Brain Res Brain Res Rev. 1998;28(1-2):118–135.
    1. Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997;25(1):130–137. doi: 10.1177/036354659702500126.
    1. Bhattacharya A, Shukla R, Bornschein R, Dietrich K, Kopke JE. Postural disequilibrium quantification in children with chronic lead exposure: a pilot study. Neurotoxicology. 1988;9(3):327–340.
    1. Mientjes MI, Frank JS. Balance in chronic low back pain patients compared to healthy people under various conditions in upright standing. Clin Biomech. 1999;14(10):710–716. doi: 10.1016/S0268-0033(99)00025-X.
    1. Luoto S, Taimela S, Hurri H, Aalto H, Pyykko I, Alaranta H. Psychomotor speed and postural control in chronic low back pain patients A controlled follow-up study. Spine. 1996;21(22):2621–2627. doi: 10.1097/00007632-199611150-00012.
    1. Nies BN, Sinnott PL. Variations in Balance and Body Sway in Middle-aged Adults: Subjects with Health Backs Compared with Subjects with Low-back Dysfunction. Spine. 1991;16:325–330. doi: 10.1097/00007632-199103000-00012.
    1. Takala EP, Korhonen I, Viikari-Juntura E. Postural sway and stepping response among working population: reproducibility, long-term stability, and associations with symptoms of the low back. Clin Biomech. 1997;12(7-8):429–437. doi: 10.1016/S0268-0033(97)00033-8.
    1. Ruhe A, Fejer R, Walker B. Center of pressure excursion as a measure of balance performance in patients with non-specific low back pain compared to healthy controls: a systematic review of the literature. Eur Spine J. 2011;20(3):358–368. doi: 10.1007/s00586-010-1543-2.
    1. Leinonen V, Kankaanpaa M, Luukkonen M, Kansanen M, Hanninen O, Airaksinen O, Taimela S. Lumbar paraspinal muscle function, perception of lumbar position, and postural control in disc herniation-related back pain. Spine. 2003;28(8):842–848.
    1. Luoto S, Taimela S, Hurri H, Alaranta H. Mechanisms explaining the association between low back trouble and deficits in information processing. A controlled study with follow-up. Spine. 1999;24(3):255–261. doi: 10.1097/00007632-199902010-00011.
    1. Lavender SA, Shakeel K, Andersson GB, Thomas JS. Effects of a lifting belt on spine moments and muscle recruitments after unexpected sudden loading. Spine. 2000;25(12):1569–1578. doi: 10.1097/00007632-200006150-00018.
    1. Leinonen V, Kankaanpaa M, Hanninen O, Airaksinen O, Taimela S. Paraspinal muscle responses during sudden upper limb loading. Eur J Appl Physiol. 2002;88(1-2):42–49. doi: 10.1007/s00421-002-0664-7.
    1. Mannion AF, Adams MA, Dolan P. Sudden and unexpected loading generates high forces on the lumbar spine. Spine. 2000;25(7):842–852. doi: 10.1097/00007632-200004010-00013.
    1. Thomas JS, Lavender SA, Corcos DM, Andersson GB. Trunk kinematics and trunk muscle activity during a rapidly applied load. J Electromyogr Kinesiol. 1998;8(4):215–225. doi: 10.1016/S1050-6411(98)00008-X.
    1. Magnusson ML, Aleksiev A, Wilder DG, Pope MH, Spratt K, Lee SH, Goel VK, Weinstein JN. European Spine Society--the AcroMed Prize for Spinal Research 1995. Unexpected load and asymmetric posture as etiologic factors in low back pain. Eur Spine J. 1996;5(1):23–35. doi: 10.1007/BF00307824.
    1. Wilder DG, Aleksiev AR, Magnusson ML, Pope MH, Spratt KF, Goel VK. Muscular response to sudden load. A tool to evaluate fatigue and rehabilitation. Spine. 1996;21(22):2628–2639. doi: 10.1097/00007632-199611150-00013.
    1. Thrasher TA, Sin VW, Masani K, Vette AH, Craven BC, Popovic MR. Responses of the trunk to multidirectional perturbations during unsupported sitting in normal adults. J Appl Biomech. 2010;26(3):332–340.
    1. Gardner-Morse MG, Stokes IA. Trunk stiffness increases with steady-state effort. J Biomech. 2001;34(4):457–463. doi: 10.1016/S0021-9290(00)00226-8.
    1. Preuss R, Fung J. Musculature and biomechanics of the trunk in the maintenance of upright posture. J Electromyogr Kinesiol. 2008;18(5):815–828. doi: 10.1016/j.jelekin.2007.03.003.
    1. Grondin DE, Potvin JR. Effects of trunk muscle fatigue and load timing on spinal responses during sudden hand loading. J Electromyogr Kinesiol. 2009;19(4):e237–e245. doi: 10.1016/j.jelekin.2008.05.006.
    1. Radebold A, Cholewicki J, Polzhofer GK, Greene HS. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine. 2001;26(7):724–730. doi: 10.1097/00007632-200104010-00004.
    1. Goodwin GM. The sense of limb position and movement. Exerc Sport Sci Rev. 1976;4:87–124.
    1. Reeves NP, Narendra KS, Cholewicki J. Spine stability: the six blind men and the elephant. Clin Biomech. 2007;22(3):266–274. doi: 10.1016/j.clinbiomech.2006.11.011.
    1. Gill KP, Callaghan MJ. The measurement of lumbar proprioception in individuals with and without low back pain. Spine. 1998;23(3):371–377. doi: 10.1097/00007632-199802010-00017.
    1. Newcomer K, Laskowski ER, Yu B, Larson DR, An KN. Repositioning error in low back pain. Comparing trunk repositioning error in subjects with chronic low back pain and control subjects. Spine. 2000;25(2):245–250. doi: 10.1097/00007632-200001150-00017.
    1. Newcomer KL, Laskowski ER, Yu B, Johnson JC, An KN. Differences in repositioning error among patients with low back pain compared with control subjects. Spine. 2000;25(19):2488–2493. doi: 10.1097/00007632-200010010-00011.
    1. Lee AS, Cholewicki J, Reeves NP, Zazulak BT, Mysliwiec LW. Comparison of trunk proprioception between patients with low back pain and healthy controls. Arch Phys Med Rehabil. 2010;91(9):1327–1331. doi: 10.1016/j.apmr.2010.06.004.
    1. O'Sullivan PB, Burnett A, Floyd AN, Gadsdon K, Logiudice J, Miller D, Quirke H. Lumbar repositioning deficit in a specific low back pain population. Spine. 2003;28(10):1074–1079.
    1. Descarreaux M, Blouin JS, Teasdale N. Repositioning accuracy and movement parameters in low back pain subjects and healthy control subjects. Eur Spine J. 2005;14(2):185–191. doi: 10.1007/s00586-004-0833-y.
    1. Lam SS, Jull G, Treleaven J. Lumbar spine kinesthesia in patients with low back pain. J Orthop Sports Phys Ther. 1999;29(5):294–299.
    1. Koumantakis GA, Winstanley J, Oldham JA. Thoracolumbar proprioception in individuals with and without low back pain: intratester reliability, clinical applicability, and validity. J Orthop Sports Phys Ther. 2002;32(7):327–335.
    1. Asell M, Sjolander P, Kerschbaumer H, Djupsjobacka M. Are lumbar repositioning errors larger among patients with chronic low back pain compared with asymptomatic subjects? Arch Phys Med Rehabil. 2006;87(9):1170–1176. doi: 10.1016/j.apmr.2006.05.020.
    1. Silfies SP, Cholewicki J, Reeves NP, Greene HS. Lumbar position sense and the risk of low back injuries in college athletes: a prospective cohort study. BMC Musculoskelet Disord. 2007;8:129. doi: 10.1186/1471-2474-8-129.
    1. Brumagne S, Cordo P, Lysens R, Verschueren S, Swinnen S. The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. Spine. 2000;25(8):989–994. doi: 10.1097/00007632-200004150-00015.
    1. Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine. 1987;12(7 Suppl):S1–59.
    1. Taves DR. Minimization: a new method of assigning patients to treatment and control groups. Clin Pharmacol Ther. 1974;15(5):443–453.
    1. Hondras MA, Long CR, Cao Y, Rowell RM, Meeker WC. A randomized controlled trial comparing 2 types of spinal manipulation and minimal conservative medical care for adults 55 years and older with subacute or chronic low back pain. J Manipulative Physiol Ther. 2009;32(5):330–343. doi: 10.1016/j.jmpt.2009.04.012.
    1. Van Zoest GG, Gosselin G. Three-dimensionality of direct contact forces in chiropractic spinal manipulative therapy. J Manipulative Physiol Ther. 2003;26(9):549–556. doi: 10.1016/j.jmpt.2003.08.001.
    1. Bergmann TF. Manual force, mechanically assisted articular chiropractic technique using long and/or short level contacts. J Manipulative Physiol Ther. 1993;16(1):33–36.
    1. Fritz S. Mosby's fundamentals of therapeutic massage. St. Louis, MO: Mosby; 2000.
    1. Parnianpour M, Nordin M, Kahanovitz N, Frankel V. 1988 Volvo award in biomechanics. The triaxial coupling of torque generation of trunk muscles during isometric exertions and the effect of fatiguing isoinertial movements on the motor output and movement patterns. Spine. 1988;13(9):982–992. doi: 10.1097/00007632-198809000-00004.
    1. Rougier PR. How spreading the forefeet apart influences upright standing control. Motor Control. 2008;12(4):362–374.
    1. Deyo RA, Battie M, Beurskens AJ, Bombardier C, Croft P, Koes B, Malmivaara A, Roland M, Von KM, Waddell G. Outcome measures for low back pain research. A proposal for standardized use. Spine. 1998;23(18):2003–2013. doi: 10.1097/00007632-199809150-00018.
    1. Bombardier C, Hayden J, Beaton DE. Minimal clinically important difference. Low back pain: outcome measures. J Rheumatol. 2001;28(2):431–438.
    1. Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine. 2000;25(24):3115–3124. doi: 10.1097/00007632-200012150-00006.
    1. Riddle DL, Stratford PW, Binkley JM. Sensitivity to change of the Roland-Morris Back Pain Questionnaire: part 2. Phys Ther. 1998;78(11):1197–1207.
    1. Deyo RA, Cherkin D, Conrad D. The Back Pain Outcome Assessment Team. Health Serv Res. 1990;25(5):733–737.
    1. Stratford PW, Binkley JM, Riddle DL. Development and initial validation of the back pain functional scale. Spine. 2000;25(16):2095–2102. doi: 10.1097/00007632-200008150-00015.
    1. van der Roer N, Ostelo RW, Bekkering GE, van Tulder MW, de Vet HC. Minimal clinically important change for pain intensity, functional status, and general health status in patients with nonspecific low back pain. Spine. 2006;31(5):578–582. doi: 10.1097/01.brs.0000201293.57439.47.
    1. Deyo RA, Battie M, Beurskens AJ, Bombardier C, Croft P, Koes B, Malmivaara A, Roland M, Von KM, Waddell G. Outcome measures for low back pain research. A proposal for standardized use. Spine. 1998;23(18):2003–2013. doi: 10.1097/00007632-199809150-00018.
    1. Ware JE, Jr, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: Manual and Interpretation Guide, Boston, The Health Institute, New England Medical Center. QualityMetric Inc Lincoln RI. 1993.
    1. Bronfort G. Spinal manipulation: current state of research and its indications. Neurol Clin. 1999;17(1):91–111. doi: 10.1016/S0733-8619(05)70116-X.
    1. Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine. 2005;30(11):1331–1334. doi: 10.1097/01.brs.0000164099.92112.29.
    1. Lauridsen HH, Hartvigsen J, Manniche C, Korsholm L, Grunnet-Nilsson N. Responsiveness and minimal clinically important difference for pain and disability instruments in low back pain patients. BMC Musculoskelet Disord. 2006;7:82. doi: 10.1186/1471-2474-7-82.
    1. Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c332. doi: 10.1136/bmj.c332.
    1. Hamaoui A, Do M, Poupard L, Bouisset S. Does respiration perturb body balance more in chronic low back pain subjects than in healthy subjects? Clin Biomech. 2002;17(7):548–550. doi: 10.1016/S0268-0033(02)00042-6.

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