Spinal manipulation and modulation of pain sensitivity in persistent low back pain: a secondary cluster analysis of a randomized trial

Casper Glissmann Nim, Kenneth Arnold Weber, Gregory Neill Kawchuk, Søren O'Neill, Casper Glissmann Nim, Kenneth Arnold Weber, Gregory Neill Kawchuk, Søren O'Neill

Abstract

Background: Pain hypersensitivity can be assessed using Quantitative Sensory Testing (QST) and is associated with persistent low back pain. Spinal manipulation appears to modify pain hypersensitivity, and this could function as one mechanism leading to clinical improvements. In the current study, we applied a comprehensive QST battery to assess pain sensitivity in a cohort of low back pain patients before and after spinal manipulation to improve our understanding of the association between QST and clinical improvements. This study addresses two questions: Are clinical improvements following spinal manipulation in low back pain patients contingent on pain hypersensitivity, and does pain sensitivity change following spinal manipulation?

Methods: We performed a secondary analysis of data from a randomized clinical trial. One hundred and thirty-two participants with persistent LBP were treated with spinal manipulation four times over two weeks. Patient-reported outcomes and QST were assessed at baseline, after the fourth spinal manipulation session, and 14-days later. The clinical outcomes were changes in low back pain intensity and disability. Using latent profile analysis, we categorized the participants into clusters depending on their baseline QST scores. We used linear mixed models to examine the association between clusters and changes in patient-reported outcomes and QST.

Results: Two clusters emerged: a Sensitized and a Not sensitized. The former had significantly lower regional pressure and thermal pain thresholds, remote pressure pain tolerance, and lower inhibitory conditioned pain modulation than the Not sensitized group. However, we only found between-cluster differences for regional pressure pain threshold following spinal manipulation. Thus, the clusters were not associated with patient-reported pain and disability changes or the remaining QST outcomes.

Conclusions: We report that the baseline QST profile was not associated with clinical improvements following spinal manipulation. We did observe a substantial change for regional pressure pain threshold, which suggests that any effect of spinal manipulation on pain sensitivity is most likely to be observed as changes in regional, mechanical pain threshold. However, the mechanism that invokes clinical improvement and pain sensitivity changes appear distinct. Due to methodological caveats, we advise caution when interpreting the results.

Trial registration: Clinical.Trial.gov identifier: NCT04086667 , registered 11 September 2019 - Retrospectively registered, https://ichgcp.net/clinical-trials-registry/NCT04086667.

Keywords: Chronic pain; Low back pain; Pain modulation; Pressure pain threshold; Quantitative sensory testing; Spinal manipulation.

Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Quantitative sensory tests for the two groups derived from latent profile analysis. Scaled mean values for the different QST parameters [mean = 0, standard deviation = 1]. QST: Quantitative sensory pain test. PPT: Regional pressure pain threshold. HPT: Regional heat pain threshold, rPPT: Remote pressure pain threshold, rPTT: Remote pressure pain tolerance threshold, TS: Temporal summation, CPM: Conditioned pain modulation
Fig. 2
Fig. 2
Stability patterns of quantitative sensory tests for two groups at three different time points. An overview of the cluster stability pattern in the latent profile analysis following spinal manipulation in persistent low back pain patients. The numbers above the arrows indicate the transition of patients over time. A red number indicates the transition to Sensitized, and a blue number indicates the transition to Not sensitized
Fig. 3
Fig. 3
Within-cluster mean changes in low back pain intensity and disability for each latent profile derived cluster after spinal manipulation. Estimated marginal means (95% confidence intervals) from baseline to post-SM and follow up, respectively, in the two groups derived from latent profile analysis. Low back pain intensity is measured on a numerical pain rating scale [0–10]. Disability is measured using the Oswestry disability index [0–100], * = a within-cluster p-value

Fig. 4

The association between clinical improvements…

Fig. 4

The association between clinical improvements and change in cluster classification following spinal manipulation.…

Fig. 4
The association between clinical improvements and change in cluster classification following spinal manipulation. The y-axis presents the change scores in patient-reported outcomes between follow-up and baseline. A negative value indicates improvement. The x-axis presents the stability of the clusters from baseline to follow-up. Low back pain intensity is measured on a numerical pain rating scale [0–10]. Disability is measured using the Oswestry disability index [0–100]. Stable (n = 78), Shift to Not sensitized (n = 20), Shift to Sensitized (n = 7)

Fig. 5

Within changes in regional pressure…

Fig. 5

Within changes in regional pressure pain threshold [kPa, 0–100] for each latent profile…

Fig. 5
Within changes in regional pressure pain threshold [kPa, 0–100] for each latent profile derived cluster faceted by segment allocation after spinal manipulation. Estimated marginal means (95% confidence intervals) from baseline to post-SM and follow up, respectively, in the two groups derived from latent profile analysis for each allocated SM segment group. * = a within-cluster p-value
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Fig. 4
Fig. 4
The association between clinical improvements and change in cluster classification following spinal manipulation. The y-axis presents the change scores in patient-reported outcomes between follow-up and baseline. A negative value indicates improvement. The x-axis presents the stability of the clusters from baseline to follow-up. Low back pain intensity is measured on a numerical pain rating scale [0–10]. Disability is measured using the Oswestry disability index [0–100]. Stable (n = 78), Shift to Not sensitized (n = 20), Shift to Sensitized (n = 7)
Fig. 5
Fig. 5
Within changes in regional pressure pain threshold [kPa, 0–100] for each latent profile derived cluster faceted by segment allocation after spinal manipulation. Estimated marginal means (95% confidence intervals) from baseline to post-SM and follow up, respectively, in the two groups derived from latent profile analysis for each allocated SM segment group. * = a within-cluster p-value

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