Changes in pain sensitivity and spinal stiffness in relation to responder status following spinal manipulative therapy in chronic low Back pain: a secondary explorative analysis of a randomized trial

Casper Glissmann Nim, Gregory Neil Kawchuk, Berit Schiøttz-Christensen, Søren O'Neill, Casper Glissmann Nim, Gregory Neil Kawchuk, Berit Schiøttz-Christensen, Søren O'Neill

Abstract

Background: In a prior randomized trial, we demonstrated that participants receiving spinal manipulative therapy at a pain-sensitive segment instead of a stiff segment experienced increased mechanical pressure pain thresholds. We hypothesized that the targeted segment mediated this increase through a segment-dependent neurophysiological reflective pathway. Presently, it is not known if this decrease in pain sensitivity is associated with clinical improvement. Therefore, we performed an explorative analysis to examine if changes in experimental pain sensitivity (mechanical and thermal) and lumbar stiffness were further dependent on clinical improvement in disability and patient-reported low back pain.

Methods: This study is a secondary explorative analysis of data from the randomized trial that compared 132 participants with chronic low back pain who received lumbar spinal manipulative therapy applied at either i) the stiffest segment or ii) the segment having the lowest pain threshold (i.e., the most pain-sensitive segment). We collected data at baseline, after the fourth session of spinal manipulation, and at 14-days follow-up. Participants were dichotomized into responders/non-responders using different clinical variables (disability and patient-reported low back pain) with varying threshold values (0, 30, and 50% improvement). Mixed models were used to assess changes in experimental outcomes (stiffness and pain sensitivity). The fixed interaction terms were time, segment allocation, and responder status.

Results: We observed a significant increase in mechanical pressure pain thresholds for the group, which received spinal manipulative therapy at the most pain-sensitive segment independent of whether they improved clinically or not. Those who received spinal manipulation at the stiffest segment also demonstrated increased mechanical pain sensitivity, but only in the subgroup with clinical improvement. We did not observe any changes in lumbar stiffness.

Conclusion: Our results suggest the existence of two different mechanistic pathways associated with the spinal manipulation target. i) A decrease of mechanical pain sensitivity independent of clinical outcome (neurophysiological) and ii) a decrease as a reflection of the clinical outcome. Together, these observations may provide a novel framework that improves our understanding of why some respond to spinal manipulative therapy while others do not.

Trial registration: ClinicalTrials.gov identifier: NCT04086667 registered retrospectively September 11th 2019.

Keywords: Lumbar stiffness; Pain sensitivity; Responder analysis; Spinal manipulative therapy.

Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Cumulative proportion of responders. A cumulative responder proportion graph for the participants treated with spinal manipulative therapy at either a pain segment or a stiff segment. The red line indicates a 0% improvement, the green line indicates a 30% improvement, and the blue line indicates a 50% improvement. Improvements are shown for disability and patient-reported low back pain. A negative value indicates worsening of the outcomes
Fig. 2
Fig. 2
Changes in pressure pain threshold following SMT. Within-group mean changes in pressure pain threshold (kPa) for 50, 30, and 0% improvement in disability and patient-reported low back pain. Estimates are presented as means with 95% confidence intervals for each time-point and within-group significance level (p < 0.05) - presented as: * = Significant changes in responders from baseline to post-SMT. ** = Significant changes in responders from baseline to follow-up. # = Significant changes in non-responders from baseline to post-SMT. ## = Significant changes in non-responders from baseline to follow-up. SMT = Spinal manipulative therapy
Fig. 3
Fig. 3
Segmental changes in pain sensitivity (mechanical and thermal) and lumbar stiffness following SMT. The segmental changes in global stiffness (N/mm), pressure pain threshold (kPa), and heat pain threshold (degrees Celsius) presented for 30% improvement in disability. Estimates are presented as mean and 95% confidence intervals for each time-point. Segments are divided into the segment targeted, the adjacent segments to the targeted segment, and all other segments. SMT = spinal manipulative therapy
Fig. 4
Fig. 4
The pathway of experimental changes following SMT in chronic low back pain patients. A pathway of changes following SMT in lumbar stiffness and pain sensitivity (mechanical and thermal), both in general and dependent on the target site (pain segment or a stiff segment). A green arrow indicates a positive specific/non-specific effect on the outcome, and a red blocked arrow indicates no effect on the outcome. SMT = Spinal manipulative therapy

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