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Olav Frode Aure, PT Jens
Hoel Nilsen, PT
Ottar Fasseljen, PhD ABSTRACT Acute LBP, according to multiple
studies, can often resolve in 90% of patients in 6-8 weeks with
conservative care. Chronic
LBP, however, has less favorable results, and the long lasting symptoms
can affect the patient and has significant socioeconomic costs.
Various studies have indicated that exercise therapy can reduce
symptoms of chronic LBP, while there are others that indicate there is not
reduction in symptoms. The
approach of this study was to determine how a specific manual therapy
approach to chronic LBP compared to an exercise program, with a follow-up
period of one year. Inclusion criteria for the study
were age range of 20-60 years, having been on the sick list for 8 weeks to
6 months, with no neurological signs, pregnancy, early retirement,
degenerative change, malignancy, osteoporosis, previous back surgery, or
mental disease. Pain
radiating into the legs was permitted, and a total of 49 subjects were
divided into either a manual therapy group (MT, N=27) and an exercise
group (ET, N=22). Patients
were treated at three different clinics and were randomly assigned to both
group and clinic. All
patients received 16 treatments, each lasting 45 minutes, with 2 visits
per week over 8 weeks. Both
groups were assigned a maximum of 6 individually designed exercises to
perform at home, and all were encouraged to exercise via cycling, jogging,
or walking at least 3 times per week.
No other forms of treatment, including alternative medicine and
chiropractic were permitted. Manual therapy was performed
according to Evjenth, Hamberg, and Kaltenborn, using the following
mobilizations or high velocity, low-force manipulations:
Traction thrust to the thoracic-lumbar junction with the patient
sitting, rotation-lateral flexion thrust for T10-L5 with the patient
sidelying, sacroiliac manipulation/mobilization using a ventral or dorsal
rotational technique with the patient either prone or lying on the side.
A subset of 5 general exercises for the spine, abdomen, or lower
limbs were used, along with 6 specific exercises for spinal segments and
pelvic girdle. The purpose
was to mobilize hypomobile areas or stretch paravertebral muscles.
Each exercise was performed for 20-30 repetitions, and manual
therapy lasted approximately 15 minutes. The exercise therapy consisted of
45 minutes of training, with the first 10 being a bicycle warm up.
Exercises were based on clinical findings and were permitted to be
modified and created according to the PT’s desires.
Outcomes included spinal ROM using
the modified Schober test, pain intensity via a 100mm VAS score, Oswestry
score, Dartmouth COOP function charts for general health, and return to
work status. Spine ROM was
carried out 2 times during the study, and all other outcomes measurements
were taken 6 times. Both groups displayed significant
improvements for pain, general health, and functional ability, with the
manual therapy group showing significantly greater gains than the exercise
group. The mean reduction in
the pain for the MT group was twice that of the ET group.
Also, the MT group had a better general health score, and the
functional disability score was 2.5 times greater.
These effects stayed stable over the course of 1 year. Both groups showed significantly greater spinal ROM, with the
MT group having greater gains at 31mm versus 9mm.
At the post-test period, 73% of the ET group was partly or totally
on sick leave, while only 33% of the MT group was. At 12 months, the numbers were 59% versus 19%. COMMENTS A study that gives a better
indication of the manual techniques used than any other study I have seen,
but does not take the extra step to provide better information as to how
this is performed. Things
were even more vague when the ET group is discussed, with really no
indication of what exercises were performed.
Could this information be transferred to the typical clinic?
Are these techniques used by all, and used only with general
exercise? Usually not.
More often, the manual therapy is combined with the ET to provide
even better outcomes. How can
we truly use this information when we do not know the exact exercises that
were performed? We could end
up with either improved or worse outcomes.
It is also unfortunate that the persons chosen were those who
responded to a questionnaire. This
could create a test group that actually differs from the normal population
by being more motivated and concerned with their health. However, the study has enough punch
that it could be used to argue an insurance denial of manual therapy for
the treatment of chronic LBP. Here is the Schober Test, from
fpnotebook.com
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