Author Names
Boff T.A, Pasinato F., Ben Â.J., Bosmans J., Tulder M., Carregaro R.
Reviewer Name
Said Mendez LAT, ATC, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Study Design: Randomized Control Trial with three months follow up. Objective: To investigate the effectiveness of spinal manipulation combined with myofascial release compared with spinal manipulation alone, in individuals with chronic non-specific low back pain (CNLBP). Participants: Seventy-two individuals (between 18 and 50 years of age; CNLBP ≥12 consecutive weeks) were enrolled and randomly allocated to one of two groups: (1) Spinal manipulation and myofascial release – SMMRG; n = 36) or (2) Spinal manipulation alone (SMG; n=36). Interventions: Combined spinal manipulation (characterized by high velocity/low amplitude thrusts) of the sacroiliac and lumbar spine and myofascial release of lumbar and sacroiliac muscles vs manipulation of the sacroiliac and lumbar spine alone, twice a week, for three weeks. Main Outcome measures: Assessments were performed at baseline, three weeks post intervention and three months follow-up. Primary outcomes were pain intensity and disability. Secondary outcomes were quality of life, pressure pain-threshold and dynamic balance. Results: No significant differences were found between SMMRG vs SMG in pain intensity and disability post intervention and at follow-up. We found an overall significant difference between-groups for CNLBP disability (SMG-SMMRG: mean difference of 5.0; 95% confidence interval of difference 9.9; −0.1), though this effect was not clinically important and was not sustained at follow-up. Conclusion: We demonstrated that spinal manipulation combined with myofascial release was not more effective compared to spinal manipulation alone for patients with CNLBP.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- No
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Cannot Determine, Not Reported, or Not Applicable
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
There were significant improvements in pain, disability, and quality of life post intervention for both groups, but was not sustainable during the 3-month follow-up visit.
Key Finding #2
There was no significant differences in improvements of pain and quality of life in groups. However, there was significant difference between groups for disability.
Key Finding #3
The authors were unable to reject their null hypothesis that a combination of spinal manipulation and myofacial release would be superior to spinal manipulation alone.
Please provide your summary of the paper
This study showed that a three-week intervention program, twice a week, for participants with non-specific low back pain showed no clinically significant results between participants who received spinal manipulation and myofascial release vs spinal manipulation alone. Although there was significant improvement in pain, disability, and quality of life in both groups, post treatment, these improvements did not carry over to their three month follow up visit. Spinal manipulation has been shown to have analgesic effects within the central nervous system and, therefore, it is possible the improvements where solely due to spinal manipulation while myofascial release did not provide additional benefits. Limitations of the study that should be taken into consideration include therapists that administered the interventions were not blinded, some participants reported doing intense exercise apart from the interventions due to feeling improvement, and overall, it was a short intervention period.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study provided some insight about using myofascial release techniques along with spinal manipulation techniques to help improve pain, disability, and quality of life in a short period of time. However, these results had no carry over to a 3-month follow-up. Physical therapists want to promote maintenance of health to help maintain independence and functional mobility. This research study further supports that therapy for non-specific low back pain is a marathon not a sprint for a patient to see sustainable improvements. Further research needs to be performed to see if a longer intervention program with appropriate home exercise programs, myofascial techniques, and spinal manipulations would provide long term maintenance of functional mobility and independence.
