Author Names

Didehdar, D., Kamali, F., Yoosefinejad, A.K., Lotfi, M.

Reviewer Name

Maggie Quarles, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

Background: In patients with chronic nonspecific low back pain (NCLBP), brain function changes due to the neuroplastic changes in different regions. Aim: The current study aimed to evaluate the brain metabolite changes after spinal manipulation, using proton magnetic resonance spectroscopy (1 H-MRS). Methods: In the current study, 25 patients with NCLBP aged 20–50 years were enrolled. Patients were randomly assigned to lumbopelvic manipulation or sham. Patients were evaluated before and 5 weeks after treatment by the Numerical Rating Scale (NRS), the Oswestry Disability Index (ODI), and 1 H-MRS. Results: After treatment, severity of pain and functional disability were significantly reduced in the treatment group vs. sham group (p < 0.05). After treatment, N-acetyl aspartate (NAA) in thalamus, insula, dorsolateral prefrontal cortex (DLPFC) regions, as well as choline (Cho) in the thalamus, insula, and somatosensory cortex (SSC) regions, had increased significantly in the treatment group compared with the sham group (p < 0.05). A significant increase was further observed in NAA in thalamus, anterior cingulate cortex (ACC), and SCC regions along with Cho metabolite in thalamus and SCC regions after treatment in the treatment group compared with the baseline measures (p < 0.05). Also, a significant increase was observed in Glx (glutamate and glutamine) levels of thalamus (p = 0.03). There was no significant difference in terms of brain metabolites at baseline and after treatment in the sham group. Conclusion: In the patient with low back pain, spinal manipulation affects the central nervous system and changes the brain metabolites. Consequently, pain and functional disability are reduced.

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

  1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?
  • Yes
  1. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
  • Yes
  1. Was the treatment allocation concealed (so that assignments could not be predicted)?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Were study participants and providers blinded to treatment group assignment?
  • Yes
  1. Were the people assessing the outcomes blinded to the participants’ group assignments?
  • Yes
  1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
  • Yes
  1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Was there high adherence to the intervention protocols for each treatment group?
  • Yes
  1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
  • Yes
  1. 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
  1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
  • Yes
  1. 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

Spinal manipulation can increase brain metabolite concentration in specific areas of the brain, which can help reduce pain.

Key Finding #2

5 weeks following intervention, the group who received spinal manipulation reported less disability compared to the “sham” group.

 

Please provide your summary of the paper

This study examined the impact of spinal manipulation on brain metabolite activity, and the resultant effect on pain and functional disability. The study randomly assigned 25 participants to an intervention group (10 participants) and a sham group (15 participants). The intervention group received 3 sessions of lumbar and sacroiliac thrust manipulations, while the sham group received 3 sessions with similar positions to the manipulations, without receiving the actual thrust technique. The results concluded that after 5 weeks, the patients in the intervention group had increased brain metabolite concentration in the thalamus, and reported less pain and functional disability, measured by the Numerical Rating Scale (NRS) and Oswestry Disability Index (ODI). There were no significant differences in pain and disability rating in the sham group.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This is the first study to look at brain metabolite activity after lumbopelvic manipulation in patients with non-specific low back pain. The results of the study help to reveal that spinal manipulation can impact the CNS, which can result in a significant impact on pain and disability. One drawback to this study is the small sample size, but overall the conclusions can be useful in the utilization of manual therapy in patients with low back pain.