The Effectiveness of Manual Therapy and PNF Compared With Kinesiotherapy in the Treatment of Non-specific Low Back Pain
Condition: Back Pain
MeSH terms: Back Pain; Low Back Pain
Study type: Interventional

Summary: 
      The aim of the study was to determine whether the use of combination therapy consisting of
      manual therapy and proprioceptive neuromuscular facilitation (PNF) is more effective than the
      use of the techniques of manual therapy, PNF method or traditional physiotherapy as single
      methods in the treatment of non-specific low back pain.

      The study was designed as single-blinded Randomized Controlled Trial (RCT) and conducted on a
      group of 200 patients of Hospital in Parczew. The patients were randomly divided into four
      50-person groups: A used manual therapy, B - PNF, C - manual therapy and PNF, and D
      -kinesiotherapy. Pain intensity was measured using VAS and Laitinen's questionnaire.
      Functional disability was assessed using Oswestry Disability Index (ODI) and Back Pain
      Functional Scale (BPFS).

      . The hypotheses were:

        1. The greatest reduction of pain is observed in the combined therapy group consisting of
           manual therapy and PNF method

        2. The range of movement of the lumbar spine is the most improved in the combination
           therapy group consisting of manual therapy and PNF method.

        3. Neurological symptoms assessed by neurodynamic tests are reduced to the greatest extent
           in the combined therapy group consisting of manual therapy and PNF method.

        4. The degree of disability due to back pain as assessed using the Oswestry Disability
           Index (ODI) decreases in all study groups.

        5. The functioning of patients in everyday life assessed using Back Pain Functional Scale
           (BPFS) shows the biggest improvement in the combination therapy group consisting of
           manual therapy and PNF method.
    

Detailed description: 
      The research was conducted upon acquiring an approval of the Bioethical Commission of the
      Medical University in Lublin, no. KE-0254/14/2014.

      The patients were qualified for physiotherapeutic treatment by a physician working in the
      given centre - a specialist on medical rehabilitation or balneotherapy and physical medicine.
      None of the physicians were personally involved in the preparation and the manner of
      performing the test. Before commencing the tests, each patient was familiarised with their
      course, expressed their informed written consent for participation and random assignment to a
      specified tested group.

      The following selection criteria were used for the groups: the patients' age between 25 and
      55, symptomatic spinal disc herniation of the lumbar spine at levels L4-L5 and/or L5-S1,
      confirmed by imaging examinations (MR, TK), and the patients' lack of use of non-steroid
      anti-inflammatory medications (NSAID) for a period of at least one week before the start of
      the tests. People with cancer, past spinal injuries with damage to anatomical structures and
      osteoporosis were excluded from the tests. Patients who did not qualify also included those
      with a severe inflammatory condition (sciatica) and a massive hernia of the intervertebral
      disc which required surgical treatment.

      The patients were randomly divided into four groups of 50 people: the manual therapy group
      (A), the PNF method group (B), the manual therapy and the PNF method group (C), as well as
      the traditional kinesiotherapy group (D).

      The analgesic effectiveness of the used treatment was evaluated by means of the commonly used
      10-point visual analogue scale of pain (VAS), the modified Laitinen questionnaire of pain
      indicators and Stratford's back pain functional scale (BPFS).

      The functional evaluation involved a goniometric examination of active movements in the
      thoracic-lumbar spine.

      Measurements of pain intensity using visual analogue pain scale (VAS) and a modified
      Laitinen's pain questionnaire were carried out four times (before the start of the therapy,
      in the middle of it, immediately after its completion and two weeks after the end of the
      treatment). The clinical examination (goniometric measurements of range of motion of the
      spine) and the evaluation of nerve root irritation (Laseque's and Mackiewicz's signs) was
      done twice - before and immediately after the treatment. At the same time the functional
      ability in patients in everyday activities using the Oswestry Disability Index (ODI) and Back
      Pain Functional Scale (BPFS) was evaluated too.

      A statistical analysis of the obtained results was performed by means of the SPSS 17.0 suite
      (Softonic, USA). Qualitative variables were described by stating the number of observations
      with the feature variant (n) and its corresponding percentage. The qualitative-nominal data
      was calculated using the following dependence coefficients based on the Chi-squared test:
      Phi, Cramér's V, and for variables in ordinal scales: Kendall's Tau-b and Tau-c.

      Quantitative variables were described based on their nonparametric distribution (verified by
      the Shapiro-Wilk and Kolmogorov-Smirnov tests) by providing descriptive characteristics: the
      mean, the median and the standard deviation. In order to compare differences between
      analogical parameters, the following nonparametric tests were used: Mann-Whitney U for two
      samples, Kruskal-Wallis for more than two samples. In the case of comparisons of equinumerous
      groups, a parametric test was used: a one-way analysis of variance ANOVA and post hoc
      comparisons.
    

Intervention name(s): Manual therapy; PNF; Manual therapy + PNF; Kinesiotherapy
Intervention type(s): Procedure; Procedure; Procedure; Procedure
Intervention description(s): Manual therapy - the mobilisation of joint segments L4-L5 and L5-S1 and mobilisation techniques for soft tissues (functional massage of soft tissues and skin relaxation using the methods of stretching).; The PNF method - the movement patterns of the scapulae and the pelvis were used (anterior and posterior elevations and depression) along with the patterns of upper extremities (e.g. bending, abduction, outward rotation) and lower extremities (e.g. bending, abduction, inward rotation with bending of the knee joint).; Combination therapy - Manual therapy and Proprioceptive Neuromuscular Facilitation; Traditional kinesiotherapy in the form of active slow exercises of back muscles, abdominal and gluteal muscles on a mat. The patients participated in a uniform treatment programme consisting of ten exercises. Each of the exercises was performed in a number of 20 repetitions.
Other intervention name(s): Proprioceptive Neuromuscular Facilitation; Manual therapy + Proprioceptive Neuromuscular Facilitation
Allocation: Randomized
Intervention model: Crossover Assignment
Intervention model description: The patients were randomly divided into four groups of 50 people: the manual therapy group (A), the PNF method group (B), the manual therapy and the PNF method group (C), as well as the traditional kinesiotherapy group (D).
Therapy in all groups proceeded for ten days during a period of two weeks. Measurements of pain intensity using visual analogue pain scale (VAS) and a modified Laitinen's pain questionnaire were carried out four times (before the start of the therapy, in the middle of it, immediately after its completion and two weeks after the end of the treatment). The clinical examination (goniometric measurements of range of motion of the spine) and the evaluation of nerve root irritation (Laseque's and Mackiewicz's signs) was done twice - before and immediately after the treatment.
Masking: Triple (Participant, Care Provider, Investigator)
Primary purpose: Treatment
Keywords: manual therapy; kinesiotherapy; pnf; back pain