Osteopathic Treatment of Low Back Pain
Condition: Low Back Pain
MeSH terms: Back Pain; Low Back Pain
Study type: Observational

Summary: 
      Eighty percent of Canadians experience low back pain (LBP) at some point in their life
      (Waddell, 1987), with a point prevalence of up to 30 percent (O'Sullivan, 2005; Waddell,
      1987). Low back pain has severe economic ramifications. Most incidents of low back pain occur
      during the prime working years of life, with an estimated cost to the economy at $14,744
      Canadian dollars per person per year (Health Canada, 1998). Indirect costs in the form of
      long-term disability were highest for disorders of arthritis and chronic back pain (Health
      Canada, 1998). It has been estimated that 12 percent of patients will experience disability
      within one year after their first episode of low back pain (Banner, 2006). Evidence based
      diagnosis and treatment is important for desirable outcomes.

      The investigators predict that there will be changes in A) trunk muscle electromyographic
      patterns and in temporo-spatial gait patterns following osteopathic treatment.
    

Detailed description: 
      Research has outlined trunk muscle activation patterns in patients with LBP are different
      from those who do not suffer from low back pain (Clarke-Davidson and Hubley-Kozey, 2005;
      Hodges, 1996 and 1997; McGill, 2001 and 2002). Osteopathic research has documented the
      effects of osteopathic manipulative therapy (OMT) on EMG activity in patients with low back
      pain (Beckman, Harrington, Dostert, et al., 1991; Ellestad, Nagle, Boesler, et al.,1988;
      Krpan, Harrington, Beckman, 1992; Steiner, Park, Guzels, 1991) however these studies were
      limited in design and methodology.

      In a controlled trial which measured levels of cellular enzymes to monitor tissue damage
      during OMT, blood serum enzyme levels did not change as a result of manipulation. More
      important, EMG levels decreased. OMT did not damage tissue but changed motor neuron activity
      (Rowane, Horner, Warner, et al., 1989). Beckman, et al., (1991) observed a reduction in EMG
      activity following OMT in patients with low back pain and found increased skin blood flow as
      measured by laser doppler flow meter. Steiner et al. (1991), reveal reduction to muscle spasm
      as measured by EMG in patients with low back pain following OMT. A further study (Ellestad,
      et al., 1988) noted decreased EMG activity during motion in patients with chronic low back
      pain. Thus there is preliminary work providing support for reduced EMG activity following OMT
      within low back pain treatment groups. However there is a need for further research in this
      area.

      We also want to determine the role of manual therapy (osteopathy) in the management of gait
      dysfunction in this patient population. Patients with LBP present with reduced gait speed,
      poor thoraco-pelvic coordination and increased erector spinae activity (Lamoth et al. 2002
      and 2006), altered weight bearing (Ellen Lee et al., 2007) and reduced single leg stance
      balance in static conditions (Louto et al., 1998).

      Reduced thoraco-pelvic coordination leads to muscular stabilizing effects, altered
      kinematics, trunk rigidity, and reduced walking velocity (Lamoth et al., 2002). Specific
      impairments of body structure and function can reduce gait speed in older adults (Kerrigan,
      Todd, Della Cruce, 1998). Osteopathic intervention targets movement impairments of body
      structure and should change gait speed in patients with chronic LBP. Mal-alignment
      contributes to pathology in the pelvis and lumbar spine which can lead to degenerative
      changes, instability and pain (Aebi, 2005; Gurney, 2002; Steinburg, Luger, Arbel, et al.,
      2003). The focus of osteopathy is to restore mobility and alignment throughout the whole
      kinetic chain (Kutchera and Kutchera, 1991; Seffinger, 2007).

      Improvement in gait speed and joint motion is shown after mobilization exercises to the ankle
      and hip in the elderly (Christiansen, 2003). A kinetic relationship links the ankle and
      pelvis (Gurney, 2002; Khamis & Yizhar, 2007; Pinto, Souza, Tede, et al., 2008).
      Cephalo-caudal (pelvis affects ankle), caudal-cephalo (ankle affects pelvis) and
      ipsilateral-contralateral (one leg affects the other via the pelvis) alignment and kinematic
      relationships occur when lower extremity joints are maintained in altered positions (Pinto,
      et al., 2008). Can movement dysfunction secondary to impaired mobility and mal-alignment
      contribute to pain and antalgic gait?
    

Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Patients with chronic mechanical low back pain (Chronic low back pain is defined as having
        "pain between the lower ribs and gluteal folds, with minimal radiation to the thigh and
        never below the knee, present for a minimum of seven weeks"