Trunk Motor Control Performance Before and After Spinal Manipulation Treatment

Study Overview
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Brief Summary
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The overall goal of this project is to develop sensitive and objective clinical research tools for the assessment of trunk motor control. In order to accomplish this goal, the investigators aim to quantify changes in trunk motor control before and after spinal manipulation treatment. The investigators hypothesize that trunk motor control will improve in the low back pain participants after 4-weeks of spinal manipulation treatment. Additionally, the investigators will compare position and force trunk motor control between healthy controls and low back pain patients. The investigators hypothesize that baseline tests of position and force trunk motor control will be better in healthy individuals than low back pain patients.

Official Title
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Trunk Motor Control Performance Before and After Spinal Manipulation Treatment

Conditions
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Low Back Pain

Intervention / Treatment
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* Procedure: Spinal manipulation treatment


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All participants must meet all of the inclusion criteria to participate in the study. Below is a list of inclusion criteria for ALL participants: Age 21-65 years Independently ambulatory Able to speak and read English Able to understand study procedures and to comply with them for the entire length of the study. Below is an additional list of inclusion criteria for low back pain participants: Willing to be randomized to either immediate or delayed treatment group. Musculoskeletal pain - primarily in the lumbar region Pain rating greater or equal to 3 out of 10 as indicated on the Numeric Rating Scale for Pain Back Disability greater or equal to 26% as indicated on the Oswestry Disability Index Exclusion Criteria: All candidates meeting any of the exclusion criteria at baseline will be excluded from study participation. Exclusion criteria will be self-reported. However, during each treatment session, the physicians will be watching for clinical signs and symptoms not consistent with physical findings that are suggestive of the presence of any of the exclusion criteria. In such a case, further treatment will be discontinued and the subject will be excluded. Below is a list of exclusion criteria for ALL participants: Inability or unwillingness of individual to give written informed consent. Physical therapy or any other form of manual medicine (e.g., Osteopathic Manipulative Medicine, Chiropractic Manipulation, etc.), acupuncture or spinal injections within one month prior to study enrollment Workers' compensation benefits in the past 3 months or ongoing medical legal issues Possibly pregnant Extreme obesity (BMI>36) Currently using electrical implants (e.g., cardiac pacemakers, drug delivery pumps, etc.) History of: Spinal surgery Spinal fracture Spinal infection (e.g., osteomyelitis) Cancer Unresolved symptoms from: Head trauma Inner ear infection with associated balance and coordination problems Orthostatic hypotension Uncontrolled hypertension Vestibular disorder (e.g. vertigo) Current diagnosis of: Significant spinal deformity (e.g., scoliosis > 20 degrees, torticollis) Ankylosing spondylitis Spondylolisthesis grades III or IV Cauda equine syndrome Rheumatoid arthritis Osteoporosis Angina or congestive heart failure symptoms Active bleeding or infection in the back Blindness Seizures Neurologic disease (e.g., Parkinson's disease, multiple sclerosis, cerebral palsy, Alzheimer's disease, amyotrophic lateral sclerosis, stroke or transient ischemic attack in the past year, cervical dystonia) Conditions recognized by a physician any time during the study: Significant or worsening signs of neurologic deficit Symptoms are not consistent with mechanical findings Other conditions impeding protocol implementation Below is an additional exclusion criterion for healthy control participants: • Based on the minimal clinically important difference of 2 points (Childs et al., 2005), healthy controls with 2 points or greater pain on NRS will not be eligible to participate.

Ages Eligible for Study
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Minimum Age: 21 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Basic Science
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Immediate treatment<br>This arm receives spinal manipulation treatment shortly after enrollment | Procedure: Spinal manipulation treatment<br>* Up to 4 sessions of spinal manipulation treatment (once per week).<br>|
| Experimental: Delayed treatment<br>This arm receives spinal manipulation treatment approximately 4 weeks after enrollment | Procedure: Spinal manipulation treatment<br>* Up to 4 sessions of spinal manipulation treatment (once per week).<br>|
| No Intervention: Healthy control (no low back pain)<br>In this arm, healthy controls are tested at baseline. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from baseline to week 4 and from week 4 to 8 in trunk position tracking accuracy | Participants will be in a seated position during the position tracking task and will wear a chest harness with an attached position sensor. The angular position of the trunk will be displayed on a monitor 1 meter in front of the participants and they will be asked to follow a moving target by moving their trunk. Accuracy will be determined by taking the difference between the target position signal and the actual trunk position (measured in degrees with string potentiometers). | Change from baseline to week 4 and from week 4 to 8 | 
| Change from baseline to week 4 and from week 4 to 8 in trunk force tracking accuracy | Participants will be in a seated position and will be asked to generate force with their trunk against a fixed pad. The pad will be attached to a load cell that monitors how much force is being generated by their trunk. The force level will be displayed on a monitor 1 meter in front of the participants and they will be asked to follow a moving target by generating force with their trunk. Accuracy will be determined by taking the difference between target force signal and the actual trunk force (measured in Newtons with the load cell). | Change from baseline to week 4 and from week 4 to 8 | 
| Change from baseline to week 4 and from week 4 to 8 in trunk position stabilization accuracy | Participants will be sitting in a seat mounted to a robotic platform (Mikrolar Hexapod Robot) and will wear a chest harness with an attached position sensor. The robotic platform will provide an angular perturbation to the participant about the lumbar spine in the sagittal plane while the participant is asked to maintain (stabilize) their trunk position in the upright posture. Accuracy will be determined by measuring the amount of trunk displacement (measured in degrees with string potentiometers) during the perturbation trial. | Change from baseline to week 4 and from week 4 to 8 | 
| Change from baseline to week 4 and from week 4 to 8 in trunk force stabilization accuracy | Participants will be sitting in a seat mounted to a robotic platform (Mikrolar Hexapod Robot) and will be asked to generate force with their trunk against a fixed pad. The pad will be attached to a load cell that monitors how much force is being generated by their trunk. The robotic platform will provide an angular perturbation to the participant about the lumbar spine in the sagittal plane while the participant is asked to maintain (stabilize) a static force level (projected on a screen in front of them) with their trunk (10% of the average maximum trunk moment). Accuracy will be determined by measuring the difference between the target force level and the actual force level maintained (measured in Newtons with a load cell) during the perturbation trial. | Change from baseline to week 4 and from week 4 to 8 | 
| Change from baseline to week 4 and from week 4 to 8 in push stabilization accuracy | Participants will be standing and will be asked to generate push force while holding onto a bar (arms along the body, elbows flexed at 90º). The bar will be attached to a load cell that monitors how much force is being applied with the hands. The robotic platform will provide a linear movement (perturbation) of the bar in the horizontal plane while the participant is asked to maintain (stabilize) a static force level (projected on a screen in front of them) with their hands (10% of the average maximum trunk moment). Accuracy will be determined by measuring the difference between the target force level and the actual force level maintained (measured in Newtons with a load cell) during the perturbation trial. | Change from baseline to week 4 and from week 4 to 8 | 
| Change from baseline to week 4 and from week 4 to 8 in pull stabilization accuracy | Participants will be standing and will be asked to generate pull force while holding onto a bar (arms along the body, elbows flexed at 90º). The bar will be attached to a load cell that monitors how much force is being applied with the hands. The robotic platform will provide a linear movement (perturbation) of the bar in the horizontal plane while the participant is asked to maintain (stabilize) a static force level (projected on a screen in front of them) with their hands (10% of the average maximum trunk moment). Accuracy will be determined by measuring the difference between the target force level and the actual force level maintained (measured in Newtons with a load cell) during the perturbation trial. | Change from baseline to week 4 and from week 4 to 8 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Patient Reported Outcomes Measurement Information System (PROMIS) | Assesses weekly changes in physical function, anxiety, depression, fatigue, sleep, satisfaction with social role, and pain with PROMIS-29 questionnaire. | The expected average is weekly for this outcome measure until the end of week 8 | 
| Change in concomitant medication | Assesses weekly changes in the use of medication for treating neck pain, including the type of medication and the quantity of medication (i.e., number of pills) with a questionnaire. | The expected average is weekly for this outcome measure until the end of week 8 | 
| Change in back-related disability | Assesses weekly changes in functional limitations related to back pain with the Modified Oswestry Disability questionnaire. | The expected average is weekly for this outcome measure until the end of week 8 | 
| Change in fear avoidance behavior | Assesses weekly changes in fear avoidance behavior using the Fear Avoidance Belief questionnaire. | The expected average is weekly for this outcome measure until the end of week 8 | 
| Treatment effectiveness belief | Assesses the patient's belief in how effective the treatment will be prior to treatment using the Credibility Expectancy questionnaire. | This outcome measure will be assessed at baseline |