Effects of the Spinal Manipulative Therapy and Myofascial Release in Individuals With Non-specific Chronic Low Back Pain

Study Overview
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Brief Summary
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The aim will be to compare a experimental group submitted to a protocol of spinal manipulation and myofascial release; and a control group composed by spinal manipulation only, in individuals with chronic non-specific low back pain. This is a randomized controlled trial, characterized by the application of manual therapy, in two modalities: spinal manipulation plus myofascial release and spinal manipulation alone. Participants will be enrolled and randomly allocated into two groups: 1) spinal manipulation plus myofascial release, totaling 6 sessions, 2x/week, for 3 weeks; 2) spinal manipulation: 6 sessions, 2x/week, for 3 weeks. Participants will be evaluated in two different moments: 1) Baseline (pre-intervention); 2) at the end of intervention period (3 weeks); and 3) after 3 months follow-up. The primary outcomes will be pain intensity (measured in centimeters with the visual analogue scale - VAS) and disability (measured by the Quebec questionnaire - QDS). The secondary outcomes will be muscle fatigue (measured by the Biering-Sorensen test), postural balance (measured by the Y Balance test), pain threshold (algometry, in kgf) and perception of recovery (Likert scale of 6-points) and health status (measured by the Eq5d3L questionnaire). Data analysis will be performed with the SPSS (Statistical Package for the Social Sciences) software version 24.0. Data normality assumptions will be confirmed by the Shapiro Wilk test. If the assumptions were met, a mixed ANOVA with repeated measures will be adopted, based on the outcomes and the independent variables (groups), for the comparison between pre-intervention and post-intervention. Spinal manipulation plus myofascial release is expected to have better effects than spinal manipulation alone, associated with the outcomes of interest.

Official Title
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Effects of the Spinal Manipulative Therapy and Myofascial Release on Pain Threshold, Muscle Function and Balance of Individuals With Non-specific Chronic Low Back Pain: Randomized Controlled Trial

Conditions
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Chronic Low Back Pain

Intervention / Treatment
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* Other: Spinal manipulation/myofascial release
* Other: Spinal manipulation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: presence of non-specific chronic low back pain for more than 12 consecutive weeks; have not performed Physical Therapy, Osteopathic and/or chiropractic sessions for at least 3 months prior to the research. Exclusion Criteria: history of trauma or fractures in the trunk and lumbar spine; presence of neural root symptoms; infection and inflammation on spine and upper and lower limbs for at least 3 months prior to research; have undergone surgery on spine, chest and abdomen; rheumatologic and myopathic diseases; renal, digestion and neurological diseases; use of anti-inflammatories drugs and analgesic drugs for at least 2 weeks prior the research.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This is a randomized controlled trial, characterized by the application of manual therapy, in which subjects will be randomly allocated into two groups: spinal manipulation plus myofascial release and spinal manipulation. The participants will be individuals with non-specific chronic low back pain. The study will be reported following the recommendations of the CONSORT Statement. For the present study, non-specific chronic low back pain was defined as uninterrupted low back pain for more than 12 weeks, with unknown causes.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Spinal manipulation/myofascial release<br>2x/week, for 3 weeks, performed by a chiropractor. Sessions will last 20 minutes, with 1 individual per session. Myofascial release will be done on paravertebral muscle (Erector spinae, quadratus lumborum) and on gluteus maximus and piriform muscles, the pressure will depend of pain tolerance of each subject. After this procedure, the spinal manipulation will be performed on the sacroiliac join and on the lumbar vertebrae with less mobility. | Other: Spinal manipulation/myofascial release<br>* The protocol will be composed by myofascial release followed by spinal manipulation. Paravertebral muscles and gluteus maximus and piriform muscles will be manually checked for tension, stiffness, spasm and painful points. The intervention will be composed by: trigger points release, release of muscle fascia and active release technique. The myofacial release will be done with a constant pressure during 30 seconds, 3x in each point. After this procedure, the spinal manipulation will be performed in high velocity and low amplitude thrust technique, on the lumbar spine and sacroiliac joint.<br>* Other names: Manual therapy;|
| Active Comparator: Spinal manipulation<br>2x/week, for 3 weeks, performed by a chiropractor. Sessions will last 20 minutes, with 1 individual per session. The spinal manipulation will be performed on the sacroiliac join and on the lumbar vertebrae with less mobility. | Other: Spinal manipulation<br>* The sacroiliac joint will be test and manually verified for any dysfunction, and the lumbar spine will be also assessed to verify any hypomobility and vertebral rotation. The segments with alterations will be manipulated with a high velocity and low amplitude thrust technique.<br>* Other names: Manual therapy;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pain intensity | Pain intensity measured by a Visual Analog Scale (in centimeters) | Change from Pre-Intervention (baseline) compared to Post-Intervention (3 weeks) and Follow up (3 months) | 
| Disability | Quebec Back Pain Disability Scale (scores ranging from 0 to 100) | Change from Pre-Intervention (baseline) compared to Post-Intervention (3 weeks) and Follow up (3 months) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Muscle fatigue | Muscle fatigue measured by the Biering-Sorensen test (in seconds) | Change from Pre-Intervention (baseline) compared to Post-Intervention (3 weeks) and Follow up (3 months) | 
| Health Status | Health Status measured by the EQ-5D-3L questionnaire, consisting of five dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression). The responses record three levels of severity | Change from Pre-Intervention (baseline) compared to Post-Intervention (3 weeks) and Follow up (3 months) | 
| Balance | Y-Balance test (in cm) | Change from Pre-Intervention (baseline) compared to Post-Intervention (3 weeks) and Follow up (3 months) | 
| Perception of Recovery | Perception of Recovery measured by a Likert scale (6-points) | Change from Pre-Intervention (baseline) compared to Post-Intervention (3 weeks) and Follow up (3 months) | 
| Pain threshold | Pain threshold measured by Algometry (in kgf) | Change from Pre-Intervention (baseline) compared to Post-Intervention (3 weeks) and Follow up (3 months) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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spinal manipulative therapy, Myofascial release, Low back pain