Litreview Manual2
Litreview Manual2
Litreview Manual2
Literature Review
INTRODUCTION
Low back pain (LBP) is a common condition treated in physical therapy practice that is
characterized by pain, muscle tension, and stiffness in the lumbar region of the spine.1 The
condition is considered chronic if it persists for 12 weeks or more.2 Non-specific low back pain is
diagnosed when there is no recognizable pathology attributing to the pain.2 LBP is a very
prevalent condition, affecting over 70% of people in developed countries.2 Additionally, with a
continuously aging population, LBP will continue to become more prevalent amongst society.1
This is problematic because it can contribute to further problems such as long-term disability and
absence from work.3,4,5 Two osteopathic methods that are commonly used to treat chronic LBP in
the physical therapy setting are high-velocity low-amplitude manipulation (HVLA) and muscle
energy techniques (MET). MET is a manual technique performed by utilizing active and passive
movement to elicit voluntary muscle contractions and relaxation in the area being treated.6 This
treatment is based off the physiological principle of reciprocal inhibition, meaning that a
contraction of the agonist muscle will inhibit the excitability of an antagonist muscle.6 This then
will mobilize the restricted spinal segments as well as reduce pain in the area.6 Meanwhile,
HVLA is a technique that involves passively moving a joint into end-range and applying a thrust
to induce mobility in that joint.5 The underlying physiological mechanisms behind HVLA are
releasing adhesions in the joint.5,7 The purpose of this review is to analyze the research that
how they can be integrated into clinical practice. This includes the work of Rishi and Arora
(2018) which explores the effect of MET as an isolated treatment in comparison to it being used
along with a supervised exercise program in treating chronic non-specific LBP.8 Additionally, a
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study done by Licciardone, Gatchel, and Aryal (2016) will be discussed, which looks at recovery
from chronic LBP after HVLA treatment.9 Lastly, a study by Sturion et al. (2020) will be
reviewed, which draws a comparison on the effects of HVLA and MET on the clinical symptoms
and neuromuscular control of the trunk in adult male workers with chronic LBP.5 Reviewing the
work of these authors will provide more insight to the research question that explores if METs
are more effective in treating chronic non-specific LBP in adults compared to HVLA techniques.
METHODS
adjunct of a supervised exercise program, Rishi and Arora (2018) looked at 30 LBP patients who
were randomly divided into 2 groups based on inclusion and exclusion criteria.8 Group A
received MET to the iliopsoas and quadratus lumborum for 2 weeks, 5 days a week.8 Group B
received MET along with a supervised exercise program for the same duration.8 The Oswestry
disability index (ODI) and a numerical pain rating scale (NPRS) were used to score pain and
disability before and after the interventions.8 Pre and post analyses were done using paired t-tests
to examine both the control and experimental groups demographics and then an unpaired t-test
was done to compare the mean difference in ODI scores between groups.8
Licciardone, Gatchel, and Aryal (2016) looked at 455 men and women between the ages of 21
and 49 years old with non-specific chronic LBP of at least 3 months.9 Patients were randomly
assigned to treatment groups: an osteopathic manipulative treatment group (OMT) or sham OMT
group.9 The sham OMT group received treatments involving range of motion and techniques that
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mimicked OMT.9 The patients had 15-minute treatment sessions over 8 weeks, and outcomes
were assessed at week 12.9 A visual analog scale (VAS) and Roland-Morris Disability
medians and groups were compared using a Mann-Whitney test. Data was then analyzed using
To compare the effectiveness of HVLA and MET in treating LBP, Sturion et al. (2020)
looked at 10 volunteers between the ages of 35 and 55 years old who were randomly allocated
into an HVLA group (n=5) and a MET group (n=5).5 Trunk neuromuscular activation patterns
were evaluated using EMG on bilateral target trunk muscles while patients performed 5-second
maximal voluntary contractions twice with 1 minute of rest in between while in a hook-lying
position.5 Static postural balance was measured with a BIOMEC 400 force platform both with
and without external load on the trunk. Balance tasks were then performed for 60 seconds with 3
minutes of rest in between trials. Clinical symptoms were assessed using a numerical pain rating
scale (NPRS) and McGill Pain Questionnaire-Short Form (SF-MPQ).5 Additionally, a RMDQ
was used to assess functional tasks and a Fear-Avoidance Beliefs Questionnaire (FABQ) was
used to look at their feelings towards physical and work activities.5 Lastly, a modified Schober
test was used to measure lumbar flexion range of motion until the onset of pain.5 The patients
received 3 weeks of one technique, a week of rest, and then a week of the other technique with
the treatments being administered once a week.5 Outcome measures were collected before and
after each treatment block. A MANOVA was used to look at each dependent variable to look at
their influence on factors such as time and groups.5 SPSS was then used for statistical analyses.5
RESULTS
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After administering MET, as well as MET combined with a supervised exercise program
for 2 weeks, Rishi and Arora (2018) found that there was a significant improvement in ODI and
NPRS in both groups.8 There was also a significant improvement in the mean difference of ODI
scores for the group who received MET combined with an exercise program.8 These results
suggest that MET alone is effective in reducing pain and improving function, but it is more
Recovery of chronic LBP following HVLA manipulation was assessed at week 12 of the
study and Licciardone, Gatchel, and Aryal (2016) found that there was a greater reduction in
VAS score for LBP intensity in the OMT group (20 mm) in comparison to the sham OMT group
(12 mm).9 This suggests that OMT is directly associated with recovery.9 The treatment was also
found to be more effective in patients between the ages of 50 and 69 years old.9
When comparing the effectiveness of MET and HVLA techniques for reducing chronic
low back pain, Sturion et al. (2010) found that both techniques were significantly effective in
reducing pain after the first session (HVLA= 26% mean decrease, MET= 39% mean decrease) as
well as after 15 days of intervention (HVLA= 52% mean decrease, MET= 73% mean decrease).5
There were no statistically significant changes in disability in the FABQ and no change in
DISCUSSION
When evaluating the quality of the literature reviewed, the PEDro scale was used to
assess internal validity and statistical significance of the studies.10 The study by Rishi and Arora
(2018) examining the effects of MET on chronic LBP received a 7/10 on the PEDro scale,
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showing it to be a reputable source.10 It was given this score because the groups were randomly
assigned, they had strict inclusion criteria of 18 to 30 year-old patients with an initial ODI score
of 30-60%, exclusion criteria of any back pain attributed to a specific pathology, and had all 30
participants finish the study.10 The study lacked in addressing whether the assessors and patients
were blinded and did not state whether allocation was concealed.10 Additionally, this study also
looked at a much younger population in comparison to the other studies discussed in this
review.10 However, very little has been published on the use of MET for chronic LBP, making
the information from this study of value.10 The study by Licciardone et al. (2016) that examined
HVLA treatment for chronic LBP received an 8/10 on the PEDro scale.10 This score was given
because the patients were randomly put into groups which were concealed, strict inclusion and
exclusion criteria, and the subjects had baseline comparability.10 The study also had blinded
comparisons, and variability in more than one key outcome.10 This study lacks in clear
instructions for the manipulative techniques used, making it difficult for repeatability. It also
only looks at short-term recovery after receiving HVLA treatments and the data cannot be used
to determine what long-term outcomes may look like.10 Finally, the study by Sturion et al. (2020)
that compares the two osteopathic treatments was given a 6/10 on the PEDro scale.10 This score
was given because of its inclusion and exclusion criteria, the patients were randomly allocated
into groups by an evaluator not involved in the study, the researchers were blinded to the
intervention allocation, they used specific outcome measures for baseline comparability, and
variability and between-group comparisons were performed for at least one key outcome.10
Further, this is the first study to compare the two techniques in regard to pain, neuromuscular
control, and posture for chronic LBP.5 The limitations for this study include the fact that only
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short-term effects were reported, there was a small sample size, and the study only included
men.5 Based on the lack of literature examining MET and HVLA techniques, as well as the high
scores on the PEDro scale, these research articles are valuable resources to consult when
CONCLUSION
The findings of the studies discussed in this review suggest that both MET and HVLA
techniques are effective treatments for non-specific chronic LBP in adults.5,8,9 This is important
information to consider for clinical practice because while they are both effective, there are many
disease.11 There are also some risks associated with HVLA such as artery tears and strokes.12
Meanwhile, MET is a more conservative treatment and a safer option for patients with
would be an ideal first course of treatment, but if that is not effective and there are no
contraindications, HVLA may be beneficial. In conclusion, while both MET and HVLA are
found to be effective treatments for non-specific chronic low back pain, MET is a safer approach
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REFERENCES
1. Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best
Practice & Research Clinical Rheumatology. 2010; 769-781.
2. Chou, R. Low Back Pain (Chronic). American Family Physician. 2011; 84(4): 437-438.
3. Wolter T, Szabo E, Becker R, et al. Chronic low back pain: Course of disease from the
patient’s perspective. International Orthopaedics. 2011; 35(5): 717-724.
4. Yang H, Haldeman S, Lu M, et al. Low back pain prevalence and related workplace
psychosocial risk factors: A study using data from the 2010 national health interview
survey. Journal of manipulative and Physiological Therapeutics. 2016; 39(7): 459-472.
5. Sturion LA, Nowotny AH, Barillec F, et al. Comparison between high-velocity low-
amplitude manipulation and muscle energy technique on pain and trunk neuromuscular
postural control in male workers with chronic low back pain: A randomized crossover
trial. South African Journal of Physiotherapy. 2020; 76(1): 1420.
6. Chaitow L. Muscle energy techniques, 3rd edition. 2006; Elsevier, London.
7. Hamilton L, Boswell C, Fryer G. The effects of high-velocity, low-amplitude
manipulation and muscle energy technique on suboccipital tenderness. International
Journal of Osteopathic Medicine. 2007; 10(2-3): 42-49.
8. Rishi P, Arora B. Impact of muscle energy technique along with supervised exercise
program over muscle energy technique on quadratus lumborum and iliopsoas on pain and
functional disability in chronic non-specific low back pain. International Journal of
Physiotherapy and Research. 2018; 6(3): 2748-2753.
9. Licciardone JC, Gatchel RJ, and Aryal S. Recovery from Chronic Low Back Pain After
Manipulative Treatment: A Randomized Controlled Trial. The Journal of the American
Osteopathic Association. 2016; 116(3): 144-155.
10. PEDro Scale- Physiotherapy Evidence Database.
https://pedro.org.au/wp-content/uploads/PEDro_scale.pdf. Revised June 21, 1999.
Accessed March 17, 2022.
11. Spinal Manipulation. Physiopedia.
https://www.physio-pedia.com/Spinal_Manipulation#cite_note-Gibbons-14. Accessed
March 20, 2022.
12. Spinal Manipulation: What you need to know. National Center for Complementary and
Integrative Health. https://www.nccih.nih.gov/health/spinal-manipulation-what-you-
need-to-know. Accessed March 20, 2022.