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A Comparison of the Effectiveness of High-Velocity Low-Amplitude and Muscle Energy

Techniques in Treating Non-Specific Chronic Low Back Pain

Anna Bradley, SPT

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

unknown, however it is hypothesized that it is related to the inhibition of nociceptors, as well as

releasing adhesions in the joint.5,7 The purpose of this review is to analyze the research that

examines the effectiveness of these techniques in order to provide a greater understanding of

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

In order to examine the effects of MET as an isolated treatment in comparison to an

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

To investigate the recovery of chronic LBP after HVLA manipulative treatment,

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

Questionnaire were used to determine outcomes.9 Continuous variables were represented as

medians and groups were compared using a Mann-Whitney test. Data was then analyzed using

SPSS and Microsoft Excel.9

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

beneficial when used with therapeutic exercise.8

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

neuromuscular activation patterns or posture balance.5

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

patients and assessors, adequate follow-up, an intention to treat analysis, between-group

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

applying these techniques to clinical practice.

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

contraindications for manipulation techniques such as osteopenia, osteoarthritis, and vascular

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

contraindicated co-morbidities to manipulation. Therefore, MET along with an exercise program

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

and is even more effective in conjunction with a supervised exercise program.

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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.

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