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Effects of unilateral posteroanterior mobilization in subjects with sacralized lumbosacral transitional vertebrae
Journal of Bodywork & Movement Therapies (2016) 20, 19e25
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
ORIGINAL RESEARCH
Effects of unilateral posteroanterior mobilization in subjects with sacralized lumbosacral transitional vertebrae Phuntsog Angmo, MPT, Dr P.P. Mohanty, Ph D, FIAP*, Monalisa Pattnaik, MPT Department of Physiotherapy, SVNIRTAR, Olatpur, P.O: Bairoi, Dist., Cuttack, PIN-754010, Odisha, India Received 21 September 2014; received in revised form 23 January 2015; accepted 31 January 2015
Summary Aim of the study: To find out the efficacy of unilateral posteroanterior (PA) mobilization over type IA and type IIA sacralized lumbosacral transitional vertebrae in patients with low back pain with or without leg pain. Research design: experimental randomized control study. Sample size: 30 subjects, Sampling: simple random sampling. GROUP A e 15 subjects e self lumbar mobility and stretching exercises þ Unilateral PA mobilization þ hot pack. GROUP B e 15 subjects e self lumbar mobility and stretching exercises þ hot pack. Before initiating treatment, subjects were assessed for dependent variables: Pain intensity by VAS, Forward bending and side bending ROM by modified finger to floor method with the help of an inch-tape and functions by Modified Oswestry Functional Disability Questionnaires. Post test measurements were taken after completion 2 weeks of therapy. The results of the study suggest that unilateral PA pressure is an effective mobilization method in reducing low back pain, improving ROM and related disability as compared to impairment based exercises alone in patients with low back pain with or without radiation to lower limbs having abnormally large transverse processes and hypomobile type IA and IIA lumbo-sacral transitional vertebrae. ª 2015 Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. E-mail address: [email protected] (P.P. Mohanty). http://dx.doi.org/10.1016/j.jbmt.2015.02.002 1360-8592/ª 2015 Elsevier Ltd. All rights reserved.
Back pain is a common complaint observed in our clinical practice and X-rays of the lumbar spine are often used to investigate this symptom. One of the most frequent congenital abnormalities detected on routine lumbosacral
20 X-rays is a lumbosacral transitional vertebra (LSTV). A lumbosacral transitional vertebra (LSTV) refers to a total or partial unilateral or bilateral fusion of the transverse process of the lowest lumbar vertebra to the sacrum. The anomalous vertebra is commonly referred to as a sacralized L5 or a lumbarized S1, on the basis of the number of nonerib bearing vertebrae shown by radiographs that include the thoracolumbar junction. Estimates on the prevalence of lumbar transitional vertebrae in the general population vary widely from 4% to 30% (Tini et al., 1977; Luoma et al., 2004; Otani et al., 2001; Hahn et al., 1992; Wigh and Anthony 1981; Chithriki et al., 2002). It was first observed by Bertolotti (1917). Although the relationship of low back pain and LSTV, termed “Bertolotti’s Syndrome,” is controversial and has been both supported and disputed (Konin and Walz, 2010). It has been hypothesized that motion between the transitional vertebra and the sacrum is reduced and asymmetrical. This asymmetry of motion can result in early degenerative changes within the neoarticulation or the normal contralateral facet, if present. Lumbar disc immediately above the transitional vertebrae were significantly more degenerative and those between the transitional vertebra and sacrum were significantly less degenerative compared with disc at other level (Aihara et al., 2000). The above processes are treated differently, requiring reliable techniques to not only identify LSTVs but also determine the type and site of the pathology generated by the lumbosacral transitional vertebrae, have been classically identified by using lateral and Ferguson radiographs. Castellvi et al. (1984), described a radiographic classification system identifying 4 types of LSTVs on the basis of morphologic characteristics: Type I: Dysplastic transverse process Unilateral (a) or bilateral (b) large triangular transverse process, at least 19 mm wide. Type II: Incomplete lumbarisation/sacralisation Enlarged transverse process with unilateral (a) or bilateral (b) Pseudoarthrosis with the adjacent sacral ala. Type III: Complete lumbarisation/sacralisation transverse process, with unilateral (a) or enlarged bilateral (b) complete fusion with the adjacent sacral ala. Type IV: Mixed Type IIa on one side and type IIIa on the other processes. While there is little consensus on the clinical significance of LSTV, even less is known about useful treatment strategies. Unfortunately, we did not come across any RCT; only scarce reports with small case series are available in the literature, describing specific treatment options in symptomatic LSTV. Surgical option (Santavirta et al., 1993), Steroid injection (Marks and Thulbourne, 1991) etc are various treatment intervention reported in the literature. Lumbosacral joint manipulation combine with the therapeutic exercises in the treatment of type IIA LSTV may be recommended (Brenner, 2005), but it is not known whether this method results in manipulation of the L4eL5, L5-S1, or the sacroiliac joints. According to Maitland et al. (2001) in most clinical cases it is wise to begin treatment with mobilizing techniques rather than manipulation and also there has been no research on the use of mobilization on patients with type IA and IIA LTV.
P. Angmo et al. So the purpose of this study is “To mobilize the hypomobile segment thereby improving movement and function by decreasing pain and stiffness, also preventing associated spinal pathologies”.
Aim of the study To find out the efficacy of unilateral PA mobilization over type IA and type IIA sacralized lumbosacral transitional vertebrae in patients with low back pain with or without leg pain.
Methodology Research design: experimental randomized control study. Sample size: 30 subjects. Sampling: simple random sampling.
Inclusion criteria 1) Age: 20e55 yrs. 2) Gender: Both Males and Females 3) Low back pain with or without radiating to unilateral lower extremity. 4) Radiological findings (Type IA and Type IIA Lumbosacral transitional vertebra of Castellvi’s classification on Ferguson projection (AP lumbar spine radiograph at 30 cranial tilt and lateral projection) 5) Restriction in forward bending and asymmetrical side bending i.e.; reduction of side-bending away from affected as compared to that towards the affected side 6) Quadrant test and passive end range in lumbar flexion with overpressure in standing reproduces symptom 7) Central and unilateral (PA) glides L5 vertebra suggest hypomobility and reproduction of symptom
Exclusion criteria 1) 2) 3) 4)
Surgically managed patients History of corticosteroid injection Low back pain with neurological deficits Loss of lumbar lordosis and presence of listing-suggestive of acute PIVD 5) Spondylolisthesis, spinal instability 6) Contraindications to manual therapy: Acute trauma, fracture and dislocation of vertebral body, Elderly patient above 55 years, Diabetes, Neurological disease, Metastatic bone disease, Pregnancy, Rheumatoid arthritis, etc .
Variables Independent Unilateral PA mobilization, Hot packs to lumbar region, Home exercise programme (lumbar mobility and stretching exercises).
Mobilization effects on sacralized lumbosacral transitional vertebrae
21
Dependent Pain intensity measurement by VAS, Forward bending and side bending ROM by modified finger to floor method with the help of an inch-tape, The Modified Oswestry Functional Disability Questionnaires to measure the functional level.
Procedure After fulfilling the inclusion and exclusion criteria, detailed clinical examination was performed. All subjects were asked to fill the consent form, and then subjects were randomly allocated to: GROUP A e 15 subjects e Home exercise programme þ Unilateral PA mobilization þ hot pack. GROUP B e 15 subjects e Home exercise programme þ hot pack. Before initiating treatment, subjects were assessed for dependent variables.
Unilateral PA mobilization Patient position: Prone lying with the arm by the side and head turned to one side. Therapist position: Stands on the side to be treated with thumb reinforced by other thumb over affected transverse process. Amplitude: End range mobilization with amplitude tolerable to patient. Frequency: 2 Hz. Repitition: 3 repetitions, each of 2 min duration. Home exercise programme for lumbar mobility and stretching exercises includes Prone Kneeling to child’s pose, McKenzie lumbar flexion in step standing e 1 min each for 3 repetitions. Total duration of treatment: 5 days per week for 2 weeks.
Data collection Measurements were taken prior to the beginning of treatment (Pre-test) and were repeated after completion of two weeks (Post-test).
Data analysis The dependent variables were analysed using 2 2 ANOVA with repeated measures of the second factor. There was one between factor (Group) with two levels (Experimental and control group) and one within factor (time) with two levels (pre, post). All pair wise post hoc comparisons were done using a 0.05 level of significance.
Results Side flexion range of motion non-sacralized side Fig. 1 illustrates that there was improvement in Side flexion range of motion on non sacralized side over time to a
Figure 1
Side flexion range of motion changes.
greater extent in experimental group patients than patients in control group. There was a main effect for Time F 1, 28, 0.05 Z 70.907, p Z 0.00; Group F 1, 28, 0.05 Z 0.001 p Z 0.973 and also Time Group interaction F 1, 28, 0.05 Z 43.455, p Z 0.00 (Table 1). Tukey’s HSD analysis shows that in experimental group there was significant improvement in Side flexion range of motion on non-sacralized side from pre to post and patients in experimental group showed significantly better improvement in side-flexion range of motion post intervention than control group (Table 2).
Flexion range of motion Fig. 2 illustrates that there was improvement in flexion range of motion over time in both the groups but to a greater extent in experimental group patients than patients in control group. There was a main effect for Time F 1, 28, 0.05 Z 115.828, p Z 0.00; Group F 1, 28, 0.05 Z 24.954, p Z 0.00 and also Time Group interaction F 1, 28, 0.05 Z 4.832, p Z 0.036 (Table 3). Tukey’s HSD analysis shows that in experimental group there was significant improvement in flexion range of motion from pre to post. The patients in control group also showed significant improvement from pre to post. However patients in experimental group showed significantly better improvement in flexion range of motion post intervention than control group (Table 4).
Pain Fig. 3 illustrates that there was reduction of pain over time to a greater extent in experimental group patients than patients in control group. There was a main effect for Time F 1, 28, 0.05 Z 241.747, p Z 0.00; Group F 1, 28, 0.05 Z 43.131, p Z 0.00 and also Time Group interaction F 1, 28, 0.05 Z 180.825, p Z 0.00 (Table 5). Tukey’s HSD analysis shows that in experimental group there was significant reduction in pain from pre to post and patients in experimental group showed significantly greater reduction in pain post intervention than control group (Table 6).
22
P. Angmo et al.
Table 1
ANOVA table for Side -Flexion non sacralized side.
Between subject effects Within subjects effect
Group Error Time Time group
Sum of sq
Df
Mean square
673.350 2484.583 1170.417 277.350
1 28 1 1
673.350 88.735 1170.417 277.350
Table 2 Tukey’s HSD Post Hoc Analysis for side flexion non-sacralized side.
Group Group Group Group
I pre I post II pre II post
Group I pre
Group I post
Group II pre
Group II post
0
9.5* 0
4.077 5.423* 0
5.234 4.266* 1.157 0
Table 4
Group Group Group Group
F
Significance 7.588
0.010
140.060 33.190
0.000 0.000
Tukey’s HSD Post Hoc analysis for flexion ROM.
I pre I post II pre II post
Group I pre
Group I post
Group II pre
Group II post
0
12.94* 0
1.26 14.2* 0
3.47* 9.47* 4.73* 0
*Indicate statistically significant difference among means.
*Indicate statistically significant difference among means.
Figure 3 Figure 2
Tukey’s HSD analysis shows that in experimental group there was significant improvement in functions as measured by Modified Oswestry low back pain disability score from pre to post. While experimental group showed significantly better improvement in Oswestry low back pain disability score post intervention than control group (Table 8).
Flexion range of motion.
Function Fig. 4 illustrates that there was improvement in Modified Oswestry low back pain disability score over time to a greater extent in experimental group patients than patients in control group. There was a main effect for Time F 1, 28, 0.05 Z 250.263, p Z 0.00; Group F 1, 28, 0.05 Z 15.135, p Z 0.00 and also Time Group interaction F 1, 28, 0.05 Z 183.825, p Z 0.00 (Table 7).
Table 3
Reduction of pain.
Discussion The overall results of the study suggest that mobilisation of unilateral transverse process in unilateral partially sacralized transverse process has significantly more beneficial effect in pain, range of motion and function over impairment based therapeutic exercise alone.
ANOVA table for flexion ROM.
Between subject effects Within subjects effect
Group Error Time Time group Error
Sum of sq
Df
Mean square
432.017 2503.467 1170.417 252.150 282.933
1 28 1 1 28
432.017 89.410 1170.417 252.150 10.105
F
Significance 4.832
0.036
115.828 24.954
0.000 0.000
Mobilization effects on sacralized lumbosacral transitional vertebrae Table 5
ANOVA table for Pain (Test of between and within subject effect).
Between subject effects Within subjects effect
Table 6
Group Group Group Group
Group Error Time Time group Error
Sum of sq
Df
Mean square
71.286 46.278 131.424 98.304 15.222
1 28 1 1 28
71.286 1.653 131.424 98.304 0.544
Table 8
Tukey’s HSD Post Hoc Analysis for pain.
I pre I post II pre II post
Group I pre
Group I post
Group II pre
Group II post
0
5.52* 0
0.38 5.14* 0
0.78* 4.74* 0.4 0
*Indicate statistically significant difference among means.
Figure 4
Modified Oswestry LBP disability score.
Range of motion (ROM) Results demonstrated that subjects of experimental group showed statistically significant improvement in non affected side lateral flexion range and flexion range measured by modified finger to floor method in comparison to control group patients. Mennell (1952) stated that when one side is sacralized, mobility of the transverse process on this side of the fifth vertebra is very limited and therefore the movement of the intervertebral joint, on this side is also very limited. Further the growth of the body on the sacralized side may be retarded. There is no such limitation on the non-
Table 7
23
Group Group Group Group
F
Significance
43.131
0.00
241.747 180.825
0.00 0.00
Tukey’s HSD Post Hoc Analysis for function.
I pre I post II pre II post
Group I pre
Group I post
Group II pre
Group II post
0
36.44* 0
3.426 39.866* 0
0.62 37.06* 2.806 0
*Indicate statistically significant difference among means.
sacralised side, the result is that lack of normal mobility on the one side, the other side being free to move, is a potential cause of hypermobility on the opposite or at least of lack of co-ordinated movement between the two sides. Also studies have shown that the lumbo-sacral junction is prone for hypomobility and degeneration due to the transitional stress produced by different orientation of L5-S1 facets. Experimental group showed significant improvement in non affected side lateral flexion range with 19.07% over control group showing 2.53% at the end of treatment, this significant difference can be attributed to the effects of mobilisation of the partially sacralized lumbo-sacral junction, which reduced pain and improved flexibility. Mechanical effects could involve a permanent or a temporary change in length of connective tissue structures such as joint capsule of the zygapophysial joints, ligaments and muscles. It seems unlikely that any observed changes in mobility associated with mobilization are due to permanent changes in the length of connective tissues. Threlkeld (1992) suggests that the forces used in mobilization are not great enough to result in micro failure of tissues and more likely to cause temporary length changes due to creep which is reversible over time. This is supported by the study done by Egwu (2008) on unilateral cervical spondylosis, they compared the relative efficacy of mobilization techniques, oscillatory pressure techniques of spinal mobilization therapy are known to have both neuro-physiological and mechanical effects.
ANOVA table for functions (Test of between and within subject effect).
Between subject effects Within subjects effect
Group Error Time Time group Error
Sum of sq
Df
Mean square
6128.63 11,338.1 5754.53 4226.83 643.835
1 28 1 1 28
6128.63 404.946 5754.53 4226.83 22.994
F
Significance
15.135
0.001
250.263 183.825
0.000 0.000
24 Paris pointed out that mobilization technique stretches tissues by taking them into the area of plastic deformation of stressestrain curve. The current finding indicate that oscillatory pressure techniques (PA unilateral pressure) stretches connective tissue and joint capsule to that point of stressestrain curve, which is ideal for stretching tissues to produce a salvo of beneficial neuro-inhibitory and mechanical effect. Unilateral spinal manual therapy can create relative movement between target and adjacent vertebrae in sagittal plane as well as axial rotation which was described by Gal et al. (1995). Biomechanical effect of spinal manual therapy were precisely studied, they investigated the absolute and relative movements between targets and adjacent vertebrae during clinical-type of spinal manual therapy to T11 in unembalmed post-rigor human cadavers, using embedded stainless steel bone pins and high speed cinematography. Significant relative movements between target and adjacent vertebrae occurred primarily in sagittal and axial rotation during the thrust phases of the spinal manual therapy. The relative positions of the vertebral bodies were compared at similar force levels, before and after the rapid thrust phases. The sagittal angles between T11 and T12 following the spinal manual therapy, were significantly different from their pre-thrust values. The goal of this work was to investigate the manner in which the vertebral column would deform under the influence of a clinically-relevant spinal manipulative thrust. Since the vertebral bodies are much stiffer than the structural elements connecting them, it was our impression that the latter would deform more readily. In our study we used the unilateral PA pressure over transverse process of partially sacralised L5 vertebra and assumed the similar response. Whereas both the groups showed significant improvement in flexion range of motion, however experimental group significantly improved with 57.10% over control showing 17.85%, this significant improvement in control group could be due to the effect of self stretching exercises. The effect of stretching in increasing range of motion has been explained by biomechanical and neurophysiological properties of muscle. When a passive stretch force is transmitted to muscle via connective tissue, the most material will be deformed in a time dependent position manner and it finally responds by aiding more sarcomeres as a result of viscoelastic properties of material and thus increasing the range of motion. Neural mechanism also contributes significantly in increasing the range of motion about a joint with stretching exercises (De Deyne, 2001).
P. Angmo et al. LSTV that may potentially be the source of pain: 1) disc degeneration, 2) disc prolapse, 3) spinal stenosis, 4) nerve root compression, 5) spondylolisthesis, 6) sacroiliac joint pain, 7) muscle, tendon, or ligament strain or sprain, 8) chemical irritation, 9) vertebral collapse, and 10) damage to other nearby structures receiving innervation (MacGibbon and Farfan, 1979; Abe et al., 1997; Vergauwen et al., 1997; Brault et al., 2001). Wright (1995) suggests that spinal manual therapy helps in pain reduction firstly by activation of joint mechanoreceptors thereby producing segmental inhibition of pain pathway at the spinal cord, secondly by activation of descending pain inhibitory system located at dorso-lateral PAG, thirdly by producing sympatho-excitation induced hypoalgesia and finally by the direct biomechanical effect of manual therapy resulting in increased mobility. George et al. (2006) proposed spinal cord pathway model suggesting a lessening of temporal summation following manual therapy mechanism mediated by dorsal horn of spinal cord. Wyke and Polacek (1975) have concluded that spinal manual therapy produces pain relief by activating the spinal component of gate control mechanism through stimulation of joint mechanoreceptors. Willett et al. (2010) demonstrated that there is no significant difference between the rates of PA mobilizations to L5 in producing mechanical hypoalgesia. However it has provided new experimental evidence that lumbar mobilisations on asymptomatic volunteers produce an immediate and significant improvement in PPT measures, which is both local and widespread. Brenner (2005) notes that spinal manipulation, along with impairment based therapeutic exercises, was considered an important intervention for the patient, as spinal manipulation in conjunction with an exercise program has been shown to be an effective intervention to increase range of motion in the lumbar spine. Improving the patient’s lumbar motion may help to decrease the patient’s pain during forward bending and when carrying heavy weight. It was determined that the patient responded well to the manipulation due to the immediate gains in total spinal motion, combined with decreased pain that was observed following the procedure. But, as indicated earlier, the LSM technique is not specific to a single segment; therefore, the outcomes can not necessarily be attributed to an increase of movement at the LTV segment itself.
Function Pain In our study all the patients with low back pain with partial unilateral sacralization had tenderness over either side or the affected side of the lumbo-sacral junction with or without radiating pain and reproduction of symptoms with unilateral posterioreanterior glides over the non-fused hypomobile type IA and type IIA transverse processes. Savage (2005) suggests that unilateral defects and the number of motion segments result in biomechanical complications that lead to LBP, prompting people to seek medical attention. There are many factors associated with
Results demonstrated that subjects of experimental group showed statistically significant improvement in function measured by Oswestry low back pain disability questionnaire in comparison to control group patients. Improvement and restoration of function is a primary aim for physiotherapy rehabilitation for patients with low back pain. The OSW is an LBP questionnaire consisting of 10 questions used to measure low back disability, stage a patient’s acuity status, and monitor change over time. The OSW has been shown to be an excellent measurement of outcome for LBP, with a minimal clinically important difference of approximately 6 points. Disability questionnaires
Mobilization effects on sacralized lumbosacral transitional vertebrae are key tools to determine the response to treatment as they provide information about a wide range of functional tasks viz. pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, travelling and employment, are directly related to patient’s pain. Normal pain free range of motion is essential for normal function, this holds true for any joint in the body and accordingly for the lumbar spine. The improvement in function as measured by Oswestry low back pain disability questionnaire can be attributed to the reduction of pain, improvement in range of motion and facilitation of muscle activation by spinal manual therapy and impairment based exercises. This is supported by a study on assessment of outcomes following surgical management of nerve root compression by McGregor and Hughes (2002) who demonstrated an association between reduction of pain (Measured by VAS) and improvements of function as measured by Oswestry low back pain questionnaire. Holm et al. (2003) did a reliability study on measuring self-reported functional status and pain in patients with chronic low back pain. They concluded that Oswestry Disability Index is highly reliable and it also strongly correlated with lumbar pain. This is consistent with our study in which patients showed significant improvement in function measured by Oswestry disability index and pain as compared with control group.
Conclusion The results of the study suggest that unilateral PA pressure is an effective mobilization method in reducing low back pain, improving ROM and related disability among patients as compared to impairment based exercises alone in patients with low back pain with or without radiation to lower limbs having abnormally large transverse processes and non-fused hypomobile type II A lumbo-sacral transitional vertebrae.
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De Deyne, Patrick G., 2001. Application of passive stretch and its implications for muscle fibers. Phys. Ther. 81 (2), 819e827. Egwu, Michael Ogbonnia, 2008. Relative therapeutic efficacy of some vertebral mobilization techniques in the management of unilateral cervical spondylosis: a comparative study. J. Phys. Ther. Sci. 20, 103e108. Gal, J.M., Herzog, W., Kawchuk, G.N., et al., 1995. Forces and relative vertebral movements during SMT to unembalmed postrigor human cadavers: peculiarities associated with joint cavitation. J. Manip. Physiol. Ther. 18 (1), 4e9. George, S.Z., Bishop, M.D., Bialosky, J.E., et al., 2006. Immediate effects of spinal manipulation on thermal pain sensitivity: an experimental study. BMC. Musculoskelet. Disord. 7, 68. Hahn, P.Y., Strobel, J.J., Hahn, F.J., 1992. Verification of lumbosacral segments on MR images: identification of transitional vertebrae. Radiology 182 (2), 580e581. Holm, I., Friis, A., Storheim, K., et al., 2003. Measuring selfreported functional status and pain in patients with chronic low back pain by postal questionnaires a reliability study. SPINE 28 (8), 828e833. Konin, G.P., Walz, D.M., 2010. Lumbosacral transitional vertebrae: classification, imaging findings, and clinical relevance. AJNR Am. J. Neuroradiol. 31 (10), 1778e1786. Luoma, K., Vehmas, T., Raininko, R., et al., 2004. Lumbosacral transitional vertebra. Relation to disc degeneration and low back pain. Spine 29 (2), 200e205. MacGibbon, B., Farfan, H.F., 1979. A radiologic survey of various configurations of the lumbar spine. Spine 4, 258e266. Maitland, G., Hengevel, E., Banks, K., et al., 2001. Maitland’s Vertebral Manipulation. Butterworth-Heinemann, Boston, MA. Marks, R.C., Thulbourne, T., 1991. Infiltration of anomalous lumbosacral articulations: steroid and anesthetic injections in 10 back pain patients. Acta Orthop. Scand. 62, 139e141. McGregor, A.H., Hughes, S.P., 2002. ;The evaluation of the surgical management of nerve root compression in patients with low back pain: Part 1: the assessment of outcome. Spine 27 (13), 1465e1470. Mennell, J., 1952. The Science and Art of Joint Manipulation. J. and A. Churchill LTD., London. Otani, K., Konno, S., Kikuchi, S., 2001. Lumbosacral transitional vertebrae and nerve-root symptoms. J. Bone Jt. Surg. (Br) 83B (8), 1137e1140. Santavirta, S., Tallroth, K., Ylinen, P., et al., 1993. Surgical treatment of Bertolotti’s syndrome. Follow up of 16 patients. Arch. Orthop. Trauma Surg. 112, 82e87. Savage, Chet, 2005. Lumbosacral Transitional Vertebrae: Classification of Variation and Association with Low Back Pain. A Thesis presented to the Faculty of the Graduate School University of Missouri-Columbia. Threlkeld, A.J., 1992. The effect of manual therapy on connective tissue. Phys. Ther. 72, 893e902. Tini, P.G., Wieser, C., Zinn, W.M., 1977. The transitional vertebra of the lumbosacral spine: its radiological classification, incidence, prevalence and clinical significance. Rheumatol. Rehabil. 16, 180e185. Vergauwen, S., Parizel, P., van Breusegem, L., et al., 1997. Distribution and incidence of degenerative spine changes in patients with a lumbo-sacral transitional vertebra. Eur. Spine J. 6, 168e172. Wigh, R.E., Anthony, H.F., 1981. Transitional lumbosacral discs. Probability of herniation. Spine 6 (2), 168e171. Willett, E., Herbron, C., Krouswel, O., 2010. The initial effects of different rates of lumbar mobilizations on pressure pain thresholds in asymptomatic subjects. Man. Ther. 15, 173e178. Wright, A., 1995. Hypoalgesia post-manipulative therapy: a review of a potential neurophysiological mechanism. Man. Ther. 1, 11e16. Wyke, B.D., Polacek, P., 1975. Articular neurology: present position. J. Jt. Bone Surg. 57B (3), 401.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
ORIGINAL RESEARCH
Effects of unilateral posteroanterior mobilization in subjects with sacralized lumbosacral transitional vertebrae Phuntsog Angmo, MPT, Dr P.P. Mohanty, Ph D, FIAP*, Monalisa Pattnaik, MPT Department of Physiotherapy, SVNIRTAR, Olatpur, P.O: Bairoi, Dist., Cuttack, PIN-754010, Odisha, India Received 21 September 2014; received in revised form 23 January 2015; accepted 31 January 2015
Summary Aim of the study: To find out the efficacy of unilateral posteroanterior (PA) mobilization over type IA and type IIA sacralized lumbosacral transitional vertebrae in patients with low back pain with or without leg pain. Research design: experimental randomized control study. Sample size: 30 subjects, Sampling: simple random sampling. GROUP A e 15 subjects e self lumbar mobility and stretching exercises þ Unilateral PA mobilization þ hot pack. GROUP B e 15 subjects e self lumbar mobility and stretching exercises þ hot pack. Before initiating treatment, subjects were assessed for dependent variables: Pain intensity by VAS, Forward bending and side bending ROM by modified finger to floor method with the help of an inch-tape and functions by Modified Oswestry Functional Disability Questionnaires. Post test measurements were taken after completion 2 weeks of therapy. The results of the study suggest that unilateral PA pressure is an effective mobilization method in reducing low back pain, improving ROM and related disability as compared to impairment based exercises alone in patients with low back pain with or without radiation to lower limbs having abnormally large transverse processes and hypomobile type IA and IIA lumbo-sacral transitional vertebrae. ª 2015 Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. E-mail address: [email protected] (P.P. Mohanty). http://dx.doi.org/10.1016/j.jbmt.2015.02.002 1360-8592/ª 2015 Elsevier Ltd. All rights reserved.
Back pain is a common complaint observed in our clinical practice and X-rays of the lumbar spine are often used to investigate this symptom. One of the most frequent congenital abnormalities detected on routine lumbosacral
20 X-rays is a lumbosacral transitional vertebra (LSTV). A lumbosacral transitional vertebra (LSTV) refers to a total or partial unilateral or bilateral fusion of the transverse process of the lowest lumbar vertebra to the sacrum. The anomalous vertebra is commonly referred to as a sacralized L5 or a lumbarized S1, on the basis of the number of nonerib bearing vertebrae shown by radiographs that include the thoracolumbar junction. Estimates on the prevalence of lumbar transitional vertebrae in the general population vary widely from 4% to 30% (Tini et al., 1977; Luoma et al., 2004; Otani et al., 2001; Hahn et al., 1992; Wigh and Anthony 1981; Chithriki et al., 2002). It was first observed by Bertolotti (1917). Although the relationship of low back pain and LSTV, termed “Bertolotti’s Syndrome,” is controversial and has been both supported and disputed (Konin and Walz, 2010). It has been hypothesized that motion between the transitional vertebra and the sacrum is reduced and asymmetrical. This asymmetry of motion can result in early degenerative changes within the neoarticulation or the normal contralateral facet, if present. Lumbar disc immediately above the transitional vertebrae were significantly more degenerative and those between the transitional vertebra and sacrum were significantly less degenerative compared with disc at other level (Aihara et al., 2000). The above processes are treated differently, requiring reliable techniques to not only identify LSTVs but also determine the type and site of the pathology generated by the lumbosacral transitional vertebrae, have been classically identified by using lateral and Ferguson radiographs. Castellvi et al. (1984), described a radiographic classification system identifying 4 types of LSTVs on the basis of morphologic characteristics: Type I: Dysplastic transverse process Unilateral (a) or bilateral (b) large triangular transverse process, at least 19 mm wide. Type II: Incomplete lumbarisation/sacralisation Enlarged transverse process with unilateral (a) or bilateral (b) Pseudoarthrosis with the adjacent sacral ala. Type III: Complete lumbarisation/sacralisation transverse process, with unilateral (a) or enlarged bilateral (b) complete fusion with the adjacent sacral ala. Type IV: Mixed Type IIa on one side and type IIIa on the other processes. While there is little consensus on the clinical significance of LSTV, even less is known about useful treatment strategies. Unfortunately, we did not come across any RCT; only scarce reports with small case series are available in the literature, describing specific treatment options in symptomatic LSTV. Surgical option (Santavirta et al., 1993), Steroid injection (Marks and Thulbourne, 1991) etc are various treatment intervention reported in the literature. Lumbosacral joint manipulation combine with the therapeutic exercises in the treatment of type IIA LSTV may be recommended (Brenner, 2005), but it is not known whether this method results in manipulation of the L4eL5, L5-S1, or the sacroiliac joints. According to Maitland et al. (2001) in most clinical cases it is wise to begin treatment with mobilizing techniques rather than manipulation and also there has been no research on the use of mobilization on patients with type IA and IIA LTV.
P. Angmo et al. So the purpose of this study is “To mobilize the hypomobile segment thereby improving movement and function by decreasing pain and stiffness, also preventing associated spinal pathologies”.
Aim of the study To find out the efficacy of unilateral PA mobilization over type IA and type IIA sacralized lumbosacral transitional vertebrae in patients with low back pain with or without leg pain.
Methodology Research design: experimental randomized control study. Sample size: 30 subjects. Sampling: simple random sampling.
Inclusion criteria 1) Age: 20e55 yrs. 2) Gender: Both Males and Females 3) Low back pain with or without radiating to unilateral lower extremity. 4) Radiological findings (Type IA and Type IIA Lumbosacral transitional vertebra of Castellvi’s classification on Ferguson projection (AP lumbar spine radiograph at 30 cranial tilt and lateral projection) 5) Restriction in forward bending and asymmetrical side bending i.e.; reduction of side-bending away from affected as compared to that towards the affected side 6) Quadrant test and passive end range in lumbar flexion with overpressure in standing reproduces symptom 7) Central and unilateral (PA) glides L5 vertebra suggest hypomobility and reproduction of symptom
Exclusion criteria 1) 2) 3) 4)
Surgically managed patients History of corticosteroid injection Low back pain with neurological deficits Loss of lumbar lordosis and presence of listing-suggestive of acute PIVD 5) Spondylolisthesis, spinal instability 6) Contraindications to manual therapy: Acute trauma, fracture and dislocation of vertebral body, Elderly patient above 55 years, Diabetes, Neurological disease, Metastatic bone disease, Pregnancy, Rheumatoid arthritis, etc .
Variables Independent Unilateral PA mobilization, Hot packs to lumbar region, Home exercise programme (lumbar mobility and stretching exercises).
Mobilization effects on sacralized lumbosacral transitional vertebrae
21
Dependent Pain intensity measurement by VAS, Forward bending and side bending ROM by modified finger to floor method with the help of an inch-tape, The Modified Oswestry Functional Disability Questionnaires to measure the functional level.
Procedure After fulfilling the inclusion and exclusion criteria, detailed clinical examination was performed. All subjects were asked to fill the consent form, and then subjects were randomly allocated to: GROUP A e 15 subjects e Home exercise programme þ Unilateral PA mobilization þ hot pack. GROUP B e 15 subjects e Home exercise programme þ hot pack. Before initiating treatment, subjects were assessed for dependent variables.
Unilateral PA mobilization Patient position: Prone lying with the arm by the side and head turned to one side. Therapist position: Stands on the side to be treated with thumb reinforced by other thumb over affected transverse process. Amplitude: End range mobilization with amplitude tolerable to patient. Frequency: 2 Hz. Repitition: 3 repetitions, each of 2 min duration. Home exercise programme for lumbar mobility and stretching exercises includes Prone Kneeling to child’s pose, McKenzie lumbar flexion in step standing e 1 min each for 3 repetitions. Total duration of treatment: 5 days per week for 2 weeks.
Data collection Measurements were taken prior to the beginning of treatment (Pre-test) and were repeated after completion of two weeks (Post-test).
Data analysis The dependent variables were analysed using 2 2 ANOVA with repeated measures of the second factor. There was one between factor (Group) with two levels (Experimental and control group) and one within factor (time) with two levels (pre, post). All pair wise post hoc comparisons were done using a 0.05 level of significance.
Results Side flexion range of motion non-sacralized side Fig. 1 illustrates that there was improvement in Side flexion range of motion on non sacralized side over time to a
Figure 1
Side flexion range of motion changes.
greater extent in experimental group patients than patients in control group. There was a main effect for Time F 1, 28, 0.05 Z 70.907, p Z 0.00; Group F 1, 28, 0.05 Z 0.001 p Z 0.973 and also Time Group interaction F 1, 28, 0.05 Z 43.455, p Z 0.00 (Table 1). Tukey’s HSD analysis shows that in experimental group there was significant improvement in Side flexion range of motion on non-sacralized side from pre to post and patients in experimental group showed significantly better improvement in side-flexion range of motion post intervention than control group (Table 2).
Flexion range of motion Fig. 2 illustrates that there was improvement in flexion range of motion over time in both the groups but to a greater extent in experimental group patients than patients in control group. There was a main effect for Time F 1, 28, 0.05 Z 115.828, p Z 0.00; Group F 1, 28, 0.05 Z 24.954, p Z 0.00 and also Time Group interaction F 1, 28, 0.05 Z 4.832, p Z 0.036 (Table 3). Tukey’s HSD analysis shows that in experimental group there was significant improvement in flexion range of motion from pre to post. The patients in control group also showed significant improvement from pre to post. However patients in experimental group showed significantly better improvement in flexion range of motion post intervention than control group (Table 4).
Pain Fig. 3 illustrates that there was reduction of pain over time to a greater extent in experimental group patients than patients in control group. There was a main effect for Time F 1, 28, 0.05 Z 241.747, p Z 0.00; Group F 1, 28, 0.05 Z 43.131, p Z 0.00 and also Time Group interaction F 1, 28, 0.05 Z 180.825, p Z 0.00 (Table 5). Tukey’s HSD analysis shows that in experimental group there was significant reduction in pain from pre to post and patients in experimental group showed significantly greater reduction in pain post intervention than control group (Table 6).
22
P. Angmo et al.
Table 1
ANOVA table for Side -Flexion non sacralized side.
Between subject effects Within subjects effect
Group Error Time Time group
Sum of sq
Df
Mean square
673.350 2484.583 1170.417 277.350
1 28 1 1
673.350 88.735 1170.417 277.350
Table 2 Tukey’s HSD Post Hoc Analysis for side flexion non-sacralized side.
Group Group Group Group
I pre I post II pre II post
Group I pre
Group I post
Group II pre
Group II post
0
9.5* 0
4.077 5.423* 0
5.234 4.266* 1.157 0
Table 4
Group Group Group Group
F
Significance 7.588
0.010
140.060 33.190
0.000 0.000
Tukey’s HSD Post Hoc analysis for flexion ROM.
I pre I post II pre II post
Group I pre
Group I post
Group II pre
Group II post
0
12.94* 0
1.26 14.2* 0
3.47* 9.47* 4.73* 0
*Indicate statistically significant difference among means.
*Indicate statistically significant difference among means.
Figure 3 Figure 2
Tukey’s HSD analysis shows that in experimental group there was significant improvement in functions as measured by Modified Oswestry low back pain disability score from pre to post. While experimental group showed significantly better improvement in Oswestry low back pain disability score post intervention than control group (Table 8).
Flexion range of motion.
Function Fig. 4 illustrates that there was improvement in Modified Oswestry low back pain disability score over time to a greater extent in experimental group patients than patients in control group. There was a main effect for Time F 1, 28, 0.05 Z 250.263, p Z 0.00; Group F 1, 28, 0.05 Z 15.135, p Z 0.00 and also Time Group interaction F 1, 28, 0.05 Z 183.825, p Z 0.00 (Table 7).
Table 3
Reduction of pain.
Discussion The overall results of the study suggest that mobilisation of unilateral transverse process in unilateral partially sacralized transverse process has significantly more beneficial effect in pain, range of motion and function over impairment based therapeutic exercise alone.
ANOVA table for flexion ROM.
Between subject effects Within subjects effect
Group Error Time Time group Error
Sum of sq
Df
Mean square
432.017 2503.467 1170.417 252.150 282.933
1 28 1 1 28
432.017 89.410 1170.417 252.150 10.105
F
Significance 4.832
0.036
115.828 24.954
0.000 0.000
Mobilization effects on sacralized lumbosacral transitional vertebrae Table 5
ANOVA table for Pain (Test of between and within subject effect).
Between subject effects Within subjects effect
Table 6
Group Group Group Group
Group Error Time Time group Error
Sum of sq
Df
Mean square
71.286 46.278 131.424 98.304 15.222
1 28 1 1 28
71.286 1.653 131.424 98.304 0.544
Table 8
Tukey’s HSD Post Hoc Analysis for pain.
I pre I post II pre II post
Group I pre
Group I post
Group II pre
Group II post
0
5.52* 0
0.38 5.14* 0
0.78* 4.74* 0.4 0
*Indicate statistically significant difference among means.
Figure 4
Modified Oswestry LBP disability score.
Range of motion (ROM) Results demonstrated that subjects of experimental group showed statistically significant improvement in non affected side lateral flexion range and flexion range measured by modified finger to floor method in comparison to control group patients. Mennell (1952) stated that when one side is sacralized, mobility of the transverse process on this side of the fifth vertebra is very limited and therefore the movement of the intervertebral joint, on this side is also very limited. Further the growth of the body on the sacralized side may be retarded. There is no such limitation on the non-
Table 7
23
Group Group Group Group
F
Significance
43.131
0.00
241.747 180.825
0.00 0.00
Tukey’s HSD Post Hoc Analysis for function.
I pre I post II pre II post
Group I pre
Group I post
Group II pre
Group II post
0
36.44* 0
3.426 39.866* 0
0.62 37.06* 2.806 0
*Indicate statistically significant difference among means.
sacralised side, the result is that lack of normal mobility on the one side, the other side being free to move, is a potential cause of hypermobility on the opposite or at least of lack of co-ordinated movement between the two sides. Also studies have shown that the lumbo-sacral junction is prone for hypomobility and degeneration due to the transitional stress produced by different orientation of L5-S1 facets. Experimental group showed significant improvement in non affected side lateral flexion range with 19.07% over control group showing 2.53% at the end of treatment, this significant difference can be attributed to the effects of mobilisation of the partially sacralized lumbo-sacral junction, which reduced pain and improved flexibility. Mechanical effects could involve a permanent or a temporary change in length of connective tissue structures such as joint capsule of the zygapophysial joints, ligaments and muscles. It seems unlikely that any observed changes in mobility associated with mobilization are due to permanent changes in the length of connective tissues. Threlkeld (1992) suggests that the forces used in mobilization are not great enough to result in micro failure of tissues and more likely to cause temporary length changes due to creep which is reversible over time. This is supported by the study done by Egwu (2008) on unilateral cervical spondylosis, they compared the relative efficacy of mobilization techniques, oscillatory pressure techniques of spinal mobilization therapy are known to have both neuro-physiological and mechanical effects.
ANOVA table for functions (Test of between and within subject effect).
Between subject effects Within subjects effect
Group Error Time Time group Error
Sum of sq
Df
Mean square
6128.63 11,338.1 5754.53 4226.83 643.835
1 28 1 1 28
6128.63 404.946 5754.53 4226.83 22.994
F
Significance
15.135
0.001
250.263 183.825
0.000 0.000
24 Paris pointed out that mobilization technique stretches tissues by taking them into the area of plastic deformation of stressestrain curve. The current finding indicate that oscillatory pressure techniques (PA unilateral pressure) stretches connective tissue and joint capsule to that point of stressestrain curve, which is ideal for stretching tissues to produce a salvo of beneficial neuro-inhibitory and mechanical effect. Unilateral spinal manual therapy can create relative movement between target and adjacent vertebrae in sagittal plane as well as axial rotation which was described by Gal et al. (1995). Biomechanical effect of spinal manual therapy were precisely studied, they investigated the absolute and relative movements between targets and adjacent vertebrae during clinical-type of spinal manual therapy to T11 in unembalmed post-rigor human cadavers, using embedded stainless steel bone pins and high speed cinematography. Significant relative movements between target and adjacent vertebrae occurred primarily in sagittal and axial rotation during the thrust phases of the spinal manual therapy. The relative positions of the vertebral bodies were compared at similar force levels, before and after the rapid thrust phases. The sagittal angles between T11 and T12 following the spinal manual therapy, were significantly different from their pre-thrust values. The goal of this work was to investigate the manner in which the vertebral column would deform under the influence of a clinically-relevant spinal manipulative thrust. Since the vertebral bodies are much stiffer than the structural elements connecting them, it was our impression that the latter would deform more readily. In our study we used the unilateral PA pressure over transverse process of partially sacralised L5 vertebra and assumed the similar response. Whereas both the groups showed significant improvement in flexion range of motion, however experimental group significantly improved with 57.10% over control showing 17.85%, this significant improvement in control group could be due to the effect of self stretching exercises. The effect of stretching in increasing range of motion has been explained by biomechanical and neurophysiological properties of muscle. When a passive stretch force is transmitted to muscle via connective tissue, the most material will be deformed in a time dependent position manner and it finally responds by aiding more sarcomeres as a result of viscoelastic properties of material and thus increasing the range of motion. Neural mechanism also contributes significantly in increasing the range of motion about a joint with stretching exercises (De Deyne, 2001).
P. Angmo et al. LSTV that may potentially be the source of pain: 1) disc degeneration, 2) disc prolapse, 3) spinal stenosis, 4) nerve root compression, 5) spondylolisthesis, 6) sacroiliac joint pain, 7) muscle, tendon, or ligament strain or sprain, 8) chemical irritation, 9) vertebral collapse, and 10) damage to other nearby structures receiving innervation (MacGibbon and Farfan, 1979; Abe et al., 1997; Vergauwen et al., 1997; Brault et al., 2001). Wright (1995) suggests that spinal manual therapy helps in pain reduction firstly by activation of joint mechanoreceptors thereby producing segmental inhibition of pain pathway at the spinal cord, secondly by activation of descending pain inhibitory system located at dorso-lateral PAG, thirdly by producing sympatho-excitation induced hypoalgesia and finally by the direct biomechanical effect of manual therapy resulting in increased mobility. George et al. (2006) proposed spinal cord pathway model suggesting a lessening of temporal summation following manual therapy mechanism mediated by dorsal horn of spinal cord. Wyke and Polacek (1975) have concluded that spinal manual therapy produces pain relief by activating the spinal component of gate control mechanism through stimulation of joint mechanoreceptors. Willett et al. (2010) demonstrated that there is no significant difference between the rates of PA mobilizations to L5 in producing mechanical hypoalgesia. However it has provided new experimental evidence that lumbar mobilisations on asymptomatic volunteers produce an immediate and significant improvement in PPT measures, which is both local and widespread. Brenner (2005) notes that spinal manipulation, along with impairment based therapeutic exercises, was considered an important intervention for the patient, as spinal manipulation in conjunction with an exercise program has been shown to be an effective intervention to increase range of motion in the lumbar spine. Improving the patient’s lumbar motion may help to decrease the patient’s pain during forward bending and when carrying heavy weight. It was determined that the patient responded well to the manipulation due to the immediate gains in total spinal motion, combined with decreased pain that was observed following the procedure. But, as indicated earlier, the LSM technique is not specific to a single segment; therefore, the outcomes can not necessarily be attributed to an increase of movement at the LTV segment itself.
Function Pain In our study all the patients with low back pain with partial unilateral sacralization had tenderness over either side or the affected side of the lumbo-sacral junction with or without radiating pain and reproduction of symptoms with unilateral posterioreanterior glides over the non-fused hypomobile type IA and type IIA transverse processes. Savage (2005) suggests that unilateral defects and the number of motion segments result in biomechanical complications that lead to LBP, prompting people to seek medical attention. There are many factors associated with
Results demonstrated that subjects of experimental group showed statistically significant improvement in function measured by Oswestry low back pain disability questionnaire in comparison to control group patients. Improvement and restoration of function is a primary aim for physiotherapy rehabilitation for patients with low back pain. The OSW is an LBP questionnaire consisting of 10 questions used to measure low back disability, stage a patient’s acuity status, and monitor change over time. The OSW has been shown to be an excellent measurement of outcome for LBP, with a minimal clinically important difference of approximately 6 points. Disability questionnaires
Mobilization effects on sacralized lumbosacral transitional vertebrae are key tools to determine the response to treatment as they provide information about a wide range of functional tasks viz. pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, travelling and employment, are directly related to patient’s pain. Normal pain free range of motion is essential for normal function, this holds true for any joint in the body and accordingly for the lumbar spine. The improvement in function as measured by Oswestry low back pain disability questionnaire can be attributed to the reduction of pain, improvement in range of motion and facilitation of muscle activation by spinal manual therapy and impairment based exercises. This is supported by a study on assessment of outcomes following surgical management of nerve root compression by McGregor and Hughes (2002) who demonstrated an association between reduction of pain (Measured by VAS) and improvements of function as measured by Oswestry low back pain questionnaire. Holm et al. (2003) did a reliability study on measuring self-reported functional status and pain in patients with chronic low back pain. They concluded that Oswestry Disability Index is highly reliable and it also strongly correlated with lumbar pain. This is consistent with our study in which patients showed significant improvement in function measured by Oswestry disability index and pain as compared with control group.
Conclusion The results of the study suggest that unilateral PA pressure is an effective mobilization method in reducing low back pain, improving ROM and related disability among patients as compared to impairment based exercises alone in patients with low back pain with or without radiation to lower limbs having abnormally large transverse processes and non-fused hypomobile type II A lumbo-sacral transitional vertebrae.
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