Restricted accessResearch articleFirst published online 2021-11
The immediate effect of sustained natural apophyseal glide on postural stability and pain in individuals presenting with flexion-dominant chronic low back pain: A randomized single-blinded placebo-controlled trial
Low back pain (LBP) is a common musculoskeletal problem, which commonly affects balance. Sustained natural apophyseal glide (SNAG) is a successful treatment approach for LPB. However, its influence on balance problems has not been studied before.
OBJECTIVE:
To investigate the immediate effect of SNAG on postural stability and pain in individuals with flexion-dominant chronic low back pain (FCLBP).
METHODS:
Randomized placebo-controlled trial in which 64 participants with FCLBP were randomly allocated into two groups (SNAG and sham). SNAG group ( 32) received central lumbar SNAG on the symptomatic lumbar level(s). Sham group ( 32) received sham SNAG. The outcome measures were postural stability indices; overall stability index (OSI), anteroposterior stability index (APSI), and mediolateral stability index (MLSI) in addition to pain intensity. Outcomes were assessed using the Biodex Balance System and visual analog scale respectively. Measures were taken before and immediately after interventions.
RESULTS:
There were statistical significance and high effect size (ES) in favor of the SNAG group regarding OSI, APSI, and pain ( 0.01, cohen’s ES 1.3, 1.4, 1.1 respectively). MLSI showed moderate ES (cohen’s 0.7) but did not reach a statistically significant level ( 0.05).
CONCLUSION:
Lumbar SNAG produces an immediate improvement in postural stability and pain in individuals with FCLBP.
UritsIBurshteinASharmaMTestaLGoldPAOrhurhuV, et al. Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. Current Pain and Headache Reports.2019; 23(3): 23.
2.
ClarkSHortonR. Low back pain: a major global challenge. Lancet (London, England).2018; 391(10137): 2302.
3.
HidalgoBDetrembleurCHallTMahaudensPNielensH. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. Journal of Manual & Manipulative Therapy.2014; 22(2): 59-74.
4.
O’SullivanP. Classification of lumbopelvic pain disorders–why is it essential for management? Manual Therapy.2006; 11(3): 169-70.
5.
SheeranLSparkesVWhatlingGBiggsPHoltC. Identifying non-specific low back pain clinical subgroups from sitting and standing repositioning posture tasks using a novel Cardiff Dempster–Shafer Theory Classifier. Clinical Biomechanics.2019; 70: 237-44.
6.
EtemadiYSalavatiMArabAMGhanavatiT. Balance recovery reactions in individuals with recurrent nonspecific low back pain: effect of attention. Gait & Posture.2016; 44: 123-7.
7.
MientjesMFrankJ. Balance in chronic low back pain patients compared to healthy people under various conditions in upright standing. Clinical Biomechanics.1999; 14(10): 710-6.
8.
RosaNQueirozBZLopesRASampaioNRPereiraDSPereiraLS. Risk of falls in Brazilian elders with and without low back pain assessed using the Physiological Profile Assessment: BACE study. Brazilian Journal of Physical Therapy.2016; 20(6): 502-9.
9.
KiersHvan DieënJHBrumagneSVanheesL. Postural sway and integration of proprioceptive signals in subjects with LBP. Human Movement Science.2015; 39: 109-20.
10.
LeveilleSGJonesRNKielyDKHausdorffJMShmerlingRHGuralnikJM, et al. Chronic musculoskeletal pain and the occurrence of falls in an older population. Jama.2009; 302(20): 2214-21.
11.
TongMHMousaviSJKiersHFerreiraPRefshaugeKvan DieënJ. Is there a relationship between lumbar proprioception and low back pain? A systematic review with meta-analysis. Archives of Physical Medicine and Rehabilitation.2017; 98(1): 120-36. e2.
12.
TaklaMK. Alterations of static and dynamic balance in patients with lumbar radiculopathy. Bulletin of Faculty of Physical Therapy.2019; 24(1): 49-55.
13.
HidalgoBPitanceLHallTDetrembleurCNielensH. Short-term effects of Mulligan mobilization with movement on pain, disability, and kinematic spinal movements in patients with nonspecific low back pain: a randomized placebo-controlled trial. J Manipulative Physiol Ther.2015; 38(6): 365-74.
14.
KonstantinouKFosterNRushtonABaxterD. The use and reported effects of mobilization with movement techniques in low back pain management; a cross-sectional descriptive survey of physiotherapists in Britain. Man Ther.2002; 7(4): 206-14.
15.
HeggannavarAKaleA. Immediate effect of modified lumbar SNAG in non-specific chronic patients: a pilot study. Int J Physiother Res. 2015; 3(3): 1018-23.
HingWHallTRivettDAVicenzinoBMulliganB. The mulligan concept of manual therapy: textbook of techniques: Elsevier Health Sciences, 2015.
18.
KonstantinouKFosterNRushtonABaxterDWrightCBreenA. Flexion mobilizations with movement techniques: the immediate effects on range of movement and pain in subjects with low back pain. J Manipulative Physiol Ther.2007; 30(3): 178-85.
19.
VicenzinoBPaungmaliATeysP. Mulligan’s mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature. Manual Therapy.2007; 12(2): 98-108.
20.
MoutzouriMPerryJBillisE. Investigation of the effects of a centrally applied lumbar sustained natural apophyseal glide mobilization on lower limb sympathetic nervous system activity in asymptomatic subjects. J Manipulative Physiol Ther.2012; 35(4): 286-94.
21.
HussienHMAbdel-RaoofNAKattabeiOMAhmedHH. Effect of mulligan concept lumbar SNAG on chronic nonspecific low back pain. Journal of Chiropractic Medicine.2017; 16(2): 94-102.
22.
SchulzKFAltmanDGMoherDGroupC. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Trials.2010; 11(1): 1-8.
23.
DelgadoDALambertBSBoutrisNMcCullochPCRobbinsABMorenoMR, et al. Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. Journal of the American Academy of Orthopaedic Surgeons Global Research & Reviews.2018; 2(3): 1-6.
24.
MoutzouriMBillisEStrimpakosNKottikaPOldhamJA. The effects of the Mulligan Sustained Natural Apophyseal Glide (SNAG) mobilisation in the lumbar flexion range of asymptomatic subjects as measured by the Zebris CMS20 3-D motion analysis system. BMC Musculoskeletal Disorders.2008; 9(1): 1-9.
25.
FreemanMDRossignolAM. A critical evaluation of the methodology of a low-back pain clinical trial. J Manipulative Physiol Ther.2000; 23(5): 363-4.
26.
HawkerGAMianSKendzerskaTFrenchM. Measures of adult pain: Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short-form mcgill pain questionnaire (sf-mpq), chronic pain grade scale (cpgs), short form-36 bodily pain scale (sf-36 bps), and measure of intermittent and constant osteoarthritis pain (icoap). Arthritis Care & Research.2011; 63(S11): S240-S52.
27.
Ferreira-ValenteMAPais-RibeiroJLJensenMP. Validity of four pain intensity rating scales. Pain?2011; 152(10): 2399-404.
28.
DawsonNDzurinoDKarleskintMTuckerJ. Examining the reliability, correlation, and validity of commonly used assessment tools to measure balance. Health Science Reports.2018; 1(12): e98.
29.
SchmitzRArnoldB. Intertester and intratester reliability of a dynamic balance protocol using the Biodex Stability System. Journal of Sport Rehabilitation.1998; 7(2): 95-101.
30.
KarimiNEbrahimiIKahriziSTorkamanG. Evaluation of postural balance using the biodex balance system in subjects with and without low back pain. Pakistan Journal of Medical Sciences.2008; 24(3): 372-7.
31.
DurlakJA. How to select, calculate, and interpret effect sizes. Journal of Pediatric Psychology.2009; 34(9): 917-28.
32.
JavaherianMTajaliSBMoghaddamBAKeshtkarAAAziziM. Immediate Effects of Maitland Mobilization and Mulligan Techniques on Flexion and Extension Range of Motion in Patients With Chronic Nonspecific Low Back Pain: A Randomized Pilot Study. Journal of Modern Rehabilitation.2017; 127-32.
33.
ZampinoCFicacciRCheccacciMFrancioliniFCatacuzzenoL. Pain control by proprioceptive and exteroceptive stimulation at the trigeminal level. Frontiers in Physiology.2018; 9: 1037.
