Intervertebral mobilization for aspecific back pain: effects on posture and pain

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Submission Date: 2019-12-05
Review Date: 2019-12-19
Pubblication Date: 2020-01-03
Printed on: Volume 2, Issue I



Low back pain pain can be defined, according to the most recent evidences, as a bio-psycho-social pathology, but in addition to the mechanical factors other elements that play an important role in the lumbar disability come into play.
In fact, during the acute phase pain has a nociceptive and mechanical origin, but over time the influence of psychological and social factors causes the maintenance and chronicization of the pathological process.
Mobilization and manipulation therapies are widely used by patients with chronic nonspecific spine pain; however, questions remain around the efficacy, dosing and safety of manual approaches, as well as how these approaches compare to other therapies.
The aim of our study project is to try to obtain a reduction in pain and disability by administering vertebral mobilizations with muscle energy techniques (MET) to subjects suffering from this disorder.
In the scientific literature there are already studies on the effects of muscle energy techniques on vertebral column mobility and pain. The results were often conflicting, whith some researches confirming the efficacy of the technique in the management of back pain and other researches confutating that.
However, the studies carried out are not very precise, both because of the difficulty of applying the technique which requires a thorough knowledge of the vertebral structures, and for the small sample of people who participated in the various projects carried out. Moreover, the major difficulty in the proposed approach appears to be represented by the subjectivity of the approach and the lack of unequivocal results in the literature.
The purpose of this study is to use an objective assessment of the postural alignement of the patient, in order to create an objective and repeatable treatment personalized for each patient by a standardized evaluation system.
Among the outcome measures, a non-invasive digital system was used for the three-dimensional reconstruction of the spine and the study of its postural alignement. A total of 20 subjects were evaluated before and after the whole protocol for parameters attesting the effect of the treatment on disability, mobility, posture and pain; during a cognitive interview, a personalized anamnestic medical record was compiled and the Oswestry Disability Index scale (ODI ) and the VAS visual analogue scale were administered.
Furthermore, the participating subjects were evaluated from the postural point of view and through the use of the 3D B.A.K. Body Analysis Kapture with 4 self calibrated cameras (Diasu Health Technologies, Rome, Italy), a computerized postural analysis that allows the 3D reconstruction of the spine, at the beginning and end of the cycle of therapies. At each session, the subjects were evaluated at the beginning and at the end with the Forward Bending Test and Side Bending Test.
From the results of 3D computerized postural analysis B.A.K. the data show that, at the end of the therapeutic protocol, patients reached a harmonious symmetry between the two hemisomes and increase the mobility of the spine. The VAS was, on the whole of the parameters examined, the index most influenced by the applied therapy, reporting a decrease of 70.9%; similar results were also found for the ODI scale score, -68.6%.
The results show that the MET can be effective at increasing the range of movement of the spine.
We can hypotize that the main explanation for these results can be the application of MET on specific areas of the spine starting from the concept of “greatest somatic dysfunction”.
The concomitant decrease in pain and increase of vertebral ROM is another key-point of the study; these results contributed to the improvement of the quality of life of patients who participated to the study. However, further scientific researches are needed for this technique to be validated and used more frequently for painful spinal diseases.


The most recent scientific literature shows that the majority of pain in the spine is not due to organic pathology, and therefore has been defined as “non-specific” or “mechanical”. Meanwhile, it is now clear and obvious that nonspecific spinal pain is responsible for a significant part of the direct costs of health care, visits to health workers, sick leave and the relative loss of productivity in our advanced society (Borghouts, J.A. et al. 1996; Cote, P. 1998).

Furthermore, most nonspecific spinal pains are not associated with major diseases or neurological signs of nerve compression, so their treatment can become more specific and precise (Maher, C. 2017). For some patients, nonspecific spine pain rarely, if at all, interferes with daily activities; for others, nonspecific spinal pain is a serious obstacle to daily functioning (Destefano, L.A. 2011). More than a third of those affected still have low grade symptoms or relapses more than a year after treatment, because it often becomes a chronic pain (Brison, R.J. et al. 2005).

The management of chronic non-specific spine pain can be treated in different ways, including analgesics, physiotherapy, educational modalities, exercise and manual therapy (Vincent, K. et al. 2013; Deyo, R.A. et al. 2014; Martin, B.I. et al. 2012; Cohen, S. 2017). The management of self-care and educational methods are usually the initial forms of treatment for chronic non-specific spinal pain. There is some evidence that educational videos are useful for patients with spinal pain related to whiplash. There is however little evidence that these types of modalities are more effective than other conservative therapies (Korthas-de Bos, I.B. et al. 2003; Peloso, P. et al. 2007).

Physiotherapy, physical exercise and manual therapies such as massages, chiropractic, occupational and osteopathic therapies, including spinal manipulation and mobilization, are used in isolation and in combination with other therapies to treat non-specific spinal pain. There are several systematic reviews about the efficacy of manual therapies, such as spinal manipulation and mobilization, in the treatment of spinal pain (Gross, A. et al. 2010).

Some of these reviews found that there is insufficient evidence o that spinal manipulative therapy is superior to other standard treatments for patients with chronic spinal pain. However, more recent systematic reviews about chronic spinal pain, as well as chronic low back pain, suggest that spinal manipulation and mobilization are “viable” options for pain treatment and disability reduction (Pasquier, M. et al. 2019;

Shekelle, P.G. 1997). Other studies have concluded that interventions commonly used by manual therapy professionals, such as chiropractic care, improve outcomes in the treatment of chronic neck pain (Shekelle, P.G. 1992). The greatest increase in benefits has been suggested for multimodal approaches, in which multiple approaches are used to treat chronic spinal pain (Furlan, A.D. et al. 2012).

The long-term benefit of manual therapy is not well defined in literature. A systematic review of manipulative therapies selected for neck and low back pain by Furlan et al (Furlan, A.D. et al. 2012), comparing manipulative therapies with other active treatments (eg. Other manipulative therapies, physiotherapy, painkillers, usual care), found that for “manipulation and intervertebral mobilization” the effectiveness varies depending on the duration of the symptoms, the result, the comparator, if there are exercises or general medical treatments and follow-up period. Although this variability can be considered an inconsistent finding, the overall evidence suggests that manipulation and intervertebral mobilization are an effective treatment modality with respect to other therapies “(Bryans, R. et al. 2014).

Different works suggested that there is little or no evidence that spinal manipulative therapy was superior to other standard treatments for chronic low back pain (Schroeder, J. et al. 2013; Bronfort, G. et al. 2004); however, recent studies suggest that spinal manipulation and mobilization are “viable” options for pain treatment (Bronfort, G. et al. 2004; Carragee, E.J. et al. 2008).

The efficacy of manipulation and mobilization may vary depending on the duration of symptoms, how the intervention is administered (eg, whether there is additional exercise or general practitioner care, at what dosages, and follow-up periods), the comparator, and types of outcomes reported. Such variability could be considered inconsistent findings; however, the overall evidence suggests that manipulation and mobilization are effective treatment modalities compared with other therapies (Shekelle, PG. et al. 1995; Gross, A. et al. 2015).

The results of this therapeutic proposal on the effects of intervertebral manipulation on spinal pain seem to be consistent with older and more recent revisions (Schenk, R.J. 2011). It therefore appears that the application of these techniques is linked to the knowledge and awareness of the health worker (physiotherapist, osteopath), of spinal anatomy and of the degree of dysfunction.

The proposal of this study is to start from an objective evaluation of the patient through computerized biometric measurements for the three-dimensional reconstruction of the spine and to highlight the real biomechanical dysfunction of the subject and operate in the most correct way through spinal mobilization with muscle energy techniques (MET).

Muscle Energy Technique (MET) is one of the manual therapies that has been used to treat chronic spinal pain. MET is a specific and safe technique used in clinical practice and manual therapy, particularly by physiotherapists and osteopaths. It is commonly used to treat hypertonic muscles and improve joint mobility.

The MET technique includes:

  1. Localization of the articular / muscular barrier by the operator (controlled joint positioning);
  2. Active muscle contraction of the patient in a specific direction for a specified time;
  3. Distinct counterforce applied by the operator against the patient’s contraction;
  4. Relaxation of the patient;
  5. The operator restores the “new” barrier (passive stretching of the muscle or increase in joint movement in a specific direction);
  6. Repeat the procedure several times (Fryer, G. 2010).

Research has shown that MET can increase muscle flexibility, (Schenk 1994) and the range of spinal movement (Coulter,I.D. et al. 2018). It is believed that the technique acts through a complex interaction of neurophysiological mechanisms that have an effect on the extensibility and tolerance of tissues due to the modulation of the stretch reflex and pain (Sharman, M.J. 2006).

Figure 1. Descriptive statistics (mean, standard deviation, and range) for subjects.
Figure 2. Recostruction 3D of spine with 3D B.A.K

Materials and Methods

20 patients were selected, 12 women and 8 males, with an average age of 41±7 years. Inclusion criteria included pain in the spine lasting no more than 12 weeks at the time of the exam, an age range of 18 to 70 years, an initial ODI score of 10% to 40% and a medical indication for manipulative treatment (MET). (Figure 1) The final inclusion criterion was a restriction of flexion and lateral flexion as assessed by clinical examination. Exclusion criteria included the presence of scoliosis or severe spinal deformities, pain from radiotherapy, paraesthesia in the gluteus muscles or lower extremities, muscle weakness, absent or diminished muscle reflexes, spondylolisthesis, chronic pain present for more than 12 weeks and surgical procedures previous spinal column. Subjects who presented infectious or degenerative diseases of the CNS, genetic or congenital alterations or malformations were excluded. Furthermore, we excluded from the research protocol patients with painful symptoms and parestial radiated to the limbs (lumbosciatalgia and cervicobrachialgia). Thus, patients who met all inclusion and exclusion criteria after medical and physiotherapic assessment were recruited on a voluntary basis to participate in the study. Complete information on risks and benefits was provided to patients and the signature of the informed consent of each individual was obtained prior to inclusion in the study.

The research carried out consisted of several phases:

  1. Compilation of a personal anamnestic card and postural analysis by the therapist;
  2. Compilation of the ODI-I 2.0 questionnaire (T0) and VAS scale before the beginning of the tratrment protocol (T0);
  3. Computerized Postural Analysis with Body Analysis System-Kapture-B.A.K. 3D – before the beginning of the treatment protocol (T0) (Contemporary acquisition with 1,2 or 4 high-resolution cameras of the structural morphology in frontal and sagittal projections and 3D reconstruction of the body and column; Diasu Health Technologies, Rome, Italy) (Figure 2);
  4. Forward Bending Test and Side Bending Test before and after each session of treatment;
  5. Computerized postural analysis with 3D BAK system at the end of the treatment cycle (T1)
  6. Compilation of the ODI-I 2.0 questionnaire and VAS scale at the end of the treatment cycle (T1)

The study was conducted in accordance with the Helsinki Declaration. Before the study, the subjects were informed of the research, including its potential risks and benefits. Written consents have been obtained from all the participants. Data collection was performed at the Physioterapy, Rehabilitation and Reeducation Center (CiFiRR) located at the “Gabriele d’Annunzio” University of Chieti-Pescara. All participants were asked to abstain from alcohol, caffeine and ergogenic aids the day before the tests. No preparation time was provided for the participants. The three-dimensional Digital Biometry Images Scanning system (3d BAK-Diasu-Technologies-Rome-Italy) was used for postural biometric analysis. We positioned 42 marker on the skin of the patient on the reper point in frontal anterior plan, frontal posterior plane and sagittal left and right.

On the frontal anterior plane the markers are positioned on (Figure 3):

  • Center of the forehead
  • Right and left zygomatic bone
  • Right and left mental foramen
  • Acromion clavicular left and right
  • Center of the sternum
  • SIAS left and right
  • Right and left ulnar styloid process
  • Patellar center right and left
  • Internal malleolus right and left
  • Left and right big toe
  • On the posterior frontal plane we have the following markers (Figure 4):
  • Spinous processes of C7-D4-D7-D12-L5
  • Lower corner of the right and left shoulder blade
  • SIPS right and left
  • Sacred bone
  • Right and left popliteal cable
  • Achilles tendon center right and left
  • Center calcagno left and right
  • Finally, on the sagittal plane, we will find (Figure 5):
  • Right and left antitragus
  • Right and left jaw angle
  • External malleolus right and left
  • V Metatarsal right and left

All participants had the modular electronic biometric test for the three-dimensional assessment of the spine and posture for the evaluation of the balance of the body and of the vertebrae in dysfunction, with the aim of directing the treatment towards the most critical areas of the spinal column. All other assessments were important for the therapeutic choice, and for the type of muscular energy to be applied to the spine.

Figure 3. Positioning of marker in frontal anterior plane.
Figure 4. Positioning of marker in frontal posterior plane.
Figure 5. Positioning of marker in right sagittal plane.


Statistical analysis was performed using NCSS 11 Data Analysis and Graphics Statistical Software. Data collection was performed using Microsoft Excel software, dedicated to the production and management of electronic spreadsheets. It was possible to organize numeric data in spreadsheets or workbooks, reformat them and analyze them automatically. The histogram shows a significant improvement in the Oswestry Disability Index score. We are witnessing a -67.96% change in the ODI-I score between T0 and T1. (Figure 6a, 6b) The graph in the figure shows that there was a significant decrease between T0 and T1.of the Oswestry Disability Index score(supported by the fact of having obtained a ɑ less than 0.005 in the T-Test used for thecheck of averages for each pair of variables). The histogram relative to the VAS Scale shows a significant improvement in its score between T0 and T1, confirming the effectiveness of the Technique examined, with a decrease of -75.43%. (Figure 7a, 7b) The graph in the figure shows that between T0 and T1 there was a statistically significant decrease in the VAS Scale score. The graphical analysis of the variation of the value of the Forward Bending Test shows how there was an increase in the ROM in the general average of the patients examined, demonstrating, as also supported by other scientific studies mentioned above, the effectiveness of the use of Muscle Energy Technique for increasing the ROM of the spine. The Hand-to-Land Index of the Forward Bending Test has changed significantly, -63.34%. (Figure 8a, 8b) The graph in the figure shows that there was a significant decrease between T0 and T1 of the score of the Forward Bending Test. The variation of the Side Bending Test referring to the right and left sides. The aim was to recreate a balance and harmony in the movement of the spine, symmetrizing the lateral inclination of the subjects under examination, initially asymmetric in all patients. The result was satisfactory, leading to a decrease of -11.86% in the right side and -12.54% in the left side. (Figure 9a, 9b) The graph in the figure shows that there was a significant decrease between T0 and T1 of the score of the Right Side Bending Test and Left Side Bending Test. (Figure 10,11) Shoulder symmetry was evaluated with the B.A.K. The values are evaluated through the scale of the biomechanical postural index (0 = physiological / 3 = severe) analyzed by single “element” or whole view, are expressed in degrees. Once again, we have a significant decrease in asymmetry in the bisacromial line. (Figure 12 a,12b) The graph in the figure shows that between T0 and T1 there was a statistically significant decrease in the Symmetry of Shoulders score with 3D B.A.K. analysis. From the 3D B.A.K Postural Analysis Report, the Degrees values of Cobb and Cifosi were also evaluated with the ultimate aim of verifying an improvement in these values following the application of Muscle Energy Techniques. The graph in the figure shows that between T0 and T1 there was a statistically significant decrease in the Cobb Angle score with 3D B.A.K. system The result was satisfactory: also from the graph it is possible to note a decrease in the degrees of kyphosis and of the Cobb angle in the subjects who were subjected to the treatment. (Figure 11a, 11b) The graph in the figure demonstrates that between T0 and T1 there was a statistically significant decrease in the score of the Degrees of Cifosi with 3D B.A.K. system. The graphical and statistical analysis of the results obtained provides an indication of how bilateral and targeted muscular energy techniques act on the individual’s posture, as demonstrated by the results of the 3dB.A.K system. Female subjects were more influenced, with an average increase in anterior spine flexion of 10.75 cm. In the lateral flexion test on both sides, we obtained satisfactory results: the goal was to obtain a symmetrical movement, restore the normal physiology of the vertebral movement and create harmony between the two hemisomes. The application of the muscular energy technique in a symmetrical and specific way has been the cornerstone to achieve this result. The results indicated that the MET was effective in increasing the range of spine movements. The key to effectiveness, according to Kimberly, is that both the patient and the MET work simultaneously by controlling the forces generated. MET can be useful for correcting defective joint positions and ipomobile junctions by restoring the original relationship. In a study published by Schenk, Adelman and Rousselles, a MET was administered to 18 asymptomatic volunteers, to determine how the MET could significantly increase ROM. The VAS was, on the whole of the parameters examined, the value most influenced by the applied therapy, followed by the Oswestry disability index. The strength of our study was the bet on the effectiveness of the application of the therapy on the pain of the patient, as well as on the disability that the latter involved. All patients undergoing the study showed a marked improvement in the performance of daily activities, confirming the return to total autonomy and the possibility of performing any activity in total absence of pain, previously constantly present. The line chart is designed for the pace of values over time. At each session, the patient was subjected both to the Forward Bending Test both before and after the treatment. The graph shows a progressively positive pace. In the first 4 sessions, in almost all patients, the value of the Forward Bending Test pre-treatment was increased compared to the value of the Test at previous sessions. This trend found a balance in the 5th and 6th sessions, where the test values were more stable. (Figure 10) The trend observed in the Forward Bending Test reflects that found in the Side Bending Test. This mainly depends on the effect of the continuity of the repetition of the muscular energy techniques, performed biweekly for three consecutive weeks. In the first sessions we see a sharp increase in values following the therapy and with the progress of the sessions, the result has gradually stabilized. (Figure 11) The trend observed in the Forward Bending Test reflects that seen in the Side Bending Test. Depends mainly on the effect of the continuity of the repetition of the techniques ad muscle energy, performed biweekly for three consecutive weeks.

Figure 6a. Outcome information of group (mean and SD) for ODI – Oswestry Disability index scores histogram for the ODI-I Scale score, comparing T0 and T1.
Figure 6b. Box Plot ODI.
Figure 7a. Outcome information of group (mean and SD) for VAS – Visual Analogue Scale score histogram for the VAS Scale score, comparing T0 and T1.
Figure 7b. Box Plot VAS
Figure 8a. Outcome information of group (mean and SD) for Forward Bending Test, histogram for the Forward Bending Test score, comparing T0 and T1.
Figure 8b. Box Plot Forward Bending Test.
Figure 9a. Outcome information of group (mean and SD) for Side Bending Test left and right, histogram comparing T0 and T1.
Figure 9b,c. Box plot Side Bending Test Left and Right.
Figure 10. Value line chart for each treatment of the Forward Bending Test.
Figure 11. Value line chart for each treatment of the Right and Left Side Bending Test.


Various physical treatments are often used instead of, or in addition to, medications to treat spine pain. Evidence from controlled trials suggests that several noninvasive physical treatments may help prevent chronic/recurrent spine pain. Spinal manipulation may be effective for pain and chronic spine pain.(Brison, R.J. et al. 2005)

Both spinal manipulation and spine exercises may be effective for spine pain. Weaker evidence suggests that other treatments may also be effective: pulsating electromagnetic fields and transcutaneous electrical nerve stimulation (TENS) for pain, and therapeutic touch, cranial and sacrum, TENS, and a combination of self‐massage/TENS/stretching for tension‐type spine pain. Although none of these treatments has conclusive evidence for effectiveness, all appear to be associated with little risk of serious adverse effects.The main finding of this study was that the MET group demonstrated a decrease (4.3 mm ± 1.5 mm) in the worst pain of the VAS in the last 24 hours. (Martin, B.I. et al. 2012) The smallest decrease in the worst pain in the last 24 hours may be due to a decrease in neurophysiological pain, thus reducing the level of pain perceived by the patient. We hypothesized that, during interaction with the patient, manual contact with him may have caused pain reduction through the neurophysiological mechanisms of the applied movement.The best results were obtained at the vertebral level thanks to the improvement of the Cobb angle in all patients, followed by the dorsal kyphosis.

We believe that these results have been influenced by the Muscle Energy techniques applied in the right areas of the column, thanks to the operator’s manual skills and thanks to the initial three-dimensional digital evaluation of the column, since the latter acted directly on the altered vertebral biomechanics, which was identified thanks to a careful initial postural analysis. Identified the cardinal dysfunction in the various tracts of the rachis (cervical, dorsal and lumbar), the manipulations that have subsequently been performed, have exploited the energy of the deep musculature of the spine in way to correct the altered biomechanics and brought back to the physiological condition. However, we have achieved the most satisfactory results in terms of the increase of the spine ROM in its entirety, with a significant increase especially in the Forward Bending Test.

Different studies indicated the short-term effects of the MET as decreased pain, increased ROM, decreased muscle tension and spasm, not excluding the possibility of applying the MET, when possible, several times during the day (Lenehan, K.L. 2006; Moore, S.D. et al. 2011).

Subjects randomized to the MET group received treatment as described by Greenman in the upright sitting position or in the side reclined position (Greenman, P.E. 1996). Large patients were treated in an sitting position so that gravity could be used as an assisted activation force while other patients were treated in the lateral reclined position on the table on the side opposite the lateral flexion dysfunction. The application of the technique provided that the patient’s trunk had been positioned in some available lumbar ROMs, depending on the dysfunction, (first evaluated with the 3d BAK system and then manually by the physiotherapist) until the barrier was reached. Dysfunctional barriers such as the elastic barrier meet before reaching the physiological barrier and show distinctive qualities of restriction due to the increase in basic muscle tone (neuromuscular barrier) which has a constant elastic resistance. Note that the subjects most affected by the therapy are aged between 23 and 47; this shows how the examined technique is able to significantly improve subjects at a young age. Those of a more advanced age have benefited from concrete and visible results, as demonstrated by the recovery of the vertebral ROM, by the reduction of pain and disability in the performance of activities of daily life, but not with the complete remission of painful symptoms. This can be explained by the physiological alteration of the musculoskeletal biomechanics that occurs with the progression of biological age.

The advantage of choosing a MET over other treatments is that, being a low-force isometric contraction in a position without pain, this technique can be achieved without causing pain or damage to the patient. The improvement after second treatment sessions was noted in pain, ROM, and disability in the group, and immediate effect was seen only on pain intensity after first treatment session. This study concluded that, along with the digitalised assessment of posture and the manual and instrumental identification of the dysfunctional area to be treated, the MET are effective for reducing pain intensity and functional disability of the spine, as well as for increasing the range of movements of the lomabre and cervix in patients with non-specific pain also due to trigger points.

Future research should use a larger sample size that includes different age groups, include advanced variables to analyze the effects of the technique, extend the duration of the study and follow-up and address the duration of pain relief associated with the group of control and its contributing factors. Muscle pain is the largest category of unrecognized and untreated chronic medical problems in clinical practice and is among the most overlooked causes of chronic pain and disability.

This study found benefits from MET and three-dimensional postural and spine assessment (3D B.A.K. System) to improve overall disability and function in non-specific spine pain. The results of this study could help determine the most effective treatment for mechanical spinal pain associated with myofascial dysfunction caused by trigger points.

Figure 12a. Outcome information of group (mean and SD) for shoulder simmetry, histogram comparing T0 and T1.
Figure 12b. Box-plot for Shoulder Simmetry.
Figure 13a. Outcome information of group (mean and SD) for Cobb angle, histogram comparing T0 and T1.
Figure 13b. Box-plot for Cobb Angle.


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