Optimization of Spinal Manipulative Therapy Protocols: A Factorial Randomized Trial Within a Multiphase Optimization...

Area of Science:

• Orthopedics
• Physical Therapy
• Rehabilitation Medicine

Background:

• Spinal manipulative therapy (SMT) is a common nonpharmacological treatment for low back pain (LBP).
• Clinical trials often show small effect sizes for SMT, necessitating protocol optimization.
• Understanding the mechanisms and components of SMT is crucial for improving its efficacy.

Purpose of the Study:

• To optimize a multicomponent spinal manipulative therapy (SMT) protocol for low back pain (LBP) using a Multiphase Optimization Strategy.
• To identify which components of SMT delivery, including exercises and additional SMT, most effectively improve patient outcomes.
• To evaluate both clinical and mechanistic outcomes to understand the effects of different SMT protocol variations.

Main Methods:

• A single-blind, fully factorial randomized trial design was employed with 241 participants experiencing LBP.
• Participants received initial SMT sessions, followed by randomization to receive combinations of multifidus activating exercise, spinal mobilizing exercise, and additional SMT.
• Outcomes including the Oswestry Disability Index, pain intensity, spinal stiffness, and multifidus muscle activation were assessed over 12 weeks.

Main Results:

• Inclusion of multifidus activating exercise in the SMT protocol significantly improved the Oswestry Disability Index at 12 weeks (mean difference: -3.62, P = .01).
• No other treatment components or their interactions showed significant effects on the primary or secondary outcome measures.
• The optimized SMT protocol consisted of SMT sessions combined with multifidus activating exercises.

Conclusions:

• The optimized SMT protocol for LBP involves combining SMT with lumbar multifidus strengthening exercises.
• Multifidus activating exercises are a key component for enhancing patient-centered outcomes in SMT protocols for LBP.
• Further research into optimizing nonpharmacological treatments is essential for managing complex conditions like LBP.