|Year : 2020 | Volume
| Issue : 1 | Page : 27-34
Comparative clinical effects of spinal manipulation, core stability exercise, and supervised exercise on pain intensity, segmental instability, and health-related quality of life among patients with chronic nonspecific low back pain: A randomized control trial
Kanchan Kumar Sarker1, Jasobanta Sethi2, Umasankar Mohanty3
1 Department of Physiotherapy, Lovely Professional University, Phagwara, Punjab, India
2 Amity Institute of Physiotherapy, Amity University Uttar Pradesh, Noida, UP, India
3 Department of Manual Therapy, Manual Therapy Foundation of India, Mangalore, Karnataka, India
|Date of Submission||20-Feb-2019|
|Date of Decision||04-Sep-2019|
|Date of Acceptance||07-Sep-2019|
|Date of Web Publication||11-Mar-2020|
Prof. (Dr.) Jasobanta Sethi
Director, Amity Institute of Physiotherapy, Amity University, Uttar Pradesh, Noida - 201 313, UP
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The purpose of this study was to investigate the comparative efficacy of spinal manipulative therapy-high-velocity low-amplitude (SMT-HVLA) thrust, core stability exercise (CSE), and supervised exercise on pain intensity (PI), segmental instability, and quality of life among patients with chronic nonspecific low back pain (CNSLBP). Materials and Methods: This was a randomized controlled trial conducted on 105 patients with CNSLBP (with duration of pain >3 months) distributed in three groups with 35 participants in each group, and an average age of the participants was 25.66 (standard deviation = 6.74) years. Participants received SMT-HVLA thrust (Group 1), CSE (Group 2), and supervised exercise (control group [CG]) with a common ergonomic advice (EA) for 2 weeks. The primary outcomes were PI measured by the Numeric Pain Rating Scale and segmental instability (postural sway) through the center of foot pressure measured by Win-Track platform. The secondary outcome was the quality of life measured by the EuroQoL questionnaire. All outcomes were assessed at baseline and 2 and 4 weeks. Two-way ANOVA followed by with post hoc Tukey's multiple comparison tests was carried out to examine treatment effects, and the relationship between the groups changes across outcome measures. Results: All participants completed the 2 weeks of intervention and the 4 weeks of follow-up. Group 1 had better outcomes than CG at 2 weeks (between-group difference in PI, P = 0.001; segmental instability, P = 0.001, and quality of life, P = 0.001) as compared to Group 2 and CG (between-group difference in PI, P = 0.03; segmental instability, P = 0.04; and quality of life, P = 0.05) as well as at 4 weeks (between-group difference in PI, P = 0.05; segmental instability, P = 0.03; and quality of life, P = 0.04). Conclusions: The SMT-HVLA thrust with EA providing pain reduction in patients with CNSLBP of high severity was associated with clinically better improvement in segmental instability (postural sway) and health-related quality of life. Thus, SMT may be an attractive option in such patients before proceeding for more invasive and costly treatments.
Keywords: Core stability exercise, high-velocity low-amplitude thrust, supervised exercise
|How to cite this article:|
Sarker KK, Sethi J, Mohanty U. Comparative clinical effects of spinal manipulation, core stability exercise, and supervised exercise on pain intensity, segmental instability, and health-related quality of life among patients with chronic nonspecific low back pain: A randomized control trial. J Nat Sc Biol Med 2020;11:27-34
|How to cite this URL:|
Sarker KK, Sethi J, Mohanty U. Comparative clinical effects of spinal manipulation, core stability exercise, and supervised exercise on pain intensity, segmental instability, and health-related quality of life among patients with chronic nonspecific low back pain: A randomized control trial. J Nat Sc Biol Med [serial online] 2020 [cited 2020 Nov 28];11:27-34. Available from: http://www.jnsbm.org/text.asp?2020/11/1/27/280120
| Introduction|| |
Chronic low back pain is a common health problem in many developed and developing countries. Individuals suffering from chronic low back pain experience major physical, social, mental, and occupational disruptions. It is not only one of the leading causes of pain but also of a costly burden on the health-care budget as chronic low back pain leads to a frequent demand for medical services. In the case of low back pain, epidemiological data give more information to assist in seeking and solving the various problems related to low back pain. Moreover, these data can prevent low back pain by avoiding or decreasing risk factors for individuals. The prevalence of low back pain has been inspected in some systematic reviews. According to the World Health Organization, Low back pain is most common between the ages of 25 -62 years, the incidence of LBP peaks between the ages 35 and 55. This is considered to replicate the work force and high prevalence in the ages between 30 to 50 is reported by Eurofound. Reported lifetime prevalence ranges widely, from 56% to 70%, and one year prevalence ranges from 15% to 45%, with point prevalence averaging 30%.
Low back pain is generally explicated as pain, muscle tension, or stiffness confined under the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica). Low back pain is predictably categorized as being “specific” or “nonspecific.” Specific low back pain makes mention of symptoms as an effect of a specific pathophysiologic mechanism, for example, herniated nucleus pulposus, infection, inflammation, osteoporosis, rheumatoid arthritis, fracture, or tumor. Approximately 10% of the patients might specific underlying conditions be diagnosed. The majority of patients (up to 90%) are categorized as having nonspecific low back pain, which is described as symptoms lack of clear particular reasons, i.e., beginning of low back pain is not known. Nonspecific low back pain (CNSLBP) is generally categorized according to duration as acute (<6 weeks), subacute (between 6 weeks and 12 weeks), or chronic (longer than 12 weeks).
According to the Punjabi concept, the spinal stabilization system depends on the three subsystems which are interdependent components with one capable of compensating for deficits in another. Low back pain can occur as a consequence of deficits in control of the spinal segment when abnormally large segmental motions cause compression or stretch on neural structures or sensitive structure. These deficits may potentially be caused by a dysfunction in any of the three systems which late a loss of joint stiffness, abnormal spinal motions, excessive neutral zone, and changes in the ration of segmental rotations and translation and increasing the segmental instability. Early attempts to define spinal instability were based on spinal pathology associated with excessive movement at the intervertebral or segmental level. Segmental instability was proposed to exist because of failure of the passive restraints (i.e., the intervertebral disc, ligaments, and facet joint capsules) that function to limit segment motion. This original, narrow concept of spinal instability was broadened when Panjabi hypothesized that the neuromuscular system might also play an important role in controlling segmental motion.
Pain is, therefore, not only a clinical sensory experience (duration, severity, and quality of pain) but is also something that adversely affects the individual's everyday life and health-related quality of life (HRQoL). Pain affects HRQoL, and HRQoL may affect the pain experience, expression, and behavior. A relatively small amount of nociception and physical pain can start a vicious circle of more pain, suffering, disability, and poorer HRQoL. In studies on the relationships between chronic pain and interference with daily life as well as HRQoL, different factors have been shown to be important. Some studies have reported interference with daily life and impaired HRQoL to be related to pain severity and the number of pain locations (spread).,, However, the relationship between HRQoL impairment and pain severity alone has been shown to be weak. Some authors have found pain severity to be insignificant as a predictor for life interference, HRQoL impairment, and disability.
Spinal manipulative therapy (SMT) includes all procedures of mobilizing or adjusting the spine by means of the hands. A manipulation usually implies a single thrust of high velocity performed at the end of a passive movement after the “slack” has been taken up and over small amplitude. It goes beyond the physiological limit but remains within the anatomical range. The precision of the movement and the control of the applied force are required. SMT is a valuable method in the treatment of mechanical spinal disorders to reduce pain and improve segmental instability. Although it has not been scientifically validated, some studies have shown a beneficial effect., The objective of Cyriax's spinal manipulative techniques is to alter the discodural or discoradicular interaction by moving a displaced cartilaginous fragment away from the sensitive dura mater and dural nerve sleeve and ruptured of ligamentous adhesion, reduced a bony subluxation. Spinal rotation manipulations apply torsion stress throughout a whole part of the spine, not only at just one level. With an intact posterior longitudinal ligament and annulus fibrosus, some of this torsion force exerts a centripetal force by suction on the protruding disc material. This effect is not confined to one level, and full reduction is not absolutely necessary for pain relief, in that when contact between dura and disc has ceased, the problem is frequently solved and improves the segmental instability and HRQoL.
Exercises for low back pain have developed more than the era of time with specific stress on the sustaining the spinal stability. These types of core stabilization exercises are aimed at improving the neuromuscular control, endurance, and strength of muscles central to sustaining dynamic segmental stability. Transversus abdominis (TrA), lumbar multifidi, and other paraspinal, abdominal, diaphragmatic, and pelvic musculature are targeted in core stabilization exercises. Different studies have reported delayed activation of TrA with respect to erector spinae with significant atrophy of multifidus in patients with chronic low back pain. The European guidelines for the management of CNSLBP recommend supervised exercise (SE) therapy as a first-line treatment. Different systematic reviews conducted in the past decade have raised a significant concern over the role of exercise in the management of low back pain, with the scarcity of concrete evidence supporting any specific type of exercise, for example, flexion/extension biased and strengthening of abdominals.
This article presents a pragmatic clinical study conducted on patients with nonspecific chronic low back pain. An objective of the study was to evaluate the comparative efficacy of SMT-high-velocity low-amplitude (HVLA) thrust, core stability exercise (CSE), and supervised exercise on pain intensity (PI), segmental instability, and quality of life among patients with chronic CNSLBP at 2 weeks of intervention and 4 weeks of follow-up using a pragmatic randomized controlled trial.
| Materials and Methods|| |
This randomized trial was conducted from August 2015 to January 2017 at the Outpatient Department (OPD), Department of Physiotherapy, Lovely Professional University (LPU), Chaheru, Phagwara, Punjab, India. Ethical approval has been granted by the Institutional Ethical Committee (No-LPU/IEC/PTY/004). The trial is registered in ClinicalTrials.gov. (NCT03016676).
One hundred and five participants have been recruited in this study according to inclusion criteria and distributed in three groups of 35 patients each; control group (CG: 18 males and 17 females), study group 1 (SG1: 16 males and 19 females), and study group 2 (SG2: 19 males and 16 females). Patients had the opportunity to participate in the trial if they suffered for >3 months with a history of chronic nonspecific low back pain, were aged between 18 and 60 years, and PI ≥3 on 0–10 Numeric Pain Rating Scale (NPRS). Participants were excluded if they have a baseline pain score of fewer than 3 points, pain referred from the lumbar to the lower extremities, serious spinal disorder, including malignancy, osteoporosis, ankylosing spondylitis, cauda equina compression and infection, previous spinal surgery, fracture of vertebrae, and administered epidural injection.
All patients met the inclusion/exclusion criteria and enrolled in the study. Patients who agreed to participate signed the consent document approved by the Institutional Ethical Committee. Sample size calculation was made taking into account a one-tailed hypothesis (patients in three groups were expected to improve), an allocation ratio between groups of 1:1:1, a large effect size (d = 0.8), an alpha value of 0.05, z value of 1.96 for a 95% confidence level, and margin of error 5%. Thirty-five patients per group were necessary to complete the study. Restricted randomization with a 1:1:1 allocation ratio has been applied using randomly block size. All participants fulfilled the remainder of the self-report and a physical examination. Each participant received general information about research (possible risks and benefits) and the ethical aspects related to it. The following self-report questionnaires were fulfilled by patients at the baseline examination: demographic data (age, height, and weight), numerical rating scale for PI, Win-Track platform (center of foot pressure [COFP]) for segmental instability, and EuroQoL questionnaire (EuroQoL questionnaire-5D-5L has 5 dimensions and 5 levels) for quality of life. For self-report measures, the patients have undergone a standardized historical and physical examination (manual palpation of the lumbar and sacral to assess local tenderness of segmental dysfunction/hypomobility) which was replicated following achievement of 2-week treatment.
The participants were assigned into three groups by consecutive convenient sampling, each group with 35 patients. All participants in the study received 2 weeks of treatment. The CG received SE with ergonomic advice (EA), whereas SG1 received SMT with EA, and SG2 received CSE with EA for 45 min per day for 2 weeks.
Three interventions were given with number of sessions, duration of each session, and common EA for all the groups. These groups have received specific intervention such as spinal manipulation, specific core exercise, and SE. The treatment was provided by three physiotherapists who have over 10 years of experience. First interventionist administered supervised exercise to control group (CG)whereas second interventionist performed spinal manipulation in study group-1(SG 1) and third interventionist performed core stability exercise in study group 2 (SG 2). In the three groups, all participants willingly came to physiotherapy OPD and underwent treatment, and data were collected. Common EA was provided to all the groups by one physiotherapist. The parameters were assessed in all the groups at 2 weeks of intervention and after 4 weeks of follow-up.
Control Group (supervised exercise and ergonomic advice)
The CG had received SE for 45 min/day for 2 weeks. Individualized sessions included advice and instruction on self-care measures, ergonomic recommendations for home and work, and a demonstration of good lifting techniques. Supervised exercise comprised of simple stretching of hamstring muscles and strengthening exercises including lumbar extension, bridging, and abdominal crunches were demonstrated and practised. The study participants were given a book and laminated cards describing these exercises and were encouraged to perform them at home on a daily basis. The patients were supervised in person for 2 weeks and then instructed to continue with the exercises for the remainder of the follow-up phase.
Study Group 1 (spinal manipulative therapy plus ergonomic advice)
The participants allocated to this group (SG1) have received SMT in addition to EA (as described above). They received two repetitions thrust in a session within 45 min per day for 2 weeks because, after the first attempt of manipulation, adjustment needs to take time for the second attempt at 20-min interval. Spinal manipulation was delivered after a systematic physical examination that included manual palpation of the lumbar and sacral areas to assess local tenderness areas of segmental dysfunction/hypomobility. Spinal manipulation technique for CNSLBP was generally performed on patients in a side-lying position on a treatment couch with the affected side upward. The therapist was to stand at the ventral aspect of the patient and hold the upper spinous process of the affected segment with the pulp of the thumb and the index fingers as well as hold the spinous process of the lower vertebra of the affected segment with pulp and index finger of the other hand. The therapist holds the arm of the patient and pulls it to create rotation and stops as soon as the movement was perceived at the affected facet joints then he applies spinal manipulation therapy-high velocity low amplitude [SMT-HVLA] thrust while applying the force to the upper vertebra toward the couch and the lower vertebra away from the couch. This thrust was often accompanied by an audible cracking or popping sound, which represents the creation and suspension of small gas bubbles within the joint cavity resulting from pressure and alters as the articular surfaces shortly split in response to the HVLA thrust.
Study Group 2 (core stability exercise plus ergonomic advice)
The patients received CSE in addition to EA. The protocol has been delivered for the duration of 45 min/day for 2 weeks to perform exercises emphasizing a high number of repetitions (2–3 sets of 15–30 repetitions for each exercise) and progressive increase in muscle load. For each exercise, the patients started at a level of difficulty that allowed them to complete a minimum of 15 repetitions at the session. They then progressed to the next level of difficulty when they were able to perform the maximum 30 numbers of repetitions. CSE s were a plank, oblique plank, and superman. Plank procedure was i) required a frontage sustain situation resting on subjects forearms with shoulders straight over subjects elbows, ii) set straight subject's legs out behind subjects and it was raised up hips to form a dead-straight line from shoulders to ankles. Subjects were balanced on forearms and toes, with lower abdomen and back working to keep the body straight. Holding was 1 minute and 15 to 30 repetitions. 2) Oblique Plank-i) patients positioned in side laying, balance on the right forearm with shoulder beyond the elbow, ii) with legs out directly to the left pelvis to have balance on forearm and feet. The patient's body was appearance a direct line and feels the oblique muscles down the side trunk working to maintain the position, (iii) hold times were 1 min and then replicate on another side, 15–30 repetitions. (3) Hanuman – (i) position of the patients was put the balance on the floor on hands and knees. The back was flat and hips parallel to the floor, ii) elevated right arm out in front of subjects and elevated left leg out iii) hold times was for one minute for 15 to 30 repetitions.
Pain intensity (Numeric Pain Rating Scale)
The NPRS is a line marked with the numbers 0–10 at equal intervals where 0 is “no pain” and 10 is “worst pain imaginable.” Patients circle the number that represents their current PI. There is evidence to support the validity and reliability of the NPRS in younger and older patients. Psychometric analyses suggested that the NPRS was the preferred PI scale. It had low error rates and higher face, convergent, divergent, and criterion validity than the other scales. Most importantly, its properties were not age-related. PI was measured before and after treatment.
Segmental instability (postural sway) measurement of the center of foot pressure
The capability to maintain balance in an upright standing posture was measured using a Win-Track platform (Win-Track, company – Medicapteurs, n0-12k0022, made in France), which measured the segmental instability (i.e., the movement of the COFP) in the anterior–posterior (X) and side-to-side (Y) directions. The participants stood (bipedal stance) quietly on a solid platform (i.e., directly on the force plate) for a period of 30 s with open eyes and bare feet. The first 30 s of data was recorded at a sample rate of 1200 Hz using monitor data acquisition software (Win-Track software)., For the eye-open testing, participants were instructed to fix their vision on a large red dot placed at eye level about four meters in front of the force platform. All stance positions were assessed among participants in bare feet with average COFP in g/cm2. Segmental instability (average COFP, g/cm2) was assessed among participants with feet at equal distance from the midline of the platform.
Health-related quality of life
HRQoL was measured by EuroQoL questionnaire (EQ-5D-5L) which was tested before and after 2 weeks of intervention and after 4 weeks of follow-up. It is a spacious established questionnaire for health-related QoL. The EQ-5D-5L has 25 questions comprising 5 dimensions and 5 levels. The EQ-5D-5L evocative system comprises the following 5 dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension has 5 levels: no problems – 1, slight problems – 2, moderate problems – 3, severe problems – 4, and extreme problems – 5. Scoring of EuroQoL questionnaire where the minimum score is 5 and the maximum score is 25, ranging minimum score of 5 to maximum score of 25.
All statistical analysis was performed using SPSS software in Windows version 16. Significance was set at P ≤ 0.05 for all analyses. Descriptive statistics were generated for continuous and categorical measures. A two-way ANOVA was performed followed by post hoc Tukey's multiple comparison tests (SPSS version 16.0) to determine differences in COFP scores, NPRS scores, and EuroQoL questionnaire scores between the groups, and Chi-square analysis was used to assess the baseline data for between-group.
| Results|| |
A total of 130 individuals were assessed for this study, of which 105 were selected for investigation. A summary of patient recruitment, participation, and attrition during the study is shown in [Figure 1]. Among the participants, 53 males and 52 females with a mean age of 26.70 years (CG = SEA), 24.30 years (SG1 = SM + EA), and 25.98 years (SG2 = CSE + EA) with an extensive period of symptoms of CNSLBP (mean duration of symptoms of pain >3 months). The demographic characteristics and outcomes were alike at baseline [Table 1].
|Table 1: Baseline measures of demographic with segmental instability, quality of life, and pain intensity variables|
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The study changeable followed a normal distribution (P< 0.05). The statistical analysis of data of comparisons of COFP score, numerical pain rating scale score, and EuroQoL questionnaire score for within the group and between groups is shown in [Table 2].
According to post hoc Tukey's comparison analysis within CG, SG1, and SG2 of baseline, after 2 weeks of intervention and after 4 weeks of follow-up, there was no statistically significant improvement for the variables such as segmental instability (postural sway), PI, and quality of life through COFP, NPRS, and EuroQoL questionnaire, respectively, but SG1 (spinal manipulation with EA) showed better improvement than other two groups (P = 0.001).
The patient-rated outcomes at all time points are shown in [Table 2]. The group differences in patients-rated outcomes at all time points with associated 95% confidence intervals are shown in [Table 3]. In CG, there was no statistical significance with effect size of small, whereas in SG1 most satisfied and statistical significance was seen with effect size of large, and in SG2 satisfied and statistical significance was seen with effect size of large but less than SG1 [Table 2].
|Table 3: Between-group differences at each time point for patient-rated outcomes|
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The groups receiving spinal manipulation or CSE improved better than the group receiving SE: at 2 weeks, the SG1 had better improvement (adjusted mean difference in pain: 4.16, 95% confidence interval [CI]: 2.22–3.11, P = 0.001; segmental instability: 200.44, 95% CI: 146.83–189.56, P = 0.001; and HRQOL: 11.77, 95% CI: 7.62–7.09, P = 0.001) and SG2 had also better improvement (adjusted mean difference in pain: 1.85, 95% CI: 0.55–1.45, P = 0.03; segmental instability: 108.74, 95% CI: 52.87–57.48, P = 0.04; and HRQOL: 4.72, 95% CI: 2.24–3.93, P = 0.05). There was a large difference between SG1 and SG2 (for pain: 2.31, 95% CI: 1.22–2.11, P = 0.01; segmental instability: 114.8, 95% CI: 54.72–78.04, P = 0.03; and HRQOL: 7.05, 95% CI: 6.17–7.28, P = 0.05). Treatment effects were greater changes being observed in the SG1 compared to SG2 at 4 weeks of follow-up.
| Discussion|| |
An increase in postural sway in participants with CNSLBP has been reported in the literature. In our study, the SMT with EA showed a greater improvement in segmental instability (decreased postural sway), PI (NPRS), and quality of life (EuroQoL questionnaire) at the end of 2 weeks of treatment and 4 weeks of follow-up compared to both the CSE with EA and SE with EA. There were slight differences between the CSEs plus EA and SE with EA group alone at all times. The SMT plus EA group has been rated their improvement higher than SE group both at the end of treatment. The two study groups have reported better improvement than CG.
This was the first trial to compare the efficacy of spinal manipulation in patients with CNSLBP, by means of objective (COFP–Win-Track platform) and subjective (NPRS and EuroQoL questionnaire) assessment tools. A limited earlier study has used the COFP as an outcome measure after SMT in CNSLBP.
There was high-class procedural evidence to sustain the use of spinal manipulation in the management of patients with CNSLBP. The intervention was also recommended by clinical practice guidelines for the management of low back pain and additional musculoskeletal disorders. In this study, both the study groups had better improvement of segmental instability (decreased postural sway) and reduction PI from baseline after treatment. Thus, these results contest that a biomechanical approach would clarify the reduction in segmental instability and PI that was practiced by participants. According to most systematic reviews and evidence-based clinical guidelines, both SMT plus EA and core stability are effective treatment options for CNSLBP. There is evidence to recommend, nevertheless, that the type, dose, and mode of delivery of both types of interventions can persuade the outcome. Regarding spinal manipulation, little is known about optimal dose, and to date, provider type (e.g., chiropractor, osteopath, or physical therapist) has not been related to any differential effect.
The quality of life of patients in Group 1 has been improved better than the other three groups. In our study, only 6.85% of patients reported no problems at all and as many as 93.3% of patients reported a moderate problem on at least one dimension of EQ-5D. This indicates that patients with nonspecific chronic low back pain have a lower quality of life as reported by Kersnik and Vodopivec-Jamsek 2001 and Antonopoulou et al. 2009 in their study.,
Postural sway (segmental instability) has been found in all the three groups of patients with CNSLBP. The segmental instability in the form of altered body inclination among young persons with CNSLBP too was reported by Brumagne et al. 2008 in their study. Spinal manipulation when applied to the spinal joints and surrounding musculature may alter afferent feedback to the central nervous system to increase proprioception, improve motor control, and improve postural sway. Individually applied, manual therapy techniques have been shown to alter short-term motor neuron activity, enhance performance in proprioception-dependent activities, increase the range of motion;, alter markers of autonomic nervous system activity, and facilitate an immediate increase in mean voluntary contraction of the paraspinal muscles. It has been hypothesized that through these mechanisms, spinal manipulation may influence postural sway.,
The reduction in segmental instability (postural sway) and PI detected in this study was more expected to be explaining by spinal, supraspinal, or still nonspecific mechanisms that can mediate pain, as recommended by a theoretical model progressed. This model advocates that a mechanical force from an SM begin a cascade of neurophysiological reply from both the peripheral and central nervous systems that would give upgrade explanation of clinical outcomes, such as postural away and PI increase in low back pain.
Only a limited number of interventions for CNSLBP have been assessed in clinical trials; as a result, there is no recognized “gold standard” treatment. We chose SE therapy an intervention because of the support of efficiency for adults with low back pain. Regarding supervised exercise therapy, regression analysis conducted to identify exercise characteristics that would most successfully decrease pain and progress function for CNSLBP. They classified exercise therapy according to program design (individual or standardized), delivery type (with or without supervision), and dose (high or low). SE therapy which focuses on individually designed and supervised programs of stretching and strengthening seems to be most effective. High-intensity regimens, whether low or high tech, accompanied by motivational strategies, seemed to further increase the effectiveness.
Limitations and strengths of this study
The study was limited to 105 patients of 18–60 years of age with 4 weeks of intervention. All prospective care was taken to make sure that the present study with a low risk of bias by including sufficient randomized trial, secret allotment, lacking perception of evaluators, the comparison at baseline, calculation of sample size and purpose-to-treat analysis. Lacking perception of the evaluators was established by the truth that the evaluators were unable to estimate which patient was devoted to EA. In differentiation, it was unobtainable to blind the clinician or the patients because of the nature of the interventions, which does not remove the risk of bias. Therefore, the lack of blinding of the clinicians or patients could be elucidating as a limitation of this study. There has been no achievable impact of long term follow-up as an additional limitation.
| Conclusions|| |
We observed that SMT has been effective on chronic nonspecific low back pain. Awareness of this low-cost therapeutic needs time to become popular among clinicians as well as clients.
We would like to thank the Department of Physiotherapy, LPU, fellow colleagues, and all participants for supporting this research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]