Active Visceral Manipulation Associated With Conventional Physiotherapy in People With Chronic Low Back Pain and Visceral Dysfunction: A Preliminary, Randomized, Controlled, Double-Blind Clinical Trial

Abstract

Objective: The purpose of this study was to generate data for conduction of a power analysis to investigate short-term effects of visceral manipulation associated with conventional physical therapy on pain intensity, lumbar mobility, and functionality of people with chronic low back pain and visceral dysfunctions.

Methods: This was a double-blinded, randomized, controlled, clinical trial preliminary study. A blinded evaluation was conducted involving 20 people with chronic low back pain with visceral dysfunction. Pain perception, lumbar mobility, and functionality were assessed in 3 moments: evaluation 1 (1 week before the intervention), evaluation 2 (immediately after the last intervention), and evaluation 3 (1 week after the last intervention). The protocol consisted of 50-minute session of conventional physical therapy and visceral manipulation. The participants were randomly allocated to 2 groups: 10 for the experimental group (conventional physical therapy and visceral manipulation) and 10 for the control group (conventional physical therapy and placebo visceral manipulation).

Results: Significant reductions were found in the experimental group for lumbar mobility and specific functionality in comparison with the control group (P < .05). There were no significant differences for pain perception and global functionality.

Conclusion: The combination of visceral manipulation and conventional physical therapy program demonstrated significant between-groups differences over time for lumbar spine mobility and specific functionality. These gains occurred after 5 sessions, once a week, and were maintained 1 week after the end of the treatment. This study generated data for conduction of a power analysis to inform the design for future clinical research in this line of inquiry.

Keywords: Exercise Therapy; Low Back Pain; Manipulation, Chiropractic; Manipulation, Osteopathic; Physical Therapy Modalities; Rehabilitation; Therapy, Soft Tissue.

Fig 1

Study flow diagram according to Consolidated Standards of Reporting Trials flow diagram 2017.

Fig 2

Conventional physical therapy protocol. (A) Erector spinae stretching: in dorsal decubitus pull the knee toward the abdomen—2 sets of 30 seconds. (B) Knee rolls: roll the knees to one side and the other maintaining both shoulders on the floor—2 sets of 10 seconds per side. (C) Piriformis stretch: in dorsal decubitus cross one ankle over the opposite knee and pull this leg toward the abdomen—2 sets of 30 seconds per side. (D) Pelvic tilts: perform pelvic anteversion and retroversion—10 to 15 repetitions. (E1) Back extensions: in ventral decubitus, extend the back supporting the upper body on flewed elbows—10 to 15 repetitions. (E2) Back extensions progression: the same position but supporting the upper body on the hands with the elbows extended. (F1) Activation of abdominal muscles, in dorsal decubitus perform isometric contraction of the profound abdominal muscles during breathing—3 sets of 10 breathings. (F2) Activation of abdominal muscles progression 1: the same exercise but lifting a flexed knee in the air and maintaining it steady during the set—2 sets of 10 breathings per side. (F3) Activation of abdominal muscles progression 2: the same exercise but lifting an extended knee in the air and maintaining it steady during the set—2 sets of 10 breathings per side. (G1) Activation of back and hip muscles: in side lying, perform isometric contraction of unilateral back and hip muscles during breathing—3 sets of 10 breathings. (G2) Activation of back and hip muscles progression 1: the same exercise but lifting a flexed knee and maintaining the ankle together and the leg steady during the set—2 sets of 10 breathings per side. (G3) Activation of back and hip muscles progression 2: the same exercise but lifting an extended knee and maintaining it steady during the set—2 sets of 10 breathings per side. (H1) Bridge exercise—3 sets of 10 repetitions. (H2) Bridge progression: perform a single leg bridge exercise—3 sets of 10 repetitions per side. (I1,2) Quadruped cat and camel exercise—10 to 15 repetitions. (J1) Single arm or leg raise: in quadruped position raise all limbs (arms and legs) one at a time and maintain the position—1 set of 30 seconds for each limb. (J2) Quadruped opposite arm and leg raise exercise progression—2 sets of 30 seconds per side. (J3) Exercise progression from J2. (K1) Plank: perform the plank exercise supporting the lower body on the knees—2 sets of 30 to 60 seconds. (K2) Plank progression: perform the plank exercise supporting the lower body on the feet—2 sets of 30 to 60 seconds. (L1) Side plank: perform the side plank exercise supporting the lower body on the knees—2 sets of 30 to 60 seconds. (L2) Side plank progression: perform the side plank exercise supporting the lower body on the feet—2 sets of 30 to 60 seconds.

Fig 3

Visceral manipulation protocol. Orientation of the pictures, cranial to the left and caudal to the right. (A) Cardia manipulation (1 minute). (B) Pylorus manipulation (1 minute). (C) Oddi sphincter manipulation (1 minute). (D) Duodenojejunal valve manipulation (1 minute). (E) Ileocecal valve manipulation (1 minute). (F) Sigmoid colon manipulation (1 minute). (G) Liver global manipulation (10 repetitions). (H) Global hemodynamic manipulation (10 repetitions with pressure during expiration and another 10 for inspiration).