Effect of Joint Mobilization and Neuromuscular Facilitation on a Patient With Chronic Low Back Pain and a Lumbar Transitional Vertebra
A 30-year old women was presented to the outpatient department for the treatment of numbness and the sharp pain in her right leg. The intensity of the pain and numbness was severe enough to interfere with her work and daily activities. The initial symptoms were developed about 18 months ago, but those were mild, and thus never affected her daily activities. She was a working woman for about the past eight years of her life and her job required her to be in a standing position for at least 6-8 hours a day. Though she was a married woman, she had not given a birth to any child till the day of her hospital visit. She weighed almost 75 kgs and never complained of having any heart ailment, diabetes related signs or any other chronic diseases.
The most likely diagnosis of this presentation is
Low back pain
Low back pain (LBP) is one of the most common conditions affecting almost 60–90% of the population at least once in their lifetime.1 It is characterized by severe pain and/or stiffness, altered muscles and muscle activity around the lumbar spine that persists for more than 12 weeks.2 Low back pain lasting for less than 12 weeks is categorized as an acute low back pain.3 The Repetitive force applied to the spine can lead to the weakening of the muscles around the spine thereby affecting the movement.1 Chronic low back pain negatively affects the range of motion, trunk muscle strength, endurance, and flexibility, thereby affecting day-to-day living and social activities and the quality of life.4 Although CLBP may affect anyone, irrespective of age, race and gender, it is closely associated with some occupational risk factors like carrying heavy weights, continues standing or sitting for long hours, desk jobs, etc., that causes imbalance of posture and muscles. Therefore, it is also considered as an occupational disorder.3,4
The patient was examined for the spinal movement (which involved the measurement of spinal curvature, flexion, and extension) severity of pain, and thickness of the multifidus. A visual analogue scale (VAS) and the Oswestry disability index (ODI) was used to identify the severity of pain. Imaging studies (computed tomography) were performed to measure the thickness of the multifidus.
The treatment plan for this patient included joint mobilization which was scheduled for about 40-minute session, thrice a week, for a month. Kaltenborn-Evjenth orthopedic manual therapy (KEOMT) and proprioceptive neuromuscular facilitation (PNF) techniques were opted for joint mobilization. KEOMT consisted lumbar segmental traction while the PNF exercise consisted shoulder flexion, abduction, and external rotation in a supine position, and slow reversal of the antagonist. After the complete treatment, the angle of spinal curvature in the thoracic vertebra and overall range of motion was found to be significantly increased (flexion - from 13° to 20°, and extension - from 2° to 4°). The angle of spinal curvature was improved from 12° to 20° in the lumbar vertebra and the range of motion of the flexion and extension was increased to 46°, and 8°, respectively. The VAS score was reduced from 8.5 to 2 indicating reduced severity of the pain and the ODI percentage score was reduced from 44.00 to 23.22. The thickness of the multifidus measured at the fourth lumbar vertebra increased from 570.10 to 666.10 mm2 (left), and 479.84 to 530.90 mm2 (right).
Ample of rest, home remedies like heat or cold treatment, massage, physiotherapy, sonography, electrical simulation, traction, joint mobilization, manipulation and physical therapy can be considered as a treatment approach for CLBP. Physical therapy (exercise) is found have a significant role in speedy recovery and also in preventing recurrence. Therefore, it is considered as a mainstream therapy for CLBP.4
Various types of exercise treatments are recommended for CLBP, but Williams flexion exercise and Mckenzie expansion exercise are considered to have a significant effect on painful symptoms.1 The most effective treatment for CLBP remains elusive but joint mobilization is believed to improve symptoms, including pain, muscle strength, alignment and motion. To be specific, KEOMT (traction or gliding on one-side) has shown to improve range of motion and intensity of the pain. The PNF technique helps to improve the symptoms like lumbar back pain, range of motion, the thicknesses of the multifidus and muscular strength.2
According to the evidences, joint mobilization has a positive effect on spinal motion, whereas PNF reduced the pain, and improved muscle muscular endurance and activity in CLBP and a lumbar transitional vertebra.2 Another study has also highlighted the role of PNF in improving muscle activity, flexibility, and stability. According to a comparative study, PNF and a trunk exercise program improved the symptoms of CLBP including balance and stability, but the PNF had a significant effect than the trunk exercise approach.4
Assessments after the treatment showed the increased angle of spinal curvature, and improved range of motion. This is suggestive of positive effects of joint mobilization using KEOMT and PNF.
Byoung-Hwan, Hong-Hyun Kim, Cheol-Yong Kim, et al. Comparison of physical function according to the lumbar movement method of stabilizing a patient with chronic low back pain. J Phys Ther Sci. 2015 Dec; 27(12): 3655–3658.
Si-Eun Park, and Joong-San Wang. Effect of joint mobilization using KEOMT and PNF on a patient with CLBP and a lumbar transitional vertebra: a case study. J Phys Ther Sci. 2015 May; 27(5): 1629–1632.
Violante FS, Mattioli S, Bonfiglioli R. Low-back pain. Handb Clin Neurol. 2015;131:397-410.
Kim Jin Young, Choi Won Je, Seo Tae Hwa, Effect of proprioceptive neuromuscular facilitation integration pattern and swiss ball training on pain and balance in elderly patients with chronic back pain. J Phys Ther Sci. 2015 Oct; 27(10): 3237–3240.