Skip to main content
SpringerLink
Log in

Comparison of two manual therapy approaches combined with exercise on pain, strength and electromyographic muscle activity in athletes with subacute mechanical low back pain

  • Original Article
  • Published:
Sport Sciences for Health Aims and scope Submit manuscript

Abstract

Background

Subacute mechanical low back pain (MLBP) has been found to increase significantly in athletes in the past decade. Manual therapy combined with exercises seems to be promising option; however, its potential effect in athletes is not fully known yet.

Aim

The study aimed to compare between the effects of mulligan sustained natural apophyseal glides (SNAG) combined with exercise, muscle energy technique (MET) combined with exercise therapy and exercise therapy alone on pain, strength and muscle activity in athletes with subacute mechanical low back pain (MLBP).

Methods

The athletes were screened for inclusion into the study using physical examination and Oswestry Disability Index (ODI). The study was a randomized 3 arm repeated measure design and a total of thirty athletes completed the study (n = 30). Athletes in group 1 received mulligan sustained natural apophyseal glides (SNAG) combined with exercise, group 2 received muscle energy technique (MET) combined with exercise while those in group 3 were submitted to exercise only. Athletes in all groups received treatment 3 times a week for 4 weeks. The outcome measures were visual analog scale (VAS) scores, back extensor strength and electromyographic (s EMG) muscle activity of longissimus lumborum (LL) and transversus abdominis (Tr A).

Results

The VAS score were decreased in all three groups (p < 0.05); however, group 2 and group 1 were more effective than group 3 (p < 0.05). The back extensor strength increased in two groups (p < 0.05): group 2 showed a significant increase compared to group 1. The s EMG muscle activity of LL and Tr A increased in two groups (p < 0.05): group 2 showed a significant increase compared to group 1. There were significant time, group and interaction effects for the three outcome measures (p < 0.05).

Conclusion

The addition of MET combined with exercise therapy reduces pain level, improves back extensor strength and muscle activity of LL and TrA in athletes suffering with subacute MLBP more than mulligan SNAG combined with exercise therapy and exercise therapy alone.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig 1

Similar content being viewed by others

References

  1. Trompeter K, Fett D, Platen P (2017) Prevalence of back pain in sports: a systematic review of the literature. Sports Med 47(6):1183–1207. https://doi.org/10.1007/s40279-016-0645-3

    Article  PubMed  Google Scholar 

  2. Bono CM (2004) Low-back pain in athletes. J Bone Joint Surg Am 86(2):382–396. https://doi.org/10.2106/00004623-200402000-00027

    Article  PubMed  Google Scholar 

  3. Greene HS, Cholewicki J, Galloway MT, Nguyen CV, Radebold A (2001) A history of low back injury is a risk factor for recurrent back injuries in varsity athletes. Am J Sports Med 29(6):795–800. https://doi.org/10.1177/03635465010290062001

    Article  CAS  PubMed  Google Scholar 

  4. Tall RL, DeVault W (1993) Spinal injury in sport: epidemiologic considerations. Clin Sports Med 12(3):441–448

    Article  CAS  PubMed  Google Scholar 

  5. Qaseem A, Wilt TJ, McLean RM, Forciea MA (2017) Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 166(7):514–530. https://doi.org/10.7326/M16-2367

    Article  PubMed  Google Scholar 

  6. Walker BF, Williamson OD (2009) Mechanical or inflammatory low back pain. What are the potential signs and symptoms? Man Ther 14(3):314–320. https://doi.org/10.1016/j.math.2008.04.003

    Article  PubMed  Google Scholar 

  7. Petering RC, Webb C (2011) Treatment options for low back pain in athletes. Sports Health 3(6):550–555. https://doi.org/10.1177/1941738111416446

    Article  PubMed  PubMed Central  Google Scholar 

  8. Nadler, S. F., Malanga, G. A., Bartoli, L. A., Feinberg, J. H., Prybicien, M., & DePrince, M. (2002). Hip muscle imbalance and low back pain in athletes: influence of core strengthening. Med Sci Sports Exerc 34(1):9–16. doi: https://doi.org/10.1097/00005768-200201000-00003.

  9. Pitcher MJ, Behm DG, MacKinnon SN (2007) Neuromuscular fatigue during a modified Biering-Sørensen test in subjects with and without low back pain. J Sports Sci Med 6(4):549–559

    PubMed  PubMed Central  Google Scholar 

  10. Storheim K, Holm I, Gunderson R, Brox JI, Bø K (2003) The effect of comprehensive group training on cross-sectional area, density, and strength of paraspinal muscles in patients sick-listed for subacute low back pain. J Spinal Disord Tech 16(3):271–279. https://doi.org/10.1097/00024720-200306000-00008

    Article  PubMed  Google Scholar 

  11. Babatunde OO, Jordan JL, Van der Windt DA, Hill JC, Foster NE, Protheroe J (2017) Effective treatment options for musculoskeletal pain in primary care: a systematic overview of current evidence. PLoS ONE 12(6):e0178621. https://doi.org/10.1371/journal.pone.0178621

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Shipton EA (2018) Physical therapy approaches in the treatment of low back pain. Pain Ther 7(2):127–137. https://doi.org/10.1007/s40122-018-0105-x

    Article  PubMed  PubMed Central  Google Scholar 

  13. Bishop MD, Torres-Cueco R, Gay CW, Lluch-Girbés E, Beneciuk JM, Bialosky JE (2015) What effect can manual therapy have on a patient’s pain experience? Pain Manag 5(6):455–464. https://doi.org/10.2217/pmt.15.39

    Article  PubMed  PubMed Central  Google Scholar 

  14. Paris SV (2000) A history of manipulative therapy through the ages and up to the current controversy in the United States. J Man Manip Ther 8(2):66–77

    Article  Google Scholar 

  15. Manchikanti L, Hirsch JA, Pampati V (2003) Chronic low back pain of facet (zygapophysial) joint origin: is there a difference based on involvement of single or multiple spinal regions? Pain Physician 6(4):399–405

    Article  PubMed  Google Scholar 

  16. Chaitow L, Crenshaw K (2006) Muscle energy techniques. Elsevier Health Sciences.

  17. Hing W, Hall T, Rivett DA, Vicenzino B, Mulligan B (2015) The Mulligan concept of manual therapy: textbook of techniques. Elsevier Health Sciences.

  18. Buyukturan O, Buyukturan B, Sas S, Karartı C, Ceylan I (2018) The effect of mulligan mobilization technique in older adults with neck pain: a randomized controlled, double-blind study. Pain Res Manag. https://doi.org/10.1155/2018/2856375

    Article  PubMed  PubMed Central  Google Scholar 

  19. Selkow NM, Grindstaff TL, Cross KM, Pugh K, Hertel J, Saliba S (2009) Short-term effect of muscle energy technique on pain in individuals with non-specific lumbopelvic pain: a pilot study. J Man Manip Ther 17(1):14–18. https://doi.org/10.1179/jmt.2009.17.1.14E

    Article  Google Scholar 

  20. Goodridge JP (1981) Muscle energy technique: definition, explanation, methods of procedure. The Principles of Palpatory Diagnosis and Manipulative Technique. J Am Osteopath Assoc 81(4):249–254

    CAS  PubMed  Google Scholar 

  21. Exelby L (2002) The Mulligan concept: its application in the management of spinal conditions. Man Ther 7(2):64–70. https://doi.org/10.1054/math.2001.0435

    Article  CAS  PubMed  Google Scholar 

  22. Wilson E (2001) The Mulligan concept: NAGS, SNAGS and mobilizations with movement. J Bodyw Mov Ther 5(2):81–89

    Article  Google Scholar 

  23. Pourahmadi MR, Mohsenifar H, Dariush M, Aftabi A, Amiri A (2018) Effectiveness of mobilization with movement (Mulligan concept techniques) on low back pain: a systematic review. Clin Rehabil. 32(10):1289–1298. https://doi.org/10.1177/0269215518778321

    Article  PubMed  Google Scholar 

  24. Rubinstein SM, De Zoete A, Van Middelkoop M, Assendelft WJ, De Boer MR, Van Tulder MW (2019) Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ 13(364):l689. https://doi.org/10.1136/bmj.l689

    Article  Google Scholar 

  25. Preyde M (2000) Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. CMAJ 162(13):1815–1820

    CAS  PubMed  PubMed Central  Google Scholar 

  26. Hidalgo B, Detrembleur C, Hall T, Mahaudens P, Nielens H (2014) The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. J Man Manip Ther 22(2):59–74. https://doi.org/10.1179/2042618613Y.0000000041

    Article  PubMed  PubMed Central  Google Scholar 

  27. Wilson E, Payton O, Donegan-Shoaf L, Dec K (2003) Muscle energy technique in patients with acute low back pain: a pilot clinical trial. J Orthop Sports Phys Ther. 33(9):502–512. https://doi.org/10.2519/jospt.2003.33.9.502

    Article  PubMed  Google Scholar 

  28. Fahmy E, Shaker H, Ragab W, Helmy H, Gaber M (2019) Efficacy of spinal extension exercise program versus muscle energy technique in treatment of chronic mechanical low back pain. Egypt J Neurol Psychiatr Neurosurg 55(1):55–77. https://doi.org/10.1186/s41983-019-0124-5

    Article  Google Scholar 

  29. Wahyuddin W, Vongsirinavarat M, Mekhora K, Bovonsunthonchai S, Adisaipoapun R (2020) Immediate effects of muscle energy technique and stabilization exercise in patients with chronic low back pain with suspected facet joint origin: a pilot study. Hong Kong Physiother J 40(2):109–119. https://doi.org/10.1142/S1013702520500109

    Article  PubMed  PubMed Central  Google Scholar 

  30. Danneels L, Coorevits P, Cools A, Vanderstraeten G, Cambier D, Witvrouw E, De Cuyper H (2002) Differences in electromyographic activity in the multifidus muscle and the iliocostalis lumborum between healthy subjects and patients with sub-acute and chronic low back pain. Eur Spine J 11(1):13–19. https://doi.org/10.1007/s005860100314

    Article  CAS  PubMed  Google Scholar 

  31. Chanda ML, Alvin MD, Schnitzer TJ, Apkarian AV (2011) Pain characteristic differences between subacute and chronic back pain. J Pain 12(7):792–800. https://doi.org/10.1016/j.jpain.2011.01.008

    Article  PubMed  PubMed Central  Google Scholar 

  32. Cherkin DC, Deyo RA, Battié M, Street J, Barlow W (1998) A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 339(15):1021–1029. https://doi.org/10.1056/NEJM199810083391502

    Article  CAS  PubMed  Google Scholar 

  33. Van Tulder MW, Koes BW, Bouter LM (1997) Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine J 22(18):2128–2156. https://doi.org/10.1097/00007632-199709150-00012

    Article  Google Scholar 

  34. Cawley N (1997) A critique of the methodology of research studies evaluating massage. Eur J Cancer Care 6(1):23–31. https://doi.org/10.1111/j.1365-2354.1997.tb00265.x

    Article  CAS  Google Scholar 

  35. Goertz MTD, Bonseil J, Bonte B (2012) ARHQ guideline: adult acute and subacute low back pain. National Guideline Clearinghouse, Guideline summary NGC-9520.

  36. Will JS, Bury DC, Miller JA (2018) Mechanical low back pain. Am Fam Physician 98(7):421–428

    PubMed  Google Scholar 

  37. Bijur PE, Silver W, Gallagher EJ (2001) Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med 8(12):1153–1157. https://doi.org/10.1111/j.1553-2712.2001.tb01132.x

    Article  CAS  PubMed  Google Scholar 

  38. Ten Hoor GA, Musch K, Meijer K, Plasqui G (2016) Test-retest reproducibility and validity of the back-leg-chest strength measurements. Isokinet Exerc Sci 24(3):209–216. https://doi.org/10.3233/IES-160619

    Article  Google Scholar 

  39. Toyoda H, Hoshino M, Ohyama S, Terai H, Suzuki A, Yamada K, Nakamura H (2019) The association of back muscle strength and sarcopenia-related parameters in the patients with spinal disorders. Eur Spine J 28(2):241–249. https://doi.org/10.1007/s00586-018-5858-8

    Article  PubMed  Google Scholar 

  40. Hermens HJFB, Freriks B, Merletti R, Hägg GG, Stegman D, Blok J, Disselhorst-Klug C (1999) SENIAM 8: european recommendations for surface electroMyoGraphy roessingh research and development bv. Enschede, The Netherlands

  41. Hongo M, Itoi E, Sinaki M, Shimada Y, Miyakoshi N, Okada K (2005) Effects of reducing resistance, repetitions, and frequency of back-strengthening exercise in healthy young women: a pilot study. Arch Phys Med Rehabil 4(7):1299–1303. https://doi.org/10.1016/j.apmr.2004.12.030

    Article  Google Scholar 

  42. Halaki M, Ginn K (2012) Normalization of EMG signals: to normalize or not to normalize and what to normalize to. Computational intelligence in electromyography analysis-a perspective on current applications and future challenges, 175–194.

  43. Hussien HM, Abdel-Raoof NA, Kattabei OM, Ahmed HH (2017) Effect of mulligan concept lumbar SNAG on chronic nonspecific low back pain. J Chiropr Med 16(2):94–102. https://doi.org/10.1016/j.jcm.2017.01.003

    Article  PubMed  PubMed Central  Google Scholar 

  44. Gignac GE, Szodorai ET (2016) Effect size guidelines for individual differences researchers. Per Indv Diff 102(2):74–78. https://doi.org/10.1016/j.paid.2016.06.069

    Article  Google Scholar 

  45. Degenhardt BF, Darmani NA, Johnson JC, Towns LC, Rhodes DC, Trinh C, DiMarzo V (2007) Role of osteopathic manipulative treatment in altering pain biomarkers: a pilot study. J Am Osteopath Assoc 107(9):387–400

    PubMed  Google Scholar 

  46. Lewit K, Simons DG (1984) Myofascial pain: relief by post-isometric relaxation. Arch Phys Med Rehabil 65(8):452–456

    CAS  PubMed  Google Scholar 

  47. Moore MA, Kukulka CG (1991) Depression of Hoffmann reflexes following voluntary contraction and implications for proprioceptive neuromuscular facilitation therapy. Phys Ther 71(4):321–329. https://doi.org/10.1093/ptj/71.4.321

    Article  CAS  PubMed  Google Scholar 

  48. Reed ML, Begalle RL, Laudner KG (2018) Acute effects of muscle energy technique and joint mobilization on shoulder tightness in youth throwing athletes: a randomized controlled trial. Int J Sports Phys Ther 13(6):1024–1031. https://doi.org/10.26603/ijspt20181024

    Article  PubMed  PubMed Central  Google Scholar 

  49. Fryer G, Morris T, Gibbons P (2004) Paraspinal muscles and intervertebral dysfunction: part one. J Manipulative Physiol Ther 27(4):267–274. https://doi.org/10.1016/j.jmpt.2004.02.006

    Article  PubMed  Google Scholar 

  50. Fryer G, Morris T, Gibbons P (2004) Paraspinal muscles and intervertebral dysfunction: part two. J Manipulative Physiol Ther 27(5):348–357. https://doi.org/10.1016/j.jmpt.2004.04.008

    Article  PubMed  Google Scholar 

  51. Hindle K, Whitcomb T, Briggs W, Hong J (2012) Proprioceptive neuromuscular facilitation (PNF): its mechanisms and effects on range of motion and muscular function. J Hum Kinet 31:105–113. https://doi.org/10.2478/v10078-012-0011-y

    Article  PubMed  PubMed Central  Google Scholar 

  52. Colloca CJ, Keller TS (2001) Electromyographic reflex responses to mechanical force, manually assisted spinal manipulative therapy. Spine J 26(10):1117–1124. https://doi.org/10.1097/00007632-200105150-00005

    Article  CAS  Google Scholar 

  53. Alhashel A, Alamri E, Sparkes V (2019) Effects of the mulligan sustained natural apophyseal glide (snag) mobilization on trunk muscle activity and vertical jump performance in healthy subjects. Orthopaedic Proceedings 101(9):55–56

    Google Scholar 

  54. Kim SY, Kim NS (2013) Effects of mulligan’s mobilization with sustained natural apophyseal glides on the paraspinal muscle activity of subjects with chronic low back pain. J Kor Phys Ther 25(1):10–15

    Article  Google Scholar 

  55. Melzack R, Wall PD (1965) Pain mechanisms: a new theory. Science 150(3699):971–979. https://doi.org/10.1126/science.150.3699.971

    Article  CAS  PubMed  Google Scholar 

  56. Thomas E, Cavallaro AR, Mani D, Bianco A, Palma A (2019) The efficacy of muscle energy techniques in symptomatic and asymptomatic subjects: a systematic review. Chiropr Man Therap 27(35):45–72. https://doi.org/10.1186/s12998-019-0258-7

    Article  Google Scholar 

  57. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J (2015) Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med 49(19):1277–1283. https://doi.org/10.1136/bjsports-2014-094386

    Article  PubMed  Google Scholar 

Download references

Acknowledgement

We would like to thank the Vice-chancellor of the university for providing the necessary support for the research work.

Funding

The study was not funded by any external funding agency.

Author information

Authors and Affiliations

  1. CPRS, Jamia Millia Islamia, New Delhi, India

    Saurabh Sharma & Samreena Akmal

  2. Enrich Physio Clinics, Melbourne, Australia

    Shalini Sharma

Authors
  1. Saurabh Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Samreena Akmal
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shalini Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Saurabh Sharma.

Ethics declarations

Ethical approval

Ethical approval was obtained from the institutional ethical committee (IEC)of the university vide no 31/10/190/JMI/IEC2018, in accordance with Declaration of Helsinki.

Informed consent

Informed consent was obtained from all participants included in the study.

Conflict of interest

The authors declare that they have no conflict of interest concerning this article.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sharma, S., Akmal, S. & Sharma, S. Comparison of two manual therapy approaches combined with exercise on pain, strength and electromyographic muscle activity in athletes with subacute mechanical low back pain. Sport Sci Health 17, 919–929 (2021). https://doi.org/10.1007/s11332-021-00750-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11332-021-00750-x

Keywords

Search

Navigation