Effect of Strain Counterstrain versus High

Velocity Low Amplitude Thrust Manipulation

on Clinical Outcomes in Acute Mechanical
Low Back Pain

Thesis
Submitted in Partial Fulfillment of the Requirements for the
Doctoral Degree in Physical Therapy for Musculoskeletal
Disorder and its Surgery

By
Ahmed Ramadan Zaki Baghdadi
BSc, 2004
MSc, 2013
 SUPERVISORS

Prof. Dr. Alaa Eldin Abdel- Dr. Ghada Mohamed Rashad

Hakim Balbaa Koura
Prof. in the Department of Physical
Lecturer in the Department of
Therapy for Musculoskeletal Disorders
Physical Therapy for Musculoskeletal
and its Surgery Faculty of Physical
Disorders and its Surgery
Therapy
Faculty of Physical Therapy
Cairo University
Cairo University
 Introduction

LBP

Non-Specific
Specific
(Mechanical)

MLBP with MLBP with

MLBP with
mobility deficits movement MLBP with
related lower
(Somatic coordination radiating Pain
extremity pain
dysfunction) impairments
 MLBP with
mobility deficits

Acute Subacute Chronic

 AMLBP with
mobility deficits

Thrust
Manipulation Advices to be
active
(Level A evidence)
 Thrust
Manipulation

HVLATM LVHATM HVHATM

Strain Counterstrain techniques
an osteopathic technique first published in 1964 (Jones, 1964).
The technique is based on the palpation of tender points used to
both diagnose and treat musculoskeletal pain throughout the
human body.
Counterstrain is the treatment of strain by passively
approximating the origin and insertion of the strained muscle and
maintained for 90 seconds (Jones et al., 1995).
Statement of the problem
At the end of this study, the results should
answer the following question: DO SCS
techniques promote restoration of function,
flexibility and decrease in pain as compared
with HVLAT technique provided to AMLBP
patients?
Purpose of the study
to assess the effectiveness of SCS by
comparing it with a gold standard technique
such as HVLAT in treating the patients with
AMLBP with mobility deficits.
Significance of the study
 Still we have higher rate of recurrent LBP.
 Although greater success of HVLAT
technique, there are several
contraindications.
 On the contrary SCS techniques are
gentle and painless techniques have no
contra-indications and can be used in
almost any condition and on patients of
any age
Significance of the study
Thus we found a need to investigate if there
is an effect of SCS techniques as an easy,
non-harmful and uncostly technique other
than HVLAT manipulation on pain,
segmental mobility and functional disabilities
in patients with AMLBP.
 Delimitations

Limited lumbar
Age ranged BMI ranged
VAS (4-8) flexion less than
from 20-30 from 20-30
3 cm
Hypothesis
 There is no significant difference between
the two experimental groups in pain.

 There is no significant difference between

the two experimental groups in ROM.

 There is no significant difference between

the two experimental groups in functional
disability.
Hypothesis
 There is significant decreasing in pain in the two
experimental groups in relation to the control
group before and after treatment.

 There is significant decreasing in disability in the

two experimental groups in relation to the
control group before and after treatment.

 There is significant improvement in ROM in the

two experimental groups in relation to the
control group before and after treatment.
SUBJECTS, MATERIALS AND
METHODS
 Subjects

Group A Group C
Group B
42 patients 42 patients
42 patients (SCS)
(HVLAT) (Advices)
Inclusion criteria
 Acute low back pain with mobility deficits
are made with a reasonable level of
certainty when the patient presents with
the following clinical findings Acute low
back, buttock, or thigh pain (duration of 1
month or less)

 Restricted lumbar range of motion and

segmental mobility
Inclusion criteria
 Pain related to the low back (lower lumbar
region, L4/L5 and/or L5/S1 region).
 Must have had more pain free days than days with
low back pain in the past year.
 Age ranged from 20-30 years.
 Limited ROM of lumbar spine (less than 3 cm in
Modified schoper's test in forward bending)
 BMI ranged from 20- 30.
 Positive segmental mobility assessment and
positive Pain Provocation With Segmental
Mobility Testing at level of L4 and L5
 Exclusion criteria
 Presence of radiculopathy
 Cauda equina symptoms
 Spine deformity such as current spinal fractures, spinal infections, or tumors of
the spine
 Current history of severe osteoporosis
 Prior lumbar spine surgery
 Pregnancy
 Psychiatric illness or lack of cognitive ability (i.e. dementia or Alzheimer’s)
 Current and known substance abuse
 Medication:
 If the patient takes anticoagulants or corticosteroids
 Trauma
 Lever use
 Instrumentations

Oswestry
Pressure Pain Dual Digital
VAS Disability
Algometer Inclinometer
Index
Group A (HVLAT)
They were treated with HVLAT
manipulation in lumbar roll position by using
two techniques, for two weeks, one session
per week.
Standard Manipulation of an
ERS Lesion
Manipulation of the underlying
Facets into Divergence
Group B (SCS group)
They were treated with SCS techniques by
using two techniques, for two weeks, two
sessions per week.
Extension Lesion of L4 and L5
Atypical Lesion of L5
 Group C (Control Group)

This group were received Advices to be active

Time of assessment
The two study groups were assessed before
treatment, after treatment and six weeks
follow up after treatment. The control group
was assessed three times as the same time
interval.
Statistical analysis
RESULTS
Mean values of age among
different groups

Age
60

55
Mean value of age (years)

50

45

40

35

30
24.09 24.04 24.07
25

20

15

10

0
Group A Group B Group C
 Mean values of BMI among
different groups

BMI
50
Mean value of body mass (Kg/m2)

40

30
24.2 24.19 24.36

20

10

0
Group A Group B Group C
 Mean values of PPT at left L5
Within group differences
10

6
Pre
5 Post I
Post II
4

0
HVLAT Group SCS Group Control Group
 Mean values of PPT at left L5
among different groups
10

HVLAT Group
5
SCS Group
Control Group
4

0
Pre Post I Post II
Mean values of PPT at right L5
Within group differences
10

Pre
5
Post I
Post II
4

0
HVLAT Group SCS Group Control Group
 Mean values of PPT at right L5
among different groups
10

HVLAT Group
5
SCS Group
Control Group
4

0
Pre Post I Post II
Mean values of Lumbar flexion
ROM Within group differences
50

45

Pre
40 Post I

Post II

35

30
HVLAT Group SCS Group Control Group
 Mean values of Lumbar flexion
ROM among different groups
50

45

HVLAT Group
40
SCS Group
Control Group

35

30
Pre Post I Post II
 Mean values of VAS scores
Within group differences
8

Pre
4
Post I
Post II
3

0
HVLAT Group SCS Group Control Group
 Mean values of VAS scores
among different groups
8

HVLAT Group
4
SCS Group
Control Group
3

0
Pre Post I Post II
 Mean values of ODI scores
Within group differences

40

35

30

25

Pre
20
Post I
Post II
15

10

0
HVLAT Group SCS Group Control Group
 Mean values of ODI scores
among different groups
40

35

30

25

HVLAT Group
20
SCS Group
Control Group
15

10

0
Pre Post I Post II
DISCUSSION
 Pain within
group
differences

PPT VAS
This improvement of pain in SCS group is related
to:
 The pain associated with primary joint can be
eased with simple positioning that feels good to
the patient.

 Pain reduction is due to relaxation of erector

spinae muscles that reflex to the same segments
for decreasing compression on facet joints and
correction of the false position of the vertebra
(Jones et al., 2005). And this is consistent with
the results of Lewis et al (2001).
This improvement of pain in HVLAT group is
related to:
 Mechanisms are theorized to result from both
spinal cord mediated mechanisms (Boal et al.,
2004) and supraspinal mediated mechanisms
(Wright, 1995).

 And this is consistent with the conclusion of

Delitto et al (2012) that illustrated that thrust
manipulation had strong evidence for treatment
of acute, subacute and chronic LBP patients with
mobility deficits.
This improvement of pain in control group may be
related to:
Preservation of regular motions help circulation
and resolving of inflammatory mediators , and this is
consistent with the results of with previous studies
(Damush et al., 2003 a , 2003b)
 Pain among
groups

PPT VAS

sig in Post I sig in Post I

and II in group and II in group
A and B vs C A and B vs C

sig in Post I in
group A vs B
 Lewis et al., (2011) did a randomized controlled
trial (RCT) comparing SCS with therapeutic
exercises (TE) in a population with LBP.
 Treatment consisted of four treatment sessions
over a two-week period.
 Numerous assessments of pain and function were
applied. Among the methods used to rate pain was
the VAS, which was assessed before intervention
and at two, six and 28 weeks after intervention.
 The only significant difference between groups
was shown at two weeks
 ROM of lumbar
flexion within group
differences

Sig ROM in all

groups except in
HVLAT (Post I vs
Post II)
 This improvement of ROM in SCS group is related
to:
 the reduction of pain associated with primary
joint or bone disease by relaxation of muscle
increase the range of motion through the impact
of muscle hyperactivity reduction on correction of
false axis (Jones et al., 2005).
 And this is consistent with the results of peer-
reviewed literature (Posadzki et al., 2011).
 This improvement of pain in HVLAT group is
related to:
 that the manipulation mechanically decompress
the facet joints and this reflect to pain reduction
and relaxation of paraspinal muscles and the final
result is improvement of ROM.
 And this is consistent with the conclusion of
(Neil et al., 2017)
 ROM of lumbar
flexion among
groups

No sig in Post I sig in Post I

and II in group A and II in group
vs B A and B vs C
 Oswestry
disability within
group differences

Sig of ODI
scores in all
groups
 Oswestry
disability Index
among groups

No sig in Post I sig in Post I

and II in group A and II in group
vs B A and B vs C
 SCS is the treatment of choice with the acute
patient because it is so gentle and atraumatic.
 The patient's body is moved slowly in non-painful
directions to positions that are non-threatening
and readily within their limited range of motion.
 The operator is guided by local decrease in tissue
tension and relief of palpatory tenderness to find
the optimal position of release.
 Dramatic changes can be made in relief of
subjective pain complaint, diminished muscle
guarding spasms, and reduction of congested
inflammatory fluid.
Summary, Conclusion and
Recommendations
We hypothesized That:
 There is significant decreasing in pain in the two
experimental groups in relation to the control
group before and after treatment. (Accept
hypothesis)
 There is significant decreasing in disability in the
two experimental groups in relation to the
control group before and after treatment. (Accept
hypothesis)
 There is significant improvement in ROM in the
two experimental groups in relation to the
control group before and after treatment.(Accept
hypothesis)
We hypothesized That:
 There is significant decreasing in pain in the two
experimental groups in relation to the control
group before and after treatment. (Accept
hypothesis)
 There is significant decreasing in disability in the
two experimental groups in relation to the
control group before and after treatment. (Accept
hypothesis)
 There is significant improvement in ROM in the
two experimental groups in relation to the
control group before and after treatment. (Accept
hypothesis)
 Conclusion
From the finding of the current study we can conclude that:
 After treatment all groups had significant improvement in
pain, ROM and disability.

 After six weeks Follow up SCS group and Control group had
improvement in pain reduction, ROM improvement and
decreasing disability

 regarding to HVLAT group after 6 weeks follow up Patients

had improvement in pain reduction and decreasing disability.

 In favor of HVLAT group and SCS group than Control

group after treatment and after six weeks follow up.
Conclusion
 There was no significant differences
among HVLAT group and SCS group in
Pain reduction, ROM, and functional
disability except in PPT after treatment.

 So we advise to use SCS techniques as an

effective approach in treating patients
with AMLBP with mobility deficits
LIMITATIONS

 Lack of objective method to detect the

ideal site of tender point for applying the
SCS technique.
 Lack of measuring tool during application
of SCS techniques.
 We can use EMG in addition to measure
the hyperactivity.
 the current study tested only short term
effects.
RECOMMENDATION
 Investigate the long term effects after six
months to one year.
 Use HVLAT manipulation and SCS
techniques as part of treatment Mixed
with exercises .
 Investigate the prolonged effect after six
months to one year and using EMG as an
outcome measure.
 Investigate the effect of SCS techniques in
different area of the body.
ACKNOWLEDGEMENTS
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