Trial design
This was a single-center, single-blind, randomized [1:1] controlled trial. The subjects were randomly grouped by the researchers using computer-generated random numbers. The researchers did not participate in the entire evaluation and treatment intervention process. The manipulation therapist, data processor and subjects were unaware of the grouping.
Participants
This study has been approved by the Medical Ethics Committee of Hebei Provincial People's Hospital, China. Participants were recruited from patients with non-specific low back pain who visited our outpatient department of Hebei Institute of Sports Science from September 2020 to October 2021. All participants underwent a basic physical examination before enrollment and were told in person the purpose of the trial, but no details of other interventions were known. The patients signed the informed consent voluntarily and had the right to opt out at any time during the study without any reason.
Inclusion criteria[13]: ① pain from the 12th pair of ribs to the crease below the hip. ② Tenderness or muscle spasm. ③ CT or MRI showed no obvious 3. ④ Duration > 12 weeks. ⑤ The age range from 20 to 45. ⑥ The NRS score is greater than 3.
Exclusion criteria: ① symptoms of nerve root irritation. ② Complicated with pathological changes of lumbar spine (fracture, lumbar disc herniation, infection, etc.). ③ Disturbance of consciousness. ④ Severe cardiopulmonary dysfunction.
Shedding criteria:① Failure to complete treatment as prescribed. ② Receiving other treatment during this study. ③ Adverse reactions or difficulty in continuing treatment.
Intervention
The two groups were treated with Mulligan manipulation. On this basis, the suspension group was combined with suspension rope training, while the control group was combined with traditional rehabilitation training, including double bridge exercises, left and right plank exercises and plank exercises. Each movement was held for 6~8 seconds, and 2 groups were repeated 10 times per group. Patients in both groups received treatment 3 times per week for 8 weeks. Specific operations are as follows:
Mulligan technique: ① Flexion and extension. The patient sits beside the treatment bed, the therapist lunges and squats behind the patient, Mulligan treatment belt bypasses the patient's abdomen and below the therapist's hip, places the ulnar side of one hand on the upper spinous process of the spine to be treated, and the other hand supports the treatment bed for fixation. Let the patient slowly do lumbar flexion forward and extension back. When the patient is painless, the range of motion is proper, and the range of activity should be gradually increased. At the same time, the therapist gives a continuous thrust obliquely upward along the treatment plane, maintains it for 10 seconds after flexing forward and extending back to the end, and then returns to upright; ② Lateral flexion. The patient straddles at one end of the treatment bed with his back to the therapist. The therapist bends standing behind the patient, places the palmar side of his thumbs on the upper spinous process of the spine to be treated, and lets the patient do the slow lateral bending movement on the left and right sides. At the same time, the therapist's hands give continuous thrust obliquely upward along the treatment plane. When the side bend reaches the end, hold it for 10 seconds and then return to upright. ③ Rotate. The patient straddles at one end of the treatment bed with his back to the therapist, the therapist bends standing on one side of the patient, places the ulnar side of one hand on the upper spinous process of the spine to be treated, and another hand is fixed around the patient's abdomen and let the patient rotate slowly. At the same time, the therapist's hand gives a continuous thrust obliquely upward along the treatment plane, holds for 10 seconds when rotating to the end, and then returns to upright. ④ Self-help SNAGS: guide patients to conduct self Mulligan technology with the help of a treatment belt. The above different operations were performed 10 times in each group, 3 times per week for 8 weeks.
Suspension rope training: the portable 4D PRO suspension training belt is used, and the suspension rope training is completed under the guidance of a professional physiotherapist, 20 ~ 30min each time, 3 times/week, for a total of 8 weeks. ① Dorsal chain training. The patient is in the supine position, puts hands on both sides of the body, and bends one knee 90 degrees. Place one suspension belt on the patient's pelvis and the other on the popliteal fossa on the flexion side of the knee. The suspension height is the height of knee flexion. Let the patient straighten the leg in the suspension belt, lift the pelvis to the neutral position, keep the body in a straight-line position, and be careful not to tilt the pelvis. It mainly trains the dorsal motor chain of the core muscle group; ② Lateral chain training. The patient lies on his side and rests on his lower hand, the upper hand is placed on the patient's side, and the suspension belts are placed at the patient's pelvis and knee joint respectively. The suspension height is horizontal with the lateral condyle of the lower leg and the greater trochanter of the upper leg. Let the patient raise the upper leg, extend the lower hip joint, and press the lower leg down the suspension belt to raise the body in the same straight line. It mainly trains the lateral movement chain of the core muscle group; ③ Inner chain training. The patient lies on his side and rests on his lower hand, with the upper hand on his side. Place one suspension belt on the patient's pelvis and the other on the knee joint of the upper leg. The suspension height is at the medial condyle of the upper leg, at the same level as the shoulder joint. Let the patient raise the lower leg, press the lower leg down the suspension belt to raise the body in the same straight line. It mainly trains the inner motor chain of the core muscle group; ④ Front chain training. The patient lies prone with both upper limbs supporting the body. The suspension belts are placed at the patient's pelvis and knee joint respectively. The suspension height is at the level of the shoulder joint. Let the patient straighten the legs in the suspension belt, raise the pelvis to the middle area, and keep the body in a straight-line position. It mainly trains the anterior motor chain of the core muscle group. All the above training should be maintained for 60 seconds each time, with an interval of 40 seconds, and 4 ~ 6 groups should be trained.
Outcome measures
NRS score [14]: the number 0-10 indicates the pain degree, in which 0 indicates no pain and 10 indicates the most severe pain. The degree of pain was evaluated by numbers according to the patients' subjective feelings.
ODI score[15]: ODI score is a scale to judge the lumbar function based on whether the patient can carry out relevant daily life behavior. This scale includes 10 aspects of patients with low back pain, such as pain intensity and self-care. The higher the score, the more serious the lumbar dysfunction is. Considering the privacy of the subjects involved, the scoring option of sexual life in the ODI questionnaire was deleted. The highest score of ODI is 45 points.
Spinal mobility score: Spinal mobility score is mainly used to evaluate the quantitative table of spinal mobility of patients with low back pain. Patients stand and bend as low as they can, the score was based on the standard that the fingertips of both hands could reach the lowest part of the lower limbs. It is divided into seven levels. The higher the score, the smaller the range of activity of the lumbar spine and the more serious the corresponding symptoms.
Muscle-bone ultrasound was used to evaluate the muscle thickness of bilateral transverse abdominal muscle and multifidus muscle [16-18]. ALOKA DF-37 ultrasonic equipment was used, and the linear array ultrasonic probe frequency was 5.0 ~ 13.3MHZ. The thickness of the transverse abdominal muscle and multifidus muscle of the subjects in the resting position is measured before and after the intervention. The room temperature of the color ultrasound room is kept at 23 ~ 28 ℃, and the same professional ultrasound doctor measures the subjects before and after the intervention, and the doctor does not know the grouping of the subjects.
Evaluation of transverse abdominal muscle: the subject lies on his back, his upper limbs are relaxed naturally and placed on his side. The probe is placed at the intersection of the anterior superior iliac spine and umbilical horizontal line. The probe is placed vertically with the skin. The image of the third layer of the abdominal muscle is transverse abdominal muscle. The thickness of the transverse abdominal muscle is measured at the end of the subject's exhalation. Intercept three pictures respectively and take the average value.
Evaluation of multifidus muscle: the subject is in the prone position, the upper limbs are naturally relaxed and placed on the side of the body, and the probe is placed between the L4 spinous process and articular process. The probe is placed vertically with the skin. The observed image of the second layer of muscle between the spinous process and the inferior articular process is multifidus muscle. The thickness of the multifidus muscle is measured at the end of the subject's exhalation, and three pictures are intercepted respectively to take the average value.
Statistical analyses
All analyses were conducted by professionals who did not participate in the study using SPSS version 24.0. The measurement data of normal distribution were represented by Mean ± Standard deviation. After homogeneity of variance test, independent sample T test was used for comparison between-group, and paired sample T test was used for within-group comparison. Count data were expressed by frequency and χ2 test was used. P<0.05 was set as the significance level.