title: Preliminary investigation of the mechanisms underlying the effects of manipulation: exploration of a multivariate model including spinal stiffness, multifidus recruitment, and clinical findings.
abstract: METHODS
  Prospective case series.
  
  
  OBJECTIVE
  To examine spinal stiffness in patients with low back pain (LBP) receiving spinal manipulative therapy (SMT), evaluate associations between stiffness characteristics and clinical outcome, and explore a multivariate model of SMT mechanisms as related to effects on stiffness, lumbar multifidus (LM) recruitment, and status on a clinical prediction rule (CPR) for SMT outcomes.
  
  
  BACKGROUND
  Mechanisms underlying the clinical effects of SMT are poorly understood. Many explanations have been proposed, but few studies have related potential mechanisms to clinical outcomes or considered multiple mechanisms concurrently.
  
  
  METHODS
  Patients with LBP were treated with two SMT sessions over 1 week. CPR status was assessed at baseline. Clinical outcome was based on the Oswestry disability index (ODI). Mechanized indentation measures of spinal stiffness and ultrasonic measures of LM recruitment were taken before and after each SMT, and after 1 week. Global and terminal stiffness were calculated. Multivariate regression was used to evaluate the relationship between stiffness variables and percentage ODI improvement. Zero-order correlations among stiffness variables, LM recruitment changes, CPR status, and clinical outcome were examined. A path analysis was used to evaluate a multivariate model of SMT effects.
  
  
  RESULTS
  Forty-eight patients (54% women) had complete stiffness data. Significant immediate decreases in global and terminal stiffness occurred post-SMT regardless of outcome. ODI improvement was related to greater immediate decrease in global stiffness (P = 0.025), and less initial terminal stiffness (P = 0.01). Zero-order correlations and path analysis supported a multivariate model suggesting that clinical outcome of SMT is mediated by improvements in LM recruitment and immediate decrease in global stiffness. Initial terminal stiffness and CPR status may relate to outcome though their relationship with LM recruitment.
  
  
  CONCLUSIONS
  The underlying mechanisms explaining the benefits of SMT appear to be multifactorial. Both spinal stiffness characteristics and LM recruitment changes appear to play a role.
authors.affiliation: Intermountain Healthcare, The University of Utah, Salt Lake City, UT 84108, USA. julie.fritz@hsc.utah.edu
authors.forename: Julie M
authors.initials: JM
authors.lastname: Fritz
authors.forename: Shane L
authors.initials: SL
authors.lastname: Koppenhaver
authors.forename: Gregory N
authors.initials: GN
authors.lastname: Kawchuk
authors.forename: Deydre S
authors.initials: DS
authors.lastname: Teyhen
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Hebert
authors.forename: John D
authors.initials: JD
authors.lastname: Childs
mesh_terms: D000328:Adult; D001696:Biomechanical Phenomena; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D016014:Linear Models; D017116:Low Back Pain / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D020393:Manipulation, Spinal; D008875:Middle Aged; D015999:Multivariate Analysis; D009119:Muscle Contraction; D018482:Muscle, Skeletal / Q000000981:diagnostic imaging / Q000503:physiopathology*; D010147:Pain Measurement; D010865:Pilot Projects; D011446:Prospective Studies; D016059:Range of Motion, Articular; D013131:Spine / Q000000981:diagnostic imaging / Q000503:physiopathology*; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography; D055815:Young Adult