title: Magnetic resonance imaging zygapophyseal joint space changes (gapping) in low back pain patients following spinal manipulation and side-posture positioning: a randomized controlled mechanisms trial with blinding.
abstract: OBJECTIVE
  The purpose of this study was to quantify lumbar zygapophyseal (Z) joint space separation (gapping) in low back pain (LBP) subjects after spinal manipulative therapy (SMT) or side-posture positioning (SPP).
  
  
  METHODS
  This was a controlled mechanisms trial with randomization and blinding. Acute LBP subjects (N = 112; four n = 28 magnetic resonance imaging [MRI] protocol groups) had 2 MRI appointments (initial enrollment and after 2 weeks of chiropractic treatment, receiving 2 MRI scans of the L4/L5 and L5/S1 Z joints at each MRI appointment. After the first MRI scan of each appointment, subjects were randomized (initial enrollment appointment) or assigned (after 2 weeks of chiropractic treatment appointment) into SPP (nonmanipulation), SMT (manipulation), or control MRI protocol groups. After SPP or SMT, a second MRI was taken. The central anterior-posterior joint space was measured. Difference between most painful side anterior-posterior measurements taken postintervention and preintervention was the Z joint "gapping difference." Gapping differences were compared (analysis of variance) among protocol groups. Secondary measures of pain (visual analog scale, verbal numeric pain rating scale) and function (Bournemouth questionnaire) were assessed.
  
  
  RESULTS
  Gapping differences were significant at the first (adjusted, P = .009; SPP, 0.66 ± 0.48 mm; SMT, 0.23 ± 0.86; control, 0.18 ± 0.71) and second (adjusted, P = .0005; SPP, 0.65 ± 0.92 mm; SMT, 0.89 ± 0.71; control, 0.35 ± 0.32) MRI appointments. Verbal numeric pain rating scale differences were significant at first MRI appointment (P = .04) with SMT showing the greatest improvement. Visual analog scale and Bournemouth questionnaire improved after 2 weeks of care in all groups (both P < .0001).
  
  
  CONCLUSIONS
  Side-posture positioning showed greatest gapping at baseline. After 2 weeks, SMT resulted in greatest gapping. Side-posture positioning appeared to have additive therapeutic benefit to SMT.
authors: Department of Research, National University of Health Sciences, Lombard, IL 60148, USA. gcramer@nuhs.edu
authors: Gregory D
authors: GD
authors: Cramer
authors: Jerrilyn
authors: J
authors: Cambron
authors: Joe A
authors: JA
authors: Cantu
authors: Jennifer M
authors: JM
authors: Dexheimer
authors: Judith D
authors: JD
authors: Pocius
authors: Douglas
authors: D
authors: Gregerson
authors: Michael
authors: M
authors: Fergus
authors: Ray
authors: R
authors: McKinnis
authors: Thomas J
authors: TJ
authors: Grieve
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D001071:Appointments and Schedules; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D017116:Low Back Pain / Q000175:diagnosis / Q000628:therapy*; D008159:Lumbar Vertebrae; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D020393:Manipulation, Spinal / Q000379:methods*; D008875:Middle Aged; D010147:Pain Measurement; D056888:Patient Positioning / Q000379:methods*; D011187:Posture; D016059:Range of Motion, Articular / Q000502:physiology; D016037:Single-Blind Method; D013997:Time Factors; D016896:Treatment Outcome; D021801:Zygapophyseal Joint / Q000473:pathology*
references: J Manipulative Physiol Ther. 2001 Jan;24(1):2-11
references: 11174689
references: Spine (Phila Pa 1976). 1979 Jan-Feb;4(1):1-8
references: 432710
references: Spine J. 2012 Jan;12(1):63-70
references: 21978519
references: Pain. 2005 Jan;113(1-2):9-19
references: 15621359
references: J Manipulative Physiol Ther. 2005 Nov-Dec;28(9):645-53
references: 16326233
references: J Manipulative Physiol Ther. 2011 Sep;34(7):420-31
references: 21875516
references: Pain. 1983 May;16(1):87-101
references: 6602967
references: J Can Chiropr Assoc. 2005 Jun;49(2):96-101
references: 17549199
references: J Anat. 1982 Dec;135(Pt 4):795-809
references: 7183677
references: Spine J. 2004 May-Jun;4(3):335-56
references: 15125860
references: Spine (Phila Pa 1976). 2002 Dec 15;27(24):2835-43
references: 12486357
references: J Manipulative Physiol Ther. 2000 Jul-Aug;23(6):380-94
references: 10951308
references: Appl Ergon. 2006 May;37(3):297-304
references: 16169512
references: Spine (Phila Pa 1976). 1998 Jan 15;23(2):168-73
references: 9474721
references: Arch Phys Med Rehabil. 2005 Sep;86(9):1745-52
references: 16181937
references: Spine (Phila Pa 1976). 1987 Sep;12(7 Suppl):S1-59
references: 2961086
references: Spine (Phila Pa 1976). 1990 Apr;15(4):295-9
references: 2353275
references: Spine (Phila Pa 1976). 2004 Jul 1;29(13):1452-7
references: 15223938
references: Phys Ther. 1987 Apr;67(4):549-53
references: 2951749
references: Ann Rheum Dis. 1981 Feb;40(1):87-9
references: 7469530
references: J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):141-54
references: 15129196
references: J Manipulative Physiol Ther. 2010 Mar-Apr;33(3):220-5
references: 20350676
references: J Manipulative Physiol Ther. 2010 Sep;33(7):508-18
references: 20937429
references: J Manipulative Physiol Ther. 1999 Jul-Aug;22(6):376-81
references: 10478769
references: J Manipulative Physiol Ther. 1989 Feb;12(1):21-5
references: 2522493
references: Spine (Phila Pa 1976). 2005 Jan 1;30(1):115-22
references: 15626991
references: Br J Rheumatol. 1987 Apr;26(2):93-8
references: 2435355
references: Spine J. 2004 Sep-Oct;4(5):574-83
references: 15363431
references: Spine (Phila Pa 1976). 2000 Dec 1;25(23):3036-44
references: 11145815
references: J Manipulative Physiol Ther. 2002 May;25(4):251-62
references: 12021744
references: BMJ. 2010 Mar 23;340:c869
references: 20332511
references: J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):160-9
references: 15129198
references: J Manipulative Physiol Ther. 1996 Nov-Dec;19(9):570-82
references: 8976475
references: J Manipulative Physiol Ther. 2009 Jul-Aug;32(6):414-22
references: 19712783
references: Spine J. 2008 Jan-Feb;8(1):213-25
references: 18164469
references: J Manipulative Physiol Ther. 2010 Jan;33(1):56-61
references: 20114101
references: N Engl J Med. 1988 Feb 4;318(5):291-300
references: 2961994
references: Eur Spine J. 2006 Jul;15(7):1070-82
references: 16341712
references: Neurosci Lett. 1998 Jan 23;241(1):45-8
references: 9502212
references: Spine (Phila Pa 1976). 2000 Dec 15;25(24):3140-51
references: 11124730
references: J Manipulative Physiol Ther. 2011 Jan;34(1):2-14
references: 21237402
references: Ann Intern Med. 2010 Jun 1;152(11):726-32
references: 20335313
references: J Manipulative Physiol Ther. 1999 Oct;22(8):503-10
references: 10543579
references: J Manipulative Physiol Ther. 2004 Oct;27(8):503-8
references: 15510093
references: Spine J. 2005 May-Jun;5(3):277-90
references: 15863084
references: Spine (Phila Pa 1976). 2002 Feb 1;27(3):291-6; discussion 297-8
references: 11805694
references: Spine (Phila Pa 1976). 2002 Nov 15;27(22):2459-66
references: 12435975
references: Chiropr Osteopat. 2010 Feb 25;18:3
references: 20184717