Chiropractic Manipulative Therapy Combined with Kinesio Tape Versus Elastic Bandage in Treatment of Chronic Lower Back Pain

Chiropractic Manipulative Therapy Combined with Kinesio Tape� Versus Elastic Bandage in Treatment of Chronic Lower Back Pain

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How to cite this thesis

Surname, Initial(s). (2012) Title of the thesis or dissertation. PhD. (Chemistry)/ M.Sc. (Physics)/ M.A. (Philosophy)/M.Com. (Finance) etc. [Unpublished]: University of Johannesburg. Retrieved from: https://ujdigispace.uj.ac.za (Accessed: Date). CHIROPRACTIC MANIPULATIVE THERAPY COMBINED WITH KINESIO TAPE VERSUS ELASTIC BANDAGE IN TREATMENT OF CHRONIC LOWER BACK PAIN

A research dissertation presented to the Faculty of Health Sciences, University of Johannesburg, as partial fulfillment for the Masters degree in Technology, Chiropractic by

Machere Venter (du Toit)

(Student number: 200700894)

Supervisor: ______Date: ______

Dr. C.Yelverton

Co-supervisor: ______Date: ______

Dr. R.Potgieter

DECLARATION

I Machere du Toit, declare that this dissertation is my own, unaided work. It is being submitted as partial fulfillment for the Masters Degree in Technology, in the program of Chiropractic, at the University of Johannesburg. It has not been submitted before for any degree or examination in any other Technikon or University.

______Machere du Toit

On this day the ______of the month of ______2014

AFFIDAVIT: MASTERS AND DOCTORAL STUDENTS

TO WHOM IT MAY CONCERN

This serves to confirm that I Machere du Toit ID number 8811170014080, Student number 200700894 am an enrolled student for the Qualification of Masters in Technology at Chiropractic Faculty of Health Science.

Herewith declare that my academic work is in line with the Plagiarism Policy of the University of Johannesburg. I further declare that the work presented in the study of chiropractic manipulative therapy combined with Kinesio tape versus elastic bandage in treatment of chronic lower back pain minor dissertation is authentic and original, and that there is no copyright infringement in the work. I declare that no unethical research practices were used or material gained through dishonesty. I understand that plagiarism is a serious offence.

Signed at ______on this ______day of ______2014. ______Signature Print name

STAMP COMMISSIONER OF OATHS Affidavit certified by a Commissioner of Oaths

DEDICATIONS

I would like to dedicate this research to my family, especially my mother Lizette Venter and brother Juan-Pierre du Toit. Thank you for all the encouragement, support, patience and unconditional love throughout my studies. I love you all dearly and will always be thankful for the opportunity that both of you made possible to pursue a passion of helping people.

To all my friends and fellow students thank you for all the great times, memories and moral support.

To my dearest friend Hugo Botha, thank you for all the support and love and always showing me the lighter side of everything, making all obstacles a lot more bearable. I love you dearly.

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ACKNOWLEDGEMENTS

To my supervisor, Dr. Chris Yelverton. Thank you for al your hard work, patience, guidance and knowledge. Your efforts are greatly appreciated and working with you was truly a great privilege.

To my co-superviser Dr. Ross Potgieter. Thank you for your advice, motivation and work, you truly made the process a lot easier.

To Dr. Gregory Duddy, thank you for sponsoring the necessary tape.

ABSTRACT

Purpose: Chronic lower back pain (LBP) is considered as one of the most prevalent conditions in our society with 70-85% of the population experiencing pain at some point in their lives and 80% having recurrent episodes. The majority of chronic LBP is treated with conservative care, with spinal manipulation being a treatment modality shown to be beneficial resulting in restoration of normal ranges of movement, decrease of muscle spasm and there is an overall biomechanical change. One of the more modern trends is combining manipulation with taping. It has been shown that with the application of Kinesio tape to the lumbar para-spinal muscles effectively increases lumbar range of motion and decreases pain with the relaxation of tense muscles as well as increase in proprioception as the tape increasingly stimulates cutaneous mechanoreceptors. Elastic bandage has been shown to improve proprioceptive acuity as it stimulates cutaneous mechanoreceptors, as well as providing support to joint structure. The purpose of this study was to determine the superiority of one tape versus the other as well as the efficacy of the individual tape and whether the combination treatment of spinal manipulative therapy and taping of the lumbar paraspinal muscles are possibly a more effective treatment protocol in the treatment of chronic lower back pain.

Method: This clinical study was a comparative study and consisted of two groups of fifteen participants who met the inclusion and exclusion criteria. The participants were between the ages of eighteen and forty-five years of age. Group 1 was treated with lumbar spine and sacroiliac joint adjustments and the application of Kinesio tape. Group 2 was treated with lumbar spine and sacroiliac joint adjustments and the application of elastic bandage. Treatment took place over a period of three weeks and participants were treated six times out of a total of seven consultations.

Procedure: Subjective data was recorded at the first and fourth consultation prior to treatment and on the seventh consultation by means of a Numerical Pain Rating Scale and an Oswestry Low Back Pain Disability Questionnaire to assess pain and disability. Objective data was recorded at the first and fourth consultation prior to treatment and on

v the seventh consultation by means of a digital inclinometer for assessing lumbar spine range of motion. Data recorded was analyzed by a statistician.

Results: Clinically and statistically significant improvements were noted in both groups over the course of the study with regards to pain, disability and lumbar spine range of motion.

Conclusion: The results show that both combination treatments of spinal manipulative therapy and the application of Kinesio™ tape or elastic adhesive bandage are effective treatment protocols, both clinical and statistical in decreasing pain, disability and improving lumbar range of motion in patients with chronic lower back pain. However neither treatment protocols proved to be superior over the other.

TABLE OF CONTENTS

DECLARATION ……………………………………………………………………………………..i AFFIDAVIT …………………………………………………………………………….……..……..ii DEDICATIONS…………..…………………………………………………………………….……iii ACKNOWLEDGEMENTS ………………………………………………………………………...iv ABSTRACT……….…………………………………………………………………………...….... v CHAPTER ONE – INTRODUCTION 1.1 Problem Statement………………………………... ………………………………………….1 1.2 Aim of the study………………………………………….……………………………………. 2 1.3 Benefits of the study……………………………….…………………………………………. .2 CHAPTER TWO – LITERATURE REVIEW 2.1 General anatomy of the lumbar spine………….…………………………………………. ...4 2.1.1 Lumbar vertebrae …………………………………….…………………………. ..4 2.1.2 Lumbar spine innervation……………………... ………………………………….6 2.1.3 Intervertebral ligaments………………………. ……………………….………….6 2.1.4 Joints of the vertebral body…………………... ………………….……………. ...7 2.1.5 The intervertebral disc………………………... ………………….……………. ...7 2.1.6 Joints of the vertebral arch…………………… …………….…………………. ...8 2.2 Sacrum…………………………………………… …………………………………………….8 2.3 Coccyx……………………………………………………………………………………….…..9 2.4 Sacroiliac joint…………………………………… ……………………………………………10 2.4.1 Anatomy of the sacroiliac joint………………. ………………………………….10 2.4.2 Ligaments of the sacroiliac joint……………… …………………………………10 2.4.3 Innervation of the sacroiliac joint……………. ………………………………….11 2.5 Spinal biomechanics……………………………. ……………………………………………11 2.5.1 Lumbar spine………….…..………….…………………………………………. ..11 2.5.2 Sacroiliac joint…………….…………………... ……………………….…………14 2.6 Lumbar spine muscles…..…………………………………………………………………. ..15 2.6.1 General anatomy of psoas major and minor………….………………………..15 2.6.2 General anatomy of quadratus lumborum……….……………………..………16 2.6.3 Extrinsic back muscles………………………….………………………………..17

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2.6.4 Intrinsic back muscles……….………………. ……………………………..…. .17 2.7 Thoracolumbar fascia……………..……………. …………………………………………. 22 2.8 Lower back pain……………………….………….…………………………………………. 23 2.8.1 Introduction and prevalence of lower back pain……………..………………. .23 2.8.2 Cause and effects of lower back pain………………………………………… .23 2.8.3 Effects of chiropractic adjustive therapy and kinesio tape on chronic lower back pain…………………………………………………..……………………………. 25 2.9 Integumentary system…………………………... …………………………………………. 26 2.9.1 Introduction………...... ………………………... ………………………….……. .26 2.9.2 Innervation of the skin………………………… ……………….………………..27 2.10 Chiropractic.…….……………………………… …………………………………………. .28 2.10.1 The Chiropractic Subluxation………………… …………..…………………...28 2.10.2 Chiropractic Manipulative Therapy defined………………. ……...…………..29 2.10.3 Effects of spinal manipulative therapy……….……………………………… ..30 2.11 Taping……………………………………….………………………………………..………37 2.11.1 MCconnel taping technique……….………. …………………….…………….37 2.11.2 White athletic taping…………………………………… ……………………. ...38 2.11.3 Proprioceptive properties of elastic bandage. ………….………….……… ...38 2.11.4 Kinesio taping…………………..…………. ………….……………………. .39 CHAPTER THREE – METHODOLOGY 3.1 Introduction …………………………………………………….……………………………. 43 3.2 Study design…………………………………………………………………………………. 43 3.3 Participant recruitment……………………………………………………………………… 43 3.4 Sample selection and size………………………………………..…………………………43 3.5 Inclusion criteria……………………………………………………………………………. ..44 3.6 Exclusion criteria……………………………….. …………………………………………. .44 3.7 Group allocation…………………………………………………………………………… ...44 3.8 Treatment protocol…………………………………………………………………………. ..45 3.8.1 First consultation……..…………………………………………………………. ..45 3.8.2 Follow-up visit………………..……….………………………………………… ..45 3.9 Motion palpation……………………………….……………………………………………. .46 3.9.1 Lumbar spine………………………..………………………………………….. ..46

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3.9.2 Sacroiliac joint…………………………………...………………………………………….48 3.10 Chiropractic manipulation……………………….……………………………………….. ...48 3.10.1 Spinous hook pull technique………..……………..…………………………. ..49 3.10.2 Thigh-ilio-deltoid technique…….…………………..…………………………...49 3.11 Application method of kinesio tape and elastic bandage to the lumbar para-spinal muscles……………………..…………………………………………………………… 50 3.11.1 The method of application...…………………….…..…………………………..50 3.12 Objective data……………………………………….……………………………………. ...51 3.12.1 Digital Inclinometer………………………….. ………………….……………. ..51 3.13 Subjective data………………………………….………………………………………… ..53 3.13.1 Oswestry Lower Back Pain and Disability Questionnaire……………………53 3.13.2 Numerical Pain Rating Scale…………..…………………………………….. .53 3.14 Data analysis………………………………………………………………………………...54 3.15 Ethical consideration………………………………………………………………………..54 CHAPTER FOUR – RESULTS 4.1 Demographic data analysis……………………………..………………………………. ….57 4.2 Objective data………………………………….…………………………………………. ….57 4.2.1 Lumbar flexion…………..…………………………………………………….… .57 4.2.2 Lumbar extension………….……………………………………………………..59 4.2.3 Lumbar left lateral flexion………………………………………………………..61 4.2.4 Lumbar right lateral flexion………….…………………………………….… ….64 4.2.5 Lumbar left rotation……………..………………………………………………..66 4.2.6 Lumbar right rotation…………….………………………………………….… ...68 4.3 Subjective data…………………………………………………………………………….....70 4.3.1 Numerical Pain Rating Scale……………………………………………..……. 70 4.3.2 Oswestry Pain and Disability Index Questionaire………………………...... 73 CHAPTER FIVE – DISCUSSION 5.1 Introduction ………………………………………………………………………………. .…76 5.2 Demographic comparability…………………………………………..…………………. ....76 5.3 Objective data analysis……………………………………………………………………...77 5.3.1 Digital Inclinometer readings of lumbar spine flexion………….……………..77 5.3.2 Digital Inclinometer readings of lumbar spine extension………………...... 77

5.3.3 Digital Inclinometer readings of lumbar left lateral flexion……..……………..77 5.3.4 Digital Inclinometer readings of lumbar spine right lateral flexion……...... 78 5.3.5 Digital Inclinometer readings of lumbar spine left rotation…….…………... ..78 5.3.6 Digital Inclinometer readings of lumbar spine right rotation….…………...... 79 5.3.7 Discussion of objective data……….…………………………...... 79 5.4 Subjective data………………………………….…………………………………………. ..82 5.4.1 Numerical Pain Rating Scale…………………..…………………………….. ..82 5.4.2 Oswestry Pain and Disability Index Questionaire ………….………….….. ...82 5.4.3 Discussion of subjective data……………………..………………………….. ..83 CHAPTER SIX – CONCLUSION AND RECOMMENDATIONS 6.1 Conclusion…………………………………………………………………………………. ...86 6.2 Recommendations………………………………..………………………………………. …87

LIST OF FIGURES

Figure 2.1: General anatomy of the lumbar spine vertebra……………………………………5

Figure 2.2: Compression and displacement of the intervertebral disc during flexion and

extension….……………………..…………………………………………………...8

Figure 2.3: Lumbar spine range of motion: Flexion, Extension, Lateral Flexion and

Rotation….………………………….………………………………………………13

Figure 2.4: Skin with the tactile receptors……………………………………………………...27

Figure 2.5: The relationship of the proposed necessary features of manipulation, compared

With other manual therapy interventions ………………...……………………..30 Figure 2.6: Afferent and efferent pathways from and to the viscera and somatic

structures…………………………………………………………………………...35

Figure 2.7: The inhibition of central pain transmission through activation of

mechanoreceptors and nociceptors……………………………………………...36

Figure 2.8: The sensory stimulation and its hypothesized effects upon the dorsal horn.…41

Figure 3.1: Numerical Pain Rating Scale ……………………………………………………..54

LIST OF TABLES

Table 2.1: Intervertebral ligaments……………………………………………………………….7 Table 2.2: Sacroiliac joint ligaments…………………………………………………………….11 Table 2.3: General anatomy of psoas major and minor………………………………………15 Table 2.4: General anatomy of quadratus lumborum…………………………………………16 Table 2.5: General anatomy of extrinsic back muscles……………………………………….17 Table 2.6: General anatomy of the intermediate layer of the intrinsic back muscles………18 Table 2.7: General anatomy of the deep layer of the intrinsic back muscles…………….…20 Table 3.1: Normal range of motion of lumbar spine…………………………………………...51 Table 3.2: Score and interpretation of the Oswestry Lower Back Pain and Disability Index Questionnaire..…………...……………….………………………………………..…53 Table 4.1: Demographic data of the participants………………………………………………57 Table 4.2: Comparative results of lumbar range of motion of lumbar flexion……………….57 Table 4.3: Non Parametric Test results for lumbar flexion – Friedman Test………………..58 Table 4.4: Non Parametric Test results for lumbar flexion – Mann-Whitney Test………….59 Table 4.5: Comparative results of lumbar range of motion of lumbar extension…………...59 Table 4.6: Non Parametric Test results for lumbar extension – Friedman Test……………60 Table 4.7: Non Parametric Test results for lumbar extension - Mann-Whitney Test………61 Table 4.8: Comparative results of lumbar range of motion of lumbar left lateral flexion…..61 Table 4.9: Non Parametric Test results for lumbar left lateral flexion – Friedman Test……………………………………………………………………………………62 Table 4.10: Non Parametric Test results for lumbar left lateral flexion – Wilcoxon signed rank Test……….…………………………………………..………………………...63 Table 4.11: Non Parametric Test results for lumbar left lateral flexion – Mann-Whitney Test….………..………………………………………………………………………63 Table 4.12: Comparative results of lumbar range of motion of lumbar right lateral Flexion….…………………………………………………………………………….64 Table 4.13: Non Parametric Test results for lumbar right lateral flexion – Friedman Test…………………………………………………………………………………...65 Table 4.14: Non Parametric Test results for lumbar right lateral flexion – Mann-Whitney Test……...……………………………………………………………………………65

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Table 4.15: Comparative results of lumbar range of motion of lumbar left rotation……….66 Table 4.16: Non Parametric Test results for lumbar left rotation – Friedman Test……….67 Table 4.17: Non Parametric Test results for lumbar left rotation – Mann-Whitney Test67 Table 4.18: Comparative results of lumbar range of motion of lumbar right rotation………68 Table 4.19: Non Parametric Test results for lumbar right rotation – Friedman Test………69 Table 4.20: Non Parametric Test results for lumbar right rotation – Mann-Whitney Test…69 Table 4.21: Comparative results of the Numerical Pain Rating Scale………………70 Table 4.22: Non Parametric Test results for Numerical Pain Rating Scale – Friedman Test ……..………………………………………………………………………………….71 Table 4.23: Non Parametric Test results for Numerical Pain Rating Scale – Wilcoxon signed rank Test……………………………..……………………………………..71 Table 4.24: Non Parametric Test results for Numerical Pain Rating Scale – Mann-Whitney Test…...………………………………………………………………………………72 Table 4.25: Comparative results of the Oswestry Pain and Disability Index Questionnaire……...………………………………………………………………...72 Table 4.26: Non Parametric Test results for Oswestry Pain and Disability Index Questionnaire–Friedman Test……………………………………………………73 Table 4.27: Non Parametric Test results for Oswestry Pain and Disability Index Questionnaire – Wilcoxon signed rank Test……………………..………………74 Table 4.28: Non Parametric Test results for Oswestry Pain and Disability Index Questionnaire – Mann-Whitney Test……………………………...………………74

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LIST OF APPENDICES

Appendix A: Advertisement Appendix B: Contra indications of chiropractic adjustive therapy Appendix C: Contra indication of Kinesio tape application Appendix D: Information and consent form Appendix E: Case History Appendix F: Physical Examination Appendix G: Lumbar spine regional examination Appendix H: SOAP note Appendix I: Digital Inclinometer readings Appendix J: Numerical Pain Rating Scale Appendix K: Oswestry Pain and Disability Questionnaire

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CHAPTER ONE – INTRODUCTION

1.1 Problem statement

Chronic lower back pain (LBP) is considered as one of the most prevalent conditions in our society with 70-85% of the population experiencing pain at some point in their lives and 80% having recurrent episodes (Liddle, Baxter and Gracey, 2004). Several anatomical structures may be contributors to pain, though Manchikanti, Singh, Pampati, Damron, Barnhill, Beyer and Cash (2001), shows that facet joints are the most common pain generators in chronic lower back pain. Chronic pain is defined by Segen (2002), as pain for 6 weeks or longer.

It has been noted by Chapman-Smith (1990), that most cases of chronic lower back pain is not caused by structural disorder but rather functional pathology, including weakness and loss of normal muscular function as well as decreased joint range of motion of the lumbar spine and pelvis.

Gatterman and Hansen (1994), define chiropractic manipulative therapy as any chiropractic therapeutic procedure that utilizes controlled force, leverage, direction, amplitude and velocity, which is directed at specific joints or anatomical regions. Spinal manipulation of lumbar facet joint or sacroiliac joints produce afferent discharge of the articular mechanoreceptors (type I and II mechanoreceptors), which have the following effects: reflexogenic effect, perceptual effects and pain suppression (Wyke, 1985). Chapman-Smith (1993), concluded that the successful manipulation of a fixated lumbar facet joint or sacroiliac joint will result in restoration of normal ranges of movement, decrease of muscle spasm and there is an overall biomechanical change that occurs that contributes to removal of certain pain referral signals.

The model of Kinesio™ taping is based in the bodies natural healing process, with the ability to activate neurological and circulatory systems promoting venous and lymphatic flow and decreasing inflammation (Kase, Wallis and Kase, 2003). It has been shown that with the application of Kinesio tape to the lumbar para-spinal muscles effectively

1 increases lumbar range of motion and decreases pain with the relaxation of tense muscles (Yoshida and Kahanov, 2007) as well as support joint structure (Jaraczewsk and Long, 2006). Murray and Husk (2001) has suggested that there is an increase in proprioception with the application of Kinesio tape as the tape increasingly stimulates cutaneous mechanoreceptors.

Elastic bandage is commonly used in the treatment of various musculoskeletal disorders (Hassan, Mockett and Doherty, 2002). It improves proprioceptive acuity as it stimulates cutaneous mechanoreceptors, as well as providing support to joint structure (Khabie, Micheal, Schwartz, Rokito, Gallagher, Cuomo, Zuckerman, 1998).

The majority of chronic LBP is treated with conservative care (Jenkins 2002), with spinal manipulation being a treatment modality shown to be beneficial (Lawrence, Meeker and Branson 2008). One of the more modern trends is combining manipulation with taping, however with the range of tapes available, little evidence is available as to the superiority of one tape versus the other as well as the efficacy of the individual tape in the treatment of chronic lower back pain.

1.2 Aim of the study

The aim of this study was to compare as well as determine the efficacy of chiropractic manipulative therapy combined with the application of Kinesio™ tape versus elastic bandage in treating chronic lower back pain.

1.3 Benefits of the study

It has been shown that chiropractic manipulative therapy and both Kinesio™ tape and elastic adhesive bandage are beneficial in the treatment of chronic LBP as entities on their own, by effectively decreasing pain, increasing function and improving proprioception. Combining chiropractic manipulative therapy with the application of Kinesio tape and Elastic bandage respectively, could prove to be more effective in reducing pain and increasing range of motion. In addition to the therapeutical benefit of the combination

2 treatment, using two different brands of tape will help to determine the efficacy of each tape as well as which is more superior to the other in the treatment of chronic lower back pain. Thus the results of this study may provide Chiropractors with an additional treatment protocol for chronic mechanical lower back pain.

CHAPTER TWO - LITERATURE REVIEW

The following chapter encompasses a review of literature associated to this study, this includes anatomy, physiology and biomechanics of the lumbar spine and sacroiliac joints. Also discussed are different entities of chronic pain, such as the functional and structural components involved, clinical presentation and prevalence. The therapeutical modalities, chiropractic manipulative therapy, Kinesio™ Tape and elastic bandage will be discussed by looking at each modality proposed mechanism of function and the relevant results related to previous research.

2.1 General anatomy of the lumbar spine

The lumbar spine is comprised of the 5 lumbar vertebrae that are located in the lower back between the sacrum and thorax. These vertebrae are the largest and assist, in conjunction with the rest of the spine, in supporting body weights and is a functional rigid yet flexible axis of the body aiding with movement and posture (Moore and Dalley, 2006).

The lumbar spine has multiple anatomical layers, which include vertebrae, ligaments, muscles, intervertebral discs, meninges and the spinal cord (Moore and Dalley, 2006).

2.1.1 Lumbar vertebrae

The five lumbar vertebrae are characterized by the large kidney shaped bodies due to the amount of weight they support, which becomes increasingly larger toward the inferior end of the vertebral column. The lumbar vertebrae are also characterized by the absence of costal facets and slender transverse processes that project posterosuperior and lateral with accessory processes on the posterior surface of the base of each transverse process. This provides an attachment site for the medial intertransverse lumborum muscle. Vertebral foramina varying from oval L1 to triangular L5 and large hatched shape spinous processes that provide surface area of attachment of lower back muscles as well as reinforces the lumbar curve. The lamina run posterior and medial joining in the midline to form these large spinous processes (Moore and Dalley, 2006; Martini 2006).

Articular processes extend vertically with the articular surfaces orientated sagitally from T12-L1 and become more coronaly orientated to L5-S1. The articular surfaces of the inferior process faces medially and the articular surface of the superior process faces laterally with mammillary processes on the posterior aspects of this process, this orientation of articulation facilitates the movement of the lumbar spine; flexion, extension and lateral flexion (Moore and Dalley, 2006; Martini, 2006).

The L5 vertebra is the largest vertebra that is deepened anterior therefore largely contributing to the lumbosacral angle that lies between the long axis of the lumbar spine and that of the sacrum (Moore and Dalley, 2006).

Figure 2.1 General anatomy of the Lumbar spine vertebra (Bergman and Peterson, 2011).

2.1.2 Lumbar spine innervation

The lumbar spine is associated with a diversity of nerves, with the lumbar spinal nerves being the central focus. The spinal nerves lie in the intervertebral foramina and are numbered agreeing to the vertebra underneath which they lie. Centrally the individual spinal nerves are connected to the spinal cord via the dorsal root that conducts sensory fibers from the spinal nerve to the spinal cord and the ventral root that largely conducts motor fibers and some sensory fibers from the spinal nerves to the spinal cord. It is also important to note that the spinal cord terminates in the vertebral canal at the level of L1-L2, as the lower lumbar nerve roots must run in the vertebral canal where they are mainly surrounded by the dural sac. Peripherally the spinal nerves divide onto smaller dorsal and larger ventral rami. There are five dorsal rami that divide into two or three branches, the medial and lateral branch that are always represented at each level and the variable third intermediate branch supplying varies structures in the lumbar spine. There are five ventral rami with L1-L4 ventral rami forming the lumbar plexus and L4-L5 ventral rami forming the lumbosacral trunk entering the lumbosacral plexus. The lumbar sympathetic trunks descend on the anterolateral aspect of the vertebral column with four ganglia present. The principal branches are the rami communicantes that are distributed to the L1-L2 ventral rami and grey rami communicantes to al ventral rami (Moore and Dalley, 2006).

2.1.3 Intervertebral ligaments

There are several ligaments showed in table 2.1 that are attached to the vertebral bodies and processes, connecting adjacent vertebrae and providing stability to the vertebral column.

Table 2.1: Intervertebral ligaments (Moore and Dalley, 2006; Martini, 2006).

Ligament Attachment Anterior longitudinal ligament Attaches to anterior surfaces of adjacent vertebral bodies Posterior longitudinal ligament Attaches to posterior surface of adjacent vertebral bodies and parallels the anterior longitudinal ligament Ligament flavum Attaches to lamina of adjacent vertebrae Interspinous ligament Attaches to spinous processes of adjacent vertebrae Supraspinous ligament Interconnects the tips of the adjacent spinous processes

2.1.4 Joints of the vertebral body

The joints of the vertebral body consists out of the intervertebral disc and two facet joints also known as the three joint complex.

2.1.5 The intervertebral disc

The intervertebral disc connects the articulating surfaces of the adjacent vertebral bodies. The intervertebral disc consists of the tough outer annulus fibrosis that surrounds the soft gelatinous internal nucleus pulposus. The nucleus pulposus allows resilience and flexibility, aiding it in absorbing shock (Moore and Dalley, 2006).

During movement of the vertebral column, the nucleus pulposus is compressed and displaced in the opposite direction of the movement and stretches the fibers of the annulis fibrosis. It is also noted that the thickness and shape of the disc, with lumbar discs being thicker anterior is related to the range of movement as well as producing secondary curvatures (Moore and Dalley, 2006; Martini, 2006).

Figure 2.2 Compression and displacement of the intervertebral disc during flexion and extension (Bergman and Peterson, 2011).

2.1.6 Joints of the vertebral arch

Zygapophysial joints are plane synovial joints between the superior and inferior articular processes of adjacent vertebrae, with a loose, thin articular capsule surrounding the structure. The zygapophysial joint allows gliding movement between the two articulating processes and is innervated by articular branches that arise from the medial branches of the posterior rami of the spinal nerve. Each articular branch supplies two contiguous joints, thus each joint is supplied by two nerves (Moore and Dalley, 2006).

2.2 Sacrum

The sacrum is a large triangular wedge shaped structure that is composed of five fused sacral vertebrae that supports the vertebral column. The sacrum is tilted slightly articulating with L5 vertebrae at the lumbosacral angle that varies from 130-160. Stability and strength is provided to the pelvis by the sacrum and transmits the weight of the body to the pelvic girdle (Moore and Dalley, 2006; Martini, 2006).

The base of the sacrum is a broad surface formed by the superior surface of S1 vertebra with the superior articular process articulating with the inferior articulating process of L5 vertebra. The pelvic surface of the sacrum is concave and smooth. Four transverse lines are visible as remnant of where the sacral vertebrae fused. The posterior surface of the sacrum is convex and rough marked with five prominent longitudinal ridges, also known as crests. The median central crest also known as the central ridge represents the fusion of the superior three or four sacral vertebrae. The intermediate sacral crest symbolizes the fused articular processes and the lateral sacral crests are the fused tips of the transverse processes. The posterior surface is broad providing a wide area for muscle attachments of the lower limbs. The apex of the sacrum is the narrow inferior portion with a oval articulating facet for the coccyx (Moore and Dalley, 2006; Martini, 2006).

The articular surface is flattened and thickened and located lateral and anterior to the lateral sacral crest, this has appearances of an auricle, thus called the auricular area. This is the site of the synovial part of the sacroiliac joint, located between the ilium and sacrum (Moore and Dalley, 2006).

The sacral canal is the continuation of the vertebral canal that extends through the length of the sacrum. It contains the cauda equina, a bundle of nerve roots arising inferior to L1. On the pelvic and posterior surface of the sacrum there are four pairs of sacral foramina functioning as exit points for the anterior and posterior rami of the spinal nerves (Martini, 2006).

2.3 Coccyx

The coccyx is a small triangular bone that articulates with the sacrum and serves as an attachment point for several muscles and ligaments. It is formed by four rudimentary coccygeal vertebrae, there may be one less or more (Moore and Dalley, 2006; Martini, 2006).

2.4 Sacroiliac joint 2.4.1 Anatomy of the sacroiliac joint

Boris, Zelle, Gary, Gruen, Brown and George (2005) states the sacroiliac joint is an atypical synovial joint with two opposing articular surfaces. The synovial part of the joint is covered by fibrous joint capsule anteriorly and posteriorly by the interosseous and posterior sacroiliac ligaments. The non synovial part of the joint located in the posterior sacroiliac ligament and interosious is know as a syndesmoses, where the joint is bounded by ligaments with no joint capsule or synovial fluid present. The adult SIJ is an auricular C- shaped joint with an average surface area of 17.5 cm in the adult. The anterior sacral surface of the joint is lined by thick hyaline cartilage, whereas the posterior iliac surface of the joint is lined by fibrocartilage. The cartilage is 2 to 3 times thicker on the sacral surface. The auricular shaped joint has a long and short arm, the long arm is oriented posterolaterally and caudal, whereas the short arm is orientated posteriorly and cephalid. The morphology of the sacroiliac joint varies extensively in each individual with respect to size, shape, and contour of the joint (Curtis, Slipman, William, Whyte, David, Chow, Chou, Lenrow and Mark, 2001).

2.4.2 Ligaments of the sacroiliac joint

The supporting structures of the SIJ include ligaments, and the muscles helping in a continuous effort to help maintain the biomechanical integrity and stability of the SIJ. The ligaments which act in concert with the SIJ capsule are the anterior and posterior sacroiliac ligament, interosseus ligament, believed to be the strongest ligament in the body, and accessory ligaments, the sacrotuberous ligament, sacrospinous ligament and iliolumbar ligament are described in table 2.2. It is also noted that al these structures important stabilizers of the sacrum. Structures that have an intimate relationship with the above mentioned ligaments are the piriformis, biceps femoris, gluteus maximus and minimus, quadratus lumborum, erector spinae, iliacus, latissimus dorsi, and thoracodorsal fascia (Curtis, et al., 2001).

Table 2.2: Sacroiliac joint ligaments (Moore and Dalley, 2006; Martini, 2006).

Ligament Function Sacroiliac ligaments Decrease posterior rotation of the sacrum relative to the ilia (counter-nutation) Interosseous ligament Resists the anterior and lateral displacement of the ilia Sacrotuberous ligament Decrease the anterior rotation of the sacrum relative to the ilia (nutation) Sacrospinous ligament Decrease the anterior rotation of the sacrum relative to the ilia (nutation) Iliolumbar ligament Limits translation between the distal lumbar spine and sacrum and prevents separation of the articulating surfaces

2.4.3 Innervation

The SIJ is richly innervated with several nociceptors and proprioceptors, with variation between the left and right SIJ in the same individual. The anterior aspect of the joint is innervated by the ventral rami of L2 – S2, especially L4 and L5. The posterior aspect of the joint is innervated by the dorsal rami of L4- S3, especially S1 and S2. Considering the wide range of innervation it may account for the wide range of pain referral patterns involved in pathology of the SIJ (Curtis, et al., 2001; Boris, et al., 2005).

2.5 Spinal biomechanics 2.5.1 Lumbar spine

The movement available in the lumbar spine is flexion, extension, lateral flexion, and rotation. The lumbar zygapophyseal facets favor flexion and extension due to the sagittal plane orientation of the facets. The amount of flexion at each interspinous space of the lumbar vertebrae varies, with most of flexion taking place at the lumbosacral joint. During

11 flexion and extension, the greatest mobility of the spine occurs between L4 and S1, which is also the area that supports majority of weight and forces (Levangie and Norkin, 2005). a) During flexion (Kapanji, 2006): The body of the upper vertebra tips and glides anterior. The thickness of the intervertebral disc decreases anteriorly and increases posteriorly as the nucleus pulposus is pushed posterior stretching the posterior fibers of the annulus fibrosus. The inferior articular process of the upper vertebra slides superior and away from the lower vertebra superior articular process. As maximal flexion is achieved the ligaments between the articular processes are maximally stretched and then limit flexion.

b) During extension (Kapanji, 2006): The body of the upper vertebra tips and glides posterior. The thickness of the intervertebral disc increases anteriorly and decreases posteriorly as the nucleus pulposus is pushed anterior stretching the anterior fibers of the annulus fibrosus. The inferior articular process of the upper vertebra and superior articular process of the vertebra below become tightly interlocked. Spinous processes approximate and touch one another. Extension is limited by the maximally stretched anterior longitudinal ligaments and approximation of the bony structures of the vertebral arch.

c) During lateral flexion (Kapanji, 2006): The vertebral body of the vertebra above tilts ipsilaterally. The disc is then wedge shaped with the base on the contralateral side due to the nucleus pulposus moving contralaterally. On the contralateral aspect the articular processes separate and the intertransverse, ligamentum flavum and capsular ligaments are stretched.

On the ipsilateral aspect the articular processes approximate and the intertransverse, ligamentum flavum and capsular ligaments are relaxed.

Figure 2.3 Lumbar spine range of motion: Flexion, Extension, Lateral Flexion and Rotation (Bergman and Peterson, 2011).

Coupled motions always occur during lateral flexion with the greatest range of motion at L2 and L3. During lateral flexion, pronounced flexion and slight ipsilateral rotation occurs (Levangie and Norkin, 2005).

Rotation is more limited because of the shape of the zygapophyseal joints that are medially orientated. During rotation the facet joints glide apart on the side of rotation and approximate on the opposite side. Coupled motions always occur during rotation with the greatest range of motion at L2 and L3. During rotation considerable lateral flexion in a contralateral direction occurs with only a slight amount of flexion (Levangie and Norkin, 2005). The amount and degree of lateral flexion and rotation decreases from the upper to lower lumbar vertebrae.

It is important to note the lumbo-pelvic-rhythm; this is the simultaneous coordinated activity of the lumbar spine and pelvis during flexion and extension. During forward flexion initially the lumbar spine will flex followed by anterior tilting of the pelvis. When returning to an

13 erect posture the pelvis will tilt posterior followed by extension of the lumbar spine. The initial pelvic motion delays lumbar extension as the trunk needs to be raised far enough, shortening the moment arm of the external load, this reduces the load on the erector spinae (Levangie and Norkin, 2005).

2.5.2 Sacroiliac Joint

The sacroiliac joint permits a small amount of motion that varies from person to person. The sacroiliac joints are interrelated to the symphysis pubis in a closed kinematic chain, thus when any motion occurs at the symphysis pubis, motion will simultaneously occur at the sacroiliac joint and vice versa (Levangie and Norkin, 2005; Kapanji, 2006). Movements that occur at the sacroiliac joint (Kapanji, 2006): a) During nutation:

The sacrum rotates about an axis made up of the axial ligaments, causing the sacral promontory to move inferior and anterior. The sacral apex and tip of the coccyx move posterior. The anteroposterior diameter of the pelvic brim decreases and The anteroposterior diameter of the pelvic outlet increases. The ischial tuberosities separate whilst the iliac bones approximate. Limited by tension developed in the sacrotuberous, sacrospinous and anterior sacroiliac ligaments.

b) During counter nutation:

The sacrum rotates about an axis made up of the axial ligaments, causing the sacral promontory to move superior and posterior. The sacral apex and tip of the coccyx move anterior and inferior. The anteroposterior diameter of the pelvic brim increases and The anteroposterior diameter of the pelvic outlet decreases.

The ischial tuberosities approximate whilst the iliac bones separate.

Limited by tension developed in the anterior and posterior sacroiliac ligaments.

2.6 Lumbar spine muscles (Moore and Dalley, 2006; Carnes and Vizniac, 2010)

The lumbar spine is surrounded by muscles that are divided into three functional groups:

1. Psoas major and minor, that covers the anterolateral aspect of the lumbar spine.

2. Quadratus lumborum (with intertransversarii, part of the intrinsic back muscles), that covers the transverse processes anteriorly.

3. Extrinsic and intrinsic back muscles that cover the posterior components of the lumbar spine.

2.6.1 General anatomy of psoas major and minor

The general anatomy of psoas major and minor, located over the anterolateral aspect of the lumbar spine is discussed in table 2.3 with relation to muscle attachment site, innervation and action.

Table 2.3: General anatomy of psoas major and minor (Moore and Dalley, 2006; Carnes and Vizniac, 2010)

Muscle Origin Insertion Nerve Supply Action

Psoas major Sides of the Posteromedial Branches of Extension of T12- L5 aspect of the the lumbar the lumbar vertebral bodies, lesser trochanter plexus L2-L4 spine. Hip intervertebral flexion, discs and abduction and transverse external processes rotation

Psoas minor Sides of the T12 Below the Branch of the Extension of and upper pectineal line on first lumbar the lumbar lumbar vertebral the superior spinal nerve spine. Hip bodies, ramus of the flexion, intervertebral pubic bone , abduction and discs and iliopectineal external transverse eminence and rotation processes iliac fascia

2.6.2 General anatomy of quadratus lumborum

The general anatomy of quadratus lumborum, located over the anterior aspect of the transverse processes is discussed in table 2.4 with relation to muscle attachment site, innervation and action.

Table 2.4: General anatomy of quadratus lumborum (Moore and Dalley, 2006; Carnes and Vizniac, 2010)

Muscle Origin Insertion Nerve Supply Action Quadratus lumborum Iliocostal fibers Arises from the Inferior aspect Branches of Unilaterally : Iliac crest and of the 12th rib the lumbar stabilize lumbar iliolumbar plexus T12- L3 spine, lateral ligament flexion of the lumbar spine, acts as a hip hiker Bilaterally : extends the lumbar spine Iliolumbar Arises from the Transverse Branches of Unilaterally : fibers Iliac crest and processes of the lumbar stabilize lumbar

iliolumbar L1-L4 plexus T12- L3 spine, lateral ligament flexion of the lumbar spine, acts as a hip hiker Bilaterally : extends the lumbar spine Lumbocostal Arises from the Inferior aspect Branches of Unilaterally : fibers transverse of the 12th rib the lumbar stabilize lumbar processes of plexus T12- L3 spine, lateral L2-L4 flexion of the lumbar spine, acts as a hip hiker Bilaterally : extends the lumbar spine

2.6.3 Extrinsic back muscles

The extrinsic back muscles consist of latissimus dorsi and the general anatomy is discussed in table 2.5 with relation to muscle attachment site, innervation and action.

Table 2.5: General anatomy of extrinsic back muscles (Moore and Dalley, 2006; Carnes and Vizniac, 2010)

Muscle Origin Insertion Nerve Supply Action Latissimus Spinous Medial lip of Thoracodorsal Anterior pelvic dorsi processes of T7- the bicipital nerve (C6-C8) tilt, elevates L5, groove of the the pelvis. thoracolumbar humerus. Depresses and

fascia, posterior rotates the sacrum and ribs scapula 9-12. downward.

2.6.4 Intrinsic back muscles a) Intermediate layer of intrinsic back muscles

The intrinsic back muscles consist of the erector spinae that makes up the intermediate layer. The general anatomy is discussed in table 2.6 with relation to muscle attachment site, innervation and action.

Table 2.6: General anatomy of the intermediate layer of intrinsic back muscles (Moore and Dalley, 2006; Carnes and Vizniac, 2010)

Muscle Origin Insertion Nerve Supply Action Erector spinae Iliocostalis Arises by a Fibers run Posterior rami Acting -lumborum broad tendon superioirly to of spinal bilaterally: -thoracis from the the angles of nerves Extends -cervicis posterior part of the lower ribs vertebral the iliac crest, and cervical column and posterior aspect transverse head as back is of the sacrum, processes flexed. sacroiliac Acting ligaments, sacral unilaterally: and inferior lateral flexion of lumbar spinous the vertebral processes and column. the supraspinous ligament. Longissimus Arises by a Fibers run Posterior rami Acting

-thoracis broad tendon superior to ribs of spinal bilaterally: -cervicis from the between nerves Extends -capitis posterior part of tubercles and vertebral the iliac crest, angles to column and posterior aspect transverse head as back is of the sacrum, processes in flexed. sacroiliac thoracic and Acting ligaments, sacral cervical regions unilaterally: and inferior and to mastoid lateral flexion of lumbar spinous of temporal the vertebral processes and bone column the supraspinous ligament. Spinalis Arises by a Fibers run Posterior rami Acting -thoracis broad tendon superiorly to of spinal bilaterally: -cervicis from the spinous nerves Extends -capitis posterior part of processes in vertebral the iliac crest, the upper column and posterior aspect thoracic region head as back is of the sacrum, and to cranium flexed. sacroiliac Acting ligaments, sacral unilaterally: and inferior lateral flexion of lumbar spinous the vertebral processes and column the supraspinous ligament.

19 b) Deep layer of intrinsic back muscles

The intrinsic back muscles consist of the transversospinal muscles that make up the deep layer and the interspinalis and intertransversarii that makes up the minor deep layer. The general anatomy is discussed in table 2.7 with relation to muscle attachment site, innervation and action.

Table 2.7 General anatomy of the deep layer of intrinsic back muscles (Moore and Dalley, 2006; Carnes and Vizniac, 2010)

Muscle Origin Insertion Innervation Action Deep layer - Transversospinal Semispinalis Arises from Fibers run Posterior rami Extends head, transverse superomedially of spinal cervical and process of C4- to occipital bone nerves thoracic regions T12 vertebrae and spinous of vertebral processes in the column and thoracic and rotates the cervical region, contralaterally spanning 4 to 6 segments Multifidus Arises from Thickest in the Posterior rami Stabilizes posterior lumbar region, of spinal vertebrae sacrum , fibers pass nerves during local posterior obliquely movements of superior iliac superomedially vertebral spine of ilium, to entire length column aponeurosis of spinous of the erector processes of spinae, vertebrae, sacroiliac located 2-4 ligaments, segments

mammillary superior to processes of origin lumbar vertebrae, transverse processes of T1-T3, articular processes C4- C7

Rotatores (brevis Arises from Fibers pass Posterior rami Stabilize and longus) transverse superomedially of spinal vertebrae and processes of ; to attach to nerves assists with best junction of local extension developed in lamina and and rotary thoracic transverse movement of region processes or the vertebral spinous column, may processes of function as vertebrae organs of immediately proprioception (brevis) or 2 segments (longus) superior to the vertebra of origin Minor deep layer Interspinalis Superior Inferior surfaces Posterior rami Aid in extension surface of of spinous of spinal and rotation of spinous processes of nerves vertebral processes of vertebrae column

cervical and superior to lumbar vertebrae of vertebrae origin Intertransversarri Transverse Transverse Posterior and Aid in lateral processes of process of anterior rami flexion of the cervical and adjacent of spinal vertebral lumbar vertebrae nerves column; acting vertebrae bilaterally, stabilizing the vertebral column

2.7 Thoracolumbar Fascia

Thoracolumbar fascia extends from the thoracic region to the sacrum and consists of three layers. The posterior layer attaches to the lumbar spinous processes, interspinous ligaments and median sacral crest. The middle layer attaches to the tips of the lumbar transverse processes and intertransverse ligaments, extending from the iliac crest to the 12th rib. The anterior layer covers the anterior aspect of the quadratus lumborum and attaches to the anterior aspects of the lumbar transverse processes, ilium and iliolumbar ligaments (Levangie and Norkin, 2005; Brolinson, Kozar and Cibor, 2003).

Thoracolumbar fascia is the main component of a multifaceted self bracing mechanism that is necessary for stability of both the lumbar spine and sacroiliac joint. Ligaments of the lumbar spine and sacroiliac joint fuse with the thoracolumbar fascia, these ligaments and thoracolumbar fascia act as primary attachment sites for the main stabilizers and movers of the spine and lower extremities. Major muscles involved include the erector spinae, quadratus lumborum, gluteus maximus and medius, lattisimus dorsi, multifidus, bicep femoris, psoas, piriformis, obliquus and transverses abdominus. Thus when muscle contractions occur it causes compression of the sacroiliac joint surfaces thus providing stability and aid with force distribution (Levangie and Norkin, 2005; Brolinson, Kozar and Cibor, 2003).

It is also important to note the contralateral crossover of the posterior layer at the level of L4-S2. The gluteus maximus and contralateral lattisimus dorsi work together and gluteus maximus and ipsilateral multifidus work together, thus bracing the area and providing stability (Levangie and Norkin, 2005).

2.8 Lower back pain 2.8.1 Introduction and prevalence of lower back pain

Chronic lower back pain (LBP) is defined by Segen (2002) as pain for 6 weeks or longer and considered as one of the most prevalent conditions in our society with 70-85% of the population experiencing pain at some point in their lives and 80% having recurrent episodes (Liddle, Baxter and Gracey, 2004). There are several anatomical structures that contribute to chronic lower back pain, including muscle, facet joints, ligaments, nerve roots, lumbar fascia, sacroiliac joints as well as intervertebral discs (Schwarzer, A.C. Aprill, C.N. Derby, R. Fortin, J. Kine. G, and Bogduk, N. 1994). Even though several anatomical structures may be contributors to pain, Manchikanti, Singh, Pampati, Damron, Barnhill, Beyer and Cash (2001) shows that facet joints are the most common pain generators in chronic mechanical lower back pain.

2.8.2 Causes and effects of lower back pain

Jenkins (2002), shows that 90% of all lower back pain cases have an underlying mechanical cause, thus it is increasingly important that the difference between relatively simple mechanical lower back pain and complex pathological causes of lower back pain are identified and differentiated. There are four underlying clinical patterns of chronic lower back pain: simple mechanical lower back pain, lower back pain with radiculopathy, lower back pain with contributing psychological factors and serious pathological lower back pain. These four categories are important to identify as this will guide the practitioner into what level of treatment is needed in each individual category (Bogduk and McGuirk, 2002).

An individual has to have 2 of the 7 following criteria in order to associate the pain pattern with joint dysfunction (Peterson and Bergmann 2002):

Localized joint pain which commonly changes with movement Local tissue hypersensitivity Decreased range of motion of the joint Altered alignment Decreased, increased or aberrant movement Altered end feel on motion palpation Local palpatory muscle rigidity

Simple mechanical lower back pain could potentially be causes by the following common conditions: facet syndrome, sacroiliac syndrome, myofascial pain syndromes, lumbar muscle strain and sprain, congenital anomilies, spondylolysis, spondylolisthesis and lumbar spine instability (Jenkins, 2002).

Lower back pain with associated radiculopathy should be seen as more of a serious condition even though it is successfully managed with conservative treatment as it directly affects the nerve roots and can cause shooting pain and paraesthesia to complete sensory and motor deficit. Possible causes could be a herniated lumbar intervertebral disc or lumbar spinal stenosis (Bogduk and McGuirk, 2002).

Pathological causes of lower back pain are rare and less than 1% of all lower back cases, considering the rare prevalence, it by no means minimize the importance of identifying these conditions. Some examples such as: Cuada equina syndrome, ankylosing spondylitis, psoriatic arthritis, reiters syndrome, enteropathic arthritis, vertebral osteomyelitis, neoplastic disease, primary and secondary bone tumors, abdominal aortic aneurism, osteoporosis (Jenkins,2002).

Lower back pain caused by psychological factors may be anxiety, depression, job or life displeasure, chronic pain syndrome and several emotional aspects. In majority of these

24 cases the pain presentation will not be true to the normal anatomical presentation and there will be inconsistency with test results and findings upon examination (Jenkins, 2002). Potentially abdominal and pelvic organs can cause pain referring to the lower back chronic cystitis, prostate cancer, endometriosis menstruation pain, hydronephrosis, colonic pain, duodenal ulcer (Bogduk and McGuirk, 2002; Jenkins, 2002).

2.9.3 Effects of chiropractic adjustive therapy and Kinesio tape on chronic lower back pain

Chiropractic manipulative therapy has been shown to be an effective treatment of CLBP and also increases lumbar range of motion. (Bronfort, G. Haas, M. Evans. R. 2008). Spinal manipulation of lumbar facet joint or sacroiliac joints produce afferent discharge of the articular mechanoreceptors (type I and II mechanoreceptors), which have the following effects: reflexogenic effect, perceptual effects and pain suppression (Wyke, 1985). Chapman-Smith (1993), concluded that the successful manipulation of a fixated lumbar facet joint or sacroiliac joint will result in restoration of normal ranges of movement, decrease of muscle spasm and there is an overall biomechanical change that occurs that contributes to removal of certain pain referral signals.

Meyer, M. Bester, C. and Landman. I. (2012), shows that chiropractic spinal manipulation and the application of Kinesio tape to the lumbar para spinal muscles to be effective treatment protocols for chronic lower back pain as entities on their own. Yet it has to be noted that the results obtained in his study showed that the combination treatment of these two treatment protocols was far more superior to the results of each treatment protocol on its own.

Kinesio tape increases lumbar range of motion and decreases pain through the neurological and circulatory effects of the tape, which will be discussed in more detail further on in the chapter. Bearing this in mind, although the application of Kinesio tape can not be considered as a substitute for therapeutic exercise in chronic lower back pain patients, it may be accepted as an added, short-term strategy to reduce pain (Youshida and Kahanov, 2007).

2.9 Integumentary system 2.9.1 Introduction

The integumentary system is the largest and one of the most important organs of the body, it is import to take note of all characteristics of this organ as it is an essential component of the study especially when we consider the mechanoreceptors of the skin as both the Kinesio tape and elastic bandage has an excessive effect on them. It is comprised out of the skin, accessory structures, such as hair, nails, glands, cutaneous membranes, muscles, nerves and receptors. The skin has roughly 640 000 sensory receptors that are connected by over half a million nerve fibers to the spinal cord. Looking at this incredible number it is of great importance not to underestimate the importance of this system (Wiles, Williams and Ahmad, 2011).

The following list describes the function of the skin: (Wiles, Williams and Ahmad, 2011; Premkumar, 2012). Protection: the skin protects the underlying tissues and organs from any harmful agents, irritation, or mechanical stress. Excretion of waste products and temperature regulation: Sweat glands produce sweat containing salt, urea, water and other organic wastes that play a role in temperature regulation. The skin helps to facilitate heat los in hot temperatures by activation of these sweat glands and vasodilation. In turn during cold conditions the skin prevents los of heat by inactivation of the sweat glands and vasoconstriction. Vitamin D synthesis. Nutrition storage. Absorption: Water and oxygen is absorbed by the skin as well as topical ointments. Lubrication: Sebaceous glands produce sebum. Immunity: Langerhans cells take up microbial antigens and transform into antigen presenting cells, in turn when these cells interact with T cells immunity is provided.

Most importantly for the purpose of this study the mechanoreceptors of the skin will be discussed: Sensation occurs through the following mechanoreceptors (Wiles, Williams and Ahmad, 2011; Premkumar, 2012):

Pacinian corpuscles – Pressure Meissners corpuscles – Point discrimination ie. Light touch Ruffinis corpuscles – Stretch and joint movement Krauses end bulbs – low frequency vibration, touch, cold Free nerve endings - Pain Hair follicle receptors – Speed and direction of movement Merkels discs – Vertical dimpling of the non hairy skin Tactile discs – Vertical dimpling of the hairy skin Nociceptors – Pain detection

Figure 2.4 Skin with the tactile receptors (Martini, 2006).

2.9.2 Innervation of the skin

The integumentary system is supplied by autonomic nerves that are made up of two types of autonomic nerves: sympathetic and parasympathetic. Sympathetic supply consists of

27 adrenergic neurons, these neurons release norepinephrine to the blood vessels, sweat glands and erector pili muscles. Parasympathetic supply consists of cholinergic neurons, these neurons release acetylcholine to the sweat glands. The skin has a sensory nerve supply that is known as the dermatome, this is an area of skin that is supplied by a specific spinal segment (Premkumar, 2012).

2.10 Chiropractic

According to the World Health Organization (2005), chiropractic can be defined as “A healthcare professional that is concerned with the diagnosis, treatment and prevention of disorders of the musculoskeletal systems and the effects of these disorders on general health. There is an emphasis on manual techniques, including joint adjustments and/or adjustment with a particular focus on subluxations.”

2.10.1 The Chiropractic Subluxation

A chiropractic vertebral subluxation should not be confused with a partial dislocation or medical subluxation and was defined by Lantz (1995), as a spinal motion segment that has altered alignment, integrity of movement and physiological function with the articular surfaces that remain in contact. Because of the altered function of the motion segment, biomechanical and neurophysiological alteration will occur (Bergman and Peterson, 2011). The importance of the vertebral subluxation is that it gives rise to the vertebral subluxation complex (VSC), a multi-faceted pathological entity. This model originally involved five components including; kinesiopathology, neuropathology, myopathology, histopathology, and biochemical abnormalities, that stimulate nociceptors resulting in pain Lantz, 1995.

Kinesiopathology involves joint fixation, hypomobility and compensation resulting in mechanical stress and degeneration.

Neuropathology involves nerve root irritation or injury due to chemical irritation, compression or stretching resulting in chronic pain and disturbed signals from the central nervous system to the intended areas of the body.

Myopathology involves pathological change of the spinal musculature resulting in altered function, hypertonicity and fibrosis.

Histopathology involves pathological changes of the spinal tissue as well as peripheral tissue affected.

Biochemical abnormalities are mainly due to inflammation of the injured tissue and cellular waste products.

Lantz (1995), modified the original five components of the VSC model by hypothesizing three more components; connective tissue pathology, vascular abnormalities, and the inflammatory response.

Gatterman (2005), suggests that spinal manipulative therapy functions to reduce the vertebral subluxation, thus normalizing the vertebral segmental motion, optimizing the physiological processes to return homeostasis and ultimately reducing pain and pathology.

2.10.2 Chiropractic Manipulative Therapy defined

Leach (2004), shows that the chiropractic joint manipulation is the most common applied chiropractic therapy and involves a short lever, low-amplitude, high velocity, controlled forceful thrust, directed at a specific articulation. This moves the joint past the physiological range of motion without exceeding the anatomical limit of safe joint play. This will restore normal nerve function and range of motion and cure disease (Bergman and Peterson, 2011).

Evans and Lucas (2010), discuss the features of a manipulation in figure 2.1, stating what is thought to be necessary for a valid definition and description of a chiropractic manipulation and is important to clearly distinguish it from other manual therapies.

Figure 2.5: The relationship of the proposed necessary features of manipulation, compared with other manual therapy interventions (Evans and Lucas, 2010)

2.10.3 Effects of spinal manipulative therapy a) Mechanical Hypothesis

Manual therapy is directed into restoring mechanical dysfunction and alleviating soft tissue pathology in musculoskeletal conditions. Soft tissue pathology that is responsible for mechanical dysfunction may be caused by repetitive movement, trauma, developmental anomilies, postural decompensating, psychological factors, reflex changes, immobilization, degenerative disease and aging. These possible causes may lead to soft tissue fibrosis, shortening of tissue, decreased flexibility, joint instability and altered biomechanics (Bergman and Peterson, 2011).

In the initial stages of soft tissue injury and repair it is of utmost importance that manual therapy is introduced, manual therapy aims to decrease pain and inflammation and improve flexible healing of tissues. This prevents the formation of scar tissue and prevents fibrosis and decreasing extensibility of tissue that could cause a disturbance in biomechanical function depending on the degree of tissue hypomobility (Bergman and Peterson, 2011).

It is important to introduce activity as soon as possible as it will minimize the effects of immobilization, this will aid in a flexible repair and remodeling and it also reduces the extent of deconditioning and illness behavior. Manual therapy is aimed to restore function and mobility (Bergman and Peterson, 2011).

Joint fixation suggests a complete or partial loss of joint motion, with numerous theories regarding the causes of joint fixation. There are inter- and extra-articular sources of derangement, with the inter-articular derangement of zygopophyseal joints, intercapsular adhesions and interdiscal derangement. Segmental muscle spasm, periarticular soft tissue fibrosis and shortening are noted as extra articular sources. The following sections describe the possible sources of joint fixation (Bergman and Peterson, 2011). b) Interarticular adhesions

Joint hypomobility may be due to interarticular adhesions between the surfaces of the zygopophysial joints, these adhesions are formed due to chronic inflammation and/or immobilization due to injury to the joint. Chiropractic adjustive therapy is shown to break these adhesions as the joint is gapped, in turn restoring normal joint mobility (Bergman and Peterson, 2011). c) Interarticular block

This refers to joint hypomobility caused by derangement within the synovial joint internal to the joint capsule. It has been hypothesized that meniscoid entrapment cause the acute episode of pain and joint locking that was potentially caused as a result of sustained

31 stressful posture or altered spinal movement. A painful myofascial cycle then develops as sustained muscle contraction ensues, leading to muscle fatigue, ischeamia and pain. Distractive adjustments have been shown to interrupts this painful cycle of muscle spasm and joint locking, releasing the entrapped meniscoid (Bergman and Peterson, 2011). d) Interdiscal block

Internal derangement of the intervertebral disc causes decreased movement of the spinal motion segment. The intervertebral disc derangement is thought to be caused by pathophysiological changes associated by age, trauma and degenerative disc disease. Farfan (1973), postulated that repetitive rotational stresses on the motion segment has been shown to lead to fatigue injury to the disc, initially with circumferential tears of the outer annular fibers and progressing to radial tears where the nuclear material is displaced externally. As with the interarticular block a painful myofascial cycle develops causing pain due to muscle spasm and joint locking. In addition to distractive effects of the zygopophyseal joints the adjustment has a potential direct effect on the disc by directing the nuclear fragments more centrally or between the lamellae of the annulus, where slighter mechanical and neurological irritation can occur (Bergman and Peterson, 2011). e) Segmental muscle spasm

Restriction of joint movement may be due to segmental muscle spasm caused by possible imbalance of agonists and antagonists. If the antagonist is not able to elongate due to involuntary constriction, the balance is lost and there is decreased joint movement. Direct injury to the myofascial structures or indirect injury or irritation of associated articular structures may cause muscle spasm (Bergman and Peterson, 2011). When there is an over stretch or tearing of muscle, numerous myofascial nociceptors initiate protective splinting of the area. The intersegment muscles of the spine are involuntary muscles with the primary function of stabilization and integrating segmental movement in relation to global movement of the region. Making them a lot more vulnerable for minor mechanical stresses and unguarded movements leading to reactive splinting (Bergman and Peterson, 2011).

The chiropractic adjustment relieves a muscle spasm through two models, a reflex response through joint distraction and direct action on the muscle. The direct muscle model shows that the adjustment produces a strong stretch on the muscle tendon complex, with the golgi tendon organ activated inducing an autogenic inhibition (Zhy, Y. Haldeman, S. and Hsieh, C. 2000). There are several mechano and nociceptors in articular soft tissue, muscle and skin. Stimulation of these low and high threshold mechanoreceptors and nociceptors has an inhibitory effect on segmental motor activity. The adjustment holds enough force and stimulates these structures, producing a spurt of somatic afferent receptor activity that may lead to muscle relaxation reflex (Herzog, W. 1993). f) Periarticular fibrosis and adhesions

Acute and repetitive injury causes articular soft tissue injury. In the process of healing, fibrosis, adhesion and contracture of the tissue may develop, leading to joint hypomobility. The adjustment helps to correct this by breaking adhesions stretching the tissue, restoring movement and correcting the input from mechano and nociceptors. In conjunction with these effects the adjustment is thought not to trigger inflammation, preventing the possibility of ongoing fibrosis (Bergman and Peterson, 2011). g) Joint instability

Clinical joint instability does not refer to the commonly thought of gross orthopedic instability, this is defined as a disorder of the spine that causes pain and is due to loss of stiffness in the intersegment tissue leading to an increase in abnormal movement. Joint instability is associated with recurrent episodes of acute joint locking, thus the chiropractic adjustment will not restore movement in this instance but rather reduce the episodic pain, muscle spasm, joint locking and joint subluxation (Bergman and Peterson, 2011).

33 h) Nerve root compression

It was theorized that a subluxation causes altered structure of the intervertebral foramina which then will lead to compressing the neurovascular bundle that passes through it, producing altered function as the axoplastic flow is impaired. Crelin, 1973 originally showed that there is an average space of 4mm at the lateral borders of the intervertebral foramina, thus the nerve root would not be anatomically vulnerable of compression. Giles, 1994 revised the theory of nerve root susceptibility and noted that his measurements taken at the interpedicular zone showed a space of only 0.4mm- 0.8mm around the nerve root and nerve root ganglion. It was concluded that the nerve root was anatomically vulnerable at the interpedicular zone and not the lateral border of the intervertebral foramina. Other possible causes of nerve root compression includes disc herniation, degenerative joint and disc disease or lateral and central stenosis. As the nerve roots are compressed by the previously mentioned conditions, associated inflammation may intensify the compressive effects when there is joint dysfunction in that area due to the compromising position. chiropractic adjustive therapy that is aimed at decreasing joint dysfunction and nerve root irritation may contribute may have an effect on reducing nerve root compression, traction and inflammation (Bergman and Peterson, 2011). i) Reflex dysfunction

When a subluxation causes compression or irritation of a nerve root, it causes a persistent nociceptive and altered proprioceptive input. This persistent afferent input results in a persistent segmental cord response which then develops into a pathologic somatosomatic or somatovisceral disease reflex. Chiropractic adjustments have the potential to arrest the local and distant somatic and visceral effects by restoring normal joint mechanics and decreasing nerve root irritation and compression (Bergman and Peterson, 2011).

Figure 2.6 Afferent and efferent pathways from and to the viscera and somatic structures (Bergman and Peterson, 2011). j) Analgesic hypothesis

Chiropractic manipulative therapy is well recognized to reduce pain and disability (Cassidy, Lopes and Yonh-Hing, 1992). Although this is true the mechanism of how the adjustment inhibits pain remains speculated and needs further investigation. It is thought that the adjustment removes the mechanical source of pain and inflammation or induces stimulus produced analgesia. Stimulus produced analgesia is supported by experimental evidence that suggests that the chiropractic adjustment produces sufficient force to stimulate and activate superficial and deep somatic nociceptors, mechanoreceptors and proprioceptors. This causes an inhibitory effect on the spinal cord sensory neurons altering the afferent input to the CNS, inhibiting the central transmission of pain, this mechanism is also known as the pain gate theory and will fully be discussed later in the chapter (Robert, Gillette and Kramis, 1987).

Figure 2.7 The inhibition of central pain transmission through activation of mechanoreceptors and nociceptors (Bergman and Peterson, 2011).

Gilette (1987) proposes that chiropractic adjustment initiates a short lived phasic response and a long lived tonic response. The short lived phasic response is elicited by the stimulation of both deep and superficial mechanoreceptors and also thought to cause a local gating effect, however the pain inhibition ends with the cessation of therapy. The long lived tonic response is elicited by noxious level of mechanical stimulation of the nociceptors and lasts longer than the duration of therapy (Gillette et al., 1991).

Vernon (1986) has suggested that adjustments are associated with short bursts of nociceptive and proprioceptive input that is thought to increase neurochemical pain inhibitors. Both the local release of enkephalins and systemic release of endorphins in plasmic and cerebrospinal fluid act as endogenous opiod pain inhibitors and may play a role in the analgesic effect of a chiropractic adjustment (Bergman and Peterson, 2011).

36 k) Circulatory Hypothesis

Chiropractic manipulative therapy produces a valuable vascular response that is a product of autonomic nervous system stimulation, removing sympathetic irritation, improving musculoskeletal function restoring segmental motion, caused by reduced segmental subluxation due to chiropractic adjustments (Bergman and Peterson, 2011).

Musculoskeletal function and integrity directly affects the circulatory system. Blood and lymphatic vessels pass through the muscle and in effect when there is muscle spasm there will be a decreased circulatory flow. Chiropractic adjustments are directed at improving mobility and functionality of the skeletal system, this will enable the muscles to function optimally and improve circulation (Greenman, 1989).

2.11 Taping

There are several different types of tapes available today to address several musculoskeletal problems involving patients and athletes. The most commonly used types of tape include: white athletic tape, McConnell tape, and Kinesio tape (Hassan, Mockett and Doherty, 2002). The choice of tape depends on what the practitioner wants to achieve, whether it is one of the more popular choices that give direct support and stabilization or more of a therapeutical effect. Both being successful in temporarily decreasing pain and symptoms (Kase, Wallis, J. and Kase 2003).

2.11.1 MCconnel taping technique

The McConnell tape is an adhesive, super-rigid tape that limits unwanted joint movement and protects and supports joint structures, primarily used for its improvements in neuromuscular re-education (Osterhues, 2004). It is also thought to affect the biomechanics of the area of application. Common conditions that it is used for are indicated as: shoulder subluxation (medical), patellofemoral syndrome and lumbar, foot and hip impingement (Kase, Wallis, J. and Kase 2003).

2.11.2 White athletic taping

The most common taping technique used in injury prevention and support of acute injuries is white athletic tape. Athletic tape is not used for rehabilitative purposes because of its rigidity it limits joint movement and the supportive characteristics negatively affect the weakened or injured muscles reducing the extent of healing and function (Simoneau, Degner, Kramper and Kittleson, 1997). The tape is typically applied prior to an activity and removed immediately after the activity as it may cause skin irritation due to the high latex content, moisture entrapment and compression of the skin, joint and muscle (Kase, Wallis and Kase, 2003).

It is important to take note of Bragg, Macmahon, Overom, Yerby, Matheson and Carter (2002), findings that athletic tape loses the function of limitation joint movement after 10-20 minutes of exercise. Consequently the effects of taping may primarily be due to the proprioceptive properties of taping (Simoneau, Degner, Kramper and Kittleson, 1997) this property has been examined using the current research topic to determine whether this suggested theory can be supported and add to the body of literature on proprioception.

2.11.3 Proprioceptive properties of elastic bandage

Proprioceptive information is collected from at least three sources: cutaneous tactile and pressure receptors, articular mechanoreceptors and muscle spindles with the golgi tendon organ. There are numerous types of cutaneous receptors that contribute to proprioception but the mechanoreceptors are of most significance to joint position as they respond to movement and touch. Some of these receptors, as discussed previously, are sensitive to movement of light objects over the skin (Meissner’s corpuscles and free nerve endings) though others are stimulated by rapid movement (Pacinian corpuscle) and some receptors detect continuous movement in joint capsules and respond to the degree of joint movement (Hassan, Mockett and Doherty, 2002). Considering all the proprioceptive structures mentioned it is obvious that there is an extensive amount of sensory input within and around the joint and serves as justification of using elastic bandage on a area where

38 maximum stimuli is needed (Khabie, Schwartz, Rokito, Gallagher, Cuomo, Zuckerman, 1998).

2.11.4 Kinesio Taping

Kinesio Taping method is applied over muscles to reduce pain and inflammation, relax overused muscles and to support muscles and joints without restricting range of motion (Kase, Wallis, J. and Kase 2003). Rather than being mainly structurally supportive, Kinesio tape is more therapeutic in nature as it is based on the bodies own natural healing process. It can activate the neurological and circulatory system, providing theraputical benefits for both acute and chronic musculoskeletal conditions and injuries (Halseth, McChesney, DeBeliso, Vaughn and Lien, 2004).

Kinesio tape may provide benefits to patients who present with the following but not limited to torticollis, compartment syndrome, thoracic outlet syndrome, herniated disk, calf cramps, plantar fasciitis, Bells palsy, and headaches, whiplash, tennis elbow, lower back and neck pain, shoulder injuries, patella tracking problems, ankle sprains, pre and post surgical oedema (Kase, Wallis and Kase 2003).

Kineso tape is 100% cotton, the fibers are thin, air permeable, latex free, non medicated and acrylic adhesive fabric and differs from other elastic tapes as it can be stretched up to 140% of its original length, in turn applying a constant pulling force to the skin and activating mechanoreceptors (Halseth, McChesney, DeBeliso, Vaughn and Lien, 2004; Kahanov, 2007). The elastic quality of the tape creates convolusions that are thought to lift the skin, relieving underlying pressure and promoting proper venous and lymphatic flow. Moisture and air flow through the porous fabric minimizes skin irritation, allowing the tape to be worn continuously for three to four days (Youshida and Kahanov, 2007).

According to Kenzo Kase, the creator of Kinesio tape, the proposed mechanisms of how Kinesio tape works may include: (Kase, Wallis and Kase 2003). correcting muscle function by strengthening weakened muscles,

improving circulation of blood and lymph by eliminating tissue fluid or bleeding beneath the skin by moving the muscle, decreasing pain through neurological suppression, and repositioning subluxed joints by relieving abnormal muscle tension, helping to return the function of fascia and muscle.

Murray and Husk (2001), has suggested a fifth mechanism that Kinesio tape causes an increase in proprioception through increased stimulation to the cutaneous mechanoreceptors. It is important to remember hat the proprioceptive information is collected by three sources mentioned under 2.14.3 thus also justifying the application of Kinesio tape. Taping provides immediate sensorimotor feedback through direct contact between the skin and tape providing a sense of awareness (Zajt-Kwiatkoska, Rajkowska- Labon, Skrobot, Bakula and Szamotulska, 2007). With the application of Kinesio tape patients often report symptom relief, improved comfort levels or stability of the joint (Kase, Wallis, J. and Kase 2003). This proposed fifth mechanism has been examined using the current research topic to determine whether this suggested theory can be supported and add to the body of literature on proprioception.

The application of Kinesio tape is fairly simple and is always applied based on the treatment goals, whether it is improving active range of motion, pain relief, adjust misalignment or improving lymphatic circulation (Kase, Wallis, J. and Kase 2003). The variables in the application include position of the affected area, amount of pre-stretch applied to the tape, and the treatment goals (Kahanov, 2007). Pain reduction occurs due to the mechanical stimulation that the tape has on the skin (Kase, K and Wallis, J. 2003), this pathway is known as the pain gate theory (Esposito and Philipson, 2005).

The “gate control” theory of pain was introduced by Malzack and Wall (1965), he proposed that pain transmission can be modulated by altering the afferent input to the dorsal horn of the spinal cord. There are large diameter fibers that transmit stimuli of stretch and touch and the small nociceptive nerve fibers carry information to two locations in the dorsal horn of the spinal cord from the site of injury; these areas are known as the “inhibitory” cells and “transmission” cells. Signals from the large and small diameter fibers excite the

40 transmission cells, when the output of these cells surpasses a critical level, pain is initiated. The inhibitory cells function to inhibit the activation of the transmission cells. The transmission cells are the gate on pain and the inhibitory cells are able to close the gate. When the large and small diameter fibers are activated by noxious stimuli, there is excitation of the transmission cell, they also act on the inhibitory cells. The small diameter fibers block the inhibitory cells, which leaves the gate open, while the large diameter fibers excite the inhibitory cells, closing the gate. Thus the more activity of large diameter fibers relative to small diameter fibers coming from the inhibitory cell receptive field, the less pain that is perceived.

It is important not to forget about the collateral branches that are given of by large diameter afferent fibers of low threshold mechanoreceptors at segmental levels of the spinal cord. These collaterals excite the inhibitory interneurons, resulting in suppressing painful afferent stimuli, causing pain relief (Guyton and Hall, 1997).

Figure 2.8 The sensory stimulation and its hypothesized effects upon the dorsal horn. (Modified from Esposito and Philipson, 2005)

An essential part of the theory is the influence of the analgesia system. The analgesia system consists of three major components: (Guyton and Hall, 1997).

The periaqueductal grey matter, located in the mesencephalon and upper pons surrounding the aqueduct of Sylvius, neurons in this area send their signals to the

Raphe Magnus nucleus, a thin midline nucleus located in the lower pons and upper medulla. From here the signals are transmitted down the dorsolateral coulombs to

A pain inhibitory complex located in the dorsal horn of the spinal cord.

At this point pain arriving from the peripheral nerves can be blocked by the analgesia signals before it is transmitted to the brain. Electrical stimulation in the periaqueductal grey matter and raphe magnus nucleus can almost completely suppress pain signals entering the dorsal horn (Guyton and Hall, 1997).

Several transmitter substances such as serotonin and enkephalins are involved in the analgesia system. Serotonin stimulates the release of enkephalins from the cord neurons and enkephalins cause pre synaptic inhibition of the small diameter nociceptive fibers in the dorsal horn of the spinal cord (Guyton and Hall, 1997). Thus pain signals can be blocked by the analgesia system at the entry of the spinal column and appears to be long standing (Guyton and Hall, 1997). Looking at the pain gate theory it is easy to understand why the application of kinesio tape will decrease pain, the tape provides a mechanical stimulation via the skin, activating the large diameter fibers, closing the gate to nociceptive stimulation that is caused by for instance in our study by chronic lower back pain.

CHAPTER THREE – METHODOLOGY

3.1 Introduction

This chapter systematically describes the design of the study, recruitment procedure and treatment protocols that were used as well as the different measurement techniques used in the study.

3.2 Study Design

This clinical study was a comparative study with random group allocation.

3.3 Participant Recruitment

Advertisements were placed all over the University of Johannesburg Doornfontein Campus and at the Chiropractic Day Clinic (Appendix A) and by word of mouth. The research was conducted at the University of Johannesburg chiropractic day clinic, Doornfontein campus.

3.4 Sample Selection and Size

Thirty participants volunteered to take part in this study and were randomly divided into two groups. Group 1 was treated with lumbar spine and sacroiliac joint adjustments and the application of Kinesio tape. Group 2 was treated with lumbar spine and sacroiliac joint adjustments and the application of elastic bandage. If any of the participants were not able to complete the study, additional participants would be recruited to complete the study.

3.5 Inclusion Criteria

The participants participating in the study had to be: Between the ages of 18-45 due to the increased prevalence of degenerative changes in individuals older than 45 years (Carnes and Vizniak, 2010)

Male or female The patients had to have 2 of the 7 following criteria associated with joint dysfunction (Peterson and Bergmann 2002): Localized joint pain which commonly changes with movement Local tissue hypersensitivity Decreased range of motion of the joint Altered alignment Decreased, increased or aberrant movement Altered end feel on motion palpation Local palpatory muscle rigidity The participants must present with chronic lower back pain (pain for longer than 6 weeks) (Segen, 2002)

3.6 Exclusion Criteria

Any contraindications to chiropractic manipulative therapy (Appendix B) Any contraindication to Kinesio tape (Appendix C) Any allergic reactions to elastic bandage Participants who have had any form of medication or treatment a week before or during study related to lower back pain

3.7 Group allocation

Thirty participants with chronic lower back pain were divided up randomly into 2 groups, with 15 participants in each group. The participants had the opportunity to select a sealed envelope, containing a card that either had Group 1 or Group 2 written on. Group 1 was treated with lumbar spine and sacroiliac joint adjustments and the application of Kinesio tape. Group 2 was treated with lumbar spine and sacroiliac joint adjustments and the application of elastic bandage.

3.8 Treatment Protocol 3.8.1 First Consultation

The first consultation included the following: The study was explained to the participant and asked to complete the information sheet and sign a consent form (Appendix D), before a full physical examination of the participant was performed Motion palpation of the lumbar spine and sacroiliac joint Lumbar range of motion was measured using a Digital Inclinometer to obtain objective data prior to treatment (Appendix I) Completion of the Oswestry Low Back Pain and Disability Questionnaire and the Numerical Pain Rating Scale (NPRS) was done to obtain the subjective measurements prior to the treatment (Appendix J and K) Treatment was chosen according to the participant’s allocated group

3.8.2 Follow-up Visits

The follow-up consultations included the following: Subjective and objective data was collected prior to treatment on the first and fourth consultation as well as the final consultation, where no treatment was provided Each group received the respective treatment protocol as allocated. Group 1 was treated with lumbar spine and sacroiliac joint adjustments and the application of Kinesio tape. Group 2 was treated with lumbar spine and sacroiliac joint adjustments and the application of elastic bandage In both groups where Kinesio tape and elastic bandage was applied, new applications were done at each treatment A total of six treatments and a seventh consultation, where no treatment was provided, took place over a 3 week period

3.9 Motion palpation

The lumbar spine and SIJ was assessed by using motion palpation of each individual lumbar segment and SIJ, noting dysfunction or restriction. The involved level and direction of the restriction was noted and used to determine the line of drive of the selected manipulative technique (Halderman, 1993).

3.9.1 Lumbar Spine

The following movement of lumbar spine was palpated by the examiner for segmental restricted movement: a) Segmental Flexion:

Patient position: Seated. Examiner position: Standing at the side of the patient. Contact: Above and below the interspinous space with the finger pads of the index and middle finger. The doctor’s forearm is draped across the patients shoulder. Procedure: Start at the level of T12-l1 and move down to the level of L5- S1. The examiner keeps the fingers in the interspinous spaces stationary, it is used to feel the spinous processes separate as the examiner induces flexion of the lumbar spine with the forearm. The examiner feels for the gap between the spinous processes to open and close. If the gap does not close the segment is restricted into flexion. b) Segmental Extension:

Procedure: Start at the level of T12-L1 and move down to the level of L5- S1. The examiner keeps the fingers in the interspinous spaces stationary, it is used to feel the spinous processes separate as the examiner induces flexion of the lumbar spine with the forearm. The examiner feels for the gap between the spinous processes to open and close. If the gap does not open the segment is restricted into extension. c) Segmental lateral flexion:

Patient position: Seated. Examiner position: Stand behind the patient. Contact: Lateral and inferior aspect of the spinous process on the homolateral side of the examiner. Contact is taken with the tips of the index and middle finger, motion palpating two segments simultaneously. The contralateral forearm of the examiner is draped around the shoulders of the patient. Procedure: Start at the level of T12 – L1 and move down to the level of L5-S1. Relaxation of the spinal tissue has to be palpated and ensured. The patient is laterally flexed, coupling into the concavity feeling for the approximation of the two spinous processes. Repeat on the opposite side. d) Segmental rotation:

Patient position: Seated Examiner position: Standing behind the patient: Contact: Lateral aspect of the spinous process on the homolateral side of the examiner. Contact is taken with the tips of the index and middle finger, motion palpating two segments simultaneously. The contralateral forearm of the examiner is draped around the shoulders of the patient. Procedure: Start at the level of T12-L1 and move down to the level of L5-S1. Rotate the patient towards the examiner and feel the movement of the spinous process relative to the one below. The upper spinous process should move away from the lower one.

3.9.2 Sacroiliac Joint

The sacroiliac joint was palpated by using the Gillets test, feeling for decreased range of motion in flexion and extension (Esposito and Philipson, 2005). a) Gillets Test

Patient position: Standing and holding onto an object for support. Examiner position: Kneeling down behind the patient with the eyes level with the contact. Contact: Thumb of one hand on the posterior superior iliac spine (PSIS) and the thumb of the opposite hand on the second sacral tubercle. Procedure: Phase I: instruct the patient to flex one hip to 90. Maintain careful contact with the PSIS of the homolateral side. The thumb contacting the homolateral PSIS will drop inferior in relation to the second sacral tubercle with normal sacroiliac extension. Have the patient return the foot to the ground. Phase II: with the same contact points ask the patient to flex the opposite hip past 90. Maintain the contact point, note what is happening at the contact point of the second sacral tubercle. In normal sacroiliac flexion the second sacral tubercle drops inferior. Repeat on the other side. Interpretation: Phase I: if the PSIS does not move inferior (or is decreased compared to the opposite side), it is understood that side has decreased in flexion. Phase II: if the second sacral tubercle does not move inferior (or is decreased compared to the opposite side), it is understood that side has decreased in extension.

3.10 Chiropractic Manipulation

After determining the direction and level of the segmental restriction, participants were adjusted by specific short lever chiropractic manipulative technique.

3.10.1 Spinous hook pull technique

The spinous hook pull was used for any lumbar spine restrictions found during motion palpation (Peterson and Bergmann, 2002).

Patient position: The patient is in a side posture position, with the dorsum of the upper foot placed in the popliteal fossa of the lower leg and the arms crossed over the chest as to balance the patient.

Doctors position: Square stance to the patient with the doctors knee placed on the patients upper knee.

Contact hand: Reinforced finger tip contact of the first three fingers of the caudal hand on the inferior aspect of the restricted spinous processes. The forearm resting on the posterolateral iliac crest of the patient.

Indifferent hand: The cephalad hand contacts the patients upside shoulder and overlapping hand.

Line of drive: The doctor’s forearm rotates the patients pelvis anteriorly. The thrust is delivered as a body drop at the end of expiration. The line of drive is anteriorly with the forearm, upward with the contact hand and inferior with the knee, all occurring simultaneously.

3.10.2 Thigh-ilio-deltoid technique

The thigh-ilio-deltoid technique was used for any sacroiliac joint restrictions found during motion palpation (Esposito and Philipson, 2005).

Patient position: Side-lying with the restricted side uppermost. The arms are placed across the chest so as to balance the patient. The dorsum of the upper foot is placed in the popliteal fossa of the lower leg which is kept straight.

Doctor position: Facing the patient, grasp the patient’s knee between the thigh at the point where the correct amount of hip flexion is achieved, adduct the patients thigh and assume fencer stance.

Contact hand: Caudal hand contacts with a specific pisiform contact on the inferomedial aspect of the PSIS. The elbow is flexed and the forearm is kept perpendicular to the contact hand. Indifferent hand: The cephalad hand takes contact on the upper shoulder and provides cephalad traction. Line of drive: Rotate the innominate anteriorly into extension. The thrust is delivered at the end of expiration as a body drop with an impulse. The line of drive is posterior to anterior and slightly superior. The contact hand drives the PSIS anteriorly with slight ulnar torque.

3.11 Application method of Kinesio tape and elastic adhesive bandage to the lumbar para-spinal muscles

Both the Kinesio tape and elastic bandage was applied in the same manner according to the Clinical Therapeutic Applications of Kinesio Taping method Manual (Kase, Wallis, J. and Kase 2003). The Kinesio tape and elastic bandage was pre-cut into 20cm x 5cm pieces ready for application and both were tan colour to ensure that none of the patients could distinguish between the two different tapes. Patients were instructed to keep the tape on for the consecutive days between treatments, as a new application of tape was applied at each treatment.

3.11.1 The method of application consist of the following steps:

Step 1: The patient was asked to stand uprights with the lower back appropriately exposed. Step 2: Two 20cm x 5cm pre cut strips was applied to the skin over bilateral PSIS. Step 3: The patient was asked to flex forward as far as possible. Step 4: Remainder of the tape was applied to the skin in the flexed position without stretching the tape. Step 5: The researcher rubbed the tape application to ensure adhesion of the tape to the skin. Step 6: The patient was then asked to stand upright.

3.12 Objective Data 3.12.1 Digital Inclinometer

Measurement of active lumbar spine range of motion was measured with a Digital Inclinometer, measuring the degree of motion in forward flexion, extension, rotation (left and right) and lateral flexion (left and right). The hand held Digital inclinometer has a LCD screen enabling visual display of its position. The Digital Inclinometer has been proven to be valid and reliable (Fisher and Johnston, 1997; Tousignant, Morissette and Murphy, 2002). In order to measure and isolate lumbar spine range of motion two readings were taken. The first reading was taken between the interspinous space of T12 and L1 and the second reading was taken between the interspinous space of L5 and S1. Thereafter the second reading was subtracted from the first reading in order to isolate the lumbar motion.

Table 3.1: Normal range of motion of the lumbar spine (Kapanje, 2006)

Forward Flexion Extension Lateral Flexion Rotation 40- 60 20 - 35 15 - 20 3 - 18

a) Flexion and Extension

Participants were asked to stand erect Researcher located the interspinous space between T12 and L1 and placed the Digital Inclinometer in that interspace and zeroed with each motion completed. Participant was instructed to fully flex forward and extend backward respectively, keeping the knees fully extended. Measurements were recorded at maximal flexion and extension. Researcher located the interspinous space between L5 and S1 and placed the Digital Inclinometer in that interspace and zeroed with each motion completed. Participant was instructed to fully flex forward and extend backward respectively keeping the knees fully extended Measurements were recorded at maximal flexion and extension.

b) Lateral Flexion

Participants were asked to stand erect Researcher located the interspinous space between T12 and L1 and placed the Digital Inclinometer in that interspace and zeroed with each motion completed. Participant was instructed to fully laterally flex left and right respectively, keeping the knees fully extended. Measurements were recorded at maximal left and right lateral flexion.. Researcher located the interspinous space between L5 and S1 and placed the Digital Inclinometer in that interspace and zeroed with each motion completed. Participant was instructed to fully laterally flex left and right respectively, keeping the knees fully extended. Measurements were recorded at maximal left and right lateral flexion. c) Rotation

Participants were asked to stand erect Researcher located the interspinous space between T12 and L1 and placed the Digital Inclinometer in that interspace and zeroed with each motion completed. Participant was instructed to fully rotate to the left and right respectively, keeping the knees fully extended. Measurements were recorded at maximal left and right rotation. Researcher located the interspinous space between L5 and S1 and placed the Digital Inclinometer in that interspace and zeroed with each motion completed. Participant was instructed to fully rotate to the left and right respectively, keeping the knees fully extended. Measurements were recorded at maximal left and right rotation.

3.13 Subjective Data 3.13.1 Oswestry Low Back Pain and Disability Questionnaire

The Oswestry Low Back Pain and Disability Questionnaire was used to measure the participants functional level of disability due to lower back pain. The participant were required to answer the questionnaire made up of ten sections with six possible choices to answer the section, including what the pain intensity was and how daily activities such as walking, sitting, and lifting were affected. Each question allows for a maximum score of 5 and a minimum score of 0 to be scored. The points assigned at each section were then calculated to get a final score out of a potential 50 points with the representation of the calculated values summarized in table 3.2. This is shown to be a valid and reliable questionnaire (Fairbank and Pynsent, 2000). Davidson and Keating 2002, shows that the Oswestry Low Back Pain and Disability Questionnaire is the most accurate in measuring chronic pain sufferer’s disability.

Table 3.2: Score and interpretation of the Oswestry Low Back Pain and Disability Questionnaire (Fairbank and Pynsent, 2000).

Score Interpretation 0 – 10 Minimal disability 11 – 20 Moderate disability 21- 30 Severe disability 31 – 40 Crippled 41 – 50 Bed-bound or malingering

3.13.2 Numerical Pain Rating Scale (NPRS)

The participants were asked to complete the Numerical Pain Rating Scale (NPRS) as shown in figure 3.1 where they chose a number on the scale. Including numbers from 0 representing no pain to 10 representing the worst pain they have ever felt that best represents their pain at that moment. The NPRS has been shown to be valid and reliable by Bolton and Wilkinson (1998).

No pain Moderate pain Severe pain 0 1 2 3 4 5 6 7 8 9 10

Figure 3.1: Numerical Pain Rating Scale (NPRS)

3.14 Data Analysis

Subjective and objective data from the above mentioned methods were collected by the researcher during the study period. The data collected was analyzed by statisticians located at the University of Johannesburg Kingsway Campus at STATKON. Inter and intra-group analyses were performed using non-parametric tests. If differences were found between the groups, the Mann-Whitney U test was used. However if there were no differences between the groups then the Independent Samples T-Test (parametric test) was used. Intra-group data will be analyzed using the Friedman Test and if there were differences over time, the Wilcoxon-Signed Ranks Test was rather used.

3.15 Ethical Considerations

All participants who wished to partake in this particular study was required to read and sign the information and consent form specific to this study (Appendix B). The information and consent form outlined the names of the researcher, purpose of the study and benefits of partaking in the study, participant assessment and treatment procedure; any risks, benefits and discomforts pertaining to the treatments involved was explained and the participants safety was ensured (prevention of harm). The information and consent form explained that the participant’s privacy was protected by ensuring their anonymity (no names and data) and confidentiality (standard patient doctor confidentiality) when compiling the research dissertation. The patient files were stored in a strong room at the University of Johannesburg Chiropractic Day Clinic. The participants were informed that their participation is on a voluntary basis and that they are free to withdraw from the study at any stage. Should the participant have had any further questions, these would have been

54 explained by the researcher. The participants were required to sign the information and consent form, signifying that they understand all that was required of them for this particular study. Results of the study were made available on request.

During this study the following risks, benefits and discomforts were noted: relieving complaint of lower back pain and increasing range of motion. This leads to a better quality of life. Slight discomfort may have occurred due to an allergic reaction to either the elastic bandage or Kinesio tape, where participants were removed from the study and advised by the researchers about treatment measurements for the allergic reaction. Some post adjustment tenderness may have been experienced.

Participants were referred when necessary.

CHAPTER FOUR- RESULTS

The following chapter is a depiction of the statistical results of the recorded data in the clinical study. The analysis of data included the demographic data consisting of age and gender distribution of the participants and the inter- (evaluating the response to treatment of each group respectively establishing the general response and outcome of the treatment protocols used) and intra-group (comparing response of treatment between the two treatment groups determining whether there are superior results in outcome of the treatment protocols) analysis of both the objective and subjective measurements. The objective measurements consist of the readings of the Digital Inclinometer during flexion, extension, lateral flexion and rotation. The subjective data consisting out of the Numerical Pain Rating Scale and the Oswestry Pain and Disability Index.

It is important to note that the sample group consisted out of 30 participants, the statistical results represent a small group of subjects, and thus no assumptions can be made with respect to the population as a whole. The p-value for statistical significant analysis was set at p≤ 0,05 for all tests, therefore any p-values noted being less than 0.05 were statistically significant and of value of being discussed.

The Shapiro-Wilk Test was performed to determine normality. Because this test was inconclusive for this study, it was decided to use the non-parametric testing. The two tests used, were the Friedman Test and the Wilcoxon Signed Rank Test. The Friedman Test was used to determine if a change occurred over time (visit 1 to visit 7) within each group. The Wilcoxon Signed Rank Test was used to determine where the change within each group occurred i.e. visit 1 to visit 4 or from visit 4 to visit 7. Furthermore the Mann-Whitney U Test was used to determine intergroup results.

4.1 Demographic data analysis

Table 4.1: Demographic data of the participants

Data Group A Group B Combined Total Age 20-32 20-30 20-32 Mean Age 25.07 24.80 24.94 Gender Male 8 8 15 Female 7 7 15

Participants in group A were between the ages of 20 and 32 years of age, with a mean age of 25.07. The group consisted of 15 participants with 7 females and 8 males. Participants in group B were between the ages of 20 and 30 years of age, with a mean age of 24.80. The group consisted of 15 participants with 7 females and 8 males. The groups were therefore found demographically comparable and no participants were excluded during the study.

4.2 Objective data 4.2.1 Lumbar flexion

Table 4.2: Comparative results of lumbar range of motion in degrees of lumbar flexion

Total Sample Consult Groups Min ROM Max ROM Mean ROM Standard Deviation 1 A 34 59 47 7.5 B 40 63 49.86 8.85 Total 37 61 48.43 8.14 4 A 30 66 46.67 10.97 B 39 75 55.67 11.12 Total 34.5 70.5 51.17 11.05

7 A 31 54 45.53 6.73 B 35 75 53.27 13.18 Total 33 64.5 49.4 9.96

With reference to table 4.2 the measurements were taken prior to treatment on the 1st and 4th consultation and finally on the 7th consultation, rendering the recorded results. The mean value decreased from 47 to 45.53 in group A and increased from 49.86 to 53.27. It is interesting to note that the degrees of flexion in group B only increased notably from the 1st to 4th consultation. a) Intragroup analysis

The intragroup analysis evaluates the response of treatment in each individual group, determining whether there is a difference over time and tests the positive outcome of the chosen treatment protocol.

Table 4.3: Non Parametric Test Results for Lumbar Flexion – Friedman Test

Non Parametric Tests

Test Group A Group B

Friedman Test 0.793 0.116

P value is >0.05 >0.05

With reference to lumbar flexion, the P-value is shown in table 4.3 for group analysis of group A was 0.793 (>0.05) and group B was 0.116 (>0.05), indicating that the results were not statistically significant, showing that there was no difference over time. b) Intergroup analysis

Intergroup analysis functioned to compare the response of treatment between the two treatment groups and treatment protocols, which then established if either protocol

58 demonstrated superior results. The results were based on the readings recorded on the first, fourth and seventh consultation.

Table 4.4: Non Parametric Test Results for Lumbar Flexion – Mann-Whitney Test

Non Parametric Tests Test Group 1st Outcome 2nd outcome Final Outcome Mann-Whitney Combined 0.575 0.056 0.140 P value is >0.05 >0.05 >0.05

With reference to table 4.4 the range of motion results showed the P-value to be 0.140 (>0.05) at the end of treatment protocol for lumbar flexion. Thus, indicating that the results were not statistically significant in treatment response, demonstrated between the groups at the end of the trial.

4.1.2 Lumbar extension

Table 4.5: Comparative results of Lumbar Range of Motion in degrees of Lumbar Extension

Total Sample Consult Groups Min ROM Max ROM Mean ROM Standard Deviation 1 A 11 44 20.20 8.71 B 9 32 19,47 5.77 Total 10 38 19.84 7.24 4 A 8 40 20.07 10.3 B 9 39 18.40 7.6 Total 8.5 39.5 19.24 8.95 7 A 7 37 20.07 8.4 B 10 26 18.07 5.19

Total 8.5 31.5 19.07 6.8

With reference to lumbar extension the measurements were taken prior to treatment on the 1st and 4th consultation and finally on the 7th consultation, rendering the recorded results that is shown in table 4.5. The mean value decreased from 20.20 to 20.07 in group A and decreased from 19.47 to 18.07. It is interesting to note that the degrees of extension in group A only decreased marginally from the 1st to 4th consultation and reaching a plateau from the 4th to 7th consultation. a) Intragroup analysis

Table 4.6: Non Parametric Test Results for Lumbar Extension – Friedman Test

Non Parametric Tests

Test Group A Group B

Friedman Test 0.819 0.766

P value is >0.05 >0.05

With reference to lumbar extension, the P-value is shown in table 4.6 for group analysis of group A was 0.819 (>0.05) and group B was 0.766 (>0.05), indicating ), indicating that the results were not statistically significant. b) Intergroup analysis

Intergroup analysis functioned to compare the response of treatment between the two treatment groups and treatment protocols, which then established if either protocol

60 demonstrated superior results. The results were based on the readings recorded on the first, fourth and seventh consultation.

Table 4.7 Non Parametric Test Results for Lumbar Extension – Mann-Whitney Test

Non Parametric Tests Test Group 1st Outcome 2nd outcome Final Outcome Mann-Whitney Combined 0.771 0.901 0.574 P value is >0.05 >0.05 >0.05

With reference to table 4.7 the range of motion results showed the P-value to be 0.574 (0.05) at the end of treatment protocol for lumbar extension. Thus, indicating that the results were not statistically significant in treatment response, demonstrated between the groups at the end of the trial.

4.1.3 Lumbar left lateral flexion

Table 4.8: Comparative results of Lumbar Range of Motion in degrees of Lumbar left Lateral Flexion

Total Sample Consult Groups Min ROM Max ROM Mean ROM Standard Deviation 1 A 13 34 19.87 6.22 B 17 29 21.93 3.41 Total 15 31.5 20.9 4.82 4 A 8 45 24.20 8.41 B 15 30 24.27 5.42 Total 11.5 37.5 24.24 6.92 7 A 12 28 20.20 5.64 B 16 31 21.13 4.02

Total 14 29.5 20.67 4.83

With reference to lumbar left lateral flexion the measurements were taken prior to treatment on the 1st and 4th consultation and finally on the 7th consultation, rendering the recorded results that is shown in table 4.8. The mean value increased from 19.87 to 20.20 in group A and decreased from 21.93 to 21.13. It is interesting to note that the degrees of left lateral flexion in group A and B only increased from the 1st to 4th consultation and decreased from the 4th to 7th consultation. a) Intragroup analysis

Table 4.9: Non Parametric Test Results for Lumbar left Lateral Flexion – Friedman Test

Non Parametric Tests

Test Group A Group B

Friedman Test 0.128 0.101

P value is >0.05 >0.05

With reference to lumbar left lateral flexion, the P-value is shown in table 4.9 for group analysis of group A was 0.128 (>0.05) and group B was 0.101 (>0.05), indicating that the results were not statistically significant, showing that there was no difference over time.

Table 4.10: Non Parametric Test Results for Lumbar left lateral Flexion – Wilcoxon signed rank test

Non Parametric Test Results Test Group Consult 1-4 Consult 4-7 Consult 1-7 Wilcoxon A 0.093 0.033 0.729 P value is >0.05 <0.05 >0.05 Wilcoxon B 0.131 0.088 0.230 P value is >0.05 >0.05 >0.05

Table 4.10 demonstrates the P-value obtained for group analysis of group A was 0.033 (<0.05), indicating a statistically significant difference between the 4th and 7th consultation results. b) Intergroup analysis

Intergroup analysis functioned to compare the response of treatment between the two treatment groups and treatment protocols, which then established if either protocol demonstrated superior results. The results were based on the readings recorded on the first, fourth and seventh consultation.

Table 4.11: Non Parametric Test Results for Lumbar left Lateral Flexion – Mann- Whitney Test

Non Parametric Tests Test Group 1st Outcome 2nd outcome Final Outcome Mann-Whitney Combined 0.168 0.516 0.818 P value is >0.05 >0.05 >0.05

With reference to table 4.11 the range of motion results showed the P-value to be 0.818 (>0.05) at the end of treatment protocol for lumbar left lateral flexion. Thus, indicating that

63 the results were not statistically significant in treatment response, demonstrated between the groups at the end of the trial.

4.2.4 Lumbar right lateral flexion

Table 4.12: Comparative results of Lumbar Range of Motion in degrees of Lumbar right Lateral Flexion

Total Sample Consult Groups Min ROM Max ROM Mean ROM Standard Deviation 1 A 12 36 19.73 6.12 B 12 27 18.93 5.20 Total 12 31.5 19.33 5.66 4 A 14 34 22.47 5.76 B 14 45 22.20 8.22 Total 14 39.5 22.34 6.99 7 A 9 34 21.27 7.33 B 10 31 20.40 5.37 Total 9.5 32.5 20.84 6.36

With reference to lumbar right lateral flexion the measurements were taken prior to treatment on the 1st and 4th consultation and finally on the 7th consultation, rendering the recorded results demonstrated in table 4.12. The mean value increased from 19.73 to 21.27 in group A and increased from 18.93 to 20.40. a) Intragroup analysis

Table 4.13: Non Parametric Test Results for Lumbar right Lateral Flexion – Friedman Test

Non Parametric Tests

Test Group A Group B

Friedman Test 0.802 0.645

P value is >0.05 >0.05

With reference to lumbar right lateral flexion, the P-value is demonstrated in table 4.13 for group analysis of group A was 0.802 (>0.05) and group B was 0.645 (>0.05), indicating that the results were not statistically significant, showing that there was no difference over time. b) Intergroup analysis

Table 4.14: Non Parametric Test Results for Lumbar right Lateral Flexion – Mann- Whitney Test

Non Parametric Tests

Test Group 1st Outcome 2nd outcome Final Outcome Mann-Whitney Combined 0.851 0.506 0.835 P value is >0.05 >0.05 >0.05

With reference to table 4.14 the range of motion results showed the P-value to be 0.835 (>0.05) at the end of treatment protocol for lumbar right lateral flexion. Indicating that the results were not statistically significant in treatment response.

4.2.5 Lumbar left rotation

Table 4.15: Comparative results of Lumbar Range of Motion in degrees of Lumbar left rotation

Total Sample Consult Groups Min ROM Max ROM Mean ROM Standard Deviation 1 A 3 17 8.07 10.67 B 2 17 10.80 4.33 Total 2.5 17 9.44 7.5 4 A 3 19 10.67 5.58 B 3 18 9.87 5.15 Total 3 18.5 10.27 5.37 7 A 2 16 9.60 4.37 B 4 15 9.27 3.52 Total 3 15.5 9.44 3.95

With reference to table 4.15 the measurements were taken prior to treatment on the 1st and 4th consultation and finally on the 7th consultation, rendering the recorded results. The mean value increased from 8.07 to 9.60 in group A and decreased from 10.80 to 9.27. a) Intragroup analysis

Table 4.16: Non Parametric Test Results for Lumbar left Rotation- Friedman Test

Non Parametric Tests

Test Group A Group B

Friedman Test 0.332 0.528

P value is >0.05 >0.05

With reference to lumbar left rotation demonstrated in table 4.16, the P-value for group analysis of group A was 0.332 (>0.05) and group B was 0.528 (>0.05), indicating that the results were not statistically significant, showing that there was no difference over time. b) Intergroup analysis

Table 4.17: Non Parametric Test Results for Lumbar left Rotation- Man-Whitney Test

Non Parametric Tests Test Group 1st Outcome 2nd outcome Final Outcome Mann-Whitney Combined 0.109 0.708 0.723 P value is >0.05 >0.05 >0.05

With reference to table 4.17 the range of motion results showed the P-value to be 0.723 (>0.05) at the end of treatment protocol for lumbar left rotation. Thus, indicating that the results were not statistically significant in treatment response demonstrated between the groups at the end of the trial.

4.2.6. Lumbar right rotation

Table 4.18: Comparative results of Lumbar Range of Motion in degrees of Lumbar right rotation

Total Sample Consult Groups Min ROM Max ROM Mean ROM Standard Deviation 1 A 7 19 11.80 3.73 B 2 19 10.18 4.35 Total 4.5 19 10.99 4.04 4 A 2 21 11.53 5.17 B 2 18 10.07 4.64 Total 2 19.5 10.8 4.91 7 A 3 20 10.20 4.96 B 3 20 8.67 4.44 Total 3 20 9.44 4.7

With reference to lumbar right rotation the measurements were taken prior to treatment on the 1st and 4th consultation and finally on the 7th consultation, rendering the recorded results as demonstrated in table 4.18. The mean value decreased from 11.08 to 10.20 in group A and decreased from 10.18 to 8.67.

a) Intragroup analysis

Table 4.19: Non Parametric Test Results for Lumbar right Rotation – Friedman Test

Non Parametric Tests

Test Group A Group B

Friedman Test 0.402 0.228

P value is >0.05 >0.05

With reference to lumbar left lateral flexion, the P-value is demonstrated in table 4.19 for group analysis of group A was 0.402 (>0.05) and group B was 0.228 (>0.05), indicating that the results were not statistically significant, showing that there was no difference over time. b) Intergroup analysis

Table 4.20: Non Parametric Test Results for Lumbar right Rotation – Mann-Whitney Test

Non Parametric Tests Test Group 1st Outcome 2nd outcome Final Outcome Mann-Whitney Combined 0.664 0.404 0.370 P value is >0.05 >0.05 >0.05

With reference to table 4.20 the range of motion results showed the P-value to be 0.370 (>0.05) at the end of treatment protocol for lumbar right rotation. Thus, indicating that the

69 results were not statistically significant in treatment response, demonstrated between the groups at the end of the trial.

4.3 Subjective Data 4.3.1 Numerical Pain Rating Scale

Table 4.21: Comparative results of Numerical Pain Rating Scale

Total Sample Consult Groups Min Max Mean Standard Deviation 1 A 2 8 4.93 1.83 B 3 9 5.80 3.60 Total 2.5 8.5 5.37 2.72 4 A 1 8 4.00 2.14 B 1 5 3.60 1.41 Total 1 6.5 3.80 1.78 7 A 0 6 2.80 2.28 B 0 3 1.80 1.09 Total 0 4.5 2.30 1.69

With reference to table 4.21 the measurements were taken prior to treatment on the 1st and 4th consultation and finally on the 7th consultation, rendering the recorded results. The mean value decreased from 4.93 to 2.80 in group A and decreased from 5.80 to 1.80. It is interesting to note that the values recorded in group A and B decreased at a equal rate from the 1st to 4th consultation and from the 4th to 7th consultation, noting that group B decreased at a rate almost double to that of group A.

70 a) Intragroup analysis

Table 4.22: Non Parametric Test Results for Numerical Pain Rating Scale – Friedman Test

Non Parametric Tests

Test Group A Group B

Friedman Test 0.001 0.000

P value is <0.05 <0.05

With reference to table 4.22 the P-values for group analysis of group A was 0.001 (<0.05) and group B was 0.000 (<0.05) are illustrated, indicating a statistically significant difference.

Table 4.23: Non Parametric Test Results for Numerical Pain Rating Scale – Wilcoxon signed rank Test

Non Parametric Test Results Test Group Consult 1-4 Consult 4-7 Consult 1-7 Wilcoxon A 0.021 0.019 0,003 P value is <0.05 <0.05 <0.05 Wilcoxon B 0,001 0,003 0.001 P value is <0.05 <0.05 <0.05

Table 2.23 shows the P-value obtained for group analysis of group A was 0.003 (<0.05) and group B 0.001 (<0.05), thus indicating a statistically significant difference between the 1st and 7th consultations

71 b) Intergroup analysis

Table 4.24 Non Parametric Test Results for Numerical Pain Rating Scale – Mann- Whitney Test

Non Parametric Tests Test Group 1st Outcome 2nd outcome Final Outcome Mann-Whitney Combined 0.200 0.866 0.310 P value is >0.05 >0.05 >0.05

With reference to table 4.24 the results showed the P-value to be 0.310 (>0.05) at the end of treatment protocol. Thus, indicating that the results were not statistically significant in treatment response, demonstrated between the groups at the end of the trial.

4.3.2 Oswestry Pain and Disability Index

Table 4.25: Comparative results of Oswestry Pain and Disability Index

Total Sample Consult Groups Min Max Mean Standard Deviation 1 A 1 20 8.07 4.98 B 3 21 8.27 4.85 Total 2 20.5 8.17 4.92 4 A 0 16 5.80 4.68 B 1 15 5.13 3.32

Total 0.5 15.5 5.47 4 7 A 0 8 3.93 2.79 B 0 10 3.07 2.46 Total 0 9 3.50 2.63

With reference to table 4.25 the measurements were taken prior to treatment on the 1st and 4th consultation and finally on the 7th consultation, rendering the recorded results. The mean value decreased from 8.07 to 3.93 in group A and decreased from 8.27 to 3.07. It is interesting to note that the values recorded in group A decreased at an almost equal rate from the 1st to 4th consultation and from the 4th to 7th consultation. The same could be said about group B. a) Intragroup analysis

Table 4.26: Non Parametric Test Results for Oswestry Pain and Disability Index – Friedman Test

Non Parametric Tests

Test Group A Group B

Friedman Test 0.000 0.000

P value is <0.05 <0.05

With reference to lumbar left lateral flexion, the P-value is illustrated in table 4.26 for group analysis of group A was 0.000 (<0.05) and group B was 0.000 (<0.05), indicating a statistically significant difference.

Table 4.27: Non Parametric Test Results for Oswestry Pain and Disability Index – Wilcoxon signed ranked Test

Non Parametric Test Test Group Consult 1-4 Consult 4-7 Consult 1-7 Wilcoxon A 0.035 0.032 0,004 P value is <0.05 <0.05 <0.05 Wilcoxon B 0,003 0,004 0.001 P value is <0.05 <0.05 <0.05

It can be seen in table 4.27 that the P-value obtained for group analysis of group A was 0.004 (<0.05) and group B was 0,001 (<0.05), indicating a statistically significant difference between the 1st and 7th consultations. b) Intergroup analysis

Table 4.28: Non Parametric Test Results for Oswestry Pain and Disability Index – Mann-Whitney Test

Non Parametric Tests Test Group 1st Outcome 2nd outcome Final Outcome Mann-Whitney Combined 0.917 0.900 0.306 P value is >0.05 >0.05 >0.05

With reference to table 4.28 the results showed the P-value to be 0.306 (>0.05) at the end of treatment protocol. Thus, indicating that the results were not statistically significant in treatment response, demonstrated between the groups at the end of the trial.

CHAPTER FIVE – DISCUSSION

5.1 Introduction

The following chapter is the discussion of the results obtained from the clinical trial of the Kinesio™ tape combination group and the elastic adhesive bandage combination group. The results will be discussed in reference to the objective and subjective results. The objective and subjective results will be discussed by looking at the mean value of the Digital Inclinometer readings, determining the increase or decrease in the respective range of motions. The Friedman test and Wilcoxon signed rank Test will be used to discuss whether the results show a difference over time in the treatment protocols. The Mann- Whitney Test will be used to discuss if either treatment protocol demonstrate superior outcome. The same will apply when discussing the subjective data, except that the increase or decrease of the mean value regarding pain, measured by the NPRS and the mean value regarding disability measured by the Oswestry Pain and Disability Questionnaire will be included. The outline of possible explanations for these results will be described by referring to the literature discussed in chapter two.

5.2 Demographic Comparability

Participants of the Kinesio™ tape combination group and the elastic adhesive bandage combination group were distributed evenly in reference to gender, both groups consisting of 8 male and 7 female participants respectively. Even though the percentage ratio is disproportionate, it did not have an effect on the study as Haldeman (1992), shows that men and woman are equally likely to suffer from chronic lower back pain.

The differences in average age between the two groups were 25.07 years for the Kinesio™ tape combination group and 24.80 years for the elastic adhesive bandage combination group, with a difference of 0.27 years. Thus the difference was statistically insignificant and shown to be demographically comparable.

5.3 Objective data analysis 5.3.1 Digital Inclinometer readings of lumbar spine flexion

The mean Digital Inclinometer reading of lumbar spine flexion for the Kinesio™ tape combination group decreased by 3.13% and the value for the elastic adhesive bandage combination group increased by 6.4%. The non-parametric Friedman test showed no statistically significant changes in lumbar flexion within the Kinesio™ tape combination group from visit 1 to 7 and within the elastic adhesive bandage combination group from visit 1 to 7. The non-parametric Wilcoxon signed rank test showed no statistically significant changes in lumbar flexion within the two groups over time. The Mann-Whitney U test showed no statistically significant differences between the Kinesio™ tape combination group and the elastic adhesive bandage combination group.

5.3.2 Digital Inclinometer readings of lumbar spine extension

The mean Digital Inclinometer reading of lumbar spine extension for the Kinesio™ tape combination group decreased by 0.65% and the value for the elastic adhesive bandage combination group decreased by 7.1%. The non-parametric Friedman test showed no statistically significant changes in lumbar extension within the Kinesio™ tape combination group from visit 1 to 7 and within the elastic adhesive bandage combination group from visit 1 to 7. The non-parametric Wilcoxon signed rank test showed no statistically significant changes in lumbar extension within the two groups over time. The Mann-Whitney U test showed no statistically significant differences between the Kinesio™ tape combination group and the elastic adhesive bandage combination group.

5.3.3 Digital Inclinometer readings of lumbar spine left lateral flexion

The mean Digital Inclinometer reading of lumbar spine left lateral flexion for the Kinesio™ tape combination group increased by 1.64% and the value for the elastic bandage combination group decreased by 3.65%. The non-parametric Friedman test showed no statistically significant changes in lumbar left lateral flexion within the Kinesio™ tape combination group from visit 1 to 7 and within the elastic bandage combination group from visit 1 to 7. The non-parametric Wilcoxon signed rank test showed statistically significant changes in lumbar left lateral flexion when comparing the results recorded in the fourth and seventh visit. The Mann-Whitney U test showed no statistically significant differences between the Kinesio™ tape combination group and the elastic bandage combination group.

5.3.4 Digital Inclinometer readings of lumbar spine right lateral flexion

The mean Digital Inclinometer reading of lumbar spine right lateral flexion for the Kinesio™ tape combination group increased by 7.24% and the value for the elastic adhesive bandage combination group increased by 7.2%. The non-parametric Friedman test showed no statistically significant changes in lumbar right lateral flexion within the Kinesio™ tape combination group from visit 1 to 7 and within the elastic adhesive bandage combination group from visit 1 to 7. The non-parametric Wilcoxon signed rank test showed no statistically significant changes in lumbar right lateral flexion within the two groups over time. The Mann-Whitney U test showed no statistically significant differences between the Kinesio™ tape combination group and the elastic adhesive bandage combination group.

5.3.5 Digital Inclinometer readings of lumbar spine left rotation

The mean Digital Inclinometer reading of lumbar spine left rotation for the Kinesio™ tape combination group increased by 15.9% and the value for the elastic bandage combination group decreased by 14.17%.

The non-parametric Friedman test showed no statistical significant changes in lumbar left rotation within the Kinesio™ tape combination group from visit 1 to 7 and within the elastic adhesive bandage combination group from visit 1 to 7. The non-parametric Wilcoxon signed rank test showed no statistical significant changes in lumbar left rotation within the two groups over time. The Mann-Whitney U test showed statistically no significant differences between the Kinesio™ tape combination group and the elastic adhesive bandage combination group.

5.3.6 Digital Inclinometer readings of lumbar spine right rotation

The mean Digital Inclinometer reading of lumbar spine flexion for the Kinesio™ tape combination group decreased by 13.56% and the value for the elastic adhesive bandage combination group decreased by 14.83%. The non-parametric Friedman test showed no statistical significant changes in lumbar right rotation within the Kinesio™ tape combination group from visit 1 to 7 and within the elastic adhesive bandage combination group from visit 1 to 7. The non-parametric Wilcoxon signed rank test showed no statistical significant changes in lumbar right rotation within the two groups over time. The Mann-Whitney U test showed no statistically significant differences between the Kinesio™ tape combination group and the elastic adhesive bandage combination group.

5.3.6 Discussion of objective data

As previously mentioned in chapter four, the Kinesio™ tape combination group showed a statistically significant increase in the Digital Inclinometer readings of lumbar spine left lateral flexion. However lumbar spine range of motion mean value for the Kinesio™ tape combination group and the elastic bandage combination group showed clinical significance in flexion (table 4.2), extension (table 4.5), left lateral flexion (table 4.8) and right lateral flexion (table 4.12) and left rotation (table 4.15) and right rotation (table 4.18) as both groups maintained a normal degree of range of motion throughout the entire study.

Even though left lateral flexion was found statistically significant (≤0.05) the margin of improvement was minimal at only 1.64%, this can not be perceived as a significant improvement on its own, thus it can be suggested that lumbar range of motion was not greatly improved over the course of the study even though mean values of flexion, extension, left lateral flexion and right lateral flexion and left rotation and right rotation was within normal range.

Decreased lumbar range of motion may be due to interarticular adhesions between the surfaces of the zygopophysial joints. These adhesions are formed due to chronic inflammation and/or immobilization due to injury to the joint (Bergman and Peterson, 2011). Restriction of lumbar range of motion may be due to segmental muscle spasm caused by possible imbalance of agonists and antagonists. If the antagonist is not able to elongate due to involuntary constriction, the balance is lost and there is decreased joint movement. Direct injury to the myofascial structures or indirect injury or irritation of associated articular structures may cause muscle spasm (Bergman and Peterson, 2011).

Chiropractic manipulative therapy is well recognized to reduce pain and disability (Cassidy, Lopes and Yonh-Hing, 1992). Although the true mechanism of how the adjustment inhibits pain remains speculated and needs further investigation. It is thought that the adjustment removes the mechanical source of pain and inflammation or induces stimulus produced analgesia. Stimulus produced analgesia is supported by experimental evidence that suggests that the chiropractic adjustment produces sufficient force to stimulate and activate superficial and deep somatic nociceptors, mechanoreceptors and proprioceptors. This causes an inhibitory effect, where spinal cord sensory neurons alter the afferent input to the CNS, inhibiting the central transmission of pain. This is also more commonly referred to as the “Pain Gate Theory” (Robert, Gillette and Kramis, 1989). It is also known that adjustments are associated with short bursts of nociceptive and proprioceptive input that is thought to increase neurochemical pain inhibitors, further promoting the analgesic effect.

80 the golgi tendon organ activated inducing an autogenic inhibition. There are several mechano and nociceptors in articular soft tissue, muscle and skin. Stimulation of these low and high threshold mechanoreceptors and nociceptors has an inhibitory effect on segmental motor activity (Bergman and Peterson, 2011).

Kinesio Taping method is applied over muscles and joints to reduce pain and inflammation, relax overused muscles and to support muscles and joints without restricting range of motion (Kase, Wallis and Kase, 2003). Rather than being mainly structurally supportive, Kinesio tape is more therapeutic in nature as it is based on the bodies own natural healing process. It can activate the neurological and circulatory system, providing theraputical benefits for both acute and chronic musculoskeletal conditions and injuries, moreover increases lumbar range of motion (Halseth, McChesney, DeBeliso, Vaughn and Lien, 2004).

Elastic adhesive bandage is commonly used in the treatment of various musculoskeletal disorders (Hassan, Mockett and Doherty, 2002). It improves proprioceptive acuity as it stimulates cutaneous mechanoreceptors, as well as providing support to joint structure (Khabie, Schwartz, Rokito, Gallagher, Cuomo, Zuckerman, 1998). It is important to take note of Bragg, Macmahon, Overom, Yerby, Matheson and Carter (2002), findings that athletic tape loses the function of limitation joint movement after 10-20 minutes of exercise. Consequently the effects of taping may primarily be due to the proprioceptive properties of taping (Simoneau, Degner, Kramper and Kittleson, 1997) this property has been examined using the current research topic.

As with an adjustment the application of both Kinesio tape and elastic adhesive bandage on the skin stimulate the deep and superficial mechanoreceptors, which in turn overrides the nociceptive input to the central nervous system caused by the lower back pain via the “Pain Gate Theory”.

81 obtained in this study were not notably statistically significant it is important to note that the lumbar range of motion remained within normal ranges of all lumbar movement. It can be proposed that the combination treatment of chiropractic manipulative therapy is more beneficial in treating chronic lower back pain in certain cases as the effects of chiropractic manipulative therapy may be enhanced and supported by the longer lasting effects of the elastic bandage and Kinesio tape to the lumbar paraspinal muscles. As both groups received chiropractic treatment it can be assumed that both groups were set at a baseline in order to have a true representation of the effects of each individual tape, therefore it can be proposed that both Kinesio™ tape and elastic adhesive bandage has equally beneficial effects as none showed superior results.

5.4 Subjective data 5.4.1 Numerical Pain Rating Scale

The mean Numerical Pain Rating Scale value for the Kinesio™ tape combination group decreased by 43.2% and the value for the elastic adhesive bandage combination group decreased by 68.97%. The non-parametric Friedman test showed statistically significant changes in the Numerical Pain Rating Scale values within the Kinesio™ tape combination group from visit 1 to 7 and within the elastic adhesive bandage combination group from visit 1 to 7. The non-parametric Wilcoxon signed rank test showed statistically significant changes in the Numerical Pain Rating Scale values when comparing the results recorded in the first fourth and seventh visit. The Mann-Whitney U test showed no statistically significant differences between the Kinesio™ tape combination group and the elastic adhesive bandage combination group in the first, fourth and seventh visit.

5.4.2 Oswestry Pain and Disability Index Questionnaire

The mean Oswestry Pain and Disability Index Questionnaire value for the Kinesio™ tape combination group decreased by 51.3% and the value for the elastic adhesive bandage combination group decreased by 62.88%.

The non-parametric Friedman test showed statistically significant changes in the Oswestry Pain and Disability Index Questionnaire values within the Kinesio™ tape combination group from visit 1 to 7 and within the elastic adhesive bandage combination group from visit 1 to 7.

The non-parametric Wilcoxon signed rank test showed statistically significant changes in the Oswestry Pain and Disability Index Questionnaire values when comparing the results recorded in the first fourth and seventh visit.

The Mann-Whitney U test showed no statistically significant differences between the Kinesio™ tape combination group and the elastic adhesive bandage combination group in the first, fourth and seventh visit.

5.4.3 Discussion of the subjective data

As previously specified the Numerical Pain Rating Scale values of the Kinesio™ tape combination group and the elastic adhesive bandage combination group indicate a considerable decrease in the participant’s perception of pain over the duration of the study. However, comparing the Numerical Pain Rating Scale values the Kinesio™ tape combination group and the elastic adhesive bandage combination group, no statistical significant differences were found.

As previously specified the Oswestry Pain and Disability Index Questionnaire values of the Kinesio™ tape combination group and the elastic adhesive bandage combination group indicate a considerable decrease in the participant’s perception of pain and disability. However, when comparing Oswestry Pain and Disability Index Questionnaire values the Kinesio™ tape combination group and the elastic adhesive bandage combination group, no statistical significant differences were found.

The mechanism of action, results and the effects of the different modalities of treatment used in the study have been fully described in chapter two. Showing that chiropractic

83 manipulative therapy of lumbar facet joints or sacroiliac joints produce afferent discharge of the articular mechanoreceptors (type I and II mechanoreceptors), which have the following effects: reflexogenic effect, perceptual effects and pain suppression (Wyke, 1985). Chapman-Smith (1993), concluded that the successful manipulation of a fixated lumbar facet joint or sacroiliac joint will result in restoration of normal ranges of movement, decrease of muscle spasm and there is an overall biomechanical change that occurs that contributes to removal of certain pain referral signals.

Meyer.M, Bester. C and Landman. (2012), shows that chiropractic spinal manipulation and the application of Kinesio tape to the lumbar para-spinal muscles to be effective treatment protocols for chronic lower back pain as entities on their own. Yet it has to be noted that the results obtained in his study showed that the combination treatment of these two treatment protocols was far more superior to the results of each treatment protocol on its own.

It has been shown that with the application of Kinesio tape to the lumbar para-spinal muscles effectively decreases pain with the relaxation of tense muscles (Yoshida and Kahanov, 2007) as well as support joint structure (Jaraczewsk and Long, 2006). Murray (2001) has suggested that there is an increase in proprioception with the application of Kinesio tape as the tape increasingly stimulates cutaneous mechanoreceptors.

It is thought that the effect of both Kinesio™ tape and elastic adhesive bandage in reducing pain and disability is as a result of the “gate control” theory of pain that was introduced by Malzack and Wall in 1965 that is fully discussed in chapter two. The mechanical stimulation from the Kinesio tape and elastic adhesive bandage on the mechanoreceotors of the skin overrides the painful stimulation, thus reducing pain.

Considering the treatment protocols discussed above, all three entities have a wide spread neurological and physiological effect on the neuromuscular and musculoskeletal systems. These treatment protocols affect pain and disability, which were greatly affected by both Kinesio™ tape and elastic adhesive bandage. The results obtained in this study were statistically significant only within each group over the period of the study and none of the groups showed superior results. Thus it can be proposed that each individual tape has the same physiological effect on the area of application and that both Kinesio™ tape and elastic adhesive bandage has equally beneficial properties.

It can be suggested that the combination treatment of chiropractic manipulative therapy is more beneficial in treating chronic lower back pain even though it has been shown that chiropractic manipulative therapy is a successful method of treatment on its own.

CHAPTER SIX –CONCLUSION AND RECOMMENDATION

6.1 Conclusion

The aim of the study was to determine whether the application of either Kinesio tape or elastic adhesive bandage in conjunction with chiropractic manipulative therapy is a more effective treatment protocol in the treatment of chronic lower back pain, with regards to lumbar range of motion, pain and disability. The effects were based on the findings of the Oswestry Pain and Disability Questionnaire, the Numerical, Pain Rating Scale and the Digital Inclinometer readings of the lumbar spine. All readings were recorded before treatment at the first, fourth and seventh visit.

Reviewing the subjective, objective measurements and clinical findings, it is clear that neither treatment protocol provide to be more beneficial or superior to the other. Therefore it can be suggested that Kinesio™ tape and elastic adhesive bandage have equally beneficial physiological effects. Having stated this, it can be proposed that the combination treatment of chiropractic manipulative therapy and taping of the lumbar spine para spinal muscles is successful in treating chronic lower back pain.

When considering the cost effectiveness of combination treatment of chiropractic manipulative therapy and taping, it will be more affordable for the practitioner to use elastic adhesive bandage, which is available at a more affordable rate compared to the conventional choice of Kinesio™ tape with the same end result in the treatment of chronic lower back pain.

It is important to note that subjectively participants commented that the elastic adhesive bandage was very uncomfortable to wear for 3 consecutive weeks, as the patients felt a sense of restricted movement and a sense of increased lumbar lordosis throughout the study. The participants that had the Kinesio tape applied had no complaints of discomfort throughout the study.

6.2 Recommendations

The following recommendations can be used to further improve the results that were obtained is this study:

Three groups should be used in further research. One treatment group receives spinal manipulative therapy alone and the other two groups receive spinal manipulative therapy in conjunction with the application of Kinesio tape or elastic adhesive bandage. A larger sample group should be used to represent the population more accurately and potentially making it more statistically viable. Subjective and objective readings should be recorded before and immediately after treatment. This allows for the immediate and prolonged effects of treatment to be investigated. A short term study could be conducted to measure the immediate effects of both kinesio tape and elastic adhesive bandage. Different techniques of kinesio tape application could be compared to each other. An objective measurement such as the Algometer should be included to measure pain and disability in the area. Follow up assessments should be performed to determine the long term effects of the treatment. A study could be performed, investigating the effects of kinesio tape or elastic adhesive bandage in conjunction with chiropractic manipulative therapy on neck pain.

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APPENDICES

Appendix A: Advertisement

FREE Chiropractic treatment !!!

CONSTANT LOWER BACK PAIN

Do you ever have a sore lower back and wonder what can I do?

Come and visit me in the University of Johannesburg Chiropractic Day Clinic and be part of my research study aimed to treat lower back pain.

Interested?

Are you between 18 and 40 years old? Call me Machere Venter or UJ Chiropractic clinic: 011 559 6495

6495 559 559 559 6495 559 6495 559 6495 559 6495 559 6495 559 6495 559 6495 559 6495 559 6495 MACHERE VENTERMACHERE 011 VENTERMACHERE 011 VENTERMACHERE 011 VENTERMACHERE 011 VENTERMACHERE 011 VENTERMACHERE 011 VENTERMACHERE 011 VENTERMACHERE 011 VENTERMACHERE 011 VENTERMACHERE 011

APPENDIX B: Contra-indications to Chiropractic Adjustments (Gatterman,1990) Vascular complications Vertebral artery syndrome Aneurysms Tumors Primary to the bone Secondary (metastasis to the bone) Bone infections Tuberculosis of the spine Osteomyelitis of the spine Traumatic injuries Fractures Instabilities Dislocation Unstable spondylolisthesis Arthritis Ankylosing spondylitis Rheumatoid arthritis Psoriatic arthritis Reiter’s syndrome Osteoarthritis Psychological considerations Malingering Hysteria Hypochondriasis Pain intolerance Dependant personality Disability Syndromes Neurological complications Cervical disc lesions and myelopathy Nerve root damage

APPENDIX C: Contra-indications to Kinesio tape application

Over active malignancy site Over active cellulitis or skin reaction Open wounds Deep vein thrombosis

APPENDIX D: Information and Consent Form

DEPARTMENT OF CHIROPRACTIC INFORMATION AND CONSENT FORM I, Machere du Toit, hereby invite you to participate in my research study. I am currently a Chiropractic student, completing my Masters Degree at the University of Johannesburg. The aim of this study is to determine the efficacy of chiropractic manipulative therapy combined with the application of Kinesio tape or elastic bandage in the treatment of chronic lower back pain. Participants will be recruited by word of mouth and by advertisements placed within and around the Chiropractic Clinic at Doornfontein Campus. Participants will be assessed as to whether they fulfil the inclusion and exclusion criteria for this research study. Participants will be randomly assigned to two groups and receive either a combination of Chiropractic manipulative therapy and application of Kinesio tape or either a combination of Chiropractic manipulative therapy and application of elastic bandage . This will be done only once you have read and signed the consent and information form. The Chiropractic adjustment involves the restoration of normal joint motion. The Chiropractic adjustment is a safe, non-invasive treatment technique.

The research study will take place at the University of Johannesburg Chiropractic Day Clinic. Your privacy will be protected by ensuring your anonymity and confidentiality when compiling the research dissertation.

All procedures will be explained to you and all participation is entirely on a voluntary basis; withdrawal at any stage will not cause you any harm. Potential benefits of this study include: relieving pain, increasing your range of motion. Discomfort may be experienced as post adjustment soreness, which is a normal effect. Any irritation of the skin due to the

99 application of the Kinesio tape or elastic bandage must be brought to the researchers immediate attention

Feedback regarding the outcomes of the study is completed will be provided if you wish so. I have fully explained the procedures and their purpose. I have asked whether or not any questions have arisen regarding the procedures and have answered them to the best of my ability.

Date: ______Researcher: ______

I have been fully informed as to the procedures to be followed and have been given a description of the discomfort risks and benefits expected from the treatment. In signing this consent form I agree to this form of treatment and understand my rights and that I am free to withdraw my consent and participation in this study at any time. I understand that if I have any questions at any time, they will be answered.

Date: ______Participant: ______

Should you have any concerns or queries regarding the current study, the following persons may be contacted.

Researcher: Machere du Toit 0796274590 Supervisor: Dr C. Yelverton 0115596218 Co-supervisor: Dr R. Potgieter -

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APPENDIX E: Case History

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APPENDIX F: Physical Examination

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APPENDIX G: Lumbar Spine Regional

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APPENDIX H: SOAP note

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APPENDIX I: Digital inclinometer readings

Consultation 1: Digital inclinometer: Flexion Extension Left Lateral Flexion Right Lateral Flexion Left Rotation Right rotation

Consultation 4: Digital inclinometer: Flexion Extension Left Lateral Flexion Right Lateral Flexion Left Rotation Right rotation

Consultation 7: Digital inclinometer: Flexion Extension Left Lateral Flexion Right Lateral Flexion Left Rotation Right rotation

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APPENDIX J: Numerical Pain Rating Scale How much pain have you had since your last treatment? Please mark in one of the boxes to indicate how severe your pain has been: 0 being no pain and 10 being the worst pain you’ve ever had.

Consultation 1: No pain Moderate pain Severe pain 0 1 2 3 4 5 6 7 8 9 10

Consultation 4: No pain Moderate pain Severe pain 0 1 2 3 4 5 6 7 8 9 10

Consultation 7: No pain Moderate pain Severe pain 0 1 2 3 4 5 6 7 8 9 10

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APPENDIX K: Oswestry Low Back Pain and Disability Questionnaire (Fairbank & Pynsent, 2000). Name: ______Visit/Date:______This questionnaire has been designed to give us information as to how your back pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply, but please just shade out the spot that indicates the statement which most clearly describes your problem.

Section 1: Pain Intensity Section 6: Standing o I have no pain at the moment o I can stand as long as I want without extra pain o The pain is very mild at the moment o I can stand as long as I want but it gives me extra pain o The pain is moderate at the moment o Pain prevents me from standing for more than 1 hour o The pain is fairly severe at the moment o Pain prevents me from standing for more than 10 o The pain is very severe at the moment minutes o The pain is the worst imaginable at the moment o Pain prevents me from standing for more than 30 minutes o Pain prevents me from standing at all Section 2: Personal Care (e.g. washing, dressing) Section 7: Sleeping o I can look after myself normally without causing extra o My sleep is never disturbed by pain pain o My sleep is occasionally disturbed by pain o I can look after myself normally but it causes extra pain o Because of pain I have less than 6 hours sleep o It is painful to look after myself and I am slow and o Because of pain I have less than 4 hours sleep careful o Because of pain I have less than 2 hours sleep o I need some help but can manage most of my personal o Pain prevents me from sleeping at all care o I need help every day in most aspects of self-care o I do not get dressed, wash with difficulty and stay in bed Section 3: Lifting Section 8: Sex Life (if applicable) o I can lift heavy weights without extra pain o My sex life is normal and causes no extra pain o I can lift heavy weights but it gives me extra pain o My sex life is normal but causes some extra pain o Pain prevents me lifting heavy weights off the floor but I o My sex life is nearly normal but is very painful can manage if they are conveniently placed (eg. on a o My sex life is severely restricted by pain table) o My sex life is nearly absent because of pain o Pain prevents me lifting heavy weights but I can o Pain prevents any sex life at all manage light to medium weights if they are conveniently positioned o I can only lift very light weights o I cannot lift or carry anything Section 4: Walking Section 9: Social Life o Pain does not prevent me walking any distance o My social life is normal and gives me no extra pain

119 o Pain prevents me from walking more than 1 mile o My social life is normal but increases the degree of pain o Pain prevents me from walking more than ½ mile o Pain has no significant effect on my social life apart o Pain prevents me from walking more than 100 yards from limiting my more energetic interests e.g. sport o I can only walk using a stick or crutches o Pain has restricted my social life and I do not go out as o I am in bed most of the time often o Pain has restricted my social life to my home o I have no social life because of pain Section 5: Sitting Section 10: Travelling o I can sit in any chair as long as I like o I can travel anywhere without pain o I can only sit in my favorite chair as long as I like o I can travel anywhere but it gives me extra pain o Pain prevents me sitting more than one hour o Pain is bad but I manage journeys over two hours o Pain prevents me from sitting more than 30 minutes o Pain restricts me to journeys of less than one hour o Pain prevents me from sitting more than 10 minutes o Pain restricts me to short necessary journeys under 30 o Pain prevents me from sitting at all minutes o Pain prevents me from travelling except to receive treatment

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