Home Manual therapy plus sexual advice compared with manual therapy or exercise therapy alone for lumbar radiculopathy: a randomized controlled trial
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Manual therapy plus sexual advice compared with manual therapy or exercise therapy alone for lumbar radiculopathy: a randomized controlled trial

  • Musa Sani Danazumi EMAIL logo , Isa Abubakar Adamu , Musbahu Hamisu Usman and Abdulsalam Mohammed Yakasai
Published/Copyright: September 12, 2024
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Journal of Osteopathic Medicine
From the journal Journal of Osteopathic Medicine Volume 125 Issue 1

Abstract

Context

The biopsychosocial approach to managing low back pain (LBP) has the potential to improve the quality of care for patients. However, LBP trials that have utilized the biopsychosocial approach to treatment have largely neglected sexual activity, which is an important social component of individuals with LBP.

Objectives

The objectives of the study are to determine the effects of manual therapy plus sexual advice (MT+SA) compared with manual therapy (MT) or exercise therapy (ET) alone in the management of individuals with lumbar disc herniation with radiculopathy (DHR) and to determine the best sexual positions for these individuals.

Methods

This was a single-blind randomized controlled trial. Fifty-four participants diagnosed as having chronic DHR (>3 months) were randomly allocated into three groups with 18 participants each in the MT+SA, MT and ET groups. The participants in the MT+SA group received manual therapy (including Dowling’s progressive inhibition of neuromuscular structures and Mulligan’s spinal mobilization with leg movement) plus sexual advice, those in the MT group received manual therapy only and those in the ET group received exercise therapy only. Each group received treatment for 12 weeks and then followed up for additional 40 weeks. The primary outcomes were pain, activity limitation, sexual disability and kinesiophobia at 12 weeks post-randomization.

Results

The MT+SA group improved significantly better than the MT or ET group in all outcomes (except for nerve function), and at all timelines (6, 12, 26, and 52 weeks post-randomization). These improvements were also clinically meaningful for back pain, leg pain, medication intake, and functional mobility at 6 and 12 weeks post-randomization and for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at 6, 12, 26, and 52 weeks post-randomization (p<0.05). On the other hand, many preferred sexual positions for individuals with DHR emerged, with “side-lying” being the most practiced sexual position and “standing” being the least practiced sexual position by females. While “lying supine” was the most practiced sexual position and “sitting on a chair” was the least practiced sexual position by males.

Conclusions

This study found that individuals with DHR demonstrated better improvements in all outcomes when treated with MT+SA than when treated with MT or ET alone. These improvements were also clinically meaningful for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at long-term follow-up. There is also no one-size-fits-all to sexual positioning for individuals with DHR.

Keywords: lumbar radiculopathy; manual therapy; randomized controlled trial; sexual advice

Low back pain (LBP) presents a major public health problem and is one of the most symptomatic causes of consulting healthcare systems globally [1]. Given the multifactorial nature of LBP, treatment strategies to ameliorate it have been very challenging, particularly when lumbar radiculopathy and psychosocial barriers to recovery exist [2, 3]. People with lumbar radiculopathy have a more severe disability, take a longer time to recover, and lose more workdays compared to those with LBP alone [2]. Up until now, the best treatment with which to manage lumbar radiculopathy remains elusive [4, 5], even though appreciable evidence of the therapeutic efficacy of some biopsychosocial-based treatment approaches exists [6, 7].

The biopsychosocial approach to managing LBP has the potential to improve the quality of care for patients [3, 8]. However, major LBP trials that have utilized the biopsychosocial approach to managing lumbar radiculopathy have largely neglected sexual activity [6, 7], which is an important social component of individuals with LBP [9, 10]. Sexual activity is a significant indicator of people’s lives and one of the inherent measures of health and disability 9], [10], [11], [12. Additionally, sexual life and a happy relationship are interrelated and are associated with depression and lack of recovery in individuals with LBP [9, 13].

Studies indicate that sexual behavior or romantic relationship induces analgesia by releasing neurotransmitters of neuropeptides (endogenous oxytocin and beta-endorphins), potentially to avoid tight sexual arousal from becoming unpleasant and raise its reward value 14], [15], [16], [17], [18], [19. Although sexual intercourse may cause or exacerbate LBP, the actual prevalence could not be examined because the problem is not widely reported 20], [21], [22. However, studies found that individuals with LBP experienced lower amounts of practiced sexual intercourse and decreased quality of life 23], [24], [25. Additionally, the main problems experienced during sexual intercourse by individuals with LBP were increased pain [25], finding suitable sexual positions [23, 24], and difficulty with spinal movements [23]. Despite evidence of the prevalence of decreased sexual activity among individuals with LBP, there are scarcities of studies that have addressed LBP-related sexual disabilities [26].

Previous studies indicated that combined manual therapy (MT) programs including Dowling’s progressive inhibition of neuromuscular structures (PINS) and Mulligan’s spinal mobilization with leg movement (SMWLM) improved the outcomes of individuals with lumbar radiculopathy; however, these studies did not incorporate sexual advice (SA) into the treatment regimen [27, 28]. Additionally, these studies did not assess the psychosocial factors that may accompany chronic pain, and they did not utilize a control group to determine the significant effects of the MT approaches [27, 28]. For these reasons, this study was conducted to examine the effects of MT+SA compared with MT or exercise therapy (ET) alone in the management of individuals with lumbar disc herniation with radiculopathy (DHR) and to determine the best sexual positions for individuals with DHR.

Methods

Study design and ethics

This was a single-blind, parallel-group randomized controlled trial approved by the Federal Medical Centre (FMC) in Nguru, Yobe State, Nigeria (#FMC/N/CL.SERV/668/VOLVII/320) and was prospectively registered with the Pan African Clinical Trial Registry (PACTR202002785212512) before it was started. The trial began on February 28, 2020 and ended on December 30, 2022.

Sample size estimation

The sample size was estimated utilizing G*Power version 3.1.1 software. The overall sample size to detect the smallest between-groups effect size (d) of at least 0.2 utilizing a repeated-measures analysis of variance (ANOVA) of within-between interactions, nonsphericity correction of 1, correlation among repeated measures of 0.5, number of follow-up measurements of 4, probability level (α) of 0.05, power (p) of 0.8, and the number of groups of 3, yielding 45 participants (15 per group). Accounting for a worst-case scenario of a 20 % attrition rate requires the total sample size to be increased to 54 participants (18 per group) [27, 28].

Eligibility criteria

Adult participants (18–65 years) with a diagnosis of chronic (>3 months) unilateral DHR that was confirmed via magnetic resonance imaging (MRI) and clinical examinations were included in the study (Supplementary File 1).

Participant recruitment

Participants were recruited from the general and surgical outpatient departments of FMC Nguru to the physiotherapy outpatient department where the study was conducted. Participants were screened for eligibility by orthopedic physiotherapists who were not involved in treating participants.

Randomization and concealment

Fifty-four participants who met the eligibility criteria and signed a written informed consent were electronically randomized via a concealed envelope allocation into the MT+SA (n=18), MT (n=18) or ET (n=18) groups in a 1:1:1 ratio (Figure 1).

Figure 1: Participants’ flow through the study.
Figure 1:

Participants’ flow through the study.

Outcome assessment

The primary outcomes were pain, activity limitation, sexual disability, and kinesiophobia at 12 weeks postrandomization, while the secondary outcomes were pain catastrophizing, sciatica bothersomeness, functional mobility, nerve function, use of pain medications, and adverse events. All outcomes were self-reported except functional mobility and nerve function, which were assessed by blinded outcome assessors. All outcomes were assessed physically at baseline, and at 6, 12, 26, and 52 weeks postrandomization (Supplementary File 2).

Intervention procedure

Treatments were administered by three independent physiotherapists who had 14, 8, and 5 years of clinical experience, respectively. To minimize bias due to expertise, trial physiotherapists switched groups after every 4 weeks of intervention. Participants in the MT+SA group received MT in addition to SA, those in the MT group received only MT, and those in the ET group received only therapeutic exercises. All participants attended two treatment sessions per week for 12 weeks (Supplementary File 3).

Home regimen compliance

After the treatment sessions ended at 12 weeks postrandomization, all participants received a regimen of therapeutic exercises to be performed on alternate days at home and were then given a handout (including an exercise diary) detailing appropriate exercise dosages and progressions (Supplementary File 4). Additionally, SA was also incorporated into the home regimen of participants in the MT+SA group (Supplementary File 5). Compliance was assessed and reinforced every 6 weeks via phone calls and at in-person visits (26 and 52 weeks postrandomization). Participants who performed their therapeutic exercises at least twice per week for 80 % of all follow-up weeks (40 weeks) were regarded as adherers to the home regimen.

Statistical analysis

All data were analyzed utilizing IBM SPSS 23.0 (SPSS Inc., Chicago, IL). Descriptive statistics were utilized to summarize the demographics and clinical parameters of the participants. A Shapiro–Wilk test was utilized to assess the normality of the data, and Levene’s test was utilized to assess the homogeneity of variances among groups. The treatment effect was evaluated utilizing a two-way repeated-measures ANOVA with the intervention groups (MT+SA, MT, and ET) as the between-subject variable and timelines (baseline and at 6, 12, 26, and 52 weeks postrandomization) as the within-subject variable. Separate ANOVAs were performed with the outcomes (leg pain, back pain, activity limitation, sexual disability, kinesiophobia, pain catastrophizing, sciatica bothersomeness, and functional mobility) as the dependent variables, and for each ANOVA, the analysis of interest was the 2-way interaction (Group × Time). The relative risk (RR) for improvement (including 95 % confidence interval [CI]) was examined utilizing a chi-square test, differences between the means were considered at a 5 % probability level (p<0.05), and RR >1.25 or <0.75 was considered clinically important [29]. The preferred sexual positions for males and females were evaluated utilizing descriptive statistics (frequencies, percentages, and bar charts). Differences between the means were considered at a 5 % probability level (p<0.05), and the value of the CI was set at 95 %. All data were analyzed according to the intention to treat (ITT) analysis [30].

Results

Participants

A total of 54 participants (age range, 25–48 years; mean age±standard deviation, 41.22±5.30 years) were enrolled in the study, with 18 participants each in the MT+SA, MT, or ET treatment groups. Thirty-seven (69.0 %) participants were males, and 17 (31.0 %) participants were females. All participants attended their treatment sessions; however, two participants in the MT+SA group, and one participant each in the MT and ET groups, were lost at 52 weeks postrandomization and their last available scores were carried forward. At 52 weeks postrandomization, overall participants’ adherence to the home routine was analyzed for each week from the exercise diary as per our adherence criteria (performing exercises at least twice per week for 32 weeks). Overall, 35 (65.0 %) participants – 11 (61.0 %) in the MT+SA group, and 12 (67.0 %) each in the MT and ET groups – were categorized as adherers to the home regimen, whereas 19 participants (35.0 %) were categorized as nonadherers. The groups were well matched in the demographic and clinical characteristics at baseline (Table 1).

Table 1:

Baseline demographics and clinical characteristics of the participants.

Characteristics MT+SA (n=18) MT (n=18) ET (n=18)
Sex, n, %
 Male 12 (67.0) 11 (61.0) 14 (79.0)
 Female 6 (33.0) 7 (39.0) 4 (21.0)
Age, years 41.26 (5.01) 42.01 (4.98) 41.33 (5.21)
Height, m
 Male 1.75 (0.46) 1.73 (0.71) 1.74 (0.90)
 Female 1.66 (0.42) 1.65 (0.66) 1.64 (0.77)
Weight, kg
 Male 67.99 (5.44) 68.03 (7.01) 67.01 (5.06)
 Female 74.31 (4.63) 71.87 (8.33) 72.43 (6.45)
BMI, kg/m 2
 Male 21.01 (8.81) 20.66 (7.11) 21.97 (5.56)
 Female 23.90 (6.01) 22.33 (5.42) 22.65 (6.72)
Duration of symptoms, months 10.96 (4.22) 11.09 (5.01) 12.01 (4.71)
Level of disc herniation, n, %
 L4/L5 12 (67.0) 9 (50.0) 13 (72.0)
 L5/S1 6 (33.0) 9 (50.0) 5 (28.0)
Positive neurodynamic testing, n, % 18 (100.0) 18 (100.0) 18 (100.0)
 Positive straight leg raising 12 (67.0) 13 (72.0) 11 (61.0)
 Positive slump test 6 (33.0) 5 (28.0) 7 (39.0)
Neurologic deficit, n, %
 Asymmetric sensory deficit 14 (78.0) 14 (78.0) 12 (67.0)
 Asymmetric reflex deficit 13 (72.0) 14 (78.0) 11 (61.0)
  Knee tendon reflex 4/13 6/14 3/11
  Ankle tendon reflex 9/13 8/14 8/11
 Asymmetric motor deficit (MRC score out of 5) 9 (50.0) 8 (44.0) 9 (50.0)
  Score of 3 2/9 0/8 1/9
  Score of 4 7/9 8/8 8/9
Currently taking pain medications, n, % 16/18 (89.0) 15/18 (83.0) 14/18 (78.0)
VAS back 6.23 (2.20) 5.87 (2.18) 5.91 (2.01)
VAS leg 7.01 (2.66) 6.98 (3.22) 6.76 (2.98)
RMDQ 14.20 (4.60) 15.01 (6.00) 14.98 (5.09)
ODI-8 3.57 (1.28) 3.61 (0.98) 3.25 (1.11)
TSK 37.61 (7.37) 35.78 (6.11) 36.04 (4.61)
PCS 25.21 (5.07) 26.04 (4.70) 24.77 (4.01)
SBI 15.56 (6.01) 14.59 (5.22) 16.02 (4.97)
TUG, s 44.40 (7.08) 42.73 (7.19) 43.88 (5.99)

  1. Meaning of some Asymmetric Reflex Deficit values: knee tendon reflex (4/13): 4 participants out of 13 have asymmetric knee tendon reflex in the MT+SA group; Ankle tendon reflex (9/13): 9 participants out of 13 have asymmetric ankle tendon reflex in the MT+SA group; The values in the other groups are interpreted as those in the MT+SA group. Meaning of some Asymmetric Motor Deficit values (MRC score out of 5): Score of 3 (2/9): 2 out of 9 participants have a score of 3/5 on MRC scale in the MT+SA group; Score of 4 (7/9): 7 out of 9 participants have a score of 4/5 on MRC scale in the MT+SA group; The values in the other groups are interpreted as those in the MT+SA group. All values are M (SD) unless otherwise stated. BMI, body mass index; ET, exercise therapy; M, mean; MRC, medical research council muscle grading system; MT, manual therapy; MT+SA, manual therapy plus sexual advice; n, number; ODI-8, Oswestry disability index item 8; PCS, Pain Catastrophizing Scale; RMDQ, Rolland-Morris disability questionnaire; SBI, sciatica bothersomeness index; SD, standard deviation; TSK, Tampa Scale for Kinesiophobia; TUG, timed up and go test; VAS, visual analogue scale.

Clinical outcomes

The results indicated that all the treatment groups significantly improved in all outcomes and at all measured timelines (6, 12, 26, and 52 weeks postrandomization). However, those treated with MT+SA demonstrated better improvements in all outcomes and at all measured timelines than those treated with MT or ET alone (p<0.05). These improvements were also clinically meaningful for back pain intensity, leg pain intensity, and functional mobility at 6 and 12 weeks postrandomization, and for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at all timelines (p<0.05). On the other hand, the MT group improved more in leg pain intensity, sciatica bothersomeness, and functional mobility outcomes than the ET group at 6 weeks (p<0.05), but these outcomes were not clinically significant (Table 2).

Table 2:

Treatment effect outcomes at 6, 12, 26 and 52 weeks postrandomization.

Outcome (weeks) Treatment groups Between-group difference mean (95 % CI)
MT+SA group (n=18) MT group (n=18) ET group (n=18) MT+SA vs. MT MT+SA vs. ET MT vs. ET
VAS back (scores ranged from 0 to 10: lower scores indicate lesser pain)
6 2.61 (1.01) 4.56 (2.36) 4.67 (2.16) −2.00 (−3.14 to −0.76)a,c −2.06 (−3.16 to −0.96)a,c −0.11 (−1.59 to 1.37)
12 1.10 (1.18) 3.16 (2.14) 3.29 (2.06) −2.06 (−3.19 to −0.93)a,c −2.19 (−3.29 to −1.09)a,c −0.13 (−1.50 to 1.24)
26 1.01 (0.51) 2.02 (0.43) 2.79 (2.06) −1.01 (−1.32 to −0.70)a −1.78 (−2.76 to −0.80)a −0.77 (−1.74 to 0.20)
52 0.43 (0.34) 1.23 (0.36) 1.63 (2.06) −0.80 (−1.03 to −0.57)a −1.20 (−2.16 to −0.24)b −0.40 (−1.37 to 0.57)
VAS leg (scores range from 0 to 10: lower scores indicate lesser pain)
6 3.08 (2.23) 5.17 (2.10) 5.87 (2.88) −2.09 (−3.51 to −0.67)a,c −2.79 (−4.47 to −1.11)a,c −0.74 (−2.35 to 0.95)b
12 2.11 (1.01) 4.12 (2.31) 4.61 (2.22) −2.01 (−3.17 to −0.85)a,c −2.50 (−3.63 to −1.37)a,c −0.49 (−1.97 to −0.99)
26 1.12 (0.58) 2.27 (1.33) 2.66 (1.54) −1.15 (−1.82 to −0.48)a −1.54 (−2.30 to −0.78)a −0.39 (−1.33 to 0.55)
52 0.64 (0.44) 1.67 (0.98) 1.98 (0.88) −1.03 (−1.53 to −0.53)a −1.34 (−1.79 to −0.89)a −0.31 (−0.92 to 0.30)
RMDQ (scores ranged from 0 to 24: lower scores indicate lesser activity limitation)
6 8.25 (3.01) 11.44 (5.78) 11.69 (4.32) −3.19 (−6.20 to −0.18)b,c −3.43 (−5.86 to −1.00)a,c −0.24 (−3.57 to 3.09)
12 6.21 (4.11) 9.01 (4.13) 8.88 (2.51) −2.8 (−5.49 to −0.11)b,c −2.67 (−4.89 to −0.45)b,c 0.13 (−2.10 to 2.36)
26 3.02 (2.15) 6.31 (3.07) 7.33 (2.71) −3.29 (−5.02 to −1.56)a,c −4.31 (−5.91 to −2.71)a,c −1.02 (−2.91 to 0.87)
52 1.02 (0.36) 4.12 (1.04) 4.34 (2.02) −3.10 (−3.61 to −2.59)a,c −3.32 (−4.27 to −2.37)a,c −0.22 (−1.27 to 0.83)
ODI-8 (scores ranged from 0 to 5: lower scores indicate better sexual disability)
6 2.11 (1.03) 3.22 (1.21) 3.17 (1.32) −1.11 (−1.84 to −0.38)a,c −1.06 (−1.83 to −0.29)b,c 0.05 (−0.78 to 0.88)
12 1.31 (0.67) 2.89 (1.42) 2.77 (1.54) −1.58 (−2.32 to −0.85)a,c −1.46 (−2.24 to −0.68)a,c 0.12 (−0.85 to 1.09)
26 0.74 (0.25) 2.76 (1.50) 2.51 (1.7) −2.02 (−2.72 to −1.32)a,c −1.77 (−2.56 to −0.98)a,c 0.25 (−0.80 to 1.30)
52 0.20 (0.01) 2.45 (1.29) 2.62 (1.86) −2.25 (−2.85 to −1.65)a,c −2.42 (−3.28 to −1.56)a,c −0.17 (−1.22 to 0.88)
TSK (scores ranged from 11 to 44: lower scores indicate less fear of movement/reinjury)
6 18.13 (4.54) 27.82 (8.66) 28.72 (7.60) −9.69 (−14.21 to −5.17)a,c −10.59 (−14.68 to −6.50)a,c −0.90 (−6.22 to 4.42)
12 16.10 (4.61) 23.88 (5.26) 24.01 (6.91) −7.78 (−11.01 to −4.55)a,c −7.91 (−11.75 to −4.07)a,c −0.13 (−4.14 to 3.88)
26 12.44 (3.01) 18.99 (3.39) 19.04 (5.31) −6.55 (−8.64 to −4.46)a,c −6.60 (−9.42 to −3.78)a,c −0.05 (−2.96 to 2.86)
52 11.61 (4.80) 18.03 (4.43) 17.68 (4.61) −6.42 (−9.44 to −3.40)a,c −6.07 (−9.14 to −3.00)a,c 0.35 (−2.67 to 3.37)
PCS (scores ranged from 0 to 52: lower scores indicate lower catastrophizing)
6 10.08 (3.54) 18.61 (5.73) 18.22 (4.73) −8.53 (−11.64 to −5.42)a,c −8.14 (−10.87 to −5.41)a,c 0.39 (−3.04 to 3.82)
12 7.45 (5.29) 15.88 (4.98) 16.54 (4.18) −8.43 (−11.79 to −5.07)a,c −9.09 (−12.20 to −6.00)a,c −0.66 (−3.66 to 2.34)
26 4.60 (3.08) 14.21 (2.77) 14.77 (3.33) −9.61 (−11.52 to −7.70)a,c −10.17 (−12.27 to −8.07)a,c −0.56 (−2.56 to 1.44)
52 1.11 (0.09) 9.16 (3.56) 9.69 (3.56) −8.05 (−9.70 to −6.40)a,c −8.58 (−10.23 to −6.93)a,c −0.53 (−2.86 to 1.80)
15.56 (6.01) 14.59 (5.22) 16.02 (4.97)
SBI (scores ranged from 0 to 24: lower scores indicate lesser sciatica bothersomeness)
6 8.03 (2.11) 10.24 (4.11) 14.02 (4.67) −2.21 (−4.34 to −0.08)b −5.99 (−8.36 to −3.62)a −3.78 (−6.65 to −0.91)b
12 4.21 (1.63) 7.32 (2.42) 8.32 (3.32) −3.11 (−4.46 to −1.76)a −4.11 (−5.82 to −2.40)a −1.00 (−2.90 to 0.90)
26 2.03 (1.30) 5.31 (2.22) 5.66 (2.69) −3.28 (−4.47 to −2.09)a −3.63 (−5.01 to −2.25)a −0.35 (−1.96 to 1.26)
52 1.42 (1.01) 4.01 (2.71) 4.78 (2.33) −2.59 (−3.93 to −1.25)a −3.36 (−4.53 to −2.19)a −0.77 (−2.42 to 0.88)
TUG, s (lower scores indicate higher mobility)
6 26.23 (5.66) 34.19 (4.53) 37.61 (3.32) −7.96 (−11.31 to −4.61)a,c −11.38 (−14.41 to −8.35)a,c −3.42 (−6.01 to −0.83)b
12 17.21 (4.33) 23.22 (3.43) 24.71 (5.55) −6.01 (−8.56 to −3.46)a,c −7.50 (−10.75 to −4.25)a,c −1.49 (−5.50 to 1.52)
26 9.88 (5.08) 12.99 (4.18) 12.98 (4.33) −3.11 (−6.15 to −0.07)b −3.10 (−6.14 to −0.06)b 0.01 (−2.72 to 2.74)
52 8.01 (2.09) 10.06 (3.56) 10.11 (2.66) −2.05 (−3.96 to −0.14)b −2.10 (−3.66 to −0.54)b −0.05 (−2.10 to 2.00)

  1. All values are M (SD) until otherwise stated. aSignificant at p<0.01. bSignificant at p<0.05. cClinically meaningful. CI, confidence interval; ET, exercise therapy; M, mean; MT, manual therapy; MT+SA, manual therapy plus sexual advice; n, number; ODI-8, Oswestry disability index item 8; PCS, Pain Catastrophizing Scale; RMDQ, Rolland-Morris disability questionnaire; SBI, sciatica bothersomeness index; SD, standard deviation; TSK, Tampa Scale for Kinesiophobia; TUG, timed up and go test; VAS, visual analogue scale.

Nerve function results

Although all participants improved in neurodynamic testing and neurological deficit (sensory, reflex, and motor deficits) in all groups and across timelines, the outcomes indicated that there were no significant between-group differences in nerve function at all measured timelines (p>0.05) (Table 3).

Table 3:

Nerve function outcomes and use of pain medications at 6, 12, 26, and 52 weeks postrandomization.

Outcomes (weeks) Treatment groups Relative risk (95 % CI)
MT+SA group (n=18) MT group (n=18) ET group (n=18) MT+SA vs. MT MT+SA vs. ET MT vs. ET
Neurodynamic testing
6 weeks 9/18 (50 %) 9/18 (50 %) 10/18 (56 %) 1.0 (0.5–1.9) 0.9 (0.5–1.7) 0.9 (0.5–1.7)
12 weeks 2/18 (11 %) 4/18 (22 %) 5/18 (28 %) 0.5 (0.1–2.4) 0.4 (0.1–1.8) 0.8 (0.3–2.5)
26 weeks 0/18 (0 %) 0/18 (0 %) 0/18 (0 %) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0)
52 weeks 0/18 (0 %) 0/18 (0 %) 0/18 (0 %) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0)
Asymmetric sensory deficit
6 weeks 5/18 (28 %) 5/18 (28 %) 7/18 (39 %) 1.0 (0.4–1.9) 0.7 (0.3–1.8) 0.7 (0.3–1.8)
12 weeks 1/18 (6 %) 2/18 (11 %) 3/18 (17 %) 0.5 (0.1–5.0) 0.3 (0.0–2.9) 0.7 (0.1–3.5)
26 weeks 0/18 (0 %) 0/18 (0 %) 0/18 (0 %) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0)
52 weeks 0/18 (10 %) 0/18 (0 %) 0/18 (0 %) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0)
Asymmetric reflex deficit
6 weeks 7/18 (39 %) 9/18 (50 %) 8/18 (44 %) 0.8 (0.4–1.6) 0.9 (0.4–1.9) 1.1 (0.6–2.3)
12 weeks 3/18 (17 %) 4/18 (22 %) 4/18 (22 %) 0.8 (0.2–2.9) 0.8 (0.2–2.9) 1.0 (0.3–3.4)
26 weeks 0/18 (0 %) 1/18 (6 %) 1/18 (6 %) 0.3 (0.0–7.9) 0.3 (0.0–7.9) 1.0 (0.1–14.8)
52 weeks 0/18 (0 %) 0/18 (0 %) 0/18 (0 %) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0)
Asymmetric motor deficit
6 weeks 2/18 (11 %) 2/18 (11 %) 4/18 (28 %) 1.0 (0.2–6.4) 0.5 (0.1–2.4) 0.5 (0.1–2.4)
12 weeks 0/18 (0 %) 0/18 (0 %) 0/18 (0 %) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0)
26 weeks 0/18 (0 %) 0/18 (0 %) 0/18 (0 %) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0)
52 weeks 0/18 (0 %) 0/18 (0 %) 0/18 (0 %) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0)
Use of pain medications
6 weeks 4/18 (22 %) 11/18 (61 %) 12/18 (67 %) 0.4 (0.1–1.0)a 0.3 (0.1–0.8)a 0.9 (0.6–1.5)
12 weeks 0/18 (0 %) 8/18 (44 %) 9/18 (50 %) 0.1 (0.0–1.0)a 0.1 (0.0–0.8)a 0.9 (0.4–1.8)
26 weeks 0/18 (0 %) 2/18 (11 %) 2/18 (11 %) 0.2 (0.01–3.9) 0.2 (0.01–3.9) 1.0 (0.2–6.4)
52 weeks 0/18 (0 %) 0/18 (0 %) 0/18 (0 %) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0)

  1. aSignificant at p<0.05. CI, confidence interval; ET, exercise therapy; M, mean; MT, manual therapy; MT+SA, manual therapy plus sexual advice; n, number.

Use of pain medications

The use of pain medications declined from baseline to year 1, with participants in the MT+SA group reporting taking fewer medications than those in the MT and ET groups. These outcomes were also clinically meaningful at 6 and 12 weeks (p<0.05) but not at 26 and 52 weeks postrandomization (Table 3).

Sexual positions for females and males

After the trial has ended (at 52 weeks postrandomization), many preferred sexual positions for females and males emerged. For female participants, five sexual positions emerged: side-lying, quadruped type 1, missionary type 2, quadruped type 2, and standing. However, side-lying was reported by all females (6) and was practiced 154 times in a year, making it the most reported sexual position by females (Figure 2A). For male participants, four sexual positions emerged: lying on the back, side-lying, missionary type 2, and sitting on a chair. Lying on the back was reported by all males (12) and was practiced 266 times in a year, making it the most reported sexual position by males (Figure 2B).

Figure 2: (A) Bar charts for female sexual positions. (B) Bar charts for male sexual positions.
Figure 2:

(A) Bar charts for female sexual positions. (B) Bar charts for male sexual positions.

Adverse events

Adverse events were not reported by the participants.

Discussion

This study was conducted to determine the effects of MT+SA compared with MT or ET alone in the management of individuals with DHR and to determine the best sexual positions for these individuals. Although all of the treatment groups improved over time, the finding of this study, which is in line with our hypothesis, revealed that the MT plus SA group improved better than the MT or ET group in all outcomes and at all measured timelines (6, 12, 26, and 52 weeks postrandomization), except for nerve function outcomes (at all timelines) and medication intake at 26 and 52 weeks. Additionally, the interpretation of the CIs showed that they span the smallest worthwhile effects for medication intake, back pain intensity, leg pain intensity, and functional mobility at 6 and 12 weeks postrandomization and for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at all measured timepoints. These findings indicated that the significant effects achieved by the MT+SA group over the MT or ET group in this study are clinically meaningful for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at long-term follow-up.

Although previous studies indicated that MT informs of SMWLM and PINS improved the outcomes of individuals with DHR, these studies did not incorporate SA into the treatment regimen [27, 28]. Additionally, these studies did not also measure some of the psychosocial factors (e.g., pain catastrophizing) that accompany chronic pain, and they did not utilize a control group to determine the significant effects of the MT approaches [27, 28]. In contrast, our current study incorporated SA to the treatment regimen, measured some of the psychosocial factors (e.g., pain catastrophizing, kinesiophobia) that accompany chronic pain and also utilized a control group to determine the significant effects of the MT approaches. These outcomes indicated that our current study is unique and has supported the scientific evidence for the effectiveness of MT+SA in the management of individuals with DHR.

The significant improvement achieved in the MT groups may be partly related to the ability of the SMWLM to relieve nerve root compression through increased intervertebral disc space gapping, nucleus deformation, and approximation of the alternate layers of the annulus, thereby producing favorable therapeutic effects on the intervertebral disc [27, 28]. Additionally, although decreased diffusion of water and loss of proteoglycans are hallmarks of disc degeneration, it has been suggested that fluid exchange is integral to maintaining disc nutrition [31]. Moreover, mobilizations such as posterior–anterior (P–A) glides have been reported to result in pain relief and improved motion in individuals with LBP while also improving disc hydration [32, 33]. Given that SMWLM is a form of P–A gliding mobilization, it is conceivable that this technique could correct the positional fault by relieving pressure from the structures that compress the nerves, improving disc hydration and reducing the extent of pain via centralization [27, 28, 34].

On the other hand, the improvement achieved in the MT groups may also be related to the ability of the PINS to relieve neuromuscular pain [27, 28]. PINS has been indicated to reduce lower limb radiating pain through increased hyperemia and washing away of the metabolites in the neuromuscular structures following myofascial trigger point deactivation [35]. Additionally, the ischemic compression applied on the sensitive neuromuscular structures utilizing PINS may also elicit a counterirritant effect in which large, fast-conducting afferent fibers in the dorsal horn of the spinal cord and collateral fibers in the substantia gelatinosa or adjacent interneurons inhibit the transmission of pain via the spinothalamic tract [35]. In this manner, pressure acts as a stimulant to neighboring tissues, reducing the sensitivity of the tender point and thus resolving pain [35, 36].

The better treatment effects achieved by the MT+SA group in this study might have been due to the ability of SA to improve pain, sexual disability, pain catastrophizing, and kinesiophobia, which are challenging aspects of chronic pain. Kinesiophobia is among the most extreme forms of fear of pain due to movement or reinjury, and is the main reason why sexual intercourse is avoided in individuals with LBP [10, 37]. This avoidance behavior can have detrimental effects on the mental and physical health of individuals and can make sexual activity less attractive [38]. Even after LBP subsides, the lingering effects of fear avoidance may still be present, which could lead to chronic sexual disability among patients [39, 40].

This study also revealed that many preferred sexual positions exist, with “side-lying” being the most practiced sexual position and “standing” being the least practiced sexual position by females. On the other hand, among males, “lying on the back” was the most practiced sexual position and “sitting on a chair” was the least practiced sexual position. Although side-lying is the most recommended sexual position for females and males with LBP [41, 42], our current findings indicated the opposite and are also in line with those of Sidorkewicz and McGill [43, 44], who reported that there was no one-size-fits-all to sexual positioning. While side-lying was proposed to reduce disc bulging via straightening of the spine due to flexing at the hips and knees [45], lying supine has been demonstrated to improve intradiscal pressure and intervertebral disc height better than standing or sitting 46], [47], [48, making it one of the ideal sexual positions for individuals with DHR.

It should be noted that the MT group improved better in leg pain intensity, sciatica bothersomeness, and functional mobility outcomes than the ET group in the short term, but not in the intermediate-term and long-term follow-ups. Although the same set of therapeutic exercises administered to the ET group was also prescribed as a home routine to all participants, these exercises cannot be utilized as a stand-alone treatment for DHR [49, 50]. However, because of the importance of lumbar segmental stability [51] and neural mechanosensitivity [52], it is understandable that these exercises may be utilized as adjunct therapies.

Strengths and limitations

This is the first study that evaluated the effects of MT+SA in the management of individuals with DHR. This study reported data for the long-term duration and interpreted outcomes based on clinical meaningfulness. Additionally, this study utilized a control group to better understand the effects of MT and SA in individuals with DHR. Furthermore, this study also assessed some of the psychosocial barriers (e.g., kinesiophobia, pain catastrophizing) to recovery that may accompany chronic pain. The limitation of this study is that it administered therapeutic exercises as a home routine, limiting the long-term improvement achieved in the study to be attributed to only MT and SA. Future trials may, therefore, be conducted to address these limitations.

Conclusions

This study found that individuals with DHR demonstrated better improvements in all outcomes when treated with MT+SA than when treated with MT alone or ET alone. These improvements were also clinically meaningful for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at long-term follow-up. There is also no one-size-fits-all to sexual positioning for individuals with DHR.

Corresponding author: Musa Sani Danazumi, MScPhysio, BPhysio, Discipline of Physiotherapy, School of Allied Health, Human Services and Sport, College of Sciences, Health and Engineering, La Trobe University, Bundoora, Victoria 3085, Australia, E-mail:

  1. Research ethics: The Health Research Ethics Committee of Federal Medical Centre, Nguru, Nigeria approved this study (#FMC/N/CL.SERV/668/VOLVII/320). Pan African Clinical Trial Registry: PACTR202002785212512.

  2. Informed consent: The patients included in the study signed a written informed consent form.

  3. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Use of large language models, AI and machine learning tools: Not applicable.

  5. Competing interests: None declared.

  6. Research funding: None declared.

  7. Data availability: All relevant data are available from the corresponding author upon request.

References

1. Hartvigsen, J, Hancock, MJ, Kongsted, A, Lou, Q, Ferreira, ML, Genevay, S, et al.. What low back pain is and why we need to pay attention. Lancet 2018;391:2356–67. https://doi.org/10.1016/s0140-6736(18)30480-x.Search in Google Scholar PubMed

2. Konstantinou, K, Hider, SL, Jordan, JL, Lewis, M, Dunn, KM, Hay, EM. The impact of low back-related leg pain on outcomes as compared with low back pain alone: a systematic review of the literature. Clin J Pain 2013;29:644–54. https://doi.org/10.1097/AJP.0b013e31826f9a52.Search in Google Scholar PubMed

3. Mescouto, K, Olson, RE, Hodges, PW, Setchell, J. A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disabil Rehabil 2022;44:3270–84. https://doi.org/10.1080/09638288.2020.1851783.Search in Google Scholar PubMed

4. Quinteros, G, Yurac, R, Zamorano, JJ, Díez-Ulloa, MA, Pudles, E, Marré, BA. Management of lumbar disc herniation with radiculopathy: results of an Iberian-Latin American survey. Surg Neurol Int 2021;12:363. https://doi.org/10.25259/SNI_262_2021.Search in Google Scholar PubMed PubMed Central

5. Dan-Azumi, MS, Bello, B, Rufai, SA, Abdurrahman, MA. Surgery versus conservative management for lumbar disc herniation with radiculopathy: a systematic review and meta-analysis. J Health Sci 2018;8:42–53. https://doi.org/10.17532/jhsci.2017.479.Search in Google Scholar

6. Hahne, AJ, Ford, JJ, Hinman, RS, Richards, MC, Surkitt, LD, Chan, AY, et al.. Individualized functional restoration as an adjunct to advice for lumbar disc herniation with associated radiculopathy. A preplanned subgroup analysis of a randomized controlled trial. Spine J 2017;17:346–59. https://doi.org/10.1016/j.spinee.2016.10.004.Search in Google Scholar PubMed

7. Foster, NE, Konstantinou, K, Lewis, M, Ogollah, R, Saunders, B, Kigozi, J, et al.. Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT. Health Technol Assess 2020;24:1–130. https://doi.org/10.3310/hta24490.Search in Google Scholar PubMed PubMed Central

8. Hodges, PW. Hybrid approach to treatment tailoring for low back pain: a proposed model of care. J Orthop Sports Phys Ther 2019;49:453–63. https://doi.org/10.2519/jospt.2019.8774.Search in Google Scholar PubMed

9. Pakpour, AH, Nikoobakht, M, Campbell, P. Association of pain and depression in those with chronic low back pain: the mediation effect of patient sexual functioning. Clin J Pain 2015;31:44–51. https://doi.org/10.1097/ajp.0000000000000076.Search in Google Scholar

10. Grabovac, I, Dorner, TE. Association between low back pain and various everyday performances: activities of daily living, ability to work and sexual function. Wien Klin Wochenschr 2019;131:541–9. https://doi.org/10.1007/s00508-019-01542-7.Search in Google Scholar PubMed PubMed Central

11. Malik, AT, Jain, N, Kim, J, Khan, SN, Yu, E. Sexual activity after spine surgery: a systematic review. Eur Spine J 2018;27:2395–426. https://doi.org/10.1007/s00586-018-5636-7.Search in Google Scholar PubMed

12. Ferrari, S, Vanti, C, Frigau, L, Guccione, AA, Mola, F, Ruggeri, M, et al.. Sexual disability in patients with chronic non-specific low back pain – a multicenter retrospective analysis. J Phys Ther Sci 2019;31:360–5. https://doi.org/10.1589/jpts.31.360.Search in Google Scholar PubMed PubMed Central

13. Bahouq, H, Allali, F, Rkain, H, Hajjaj-Hassouni, N. Discussing sexual concerns with chronic low back pain patients: barriers and patients’ expectations. Clin Rheumatol 2013;32:1487–92. https://doi.org/10.1007/s10067-013-2299-y.Search in Google Scholar PubMed

14. Khajehei, M, Behroozpour, E. Endorphins, oxytocin, sexuality and romantic relationships: an understudied area. World J Obstet Gynecol 2018;7:17–23. https://doi.org/10.5317/wjog.v7.i2.17.Search in Google Scholar

15. Frye, CA. Neurosteroids’ effects and mechanisms for social, cognitive, emotional, and physical functions. Psychoneuroendocrinology 2009;34:S143–61. https://doi.org/10.1016/j.psyneuen.2009.07.005.Search in Google Scholar PubMed PubMed Central

16. Esch, T, Stefano, GB. The neurobiology of love. Neuroendocrinol Lett 2005;26:175–92.Search in Google Scholar

17. Meston, CM, Levin, RJ, Sipski, ML, Hull, EM, Heiman, JR. Women’s orgasm. Annu Rev Sex Res 2004;15:173–257.10.1080/10532528.2004.10559820Search in Google Scholar

18. Gordon, I, Martin, C, Feldman, R, Leckman, JF. Oxytocin and social motivation. Dev Cogn Neurosci 2011;1:471–93. https://doi.org/10.1016/j.dcn.2011.07.007.Search in Google Scholar PubMed PubMed Central

19. Levin, R, Meston, C. Nipple/Breast stimulation and sexual arousal in young men and women. J Sex Med 2006;3:450–4. https://doi.org/10.1111/j.1743-6109.2006.00230.x.Search in Google Scholar PubMed

20. Costa, M, Marshman, LA. Sex life and the Oswestry Disability Index. Spine J 2015;15:1225–32. https://doi.org/10.1016/j.spinee.2015.02.022.Search in Google Scholar PubMed

21. Korse, NS, Nicolai, MP, Both, S, Vleggeert-Lankamp, CLA, Elzevier, HW. Discussing sexual health in spinal care. Eur Spine J 2016;25:766–73. https://doi.org/10.1007/s00586-015-3991-1.Search in Google Scholar PubMed

22. Maigne, JY, Chatellier, G. Assessment of sexual activity in patients with back pain compared with patients with neck pain. Clin Orthop Relat Res 2001;385:82–7. https://doi.org/10.1097/00003086-200104000-00014.Search in Google Scholar PubMed

23. Bahouq, H, Fadoua, A, Hanan, R, Ihsane, H, Najia, HH. Profile of sexuality in Moroccan chronic low back pain patients. BMC Musculoskelet Disord 2013;14:63. https://doi.org/10.1186/1471-2474-14-63.Search in Google Scholar PubMed PubMed Central

24. Nikoobakht, M, Fraidouni, N, Yaghoubidoust, M, Burri, A, Pakpour, AH. Sexual function and associated factors in Iranian patients with chronic low back pain. Spinal Cord 2014;52:307–12. https://doi.org/10.1038/sc.2013.151.Search in Google Scholar PubMed

25. Danazumi, MS, Yakasai, AM. Prevalence of sexual disability and its relationship with pain intensity, quality of life and psychological distress among individuals with chronic low back pain in Nigeria: a cross-sectional study. Sex Disabil 2024;42:349–60. https://doi.org/10.1007/s11195-024-09847-w.Search in Google Scholar

26. Danazumi, MS, Yakasai, AM, Ibrahim, SU, Falke, MA, Hassan, AB, Zakari, UU, et al.. Is there sexual activity after low back pain? A clinical commentary. Niger J Med 2021;30:729–32. https://doi.org/10.4103/njm.njm_162_21.Search in Google Scholar

27. Danazumi, MS, Bello, B, Yakasai, AM, Kaka, B. Two manual therapy techniques for management of lumbar radiculopathy: a randomized clinical trial. J Osteopath Med 2021;121:391–400. https://doi.org/10.1515/jom-2020-0261.Search in Google Scholar PubMed

28. Bello, B, Danazumi, MS, Kaka, B. Comparative effectiveness of 2 manual therapy techniques in the management of lumbar radiculopathy: a randomized clinical trial. J Chiropr Med 2019;18:253–60. https://doi.org/10.1016/j.jcm.2019.10.006.Search in Google Scholar PubMed PubMed Central

29. Guyatt, GH, Oxman, AD, Kunz, R, Brozek, J, Alonso-Coello, P, Rind, D, et al.. GRADE guidelines 6. Rating the quality of evidence – imprecision. J Clin Epidemiol 2011;64:1283–93. https://doi.org/10.1016/j.jclinepi.2011.01.012.Search in Google Scholar PubMed

30. Elkins, MR, Moseley, AM. Intention-to-treat analysis. J Physiother 2015;61:165–7. https://doi.org/10.1016/j.jphys.2015.05.013.Search in Google Scholar PubMed

31. Johannessen, W, Vresilovic, EJ, Wright, AC, Elliott, DM. Intervertebral disc mechanics are restored following cyclic loading and unloaded recovery. Ann Biomed Eng 2004;32:70–6. https://doi.org/10.1023/b:abme.0000007792.19071.8c.10.1023/B:ABME.0000007792.19071.8cSearch in Google Scholar PubMed

32. Beattie, PF, Arnot, CF, Donley, JW, Noda, H, Bailey, L. The immediate reduction in low back pain intensity following lumbar joint mobilization and prone press-ups is associated with increased diffusion of water in the L5-S1 intervertebral disc. J Orthop Sports Phys Ther 2010;40:256–64. https://doi.org/10.2519/jospt.2010.3284.Search in Google Scholar PubMed

33. Beattie, PF, Donley, JW, Arnot, CF, Miller, R. The change in the diffusion of water in normal and degenerative lumbar intervertebral discs following joint mobilization compared to prone lying. J Orthop Sports Phys Ther 2009;39:4–11. https://doi.org/10.2519/jospt.2009.2994.Search in Google Scholar PubMed

34. Danazumi, MS, Nuhu, JM, Ibrahim, SU, Falke, MA, Rufai, SA, Abdu, UG, et al.. Effects of spinal manipulation or mobilization as an adjunct to neurodynamic mobilization for lumbar disc herniation with radiculopathy: a randomized clinical trial. J Man Manip Ther 2023;31:408–20. https://doi.org/10.1080/10669817.2023.2192975.Search in Google Scholar PubMed PubMed Central

35. Dowling, DJ. Progressive inhibition of neuromuscular structures (PINS) technique. J Am Osteopath Assoc 2000;100:285–6.Search in Google Scholar

36. Wong, CK. Strain counterstrain: current concepts and clinical evidence. Man Ther 2012;17:2–8. https://doi.org/10.1016/j.math.2011.10.001.Search in Google Scholar PubMed

37. Leeuw, M, Goossens, MEJB, Linton, SJ, Crombez, G, Boersma, K, Vlaeyen, JWS. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 2007;30:77–94. https://doi.org/10.1007/s10865-006-9085-0.Search in Google Scholar PubMed

38. Payne, KA, Binik, YM, Amsel, R, Khalifé, S. When sex hurts, anxiety and fear orient attention towards pain. Eur J Pain 2005;9:427–. https://doi.org/10.1016/j.ejpain.2004.10.003.Search in Google Scholar PubMed

39. Curtin, KB, Norris, D. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: adjustments to the fear-avoidance model of chronic pain. Scand J Pain 2017;17:156–66. https://doi.org/10.1016/j.sjpain.2017.08.006.Search in Google Scholar PubMed

40. Thomas, CM, Levene, HB. Lack of current recommendations for resuming sexual activity following spinal surgery. Asian Spine J 2019;13:515–18. https://doi.org/10.31616/asj.2018.0106.Search in Google Scholar PubMed PubMed Central

41. Infante, MC. Sexual dysfunction in the patient with chronic back pain. Sex Disabil 1981;4:173–8. https://doi.org/10.1007/bf01277435.Search in Google Scholar

42. Osborne, D, Maruta, T. Sexual adjustment and chronic back pain. Med Aspect Hum Sex 1980;14:94–113.Search in Google Scholar

43. Sidorkewicz, N, McGill, SM. Male spine motion during coitus: implications for the low back pain patient. Spine 2014;39:1633–9. https://doi.org/10.1097/BRS.0000000000000518.Search in Google Scholar PubMed PubMed Central

44. Sidorkewicz, N, McGill, SM. Documenting female spine motion during coitus with a commentary on the implications for the low back pain patient. Eur Spine J 2015;24:513–20. https://doi.org/10.1007/s00586-014-3626-y.Search in Google Scholar PubMed

45. White, AA, Panjabi, MM. Clinical biomechanics of the spine, 2nd ed. Philadelphia, PA: J.B. Lippincott Company; 1990.Search in Google Scholar

46. Claus, A, Hides, J, Moseley, GL, Hodges, P. Sitting versus standing: does the intradiscal pressure cause disc degeneration or low back pain? J Electromyogr Kinesiol 2008;18:550–8. https://doi.org/10.1016/j.jelekin.2006.10.011.Search in Google Scholar PubMed

47. Splendiani, A, Bruno, F, Marsecano, C, Arrigoni, F, Di Cesare, E, Barile, A, et al.. Modic I changes size increase from supine to standing MRI correlates with increase in pain intensity in standing position: uncovering the “biomechanical stress” and “active discopathy” theories in low back pain. Eur Spine J 2019;28:983–92. https://doi.org/10.1007/s00586-019-05974-7.Search in Google Scholar PubMed

48. Son, S, Lee, SG, Kim, WK, Ahn, Y, Jung, JM. Disc height discrepancy between supine and standing positions as a screening metric for discogenic back pain in patients with disc degeneration. Spine J 2021;21:71–9. https://doi.org/10.1016/j.spinee.2020.07.006.Search in Google Scholar PubMed

49. Kreiner, DS, Hwang, SW, Easa, JE, Resnick, DK, Baisden, JL, Bess, S, et al.; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 2014;14:180–91. https://doi.org/10.1016/j.spinee.2013.08.003.Search in Google Scholar PubMed

50. Efstathiou, MA, Stefanakis, M, Savva, C, Giakas, G. Effectiveness of neural mobilization in patients with spinal radiculopathy: a critical review. J Bodyw Mov Ther 2015;19:205–12. https://doi.org/10.1016/j.jbmt.2014.08.006.Search in Google Scholar PubMed

51. Areeudomwong, P, Jirarattanaphochai, K, Ruanjai, T, Buttagat, V. Clinical utility of a cluster of tests as a diagnostic support tool for clinical lumbar instability. Musculoskelet Sci Pract 2020;50:102224. https://doi.org/10.1016/j.msksp.2020.102224.Search in Google Scholar PubMed

52. Fourré, A, Monnier, F, Ris, L, Telliez, F, Michielsen, J, Roussel, N, et al.. Low-back related leg pain: is the nerve guilty? How to differentiate the underlying pain mechanism. J Man Manip Ther 2023;31:57–63. https://doi.org/10.1080/10669817.2022.2092266.Search in Google Scholar PubMed PubMed Central

Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/jom-2023-0075).

Received: 2023-04-27
Accepted: 2024-06-06
Published Online: 2024-09-12

© 2024 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

Articles in the same Issue

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  2. Cardiopulmonary Medicine
  3. Review Article
  4. Comprehensive review of the heart failure management guidelines presented by the American College of Cardiology and the current supporting evidence
  5. Medical Education
  6. Original Article
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  8. Musculoskeletal Medicine and Pain
  9. Review Article
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  11. Original Article
  12. Manual therapy plus sexual advice compared with manual therapy or exercise therapy alone for lumbar radiculopathy: a randomized controlled trial
  13. Neuromusculoskeletal Medicine (OMT)
  14. Original Article
  15. Why do physicians practice osteopathic manipulative treatment (OMT)? A survey study
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  19. Letter to the Editor
  20. Educating our colleagues and hospital administrators regarding osteopathic medicine
https://doi.org/10.1515/jom-2023-0075
Keywords for this article
lumbar radiculopathy; manual therapy; randomized controlled trial; sexual advice
Creative Commons
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Articles in the same Issue

  1. Frontmatter
  2. Cardiopulmonary Medicine
  3. Review Article
  4. Comprehensive review of the heart failure management guidelines presented by the American College of Cardiology and the current supporting evidence
  5. Medical Education
  6. Original Article
  7. The predictive validity of MCAT scores and undergraduate GPA for COMLEX-USA licensure exam performance of students enrolled in osteopathic medical schools
  8. Musculoskeletal Medicine and Pain
  9. Review Article
  10. Foot and ankle fellowship-trained osteopathic orthopaedic surgeons: a review, analysis, and understanding of current trends
  11. Original Article
  12. Manual therapy plus sexual advice compared with manual therapy or exercise therapy alone for lumbar radiculopathy: a randomized controlled trial
  13. Neuromusculoskeletal Medicine (OMT)
  14. Original Article
  15. Why do physicians practice osteopathic manipulative treatment (OMT)? A survey study
  16. Obstetrics and Gynecology
  17. Original Article
  18. Uncovering gaps in management of vasomotor symptoms: findings from a national need assessment
  19. Letter to the Editor
  20. Educating our colleagues and hospital administrators regarding osteopathic medicine
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