Abstract
Background:
Malalignment in the pelvic and spinal column disturbs the balance and decreases the postural control ability. Malalignment is known as one of the main causes of back pain particularly the nonspecific chronic low back pain (NSCLBP). The aim of the study is to compare the effect of muscle energy technique (MET), craniosacral therapy (CST), and sensorimotor training (SMT) on postural control in patients with NSCLBP.
Materials and Methods:
In this randomized clinical trial study, 45 NSCLBP patients were accidentally allocated in three groups including CST (n = 15), MET (n = 15), and SMT (n = 15). Clinical interventions including CST, MET, and SMT were performed in 10 sessions in 5 weeks (2 sessions per week). The parameters of center of pressure (COP) were assessed in 8 positions such as standing position on double or single leg with open or closed eyes or half squat position on double or single leg with open or closed eyes.
Results:
The results of this study showed that all three methods of CST, MET, and SMT are effective in postural control in patients with NSCLBP, although it seems that CST is effective on more balance factors. CST has a greater effect on balance in standing position on a single leg with closed eye. It was also found that the effect of CST was continuous after follow-up.
Conclusion:
Moreover, MET and SMT methods were effective in balance control in NSCLBP patients and postural control was more affected by CST.
Keywords: Craniosacral therapy, muscle energy technique, postural control, sensorimotor training
Introduction
Malalignment in the pelvic and spinal column regions exists in 90–80% of the adult population.[1] Malalignment leads to asymmetry in bones and joints in pelvis, trunk, and limbs and affects the muscles and lower limbs and disturbs the balance and decreases the postural control ability.[2] It is known as an early and significant cause or an exacerbating factor in 50–60% of people suffering from back pain[1] particularly the nonspecific chronic low back pain (NSCLBP) which is the most common form of low back pain.[3]
Treatment techniques such as sensorimotor training have been claimed to be effective in postural control.[4,5] It means that, decrease in proprioceptive sensitivity affects balance and postural control.[6] It was shown that sensorimotor training can improve the proprioceptive sense.[7] Muscle energy technique (MET) is a technique that is used to address muscular tension, pain, and dysfunction of joints and to improve the range of motion (ROM).[8] Craniosacral therapy (CST) is a complementary treatment that is believed to release the tension of the muscles, ligaments, and fascia in the sacral zone.[9]
Although there are studies that evaluated the effect of SMT methods on correction of malalignment and postural control in NSCLBP patients, yet no study compared the effect of all these three methods. Therefore, the aim of the present study was to compare the effectiveness of MET, CST, and CST on postural control in patients with NSCLBP.
Materials and Methods
Subjects
This is a randomized clinical trial study. Forty-five NSCLBP patients who were referred to the physiotherapy clinic of the School of Rehabilitation of Iran University of Medical Sciences, Iran were selected for this study. A convenience sampling method was used to select the participants. The ethics committee of Iran University of Medical Sciences has approved the study (IR.IUMS.REC139509211342216). All participants signed written consent. The inclusion criteria included patients suffering from anterior or posterior rotation of the right or left innominate or sacroiliac joint upslip, aged between 20 to 40 years, having low back pain (LBP) below the costal margin and above the inferior gluteal folds, and suffering from low back pain for more than 6 months while the exclusion criteria included pregnancy, seizure, tumor, history of neurologic disorder, lumbar fracture, and lumbar surgery. The appropriate individuals were accidentally allocated in three groups including CST (n = 15), MET (n = 15), and SMT (n = 15).
Before starting the first session of treatment the parameters of the center of pressure (COP) including standard deviation COP amplitude in frontal plane (SD-Ax), standard deviation COP amplitude in sagittal plane (SD-Ay), standard deviation velocity of COP in frontal plane (SD-Vx), standard deviation velocity of COP in sagital plane (SD-Vy), anterior-posterior phase plane portrait (PPP-AP), mediolateral phase plane portrait (PPP-ML), anterior-posterior mediolateral phase plane portrait (PPP-APML), mean total velocity (MTV), and area were measured in 8 positions including standing on two legs with open eyes (STLOE), standing on two legs with closed eyes (STLCE), standing on single leg with open eyes (SSLOE) (the dysfunction side leg), standing on single leg with closed eyes (SSLCE), half squat on two legs with open eyes (HSTLOE), half squat on two legs with closed eyes (HSTLCE), half squat on single leg with open eyes (HSSLOE), and half squat on single leg with closed eyes (HSSLCE) were measured. Force plate (Model 9260AA6, Kistler Company, Switzerland) was used to measure the parameters. The signals were collected at a sampling frequency of 100 Hz. Patients were placed on a force plate with bare feet. The distance of the legs during the test was the same as per the width of the pelvis to avoid the effect of the variation on the base of support. Hands were also attached to the body. The blindfold was also made to close the eyes while measuring the desired parameters on the force plate. The reliability of the COP parameters was confirmed through Salavati, Mazaheri, and Moghadam studies.[10,11,12,13]
Intervention
The CST, MET, and SMT interventions were done as follow:
For craniosacral therapy modified protocol by Upledger and Vredevoogd was used.[14] About 10 sessions of CST were performed for the CST group for 5 weeks, i.e., 2 sessions per week. Each CST session comprised of four phases, namely, in prone position, in side-lying position in front of the therapist, in side-lying position behind the therapist, and in supine position. In this treatment protocol, the therapist did not personally modify the patient's CRI (cranial rhythmic impulse) rhythm but only followed and monitored it by releasing and relaxing his mind and paying close attention to the patient's rhythm. Later, after the rhythm of the area was corrected, she moved her hand and again observed the rhythm of the new area carefully. In this way, the erroneous and defective rhythm of the cranial sutures were corrected by the careful attention of the therapist. That is, without any intervention and resistance of the therapist's mind, these positive changes in rhythm occurred.
MET group received 10 sessions of muscle energy technique during 5 weeks; 2 sessions per week were conducted for treatment of posterior rotation of the right or left innominate (to restore anterior rotation) and anterior rotation of the right or left innominate (to restore posterior rotation) dysfunctions (with regard to the dysfunction side)[15] and correction of a sacroiliac joint upslip.[1]
Patients in the SMT group received 10 sessions of sensorimotor training during 5 weeks; 2 sessions per week, according to a global approach by page. Base on this method, patients’ improvement was assessed through three phases; static, dynamic, and functional.[16] In each phase, patients experience different postures and bases of support and their center of gravity was challenged.
After the last session of treatment and after 2 months follow-up, all the parameters of COP were measured in 8 positions again.
Statistical analysis
SPSS software (version 22) was used for analyzing data. ANOVA and Tukey post-hoc tests were used to compare the data. Repeated measures of analysis of variance (ANOVA, Wilks’ Lambda test) were used to assess the effects of group, time, and interaction. P < 0.05 was considered significant.
Results
The result of repeated measurement of ANOVA in determination of the interactions between SD-Ax and time showed that the pattern of recovery in the three groups (SMT, MET, and CST) does not differ significantly in STLOE (P = 0.538), STLCE (P = 0.988), SSLOE (P = 0.213), SSLCE (P = 0.177), HSTLOE (P = 0.139), HSSLOE (P = 0.052), and HSSLCE (P = 0.492) positions.
The result of repeated measurement of ANOVA test in determination of the interactions between SD-Ax and time and SD-Ay and time showed that the pattern of recovery in the three groups (SMT, MET, and CST) had a significant difference in HSTLCE and SSLCE position respectively (P = 0. 049) [Table 1].
Table 1.
Postural control variables with a significant difference between three methods of the CST, MET, and SMT with regard to the position
| Position | Intervention Group | Time (mean±SD) | P | |||||
|---|---|---|---|---|---|---|---|---|
| Base Time | Post Treatment | Follow-up | P0 | P1 | P2 | P12 | ||
| SD-Ax | ||||||||
| HSTLCE | CST | 0.0079±0.0033 | 0.0037±0.0015 | 0.0021±0.0011 | 0.001 | <0.001 | 0.015 | <0.001 |
| MET | 0.0087±0.0025 | 0.0061±0.0022 | 0.0061±0.0022* | 0.010 | 0.017 | 1.000 | 0.001 | |
| SMT | 0.0103±0.0027 | 0.0061±0.0011 | 0.0058±0.0010 | <0.001 | <0.001 | 1.000 | <0.001 | |
| P | 0.083 | 0.270 | 0.031 | |||||
| Result of Repeated Measurement of ANOVA | Time effect | P<0.001 | F=59.344 | Effect size=0.580 | ||||
| Group effect | P<0.001 | F=18.636 | Effect size=0.464 | |||||
| Interaction Effect | P=0.049 | F=2.710 | Effect size=0.112 | |||||
| SD-Ay | ||||||||
| SSLCE | CST | 0.0237±0.0123 | 0.0091±0.0022 | 0.0054±0.0036 | 0.001 | <0.001 | 0.003 | <0.001 |
| EMT | 0.0140±0.0123* | 0.0093±0.0022* | 0.0096±0.0022* | - | - | - | 0.200 | |
| SMT | 0.0124±0.0044* | 0.0112±0.0027* | 0.0115±0.0033* | - | - | - | 0.688 | |
| P | 0.008 | 0.005 | <0.001 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=18.647 | Effect size=0.302 | ||||
| Group effect | P=0.374 | F=1.007 | Effect size=0.045 | |||||
| Interaction Effect | P<0.001 | F=8.105 | Effect size=0.274 | |||||
| HSTLOE | CST | 0.0091±0.0042 | 0.0051±0.0016 | 0.0045±0.0017 | 0.010 | 0.006 | 1.000 | 0.001 |
| EMT | 0.0071±0.0029 | 0.0064±0.0026 | 0.0065±0.0027 | - | - | - | 0.735 | |
| SMT | 0.0113±0.0055* | 0.0043±0.0012* | 0.0043±0.0012* | 0.001 | <0.001 | 1.000 | <0.001 | |
| P | 0.043 | 0.003 | <0.003 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=28.082 | Effect size=0.395 | ||||
| Group effect | P=0.757 | F=0.280 | Effect size=0.013 | |||||
| Interaction Effect | P=0.001 | F=5.816 | Effect size=0.213 | |||||
| SD-Vx | ||||||||
| HSTLOE | CST | 0.0247±0.0176 | 0.0095±0.0037 | 0.0080±0.0066 | 0.012 | 0.015 | 1.000 | 0.003 |
| EMT | 0.0404±0.0168 | 0.0183±0.0116 | 0.0201±0.0.134 | 0.004 | 0.016 | 1.000 | 0.001 | |
| SMT | 0.0575±0.0211*# | 0.0210±0.0093* | 0.0208±0.0094* | <0.001 | <0.001 | 1.000 | <0.001 | |
| P | <0.001 | 0.025 | 0.034 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=48.323 | Effect size=0.529 | ||||
| Group effect | P<0.001 | F=29.958 | Effect size=0.582 | |||||
| Interaction Effect | P=0.026 | F=3.106 | Effect size=0.126 | |||||
| HSTLCE | CST | 0.0337±0.0199 | 0.0111±0.0046 | 0.0072±0.0055 | 0.001 | 0.001 | 0.057 | <0.001 |
| EMT | 0.0497±0.0181 | 0.0264±0.0167 | 0.0266±0.0149 | 0.002 | 0.001 | 1.000 | <0.001 | |
| SMT | 0.0620±0.0204* | 0.0238±0.0.103 | 0.0207±0.0068# | <0.001 | <0.001 | 0.993 | <0.001 | |
| P | 0.001 | 0.065 | 0.042 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=75.205 | Effect size=0.636 | ||||
| Group effect | P<0.001 | F=18.058 | Effect size=0.456 | |||||
| Interaction Effect | P=0.044 | F=2.558 | Effect size=0.106 | |||||
| HSSLOE | CST | 0.0426±0.0197 | 0.0378±0.0061 | 0.0320±0.0194 | - | - | - | 0.239 |
| EMT | 0.0819±0.0377* | 0.0356±0.0067* | 0.0358±0.0064* | 0.001 | 0.001 | 1.000 | <0.001 | |
| SMT | 0.0858±0.0412* | 0.0411±0.0071* | 0.0406±0.0071* | 0.002 | 0.002 | 1.000 | 0.001 | |
| P | 0.001 | 0.001 | 0.012 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=38.402 | Effect size=0.472 | ||||
| Group effect | P=0.001 | F=8.623 | Effect size=0.286 | |||||
| Interaction Effect | P=0.003 | F=5.834 | Effect size=0.213 | |||||
| PPP-AP | ||||||||
| SSLOE | CST | 0.19357±0.0338 | 0.1798±0.0196 | 0.1101±0.0517 | 0.562 | 0.001 | <0.001 | <0.001 |
| EMT | 0.2632±0.1439 | 0.1670±0.0121* | 0.1670±0.0121 | 0.068 | 0.052 | 1.000 | 0.019 | |
| SMT | 0.2623±0.0404 | 0.1960±0.0140 | 0.1965±0.0142 | <0.001 | <0.001 | 1.000 | <0.001 | |
| P | 0.048 | 0.041 | 0.661 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=28.455 | Effect size=0.398 | ||||
| Group effect | P<0.001 | F=12.229 | Effect size=0.363 | |||||
| Interaction Effect | P=0.039 | F=3.264 | Effect size=0.132 | |||||
| SSLCE | CST | 0.3668±0.2802 | 0.2353±0.0389 | 0.0072±0.0055 | 0.264 | 0.022 | <0.001 | 0.013 |
| EMT | 0.2747±0.0923 | 0.2344±0.0212 | 0.0266±0.0149 * | - | - | - | 0.133 | |
| SMT | 0.2792±0.0296 | 0.2639±0.0297 | 0.2599±0.0469* | - | - | - | 0.345 | |
| P | 0.261 | 0.175 | 0.004 | |||||
| Results of repeated measure of ANOVA | Time effect | P=0.003 | F=9.324 | Effect size=0.178 | ||||
| Group effect | P=0.498 | F=0.708 | Effect size=0.032 | |||||
| Interaction Effect | P=0.009 | F=4.831 | Effect size=0.183 | |||||
| HSSLCE | CST | 0.2027±0.0420 | 0.1940±0.0155 | 0.1713±0.0553 | - | - | - | 0.124 |
| EMT | 0.2806±0.0632* | 0.1881±0.0178* | 0.1887±0.0170* | <0.001 | <0.001 | 1.000 | <0.001 | |
| SMT | 0.2865±0.0667* | 0.2020±0.0181* | 0.2008±0.0183 | 0.001 | 0.001 | 1.000 | <0.001 | |
| P | <0.001 | <0.001 | 0.033 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=42.148 | Effect size=0.495 | ||||
| Group effect | P<0.001 | F=11.684 | Effect size=0.352 | |||||
| Interaction Effect | P=0.002 | F=5.620 | Effect size=0.207 | |||||
| PPP-ML | ||||||||
| SSLCE | CST | 0.4195±0.3123 | 0.1934±0.0267 | 0.1222±0.0423 | 0.035 | 0.007 | <0.001 | 0.004 |
| EMT | 0.2730±0.1561 | 0.1964±0.0220 | 0.1986±0.0200* | - | - | - | 0.086 | |
| SMT | 0.2592±0.0747 | 0.2140±0.0159 | 0.2132±0.0210* | 0.097 | 0.138 | 1.000 | 0.037 | |
| P | 0.071 | 0.048 | 0.004 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=16.469 | Effect size=0.277 | ||||
| Group effect | P=0.646 | F=0.442 | Effect size=0.020 | |||||
| Interaction Effect | P=0.010 | F=5.036 | Effect size=0.190 | |||||
| HSSLOE | CST | 0.2008±0.0589 | 0.1583±0.0201 | 0.1458±0.0246 | 0.037 | 0.009 | 0.183 | 0.004 |
| EMT | 0.2926±0.1053* | 0.1561±0.0271* | 0.1552±0.0275 | <0.001 | 0.001 | 1.000 | <0.001 | |
| SMT | 0.2827±0.1224 | 0.1667±0.0103 | 0.1646±0.0087 | 0.007 | 0.006 | 1.000 | 0.002 | |
| P | 0.024 | 0.024 | 0.064 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=47.124 | Effect size=0.523 | ||||
| Group effect | P=0.013 | F=4.767 | Effect size=0.181 | |||||
| Interaction Effect | P=0.037 | F=3.401 | Effect size=0.137 | |||||
| PPP-APML | ||||||||
| SSLCE | CST | 0.5606±0.4149 | 0.3050±0.0443 | 0.1800±0.0851 | 0.087 | 0.011 | <0.001 | 0.007 |
| EMT | 0.39049±0.1742 | 0.3060±0.0288 | 0.3107±0.0232* | - | - | - | 0.092 | |
| SMT | 0.3825±0.0724 | 0.3403±0.0275 | 0.3367±0.0477* | - | - | - | 0.064 | |
| P | 0.122 | 0.080 | 0.003 | |||||
| Results of repeated measure of ANOVA | Time effect | P=0.001 | F=13.367 | Effect size=0.237 | ||||
| Group effect | P=0.852 | F=0.160 | Effect size=0.007 | |||||
| Interaction Effect | P=0.009 | F=5.099 | Effect size=0.192 | |||||
| HSSLOE | CST | 0.2860±0.0697 | 0.2507±0.0223 | 0.2267±0.0534 | 0.239 | 0.062 | 0.292 | 0.013 |
| EMT | 0.4089±0.1102* | 0.2450±0.0276* | 0.2449±0.0277* | <0.001 | <0.001 | 1.000 | <0.001 | |
| SMT | 0.4045±0.1331* | 0.2621±0.0179* | 0.2598±0.0179 | 0.002 | 0.002 | 1.000 | 0.001 | |
| P | 0.003 | 0.003 | 0.029 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=51.626 | Effect size=0.546 | ||||
| Group effect | P=0.001 | F=7.980 | Effect size=0.271 | |||||
| Interaction Effect | P=0.007 | F=5.019 | Effect size=0.189 | |||||
| MTV | ||||||||
| SSLCE | CST | 0.0015±0.0016 | 0.0005±0.0001 | 0.0002±0.0001 | 0.113 | 0.024 | <0.001 | 0.014 |
| EMT | 0.0007±0.0004 | 0.0005±0.00009 | 0.0005±0.00007* | - | - | - | 0.113 | |
| SMT | 0.0008±0.0002 | 0.0007±0.0001 | 0.0006±0.0001* | - | - | - | 0.115 | |
| P | 0.074 | 0.052 | 0.004 | |||||
| Results of repeated measure of ANOVA | Time effect | P=0.002 | F=10.129 | Effect size=0.191 | ||||
| Group effect | P=0.455 | F=0.802 | Effect size=0.036 | |||||
| Interaction Effect | P=0.011 | F=4.923 | Effect size=0.186 | |||||
| HSSLOE | CST | 0.0004±0.0002 | 0.0003±0.00006 | 0.0002±0.001 | 0.297 | 0.018 | 0.018 | 0.008 |
| EMT | 0.0009±0.0004* | 0.0003±0.00006* | 0.0003±0.00006* | <0.001 | <0.001 | 1.000 | <0.001 | |
| SMT | 0.0009±0.0005* | 0.0004±0.00005* | 0.0004±0.00005 | 0.003 | 0.003 | 1.000 | 0.001 | |
| P | 0.003 | 0.002 | 0.025 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=51.626 | Effect size=0.546 | ||||
| Group effect | P=0.001 | F=7.980 | Effect size=0.271 | |||||
| Interaction Effect | P=0.007 | F=5.019 | Effect size=0.189 | |||||
| Area | ||||||||
| HSTLOE | CST | 0.0010±0.0007 | 0.0003±0.0002 | 0.0002±0.0002 | 0.004 | 0.003 | 0.883 | 0.001 |
| EMT | 0.0009±0.0006 | 0.0005±0.0002 | 0.0005±0.0003 | - | - | - | 0.053 | |
| SMT | 0.0024±0.0029 | 0.0004±0.0002# | 0.0004±0.0002# | 0.051 | 0.049 | 1.000 | 0.016 | |
| P | 0.036 | 0.037 | 0.039 | |||||
| Results of repeated measure of ANOVA | Time effect | P<0.001 | F=16.352 | Effect size=0.276 | ||||
| Group effect | P=0.027 | F=3.951 | Effect size=0.155 | |||||
| Interaction Effect | P=0.037 | F=3.447 | Effect size=0.138 | |||||
The result of repeated measurement of ANOVA test in determination of the interactions between SD-Ay and time and SD-Vx and time showed that the pattern of recovery in the three groups (SMT, MET, and CST) had a significant difference in HSTLOE position.
The result of repeated measurement of ANOVA test in determination of the interactions between mean SSLOE and time showed that the pattern of recovery in the three groups (SMT, MET, and CST) had a significant difference in HSTLOE position (P = 0. 039).
The result of repeated measurement of ANOVA test in determination of the interactions between mean PPP.AP and time and PPP.ML and time showed that the pattern of recovery in the three groups (SMT, MET, and CST) had a significant difference in HSSLOE and SSLCE positions, respectively (P = 0. 002).
The result of repeated measurement of ANOVA test in determination of the interactions between mean PPP.APML and time and MTV and time showed that the pattern of recovery in the three groups (SMT, MET, and CST) had a significant difference in HSSLOE and SSLCE positions (P = 0. 007).
The result of repeated measure test showed that the mean of MTV was significantly different at different times (pretreatment, post-treatment, after follow-up) in the CST group but not in MET and SMT groups (P = 0.014, P = 0.113, and P = 0.115 respectively).
The result of repeated measurement of ANOVA test in determination of the interactions between mean area and time showed that the pattern of recovery in the three groups (SMT, MET, and CST) had a significant difference in HSTLOE position (P = 0. 037). The result of repeated measure test showed that the mean of area was significantly different at different times (pretreatment, post-treatment, after follow-up) in CST and SMT groups but in MET group (P = 0.001, P = 0.016, and P = 0.053). The result of ANOVA test showed that the mean area was significantly different between groups in pretreatment, after treatment, and follow-up times (P = 0.036, P = 0.037, and P = 0.039, respectively) [Table 1].
APX: anterior-posterior amplitude in the axis X; APY: anterior-posterior amplitude in the axis Y; APvX: anterior-posterior velocity in the axis X; APvY: anterior-posterior velocity in the axis Y; SD Ax: standard deviation COP amplitude in frontal plane, SD Ay: standard deviation COP amplitude in sagittal plane, SD Vx: standard deviation velocity of COP in frontal plane, SD Vy standard deviation velocity of COP in sagital plane, PPP AP: anterior posterior phase plane portrait, PPP ML: medio-lateral phase plane portrait, PPP APML: anterior posterior medio-lateral phase plane portrait, MTV: mean total velocity, and area.
Discussion
The results indicate that all three methods were effective on postural control in NSCLBP patients but CST had an effect on more balanced variables. Moreover, CST was more effective in SSLCE. Another point was that the effect of CST continued on most of the balance variables even after 2 months follow-up.
Duray et al. (2018) investigated the effect of proprioceptive exercise on balance control in patients with chronic neck pain. The results of the four-step square test, SSLCE and SSLOE were significantly better after treatment and follow-up.[4] In the study by Paolucci et al. the effect of the proprioceptive training on postural control in patients with NSCLBP were assessed and a significant decrease was observed in sway length and the mediolateral sway velocity in those who underwent perceptive rehabilitation, indicating improvement in postural stability for the realignment of the trunk.[5] Similar studies have not been conducted on the effect of CST and MET on balance control as well as the comparison of these three methods, and this study seems to be the first study in this field.
Rectus capitis posterior minor (RCPM) is an important postural muscle that plays a significant role in balance and proprioceptive sense.[17] This muscle has a high compression of muscle spindles, which expresses its role in controlling the proprioceptive sense. The proprioceptive sense possesses the ability to feel and understand the spatial position of the joint and body movements without using eyes and the special receptors transfer the data of this sense to central nervous system (CNS).[18] The relative effect of the proprioceptive sense and the vestibular system in the absence of the vision system on the balance of individuals in different age groups were studied[19] and all age groups were dependent on the proprioceptive sense to maintain balance.[20] It seems that CST, by removing pressure from this muscle, strengthens the proprioceptive sense and ultimately controls the balance.
CST can change the cerebrospinal fluid and the biomechanical properties of connective tissue around the spinal cord. The presence of a limitation in the normal fascia movement, in any part of the body, provides the potential to disrupt the optimal function of the craniosacral system as well as the boundaries and edges formed by the fascia in the form of dura mater in the body. Therefore, any limitation in the normal motion of a dural fascia can affect the normal functioning of the craniococal system. CST can release the limits around the brain and the spinal cord, and subsequently, restore normal functioning of the body.[21] CST prompts the rectangular, normal, and rhythmic cranial cycles to regulate the muscle tone to create and achieve normal alignment and muscle strength symmetry.[1] CST by normalizing the environment around the brain can improve the self-healing system of the body[9] due to which its effect on balance remains continuous.[22]
CST by freeing up the limitations of the CNS and by removing pressure from the tissues of this section may improve the performance of the cerebrospinal fluid and the interpretation and dissemination of environmental information sent through the proprioceptive receptors of the muscles and joints to the CNS.[21,23] The two other therapies can only improve the quality of the messages sent to the brain by strengthening the proprioceptive system. That is, even though the non-symmetric environmental signals are corrected through MET and SMT and send natural and symmetric messages to higher centers of the central nervous system, which (these systems) are responsible for processing, interpretation and coordination between this information and environmental messages, when(or if) higher nervous centers (CNS) be disturbed and restricted, again, the central sections (I means central tissues) interpret and process these environmental messages incorrectly, and will not be able to communicate and coordinate between them. As a result, after the end of the treatment period, nonsymmetric patterns in muscle strength and tension are created and the treatment process will be discontinuous.
CST seems to be induced by subtle stimulation of the mechanoreceptors in the fascia, especially the receptors of the raffini or the free nerve endings, which can cause changes in the autonomic system and lead to inhibition of sympathetic activity and increased parasympathetic activity. Therefore, due to the existence of a two-way interaction between the activity of the autonomic system and the fascial tonicity,[24,25] one can expect that CST, by regulating the autonomic system and regulating the fascial tonicity, frees up the fascial constraints in all parts of the body.
CST by removing pressure from the muscles and peripheral joints strengthens the proprioceptive sense of these muscles and joints, and thus, proprioceptive receptors send balanced signals to higher motor centers.[26] Moreover, due to removal of pressure from the tissue of the brain and the spinal cord, it improves the function of the tissues of the CNS[27] and makes these centers, as the main areas for interpreting and coordinating environmental information, to ensure better and more accurate reading of the symmetrical and natural messages received from the muscles and joints. This issue will also result in the issuance of more specific and more symmetrical motoring messages to lower environmental sectors. For this reason, muscle patterns are also natural and symmetrical, which can ultimately lead to improvements in balance and postural control.
Thus, CST can finally lead to the normal and symmetrical messages received from the peripheral receptors which can be interpreted and coordinated by the specialized centers of the brain and the spinal cord like the cerebellum, and to symmetric signals send to peripheral muscles and joints. Thus, it seems that nonsymmetric muscular patterns will be largely corrected. By reducing the imbalance in the strength and tension of these muscles, the parameters of balance and posture control of individuals in all conditions, even in the blind eye, will improve. In other words, even in standing position on a single leg, which is mainly observed, there is a need to rely on proprioceptive receptors signals. Due to the improvement of the proprioceptive system and central processing system, we see improvements in balance and postural control of those who are treated with CST.
Conclusion
The results of this study showed that all three methods of CST, MET, and SMT are effective in postural control in patients with NSCLBP, although it seems that CST is effective on more balanced factors. CST has a greater effect on balance in SSLCE. It was also found that the effect of CST was continuous after follow up.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
- 1.Schamberger W. Edinburgh London, New York: Oxford Philadelphia St Louis Sydney Toronto; 2013. The Malalignment Syndrome: Diagnosis and Treatment of Common Pelvic and Back Pain. Churchill Livingstone Elsevier. [Google Scholar]
- 2.Schamberger W. The Malalignment Syndrome: Implications for Medicine and Sport. Edinburgh: Churchill Livingstone; 2002. [Google Scholar]
- 3.Balague F, Mannion AF, Pellise F, Cedraschi C. Non-specific low back pain. Lancet. 2012;379:482–91. doi: 10.1016/S0140-6736(11)60610-7. [DOI] [PubMed] [Google Scholar]
- 4.Duray M, Şimşek Ş, Altuǧ F, Cavlak U. Effect of proprioceptive training on balance in patients with chronic neck pain. AĞRI-The Journal of The Turkish Society of Algology. 2018;30:130–7. doi: 10.5505/agri.2018.61214. [DOI] [PubMed] [Google Scholar]
- 5.Paolucci T, Fusco A, Iosa M, Grasso MR, Spadini E, Paolucci S, et al. The efficacy of a perceptive rehabilitation on postural control in patients with chronic nonspecific low back pain. Int J Rehabil Res. 2012;35:360–6. doi: 10.1097/MRR.0b013e328356427c. [DOI] [PubMed] [Google Scholar]
- 6.Brumagne S, Cordo P, Verschueren S. Proprioceptive weighting changes in persons with low back pain and elderly persons during upright standing. Neurosci Lett. 2004;366:63–6. doi: 10.1016/j.neulet.2004.05.013. [DOI] [PubMed] [Google Scholar]
- 7.Cholewicki J, Polzhofer G, Radebold A. Postural control of trunk during unstable sitting. J Biomech. 2000;33:1733–7. doi: 10.1016/s0021-9290(00)00126-3. [DOI] [PubMed] [Google Scholar]
- 8.Clark BC, Russ DW, Nakazawa M, France CR, Walkowski S, Law TD, et al. 2018. A randomized control trial to determine the effectiveness and physiological effects of spinal manipulation and spinal mobilization compared to each other and a sham condition in patients with chronic low back pain; pp. 41–52. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Upledger JE. Craniosacral therapy: Touchstone for natural healing: North Atlantic Books. 2001 [Google Scholar]
- 10.Salavati M, Mazaheri M, Negahban H, Ebrahimi I, Jafari AH, Kazemnejad A, et al. Effect of dual-tasking on postural control in subjects with nonspecific low back pain. Spine (Phila Pa 1976) 2009;34:1415–21. doi: 10.1097/BRS.0b013e3181a3a917. [DOI] [PubMed] [Google Scholar]
- 11.Salavati M, Hadian MR, Mazaheri M, Negahban H, Ebrahimi I, Talebian S, et al. Test-retest reliability [corrected] of center of pressure measures of postural stability during quiet standing in a group with musculoskeletal disorders consisting of low back pain, anterior cruciate ligament injury and functional ankle instability. Gait Posture. 2009;29:460–4. doi: 10.1016/j.gaitpost.2008.11.016. [DOI] [PubMed] [Google Scholar]
- 12.Moghadam M, Ashayeri H, Salavati M, Sarafzadeh J, Taghipoor KD, Saeedi A, et al. Reliability of center of pressure measures of postural stability in healthy older adults: Effects of postural task difficulty and cognitive load. Gait Posture. 2011;33:651–5. doi: 10.1016/j.gaitpost.2011.02.016. [DOI] [PubMed] [Google Scholar]
- 13.Mazaheri M, Salavati M, Negahban H, Parnianpour M. Test-retest reliability of postural stability measures during quiet standing in patients with a history of nonspecific low back pain. Biomed Eng. 2010;22:255–62. [Google Scholar]
- 14.Upledger J, Vredevoogd J. Craniosacral Therapy. Seattle, WA: Eastland Press; 1996. The Spinal Dura Matter and Sacrococcygeal Complex; pp. 131–51. [Google Scholar]
- 15.Donatelli RA, Wooden MJ. Orthopaedic Physical Therapy. 4th ed. Churchil Livingstone: Elsevier; 2010. [Google Scholar]
- 16.Page P. Sensorimotor training: A “global” approach for balance training. J Bodyw Mov Ther. 2006;10:77–84. [Google Scholar]
- 17.McPartland JM, Brodeur RR. Rectus capitis posterior minor: A small but important suboccipital muscle. J Bodyw Mov Ther. 1999;3:30–5. [Google Scholar]
- 18.Rojhani SZ, Satian NF, Hemati L. Comparison of speed of walking, balance and proprioception of knee and ankle joints between diabetic and healthy subjects. J Gorgan Univ Med Sci. 2012:14. [Google Scholar]
- 19.Vaugoyeau M, Viel S, Amblard B, Azulay JP, Assaiante C. Proprioceptive contribution of postural control as assessed from very slow oscillations of the support in healthy humans. Gait Posture. 2008;27:294–302. doi: 10.1016/j.gaitpost.2007.04.003. [DOI] [PubMed] [Google Scholar]
- 20.Ergen E, Ulkar B. Proprioception and ankle injuries in soccer. Clin Sports Med. 2008;27:195–217. doi: 10.1016/j.csm.2007.10.002. x. [DOI] [PubMed] [Google Scholar]
- 21.Jakel A, von Hauenschild P. A systematic review to evaluate the clinical benefits of craniosacral therapy. Complement Ther Med. 2012;20:456–65. doi: 10.1016/j.ctim.2012.07.009. [DOI] [PubMed] [Google Scholar]
- 22.Rivera F. Reconnecting the Mind and Body: Using Bodywork to Help Improve Mental Health. Loma Linda University Electronic Theses, Dissertation and Projects. 2016. p. 326. Available from: http://scholarsrepository.IIu.edu/etd/326 .
- 23.Gillespie BR. Case study in attention-deficit/hyperactivity disorder: The corrective aspect of craniosacral fascial therapy. Explore (NY) 2009;5:296–8. doi: 10.1016/j.explore.2009.06.003. [DOI] [PubMed] [Google Scholar]
- 24.Schleip R, Findley TW, Chaitow L, Huijing PA. Edinburgh London, New York: Oxford Philadelphia St Louis Sydney Toronto; 2012. Book Review of Fascia: The Tensional Network of the Human Body; Churchill Livingstone Elsevier. [Google Scholar]
- 25.Schleip R. Fascial plasticity – A new neurobiological explanation: Part 1. J Bodyw Mov Ther. 2003:11–9. [Google Scholar]
- 26.Pishyareh E, Ebrahimi E, Hosseini SA, Kazem-Nejad A, Ramin M. The impact of cranios acral therapy on inhibition of hypertonicity of the lower limb in children with dipelgia spastic cerebral palsy of 3-8 years old. Arch Rehabil. 2001;1:7–11. [Google Scholar]
- 27.Upledger J, Wanveer T. Helping the Brain Drain: How CranioSacral Therapy Aids ADD/ADHD. Massage Today; 2007. [Google Scholar]