Original researchInfluence of Spinal Manipulation on Muscle Spasticity and Manual Dexterity in Participants With Cerebral Palsy: Randomized Controlled Trial
Introduction
Muscle spasticity is an important clinical syndrome in people with cerebral palsy (CP) and other neurologic diseases resulting from upper motor neuron lesions.1 It manifests with an increased stretch reflex, which intensifies with movement velocity.2
Spasticity affects motor development and functioning of a child, and its reduction is an important therapeutic target for optimizing motor performance. The range of treatments for excess muscle tone is vast: from simple stretching exercises or pharmacotherapy to surgery.3 However, because of limited effectiveness of conventional treatments, a wide range of complementary and alternative therapies are used for muscle tone management in patients with CP, including spinal manipulation (SM).4, 5
Resent research indicates possible influence of SM on muscle spasticity. The literature points to the effect of SM on spinal cord neural circuits as a factor that possibly modifies stretch reflexes.6, 7 Neural responses to SM have been reported in studies on animal models.8, 9 There is preliminary evidence that SM is followed by a short-term reduction in local spinal muscle electromyographic activity in hypertonic muscles.10 Decrease in motoneuron excitability (H-reflex) after sacroiliac joint manipulation was observed in patients with low back pain.11, 12 There are several clinical studies suggesting the influence of SM on spasticity. Decrease of spasticity after SM was noted in post-stroke patients.13 Reduction in wrist muscle spasticity after SM was also reported in patients with CP.14, 15
In addition, there is growing body of research on the effects of SM on sensory processing, motor output, and functional performance, including hand function.8, 16 Studies suggest possible changes of muscle strength after a single session of manual therapy (MT).17 Improvement of manual dexterity after SM was also noted in patients with CP.18
However, there are no studies directly measuring the relationship between SM and reduction of muscle spasticity. Therefore, the primary aim of this study was to evaluate the effect of SM on muscle spasticity in participants with CP. A secondary aim of this study was to test the hypothesis that SM influences manual dexterity in participants with reduced hand function due to CP.
Section snippets
Study Design
This was a prospective, randomized controlled trial with 2 groups: experimental (receiving SM) and control (receiving sham of SM).
After the baseline examination, participants were randomized into 2 equal arms (1:1): the SM group (experimental) and the sham group (control). We used stratified block randomization with a block size of 4 by the form of CP (unilateral or bilateral) and level of wrist spasticity (low or high). Stratified block randomization helped to achieve balance between the
Results
Participants’ demographic and baseline assessment data are summarized in Table 1. Values of each variable for experimental and control group, as well as between-group difference, are presented. Between-group difference probability (P value) was calculated using the independent samples t test for normally distributed data, χ2 test for binary data, and the Mann-Whitney U test for nonparametric variables.
There was no significant difference between experimental and control groups in any of the
Discussion
To our knowledge, this is the first trial to measure the immediate effect of SM on muscle spasticity and hand dexterity in participants with spastic forms of CP. The contribution of this study is that it corroborates the hypothesis that SM may decrease muscle spasticity temporarily in participants with disordered muscle tone regulation, specifically in children with CP.
At present, the mechanisms through which SM alters muscle spasticity are not fully understood. Experimental evidence
Conclusion
These findings suggest that SM may, in the short term, help to reduce spasticity in participants with CP. Long-term effects of this influence were beyond the scope of the study and will have to be studied in the future. No evidence about the influence of SM on hand dexterity in participants with spasticity was obtained.
Funding Sources and Conflicts of Interest
Research was supported by a grant from the Institute of Medical Rehabilitation, Ukraine (state registration number: 23272758). No conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): O.K.
Design (planned the methods to generate the results): O.K., A.K.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): O.K.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): A.K., O.M., M.H.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): O.K., A.K.
Literature search
References (29)
Management of spasticity in children with cerebral palsy
Semin Pediatr Neurol
(2009)Neurophysiological effects of spinal manipulation
Spine J
(2002)- et al.
Neural responses to the mechanical characteristics of high velocity, low amplitude spinal manipulation: effect of specific contact site
Man Ther
(2015) The biomechanics of spinal manipulation
J Bodyw Mov Ther
(2010)- et al.
Short-term effects of spinal manipulation on H-reflex amplitude in healthy and symptomatic subjects
J Manipulative Physiol Ther
(2005) - et al.
Understanding inhibitory mechanisms of lumbar spinal manipulation using H-reflex and F-wave responses: a methodological approach
J Neurosci Methods
(2012) - et al.
Changes in muscle spasticity in patients with cerebral palsy after spinal manipulation: case series
J Chiropr Med
(2016) - et al.
The role of spinal manipulation in addressing disordered sensorimotor integration and altered motor control
J Electromyogr Kinesiol
(2012) - et al.
Guideline for Reporting Interventions on Spinal Manipulative Therapy: Consensus on interventions reporting criteria list for spinal manipulative therapy (CIRCLe SMT)
J Manipulative Physiol Ther
(2017) - et al.
Spasticity and its contribution to hypertonia in cerebral palsy
Biomed Res Int
(2015)