Global Postural Re-education in non-specific neck and low back pain treatment: A pilot study

Abstract

BACKGROUND:

Spinal pain is an important public health issue that brings biopsychosocial problems. Global Postural Re-education (GPR) is one of its treatments.

OBJECTIVE:

Evaluate the effects of GPR on pain, flexibility, and posture of individuals with non-specific low back pain and/or neck pain for more than six weeks.

METHODS:

The study enrolled 18 individuals, which were randomized into two groups: GPR group (GPRG; $n=$ 09), submitted to 10 sessions of GPR and control group (CG; $n=$ 09), not submitted to any technique. The evaluations were done before and after the GPRG sessions, for pain perception (Visual Analogue Scale – VAS), flexibility (finger-floor test) and posture (SAPO). The re-evaluation was done in the GPRG after the end of 10 treatment sessions and, in the GC, after the time equivalent to 10 sessions. The level of significance was set at $p<$ 0.05.

RESULTS:

This pilot study has no homogeneity between groups. GPRG presented improvement in pain and flexibility, but showed no changes in posture. In the CG, there was no difference in the variables evaluated in this study.

CONCLUSION:

GPR had positive effects on pain and flexibility, but did not present a significant effect on posture.

Keywords

Low back pain neck pain flexibility posture Global Postural Re-education

1. Introduction

Spine pain are complaints of painful symptomatology in the spine, preferentially affecting the cervical and lumbar segments, which occur due to congenital, degenerative, inflammatory, infectious, tumoral or traumatic factors, classified as acute or chronic [1, 2].

Given this scenario, low back pain is a condition with or without stiffness, considered one of the most common musculoskeletal disorders and affects approximately 70% to 85% of the young adult population, mainly in the economically active phase [2]. Nonspecific low back pain is also responsible for most of the back pains and has no pathology associated [3, 4].

About 80% of adults will have at least one low back pain crisis in their lives, and 90% of them will have more than one episode [2]. It is considered the main cause of work-related absenteeism with personal, socioeconomic [4, 5] and biopsychosocial repercussions among office workers related to nonspecific low back pain [6]; incapacitating approximately 10 million of people in Brazil [7] and worldwide [8].

A systematic review [9] inferred that there is a weak relation regarding psychological factors and musculoskeletal pain, pointing to a stronger relationship between depression and pain. However, Hampel and Tlach [10] suggest that psychological and depressive symptoms aggravate the disease’s chronicity and a biopsychosocial approach in treatment can improve its efficacy.

At the same time, cervicalgia, characterized by painful symptoms in the neck region, occurs at some point in their lives, presenting great relation with an incapacity for work and daily life [5, 11]. Cervicalgia affects about 86,8% of the general population, presenting a higher prevalence among high-income countries and women [12].

Medical, surgical and physiotherapeutic treatments are indicated to minimize the low back pain and neck pain. Within the scope of physical therapy treatments, there are several resources such as Therapeutic Exercises, Electrotherapy, Massotherapy, Pilates, Osteopathy and Global Postural Re-education (GPR) [5, 11].

Based on the concept of muscular chains, in which the muscles organize and work in synergism, the GPR preconizes the individual totality. According to previous studies, GPR tends to reduce symptoms (un)related to a disease. It also improves the patient’s body awareness and proprioception associated with breathing and joint decompression [13, 14, 15].

The global stretching through the GPR method has shown positive results [2, 13, 16, 17], in addition, according to our review, we cannot affirm that there are negative results regarding the GPR treatment. Nevertheless, the goal of this study was to evaluate the GPR effects regarding pain, flexibility, and posture in subjects with nonspecific low back pain and/or neck pain for more than six weeks.

2. Methods

This is a pilot study of a randomized controlled trial with subjects from both sexes, 18–35 years, with nonspecific pain for more than six weeks in the cervical and/or lumbar spine. We excluded subjects who were under the influence of other postural treatments or had intervals of more than 120 hours between the GPR sessions, and pregnant subjects.

This research was carried out in the Laboratory of Kinesiotherapy and Manual Therapy Resources (Laboratório de Cinesioterapia e Recursos Terapêuticos Manuais; LACIRTEM), Department of Physiotherapy of the Universidade Federal de Pernambuco (UFPE), approved by its ethics committee under the Resolution 196/96 of the National Health Council, number 315/09. The research is registered in the Brazilian Registry of Clinical Trials (Registro Brasileiro de Ensaios Clínicos; ReBEC) – RBR-78bq5x.

Thirty subjects were previously tried; initially, eight were excluded (two due to pain for less than six weeks, one had an absence of pain, and three presented diagnostic of osteopenia, osteoporosis, and osteophytes) and 22 were selected. However, four dropped out due to time incompatibility. The final sample size therefore consisted of 18 individuals, which were randomized, using the website www.randomizer.org, into two groups: i) control (CG; $n=$ 9); and ii) GPR (GPRG; $n=$ 9). First, all subjects signed the Consent Form and then independent researchers collected personal information and anthropometric data.

Pain perception was measured through the Visual Analogue Scale – VAS. A score from 0 meant “no pain” and 10 meant “worst possible pain” [18]. Flexibility was measured through the finger-floor test. From the orthostatic position, the subject with parallel and joined feet performed maximum flexion of the trunk while keeping the arms and head relaxed. An independent evaluator measured the distance from the third finger of the subject’s right hand to the floor [19, 20, 21]; and the posture was analyzed through the images of the individuals by the Postural Assessment Software – SAPO) [22, 23], with anatomical markers adapted from the original protocol [24].

The anatomical markers were the tragus, glabella, mentum, sternum manubrium, acromion, lower angle of the scapula, transition point between the scapula’s medial border and spine, greater trochanter of the femur, anterior-superior iliac spine and posterior-superior iliac spine, joint line of the knee and spinous processes of C7, T3, L5, S1, and S2.

Photographic registration of the subjects was carried out in the anterior, posterior, right and left lateral views, with the digital camera (SONY™, model DSC-S650) attached to a tripod at a distance of 3 meters from the subject. The angles and distances between the anatomical markers were quantified in degrees and centimeters; they were calculated with the guidelines drawn with SAPO.

Neck and head posture were measured with an angle formed between a line in the horizontal plane traced in the C7 level and a diagonal line from C7 to the meatus acusticus externus; lumbar posture was assessed by the angle formed between the points of higher convexity of the thoracic spine and gluteal region. Both measures were accessed in the lateral view.

Table 1
Posture assessed by SAPO software in subjects with nonspecific lumbar and/or cervical pain for over six weeks

	Control group				GPR group
	Evaluation	Reevaluation	$\Delta$	$p$	Evaluation	Reevaluation	$\Delta$	$p$
Head posture ( ${}^{\circ}$ )	53 $\pm$ 2.5	50 $\pm$ 5.2	3	0.29	55 $\pm$ 5.3	54 $\pm$ 4.1	1	0.08
Shoulder posture (cm)	0.7 $\pm$ 0.7	0.8 $\pm$ 0.5	0.1	0.76	1.0 $\pm$ 0.6	0.9 $\pm$ 0.8	0.1	0.83
Thoracic kyphosis ( ${}^{\circ}$ )	215 $\pm$ 3.6	215 $\pm$ 3.1	0	0.09	211 $\pm$ 7.2	211 $\pm$ 6.7	0	0.09
Lumbar lordosis ( ${}^{\circ}$ )	214 $\pm$ 5.4	211 $\pm$ 10.8	3	0.32	212 $\pm$ 6.6	213 $\pm$ 7.0	1	0.10

Values indicate the mean $\pm$ standard deviation of head posture. thoracic kyphosis and lumbar lordosis measured in degrees ( ${}^{\circ}$ ) and shoulders posture measured in centimeters (cm) of the subjects before (evaluation) and after (reevaluation) of the therapy sessions, in the GPR group, or after six weeks in the control group. $\Delta$ Absolute difference between valuation and revaluation.

The GPRG attended to ten GPR sessions, performed twice a week for an uninterrupted five week-period. The minimum interval between sessions was 48 hours and the maximum was 120 hours. Each session addressed two postures in the dorsal position for each subject: “frog on the floor” and “frog in the air”. Each posture lasted 20 minutes, with an interval of 5 minutes between them, totalizing 45 minutes. The CG did not receive any intervention and was oriented to the maintenance of daily activities normally. After completion of the research, the individuals received 10 GPR sessions similar to GPRG.

To analyze the outcome variables, two evaluations were performed in both groups: the baseline (T0) and a reevaluation (T1) after the end of the 10 GPR sessions and in the GC, after the time equivalent to the 10 sessions.

A descriptive analysis was performed using central tendency and dispersion measures (mean, standard deviation and/or standard error) for the quantitative variables and frequencies for the categorical variables, for the characterization of the sample. After the normal distribution of variables was measured by the Kolmogorov-Smirnov test, the outcome variables were analyzed: the intra-group analysis (baseline versus reevaluation) was performed by paired $t$ -test; and the comparative analysis between the groups (CG versus GPRG) was performed by the $t$ -test for independent samples. The level of significance was set at $p<$ 0.05. The statistical program used was the SPSS (Statistical Package for Social Sciences) version 23.0.

3. Results

This study has been described according to the CONSORT guidelines for the presentation of clinical trials [25] (Fig. 1).

Figure 1.

Volunteer recruitment flowchart (CONSORT). CG: control group; GPRG $=$ Global Postural Re-education group.

Both GPRG and CG analysis showed a predominance of the female gender, 55.6% and 77.8%, respectively, presenting no homogeneity between groups. The results show statistically significant variability between the groups in relation to categorical variables: age ( $p=$ 0.33), height ( $p=$ 0.08) and BMI ( $p=$ 0.17). However, the variable weight presented a $p=$ 0.03 value.

Figure 2.

Analysis of the Visual Analogue Scale (VAS) for pain perception in 18 subjects with nonspecific lumbar and/or cervical spine for over six weeks. VAS Score: from 0 meaning “no pain” and 10 meaning “worst possible pain”; Evaluation (T0): baseline measure; Reevaluation (T1): after the end of the 10 GPR sessions; Control: group not submitted to any technique; GPR: group submitted to 10 GPR sessions. ${}^{*}$ Significant difference between evaluation and reevaluation values in the GRP group ( $p<$ 0.05).

Figure 3.

Finger-floor test in 18 subjects with nonspecific lumbar and/or cervical pain for over six weeks. Length (cm): distance from the third finger of the subject’s right hand to the floor in maximum flexion of the trunk; Evaluation (T0): baseline measure; Reevaluation (T1): after the end of the 10 GPR sessions; Control: group not submitted to any technique; GPR: group submitted to 10 GPR sessions. ${}^{*}$ Significant difference between evaluation and reevaluation values in the GRP group ( $p<$ 0.05). Source: Research data.

The VAS score (Fig. 2) decreased significantly after the GPRG sessions (T0 $=$ 6.33 $\pm$ 0.5, T1 $=$ 3.00 $\pm$ 0.5, $p=$ 0.01). In CG, the reduction of the score of 5.67 $\pm$ 0.6 in T0, to 4.67 $\pm$ 0.5 in T1, was not statistically significant ( $p=$ 0.20). The intergroup analysis in the T1 moment did not present a statistical difference ( $p=$ 0.73).

The distance of the finger-floor test decreased after the GPRG sessions (T0 $=$ 23.88 $\pm$ 6.26, T1 $=$ 10.33 $\pm$ 3.6; $p=$ 0.01). In CG, the increase in distance from 12.28 cm $\pm$ 3.78 in T0 to 15.28 cm $\pm$ 4.43 in T1 did not present as statistically significant ( $p=$ 0.36). There was no difference in the finger-floor test ( $p=$ 0.48) according to the intergroup analysis (Fig. 3).

Despite the variation in the head, shoulder and lumbar lordosis postures between T0 and T1 in the GPRG (Table 1), the 10 GPR sessions were not sufficient to alter any of the postures analyzed ( $p>$ 0.05). No differences were found between the groups in the postural evaluation.

4. Discussion

In this study, we observed a decrease in pain perception quantified by VAS in individuals with nonspecific low back pain and/or neck pain for more than six weeks. These data corroborate the study by Cunha et al. [26], which presents pain reduction in women with chronic neck pain submitted to two GPR sessions per week for a period of six weeks.

This research presents similar results to those found in other studies [2, 17], in which the pain had a greater improvement for both low back pain and neck pain secondary to GPR sessions. The .Reeducation-GPR [27] also shows a significant improvement of pain in several subjects with epidural fibrosis submitted to 15 GPR sessions.

The CG did not exhibit a significant improvement in pain in the reevaluation. There are two hypotheses that justify this behavior: the subjectivity of the EVA measurement and/or the variation of chronic pain, especially because the CG did not receive an intervention [28, 29]. Linton and Melin [28] demonstrate that patients with chronic pain do not remember pain levels already experienced, which makes their quantification difficult, regardless of the scale used.

Regarding the flexibility, GPRG presented a decrease in the finger-floor test, which we can attribute to the patient’s higher pain tolerance, the viscoelastic properties of the tendon and the increase of sarcomeres in series [26].

Since the sample has a larger number of females, the findings confirm the results from do Rosário et al. [14], in which women without musculoskeletal injuries practice GPR twice a week; in eight sessions they improved the flexibility analyzed by the finger-floor test. Similarly, there was an improvement in flexibility in basketball athletes subjected to twenty GPR sessions for two and a half months [30]. Even though the sample was verified to be at a normal distribution in our study, this interpretation should be read carefully, given that our study has a small number of males in each group.

Pillastrini et al. [17] found an improvement for cervical range of motion post-GPR treatment, which can be related to our study: using the finger-floor test also encounters a higher flexibility in the GPRG. However, the CG presented a decrease in flexibility, probably because there was no activity to reduce the muscle shortening, limiting the anterior flexion of the trunk in the finger-floor test.

Regarding the postural evaluation, there were no significant results for the head, shoulder, thoracic kyphosis and lumbar lordosis in both groups. However, in the study by Castro and Lopes [31], a patient with postural impairment submitted to 21 GPR sessions, had a decrease in head anteriority, cervical lordosis, and thoracic kyphosis, as well as rectification of lumbar lordosis.

Diverging from this study, Basso et al. [32] proposed similar methods, which affirmed that there was a postural improvement assessed by the SAPO. These findings may be justified by the use of different GPR postures that varied in each patient, wherein, in this study, it was applied to two specific postures.

Also regarding different postures that aim to treat a different population, Gomes et al. [33] reported an improvement in the posture of a hemiparetic patient after stroke treated with 10 GPR sessions, since it decreased the patient’s thoracic kyphosis and shoulder asymmetry.

Veronesi Junior and Tomaz [34] also presented divergent results compared to this research: improvement of head alignment, thoracic and lumbar scoliosis in almost 50% of the 48 patients submitted to 5 GPR sessions in 5 consecutive days. In this case, the number of GPR sessions was smaller when compared to the present research, however, their sessions occurred on subsequent days, unlike the 48 to 120 hour interval used in this research. In addition, the protocols of postures used in the studies were different, which might contribute to the difference in the results.

This research did not present significant results regarding posture, probably our intervention time was insufficient to alter an already adapted and corticalized body structure. In addition, it is beyond our control how the subjects go through their daily living activities regarding the posture awareness. We did not use any tools to access these variables; this can be a setback in our results. However, our research achieved satisfactory results in terms of pain and flexibility in only 5 weeks of treatment, emphasizing the effectiveness at the time of interventions.

We emphasize that this study had limitations regarding the non-homogeneity of the sample in the evaluation (baseline) moment and related to gender, given that males and females tend to respond differently to exercises, a lack of a psychosocial factor assessment and a longer follow up. Further studies and the continuation of this research with a higher number of sessions, a larger gender-based sample, and at least a 3-month follow up are necessary to amplify the comprehension regarding the GPR effects under pain perception, flexibility, and posture.

Footnotes

Conflict of interest

The authors declare that there is no conflict of interest.

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Global Postural Re-education in non-specific neck and low back pain treatment: A pilot study

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Methods

Table 1 Posture assessed by SAPO software in subjects with nonspecific lumbar and/or cervical pain for over six weeks

Footnotes

Conflict of interest

References

Table 1
Posture assessed by SAPO software in subjects with nonspecific lumbar and/or cervical pain for over six weeks