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Clinical Study
Clinical Study
Clinical Study
Effects in Short and Long Term of Global Postural
Reeducation (GPR) on Chronic Low Back Pain: A Controlled
Study with One-Year Follow-Up
Chiara Castagnoli,1 Francesca Cecchi,1 Antonio Del Canto,1 Anita Paperini,1 Roberta Boni,1
Guido Pasquini,1 Federica Vannetti,1 and Claudio Macchi1,2
1
Fondazione Don Carlo Gnocchi, IRCCS, Scientific Institute, 50143 Florence, Italy
2
Department of Medical and Surgical Critical Area, Universita degli Studi di Firenze, Florence, Italy
Copyright 2015 Chiara Castagnoli et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Objective. Comparing global postural reeducation (GPR) to a standard physiotherapy treatment (PT) based on active exercises,
stretching, and massaging for improving pain and function in chronic low back pain (CLBP) patients. Design. Prospective controlled
study. Setting. Outpatient rehabilitation facility. Participants. Adult patients with diagnosis of nonspecific, chronic (>6 months) low
back pain. Interventions. Both treatments consisted of 15 sessions of one hour each, twice a week including patient education.
Measures. Roland Morris Disability Questionnaire to evaluate disability, and Numeric Analog Scale for pain. A score change >30%
was considered clinically significant. Past treatments, use of medications, smoking habits, height, weight, profession, and physical
activity were also recorded on baseline, on discharge, and 1 year after discharge (resp., T0, T1, and T2). Results. At T0 103 patients
with cLBP (51 cases and 52 controls) were recruited. The treatment (T1) has been completed by 79 (T1) of which 60 then carried
out the 1-year follow-up (T2). Both GPR and PT at T1 were associated with a significant statistical and clinical improvement in pain
and function, compared to T0. At T2, only pain in GPR still registered a statistically significant improvement.
under the supervision of a physiotherapist. It was also seen others just provide a generic prescription of individual PT,
that stretching exercises and muscle strengthening are those leaving the choice of approach to the physiotherapist. For the
which combined with stabilization exercises of the trunk are purpose of our study, further inclusion criteria were 1880
associated with the best results in terms of pain reduction year old patients, and chronic LBP, defined as persisting from
and the recovery of function. Individual-based physiotherapy very often to always for at least 6 months. Exclusion cri-
exercise protocols for chronic low back pain are widely used, teria were neurological signs (irritation/deficit) and/or pain
even if the cost-benefit ratio is now still under discussion [9]. below the kneecap; severe osteoporosis; spondylolisis and
In the rehabilitative treatment of low back pain many spondylolisthesis; arthritis (rheumatoid arthritis, spondyli-
approaches are used around the world, requiring specifically tis, etc.); tumors; infections; previous spinal surgery; other
trained physiotherapists but claiming long lasting benefits. debilitating and/or very painful musculoskeletal conditions;
Global postural reeducation (GPR) is an approach based recent trauma (<30 days); acute illness; anticoagulant therapy
on an integrated idea of the muscular system as formed or phenobarbital or radio/chemotherapy; psychiatric illness;
by muscle chains, which can face shortening resulting from and medical-legal disputes in progress; pregnancy. Eligible
constitutional, behavioral, and psychological factors. The aim patients meeting the above criteria were invited to participate
of GPR is to stretch the shortened muscles using the creep in the study and were asked for their written consent. The
property of viscoelastic tissue and to enhance the contraction Institutional Review Board of the Don Gnocchi Foundation
of the antagonist muscles [4, 10]. The GPR assessment inves- approved the study protocol. The patients who already had
tigates the role and status of the so-called muscle chains, a specific prescription of individual PT-GPR were assigned
the functional groups of muscles responsible for posture and to the GPR group, while those with a general prescription
its alterations. It also analyzes the extent to which muscle of individual PT and no contraindications to GPR (assessed
chains influence each other and how their alterations can by a specialist in physical medicine and rehabilitation) were
accumulate in each subject and whether and to what extent either addressed to GPR or to PT to form a matched control
these alterations are responsible for the symptoms reported. group. Six qualified physiotherapists, with basic training and
This is a method that is not currently part of university two courses of higher education in accordance with GPR
teaching and requires a specific training for physiotherapists Souchard and with at least 5-year experience, assessed and
in private schools after graduation; the basic course lasts four delivered the rehabilitation program, delivering either GPR
weeks distributed over a year followed by several courses of or PT according to group assignment.
superior training.
The scientific literature regarding the use of GPR for the
treatment of chronic low back pain is scarce. A recent review 2.3. Intervention. For both interventions the program pro-
of the literature identified 11 studies [11] concerning scientific vided 15 sessions of 60 minutes each, two times a week. Ther-
evidence of the effectiveness of GPR in the treatment of apist assessment was individually performed the day before
various conditions. Four of these studies were random- the start of the treatment, while the final assessment was
ized controlled trials. Important results were reported by delivered immediately after the end of the last session. The
Moreno et al. [12] about the effect of GPR on respiratory exercise treatment protocol (PT) was formulated according to
capacity, Cabral et al. [13] about positive effects on the national and international guidelines on the treatment of per-
patellofemoral syndrome, and Fernandez de-la-pena in 2005 sistent low back pain with exercises [10, 15] and in accordance
about ankylosing spondylithis [14]. However only one study with the Tuscany Region resolution. Exercise was focused
[2] investigates the effects of GPR on neck pain and no studies on stimulating awareness of the body scheme, balancing
were considered for LBP. muscle function (decontraction of the shortened muscles,
Our pragmatic clinical study aims at describing the short strengthening of weakened muscles), stabilizing the spine,
and long term effects of GPR on patients with nonspecific and correcting any alteration of postural alignment. Each
cLBP, compared with a similar sample of control that received treatment was individualized for every patient and for his/her
standard individual physiotherapy (PT). pain-related limitation. The physiotherapists chose the most
appropriate exercises from the standardized protocol.
In GPR group patients were subjected to a postural assess-
2. Subjects and Methods ment according to the Souchard approach. Different body
segments were observed in relation to patients and space, in
2.1. Oversight. All patients signed their informed consent order to identify possible disharmonies. Patient assessment is
form to be included in the study. The Institutional Review global and takes into account any changes in vision, dental
Board approved the study protocol. occlusion, the support of the foot, visceral or psychological
problems, past neurological or orthopedic problems, and a
2.2. Participants. All patients at the Don Gnocchi Foun- search for shortened muscle chains. According to specific
dation IRCCS Florence from June 2011 to February 2011 assessment, appropriate postures were selected to correct
with a prescription of individual PT for persisting nonspe- identified muscle imbalances [1618].
cific low back pain were considered eligible. Diagnosis and At the beginning of the treatment, each patient, in
prescription were given by community health specialists in both groups, received an informative brochure with evi-
physical medicine and rehabilitation: some specify the type of dence based standardized educational information on basic
individual PT prescription (e.g., GPR, McKenzie etc.) while back anatomy and biomechanics, optimal postures, correct
The Scientific World Journal 3
movements in daily living activities, and ergonomics. On For analyzing the differences concerning the score of
discharge each patient received an individual short set of disability and pain before/after within the same group we
exercise programs to carry out at home. These were generally used the Wilcoxon sign rank test.
recommended as well as the regular practice of low-impact For analyzing the differences between groups concerning
physical activity of low to moderate intensity, according to the the score of disability and pain we used the Kruskal-Wallis
clinical profile and preferences of the patients. rank test and Pearson 2 test.
In the text (Tables 2-3) the score of disability (Roland
Morris score) and pain (NRS score) were reported as mean
2.4. Measures. Measures were taken at T0 (baseline), T1
and standard deviation but the analyses of these variables
(discharge, 15 working days from baseline), and T2 (twelve
were conducted appropriately with rank tests as mentioned
months from discharge). Baseline assessment was of general
above.
characteristics: age, sex, BMI, smoking, number of years or
months of low back pain suffering, pain frequency in the last
6 months, pain related to the use of drugs, whether previous 3. Results
LBP treatments performed also with different approach
From June 2011 to February 2011, 103 patients diagnosed
(massage, physical therapy, acupuncture, etc.), profession,
with persistent chronic low back pain attended our facil-
number of work days lost due to back pain, and physical
ity for rehabilitation treatment. 32 of them had a specific
activity. The primary outcome measure was low back pain-
prescription of GPR, while 71 had a generic prescription
related functional disability, assessed by the Roland and
of individual PT. All the patients were assessed as eligible
Morris Disability Questionnaire (RMDQ) [8].
with no contraindications for GPR and all of them met the
The Roland Morris score ranges from 0 to 24 ranging, inclusion criteria. Those with GPR prescription were assigned
respectively, from zero to maximum low back pain- to GPR, while the others were alternatively assigned to GPR
related disability. We regarded as respondent patients with or to PT to form a paired control group. Of the 52 patients
a minimal clinically important difference (MCID) in scores assigned to GPR and the 51 to PT only 79 patients (39 for the
from the Roland Morris Disability Questionnaire (RMDQ), GPR group and 40 for the PT group) were part of the final
indicated by the literature as an improvement equal to or sample at T1 because 13 eligible patients refused to participate
greater than 30% compared to baseline at both ends of the in the study (7 for the FKT group and 6 for the GPR group)
treatment and follow-up [9]. In addition, the NRS (Numeric and 11 patients discontinued the treatment (5 for the PT group
Rating Scale) consists of a line numbered from 0 to 10 that and 6 for the GPR group). Of the 79 patients recruited 19 did
represents pain severity levels from none to most intense not complete the 1 year follow-up. The final sample to T2 was
pain imaginable [19]. composed of 60 persons, 30 for each group (Figure 1).
Afterwards, between December 2012 and February 2013 Demographic, clinical, and general characteristics of the
(T2), all the patients who completed the treatment were two groups at baseline (T0) are summarized in Table 1.
contacted for a follow-up interview, performed by an inde- No statistically significant differences were observed
pendent researcher, reassessing the RMDQ and NRS and between the two groups in the examined variables. The distri-
enquiring about any medication or other treatment for CLBP bution of the two sexes in the two groups was homogeneous.
received, about the practice of any regular physical activity, The two groups were not homogeneous regarding profession;
any changes in activity or profession in the previous year, and in the GPR group, in fact, employees are 50% (=15 subjects)
any adherence to a specific exercise program. while in the PT group only 8 patients (26%) were employed.
Therefore, in both groups and for both outcomes there
2.5. Statistical Analysis. The sample sizes were calculated with was a statistically significant improvement in RMDQ and
a priori sample size analysis. From data of previous studies NRS scores on discharge ( < 0, 001). Improvement equal or
[20, 21] hypothesizing an anticipated effect size (Cohens d) of above 30% was considered a clinically significant difference,
0.8 and a statistical power of 0.8 and a probability level of 0.05 as indicated in literature both for NRS and for RMDQ scores
the minimum sample size per group (two-tailed hypothesis) [22]. We thus classified those who improved their RMDQ
results in being 26 subjects. So we can retain our sample (30 score by at least 30% as responders. For both outcomes, we
subjects per group) as being appropriate. found a greater number of responders in the GPR group
compared to the PT group, although the difference was not
Statistical analysis was performed using the software statistically significant. At follow-up, 1 year after discharge
STATA 7.0, from Stata Corporation (College Station, Texas, (T2) we found an improvement in both NRS and RMDQ
USA). compared to T0, but only pain relief, expressed by NRS
For analyzing the differences between the two groups we improvement, was statistically but not clinically significant in
used the GPR group ( < 0.02). Comparing responders in the
two groups at T2, we found that their percentage was not
(a) for continuous variables such as age, weight, height, significantly different between groups, either for NRS ( <
the Students -test for independent sample. 1.00) or RMDQ ( < 0.27) (Tables 2 and 3).
Table 4 shows the comparison between the two groups of
(b) For categorical variables such as sex, smoke yes/no, the variables collected by the structured follow-up question-
use of drugs we used the Pearson 2 test. naire (T2).
4 The Scientific World Journal
Initial sample
n = 103
FKT GPR
n = 52
n = 51
Refused Refused
n=7 n=6
Patients Patients
recruited recruited
n = 45 n = 45
Interrupted
treatment Interrupted
treatment
n=5 n=6
Group FKT to Group GPR to
T1 T1
n = 40 n = 39
Refused to answer n = 3 Refused to answer n = 2
Disease n = 4 Disease n = 3
Change phone number Change phone number
n=2 n=3
Incomplete data n = 1 Incomplete data n = 1
Final sample to Final sample to
T2 T2
n = 30 n = 30
We found a statistically significant difference only for the with statistically significant pain relief at the one-year follow-
time elapsed before receiving further treatment in follow-up. up.
( < 0.02): In fact, during the year following the end of In the literature [19, 23, 24] a RMDQ score difference
treatment, GPR patients reported that they were subjected to from 2,5 to 6,8 in low initial scores (less than 15) and
further physiotherapy treatments later in time than patients from 5,5 to 13,8 in high initial scores (more than 15) is
in the PT group. considered clinically significant; this is greater than the
normally anticipated score considering the natural history
of the disorder. As to the NRS score, a score reduction
4. Discussion of at least 30% is considered as the minimal important
clinical difference (MICD) [22]. Thus, we can conclude that,
The findings of this prospective controlled study on patients in our sample, both treatments under consideration were
with cLBP show that GPR patients reported similar improve- associated with clinically significant improvements in related
ment in pain and function as those who received standard pain and disability in the short term. This result differs from
physical therapy in the short term, as both treatments a recent Italian nonrandomized trial comparing GPR with
were associated with statistically significant improvements in stabilization exercises in persistent low back pain [3] which
function and pain, while only GPR treatment was associated showed a greater improvement in the GPR group in outcomes
The Scientific World Journal 5
Pearson 2 test.
Table 2: Differences in NRS results per group before, after and between groups.
Significativity Significativity
NRS T0 NRS T1 Responders NRS T2 Responders
NRS T0 NRS T0
Mean SD Mean SD NRS T1 () Mean SD NRS T2 ()
versus T1 () versus T2 ()
GPR 6,7 2,28 3,73 2,68 21/30 5,73 4,38 8/30 <0,001 0,02
FKT 7,2 2,25 4,43 2,35 16/30 6,5 2,03 8/30 <0,001 0,12
GPR versus FKT () 0,3 0,15 0,18 0,23 1
Pearson 2 test.
in short and middle terms (36 months). While another study however patients who received GPR still reported statistically
(the randomized controlled trial of GPR in the treatment significant pain relief compared to baseline and a lower
of mechanic back pain) concerning neck pain [2] provided frequency of pain which may indicate a longer-lasting effect
results more similar to ours: in this study GPR is compared of such treatment on pain.
with traditional stretching in a sample of women (31); both However, since we have evaluated patients not earlier
groups showed significant pain relief and a range of motion than one year after discharge, we can not say if significant
improvement results following the treatment and a small improvements were maintained longer in RPG because we
reduction at follow-up time. At follow-up (six weeks after the could not assess whether improvements have been lost more
end of the treatment) there was improvement in all domains, in the first than in the second half after the end of treatment,
except that both groups reported increased pain. There were as it suggests a recent study LBP. [19].
no significant differences between groups. In a randomized clinical trial in 2008, conventional
In the long term (1 year follow-up) we found an improve- stretching and muscle chain stretching in association with
ment in both NRS and RMDQ scores compared to T0 in both manual therapy were equally effective in reducing pain and
groups, but neither of the two scores was clinically significant. improving the range of motion and quality of life of female
In our findings, discharge improvements were attenuated in patients with chronic neck pain, immediately after treatment
time and were no more clinically significant in either group; and the results were maintained at a six-week follow-up,
6 The Scientific World Journal
Table 3: Differences in RMDQ results per group before, after and between groups.
Pearson 2 test.
Pearson 2 test.
differing from our sample [2]. This suggests the need for a subgroups with similar characteristics at clinical assessment
continuous exercise program; we did not anticipate this in and to subject the patients to single interventions, comparing
our protocol, but it could be included in the future to enable these results to a control group [20, 25]. In particular,
patients to maintain the positive results obtained from the after GPR assessment, the choice to divide the sample into
treatment. subgroups according to similar patterns of muscle retraction
The main limitation of our study was the assignment would allow a more focused comparison [18].
of patients to the two groups that were not possible to Since treatments provided similar clinically significant
randomize. Although all our patients had a clinical indication improvements in both pain and disability, without signifi-
for GPR, only those who had a general prescription could cant differences between groups, we can say that the two
be casually assigned to either group, while the few that approaches were equivalent for our cLBP patients.
already came to our facility with a prescription of GPR were
necessarily assigned to the GPR group. Although we verified
that the two groups were similar for all relevant general and 5. Conclusions
clinical characteristics, our findings do not have the strength
of a randomized controlled study. This study compared the short and long term effects of GPR
LBP shows complex and variable clinical features. Fur- and individual PT on cLBP. Our result showed equivalent
ther, in future studies, in order to give more solid proof to improvements both in function and pain: both outcomes
our thesis it would be interesting to divide the sample into presented short term improvements above the clinically
The Scientific World Journal 7
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The authors certify that no party having a direct interest in the [14] C. Fernandez-De-Las-Penas, C. Alonso-Blanco, M. Morales-
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