Physical Medicine and Rehabilitation

LITERATURE REVIEW

Effectiveness of Global PosturalRe-education for Treatmentof Spinal DisordersA Meta-analysis

ABSTRACT

Lomas-Vega R, Garrido-Jaut MV, Rus A, del-Pino-Casado R: Effectiveness of

global postural re-education for treatment of spinal disorders: a meta-analysis.

Am J Phys Med Rehabil 2016;00:00Y00.

Objective: The aim of this study was to investigate the effects of global pos-

tural re-education (GPR) on the treatment of spinal disorders by performing a

systematic review and a meta-analysis.

Design: MEDLINE, Scopus, and PEDro databases were searched without

language or publication date restrictions. Data on pain and function were used to

evaluate the effectiveness of GPR. Randomized controlled trials and controlled

clinical trials analyzing the effectiveness of GPR on spinal disorders were selected.

The standardized mean difference (SMD) and the corresponding 95% confi-

dence interval (95%CI) were calculated. Themeta-analysis was performed using

the Comprehensive Meta-analysis 3.3 software.

Results: Seven randomized controlled trials and 4 controlled clinical trials

were included in the meta-analysis. The results showed a medium improvement

on pain (SMD=j0.63; 95%CI,j0.43 toj0.83) and function (SMD=j0.48;

95% CI, j0.25 to j0.72) after GPR treatment. The positive effect, which

was greater in patients with ankylosing spondylitis followed by low back pain and

neck pain, was more significant during the intermediate follow-up than imme-

diately after treatment.

Conclusions: This meta-analysis provides reliable evidence that GPR may

be an effective method for treating spinal disorders by decreasing pain and

improving function.

Key Words: Low Back Pain, Physical Therapy Techniques, Rehabilitation, Spinal

Disorders

Spinal disorders encompass a broad spectrum of pathologic findings suchas congenital, developmental, degenerative, traumatic, infectious, inflammatory,and neoplastic disorders1 and can include pain syndromes, disk degeneration,spondylosis, radiculopathy, stenosis, spondylolisthesis, fractures, tumors, and

Authors:Rafael Lomas-Vega, PhDMarıa Victoria Garrido-Jaut, PTAlma Rus, PhDRafael del-Pino-Casado, PhD

Affiliations:From the Department of HealthScience, University of Jaen, Jaen(RL-V); Center BEl Carmen[ of PRODE(Asociacion para la promocion de lasPersonas con Discapacidad enCordoba), Cordoba (MVG-J);Department of Cellular Biology,University of Granada, Granada (AR);and Department of Nursing, Universityof Jaen, Jaen (RP-C), Spain.

Correspondence:All correspondence and requests forreprints should be addressed to: RafaelLomas-Vega, PhD, Department of HealthScience, University of Jaen, Paraje LasLagunillas s/n, 23071, Jaen, Spain.

Disclosures:Financial disclosure statements havebeen obtained, and no conflicts ofinterest have been reported by theauthors or by any individuals in controlof the content of this article.

Editor’s Note:Supplemental digital content isavailable for this article. Direct URLcitations appear in the printed text andare provided in the HTML and PDFversions of this article on the journal_sWeb site (www.ajpmr.com).

0894-9115/16/0000-0000American Journal of PhysicalMedicine & RehabilitationCopyright * 2016 Wolters KluwerHealth, Inc. All rights reserved.

DOI: 10.1097/PHM.0000000000000575

www.ajpmr.com Global Postural Re-education and Spinal Disorders 1

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

osteoporosis.2 Musculoskeletal diseases, includingarthritis and back pain, are the second greatestcause of disability and represent the fourth greatestimpact on overall health in the world population, evenif high heterogeneity exists in rankings of leadingcauses of disease burden among regions.3 The directand indirect costs of treating spinal disorders are es-timated at more than $100 billion per year.4

Spinal disorders can be treated by active(exercise, education, prevention, and multimodaltherapies) or passive therapies (physical modalities,manual therapies, reflex therapies, assistive devices,and drugs).5 The global postural re-education (GPR)method has been widely used in clinical practice inmany countries and has been reported to treat severalconditions such as temporomandibular disorders,urinary incontinence, musculoskeletal diseases, and,above all, spinal disorders.6Y12 The GPR is a methodthat mainly involves global stretching, breath con-trol, and manual control by the therapist in orderto provide proprioceptive information to the patient.Therefore, it is halfway between active techniquessuch as stretching and passive techniques such asmanual therapy. Breath control plays an importantrole during the exercises and may be proposed as oneof the beneficial mechanisms of action. A previousstudy found an increase in maximal respiratory pres-sures, thoracic expansion, and abdominal mobility13

after application of GPR.The GPR method is based on the global

stretching of antigravitational muscles and thestretching of muscles that are organized on musclekinetic chains for approximately 15 to 20 minutes.6

Treatment postures of GPR especially affect thebalance of 2 major chains, usually called anteriorchain and posterior chain. The analysis of flexibilityof both determines the chain that should be spe-cially treated. The possible mechanism of action ofGPR may be the re-equilibrating effect of the dif-ferent treatment postures on areas of motor cortexthat control muscles belonging to the posterior oranterior chains. Global postural re-education ma-neuver applied in standing subjects increases inhibi-tion in cortical areas controlling flexor muscles, whileincreasing the excitation of cortical areas controllingextensor muscles. However, when GPR maneuver isapplied in subjects in supine position, increased inhi-bition in cortical areas controlling flexor muscles isnot paralleled by excitation of extensor ones.14

The literature provides conflicting results re-garding the effectiveness of GPR, including studiesthat showed favorable results and others that didnot show significant effects. In addition, there are nometa-analyses available focused on spinal disorders.

Therefore, this study aimed to perform a systematicreview and a meta-analysis on the effects of GPR onthe treatment of spinal disorders, as well as to mea-sure the eventual heterogeneity of results across in-dividual studies and its causes.

METHODSThis systematic review and meta-analysis has

been performed according to the guidelines of thePRISMA (Preferred Reporting Items for SystematicReviews and Meta-analysis) statement.15

Eligibility CriteriaThe following criteria were used for the eligi-

bility of the included studies: (1) the studies involvedpatients with spinal disorders; (2) the main inter-vention should be the GPR method; (3) comparedwith sham treatment, no treatment, usual care, orother therapies; (4) studies with outcome measure-ments including relief of spinal pain or function,which provided sufficient information about results;and (5) whose methodology was randomized con-trolled trial (RCT) or controlled clinical trial (CCT).

Systematic Literature SearchTwo authors independently searched in MEDLINE,

Scopus, and PEDro databases. No language or pub-lication date restrictions were set. The last search wasrun on November 26, 2015. A sensitive search strat-egy was used with the following free search terms:(global posture reeducation or global postural re-education or GPR or RPG or postural re-educationor posture re-education) AND (low back pain orback pain or neck pain or ankylosing spondylitis orspondyloarthritis or spinal disorders). The referencesof retrieved full-text articles and other reviews weresearched to identify additional references of interest.

Data ExtractionData were extracted independently by 2 authors.

The information extracted from the selected studiesincluded sample size, patient demographic char-acteristics, disease diagnosis, treatment approachesin control group, design of study, duration and fre-quency of exercise sessions, overall duration of treat-ment, outcome measures, and others. Discussionand consensus were used to resolve discrepanciesbetween authors.

Risk of Bias in Individual StudiesThe Cochrane Collaboration Tool16 was used to

assess the risk of bias in individual studies.

2 Lomas-Vega et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016

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Summary of ResultsThe combined effect was determined by the

Hedges_ g adjusted by the inverse of the varianceusing a fixed-effects model. Following the recom-mendations of Borenstein et al.,17 a fixed-effectmodelwas used for the meta-analysis because a commonunderlying effect was assumed, given that onlystudies on spinal disorders were included. The se-lected studies used different scales to measure func-tion; therefore, the standardized mean difference(SMD) was used as the measure of the effect.According to Cohen,18 values for effect size of 0.2 to0.3, 0.5, and 0.8 correspond to the 3 bands of inter-pretation of the effect size as small, medium, andlarge, respectively. The Q test was used for the anal-ysis of heterogeneity, together with the degree ofinconsistency (I2) of Higgins et al.19 The Egger test20

was used to determine the funnel plot asymmetry,according to which the publication bias is probable ifP G 0.10. The estimate of the combined effect consid-ering the possible publication bias was conducted bythe trim-and-fill method.21 Metaregression was usedto analyze the moderator variables that explained theheterogeneity of results across the individual studies.

Analyses were performed using the ComprehensiveMeta-analysis 3.3 software (Biostat; Englewood, NJ).

Sensitivity AnalysisSensitivity analyses (subgroups) were performed

to check differences between results at the differentmethodological quality levels of the studies.

RESULTSThe initial search identified 87 articles in the da-

tabases used. After removing duplicates, 12 articles22Y33

were selected from 61 according to the eligibilitycriteria. Of these, 2 were eliminated because 1 article30

was the French translation of the article of Lawandet al.,31 and another29 analyzed the same sample asthat of Fernandez de las Penas et al.28 In the lattercase, the same sample, the same intervention, and thesame results were published immediately aftertreatment29 and after a year_s follow-up.28 Afterreviewing references of the full-text articles and otherrelevant reviews, an additional study34 was included.The number of excluded studies for each inclusioncriterion is shown in the flowchart (Fig. 1).

FIGURE 1 Flowchart of the selection of the studies included in the review.

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At the end of the process, 11 studies were in-cluded. The main characteristics of these studies arepresented in Table 1. Seven studies were RCTs, and4 were CCTs. Four studies included patients withlow back pain (LBP), 4 works analyzed patients withneck pain (NP), and 3 studies included patientswith ankylosing spondylitis (AS). Pain was evalu-ated in 10 studies and function in 6 studies. The agerange of subjects of the selected studies was between18 and 65 years. Follow-up ranged from no follow-upto 12 months_ follow-up.

Table 2 shows the evaluation of quality of thestudies. Results revealed that the most importantthreat to quality was related to the blinded outcomemeasurement. In one of the selected studies,26 datacollection was performed by a member of the re-search team without specifying whether the re-searcher was blinded to the origin of each participant.Similarly, it was not informed who performed datacollection in 4 of the selected studies.22,23,27,34 Therewas risk of bias in only 2 studies.25,27 Only one of theRCTs29 included in this study did not report whether

the researchers responsible for the assignment tothe experimental groups were blinded to the ran-domization sequence.

PainTen studies (6 RCTs and 4 CCTs), with 11 in-

dependent comparisons, presented data for pain.The pain scales used were the visual analog scaleand the numeric rating scale. The results of indi-vidual studies are shown in Figure 2. Of the 11 validcomparisons, 6 showed statistically significant dif-ferences (negative direction), and 5 did not revealsignificant differences (3 with negative directionand 2 with positive direction). The combined effectof all the studies yielded a value of SMD = j0.63(95% confidence interval [CI], j0.43 to j0.83),which means a medium effect on pain, measured instandard scores, favorable to the GPR group. Indi-vidual results showed a moderate degree of het-erogeneity (P for the Q test = 0.024; I2 = 51.4%).The analysis of the funnel plot (Fig. 3) and the re-sults of the Egger test (P = 0.80) suggested the

TABLE 1 Characteristics of the studies included in the review

Reference N Design

Participants

OutcomeVariable Comparison Follow-up, mo

Age (Rangeand/or Mean), y Pathology

Adorno andBrasil-Neto,22 2013

20 RCT 19Y60 CNLBP Pain Stretching 020 3

Amorim et al,23 2014 30 RCT 18Y65 (38) SDANP Function Exercises 030 Pain 0

Bonetti et al,24 2010 78 CCT 47 PLBP Function Stabilization 687 378 Pain 687 3

Castagnoliet al,25 2015

50 CCT 60 CLBP Function Exercises 020 1237 Pain 016 12

Cunhaet al,26 2008

31 RCT 35Y60 CNP Pain Stretching 031 1,5

Durmus$et al,27 2009

32 CCT 38.6 AE Function Control 038 Exercises 032 Pain Control 038 Exercises 0

Fernandez de las Penaset al,28 2006

40 RCT 45Y46 AE Function Physical therapy 040 12

Lawand et al,30 2015 60 RCT 48.5 CLBP Function Control 660 360 Pain 660 3

Maluf et al,32 2010 24 RCT 19Y40 TMDs (NP) Pain Exercises 024 2

Radhakrishnanet al,34 2015

60 RCT 35Y45 CNP Pain Exercises 0

Silva et al,33 2012 35 CCT 18Y65 (39) AE Pain Exercises 0

CNLBP indicates chronic nonspecific LBP; SDANP, scapular dyskinesis associated with NP; PLBP, persistent LBP; CLBP,chronic LBP; CNP, chronic NP; TMDs (NP), NP associated with temporomandibular disorders.

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absence of publication bias. The estimate of thecombined effect considering the possible publica-tion bias by the trim-and-fill21 method matched thecombined effect previously calculated (SMD,j0.63;95% CI, j0.43 to j0.83).

The main problem of quality of the individualstudies included in this section was the lack of infor-mation about the blinded outcome measurement.Therefore, a sensitivity analysis (subgroups) wasperformed (see forest plot in http://links.lww.com/PHM/A302), and results showed that the combinedeffect for the subgroup of studies conducted withblinded outcome measurement was SMD = j0.67(95% CI,j0.39 toj0.95), and that for the subgroupof studies without information about such a criterionof quality was SMD=j0.59 (95%CI,j0.31 toj0.87).An analysis of subgroups according to the type ofdesign (RCT or CCT) was also performed (see forestplot in http://links.lww.com/PHM/A302), and resultsshowed values of SMD = j0.55 (95% CI, j0.28 toj0.82) for the RCT subgroup and j0.72 (95% CI,j0.43 to j1.02) for the CCT subgroup. All these

results show a medium improvement in pain favor-able to the GPR group.

Metaregression was performed to identify var-iables that may explain the heterogeneity found inthe results derived from the individual studies. Thisanalysis revealed that the duration of the follow-upand the type of pathology accounted for 56% ofheterogeneity (I2 = 31.7%, P = 0.19) (see scatterplotsin http://links.lww.com/PHM/A302). The type of de-sign (RCT or CCT), the type of comparison (control orother intervention), and the number of hours oftreatment did not contribute to the regressionmodel.

Table 3 shows the values of the combined effectfor pain, stratified by follow-up and pathology.The combined effect values were slightly higher inthe different follow-up times in comparison to theimmediate posttest, although these differenceswere not statistically significant. Patients with ASshowed the highest effect of GPR treatment, followedby patients with LBP, and finally NP patients, al-though these differences were not statisticallysignificant.

TABLE 2 Analysis of the methodological quality of the studies included in the review

Reference

Generation ofRandomization

Sequence

Concealment ofRandomization

Sequence

BlindedOutcome

Measurement Losses

Publicationof All theResultsExpected Others

Adorno and Brasil-Neto,22 2013 j j ? j j

Amorim et al,23 2014 j j ? j j

Bonetti et al,24 2010 NA NA j j j

Castagnoli et al,25 2015 NA NA j + j

Cunha et al,26 2008 j j ? j j

Durmus$ et al,27 2009 NA NA ? + j

Fernandez de las Penas et al,28 2006 j j j j j

Lawand et al,30 2015 j j j j j

Maluf et al,32 2010 j j j j j

Radhakrishnan et al,34 2015 j ? ? j j

Silva et al,33 2012 NA NA j j j

+ Indicates high risk of bias; j, low risk of bias; ?, no information available; NA, not applicable.

FIGURE 2 Forest plot of individual results regarding pain of the studies included in the review.

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FunctionSix studies (3 RCTs and 3 CCTs), with 7 inde-

pendent comparisons, presented data for function.Several scales were used to measure function, in-cluding the Roland-Morris Questionnaire and theOswestry Disability Index for LBP, the Neck DisabilityIndex for NP, and the Bath Ankylosing SpondylitisFunctional Index for AS. Results of the individualstudies are shown in Figure 4. Of the 7 valid com-parisons (all with negative direction), only 4 showedstatistically significant differences.

The combined effect of all the studies yieldeda value of SMD = j0.48 (95% CI, j0.25 to j0.72),which means a medium effect on function, mea-sured in standard scores, favorable to the GPRgroup. The results of the individual studies did notshow heterogeneity (P for the Q test = 0.772; I2 =0.0%). The Egger test results (P = 0.66) suggestedthe absence of publication bias, whereas the funnelplot analysis (Fig. 3) revealed some degree of asym-metry. Therefore, the combined effect was alsocalculated using the trim-and-fill21 method, and the

same value as that obtained previously (SMD,j0.48;95% CI,j0.25 to j0.72) was found.

The results of the sensitivity analysis (sub-groups) (see forest plot in http://links.lww.com/PHM/A302) showed that the combined effect for the sub-group of studies conducted with blinded outcomemeasurement was SMD = j0.44 (95% CI, j0.15 toj0.72), and that for the subgroup of studies withoutinformation about such a criterion of quality wasSMD =j0.58 (95% CI,j0.18 toj0.98). An analysisof subgroups according to the type of design (RCTor CCT) was also performed (see forest plot in http://links.lww.com/PHM/A302), and results showed valuesof SMD = j0.41 (95% CI, j0.06 to j0.76) for theRCT subgroup andj0.54 (95% CI,j0.23 toj0.85)for the CCT subgroup. All these results show amedium improvement in function favorable to theGPR group.

DISCUSSIONThis study is the first meta-analysis that in-

vestigates the effects of GPR on the treatment of

FIGURE 3 Funnel plot of individual results regarding pain of the studies included in the review.

TABLE 3 Combined effect on pain stratified by follow-up or pathology

k Point Estimate Lower Limit Upper Limit Heterogeneity (I2)Publication Bias(P for Egger Test)

Stratification by follow-upPosttest 9 j0.54 j0.78 j0.31 65.3 0.64G6 mo 5 j0.79 j1.07 j0.51 79.3 0.21Q6 mo 3 j0.64 j0.96 j0.31 0.0 0.003

Stratification by pathologyLBP 4 j0.65 j0.96 j0.35 0.0 0.5NP 4 j0.47 j0.80 j0.13 72.2 0.65AS 3 j0.82 j1.23 j0.41 71.8 0.22

k Indicates number of studies.

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spinal disorders by improving pain and function. Ofthe 11 studies included, 10 studies evaluated theeffect of GPR on pain and 6 studies on function.Four studies focused on LBP, 4 on NP, and 3 studieson AS. A moderate heterogeneity was found in theanalysis of pain, whereas null heterogeneity wasrevealed for function. An analysis of meta-regression was performed to determine the factorsthat explained the heterogeneity, and results showedthat much of the heterogeneity was explained byboth the type of pathology and the duration of thefollow-up. The type of design, the type of com-parison (control or other intervention), and theduration of the treatment did not influence theeffect found.

In this study, GPR showed an average effect onpain improvement of SMD =j0.63 (95% CI,j0.43to j0.83) and a slightly lower effect on function(SMD,j0.48; 95% CI, j0.25 toj0.72) in differentpathologic findings. The sensitivity analysis re-ported both that the effect on pain may be greaterduring the follow-up versus the immediate posttestand that the pathology most benefited by GPR maybe AS, followed by LBP and NP, although differ-ences were not statistically significant. No evidenceof publication bias was found, concluding that re-sults may be consistent.

Global postural re-education is a method ofpostural treatment; thus, the evaluation of posturaldisorder in patients is key for the implementationand dosage of this technique. A previous study35

examined reliability of the muscular chain evalua-tion and found that reliability was moderate tosubstantial for 12 of 23 evaluated posture indices(PIs) for physical therapists and perfect for 19 of23 evaluated PIs in the case of experts on GPR.Reliability on posture evaluation was moderate tosubstantial for 12 PIs for physical therapists andmoderate to perfect for 18 PIs for the experts.The agreement between physical therapists andexperts was good for most muscular chain evalu-

ations and PI. Therefore, these results suggestthat the evaluation of both chains restrictionand postural disorder with the GPR method is re-liable if performed by therapists with a certain levelof expertise.

The results of this study showed that the ben-efit of GPR for the treatment of NP is significant,but lower than that for other pathologic findings. Arecent review has suggested that breathing exer-cises, general fitness training, stretching alone, andfeedback exercises combined with pattern synchro-nization may not change pain or function from theimmediate posttest to the short-term follow-up.36

The results of the present work are consistent withthese findings, because in this study the short-termeffect of GPR was lower than during the long-termfollow-up. Global postural re-education may alsobe used in combination with other therapeutictechniques, as it has been found that the additionof stretching and aerobic exercise may improvethe effectiveness of other physical interventions totreat NP.37

Results in LBP patients showed a medium ef-fect of GPR on pain and function that was more sig-nificant over the middle term. Other methods, suchas Pilates, may be more effective on pain and func-tionality over the short term than a minimal inter-vention, usual care, or other exercises. However,Pilates may be similar or less effective than othertherapies or exercises over the middle term.38,39 Arecent meta-analysis has found a beneficial but smalleffect (SMD, j0.32; 95% CI, j0.44 to j0.19) forstrength/resistance and coordination/stabilizationexercise programs in comparison with other in-terventions in the treatment of chronic LBP.40

However, function was not analyzed in this study.The effect of GPR may be similar to that of aerobicexercise, which showed a small to medium effect onpain and function for chronic LBP.41

Several reviews in AS patients have reportedbeneficial effects of exercise by improving functionality

FIGURE 4 Forest plot of individual results regarding function of the studies included in the review.

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and quality of life.42Y44 In this study, GPR showedsignificant improvements in both pain and func-tion compared with control groups and with otherphysical treatments. However, the numberof studies examined has been scarce, which sug-gests to be cautious when drawing conclusions.

Global postural re-education may be a safemethod of treatment. Some of the most demandingexercises used in GPR (sedestation) may increasecardiovascular demand. However, this responsemay decrease to baseline values within 5 minutesafter completing the exercises.45 In addition, thestudies included in this review reported no adverseeffects of GPR.

This review has several limitations. First, de-spite the sensitive strategy used for searchingstudies, few works were found that evaluated theeffect of GPR on pain and function. Second, bothCCTs and RCTs were included in this review, andthe sensitivity analysis performed showed a slightoverestimation of the effect due to the CCTs, bothfor pain and function. However, the findings foundin this study are consistent, because no heteroge-neity was found in the analysis of the effect onfunction, and the main sources of heterogeneityfound in the analysis of the effect on pain wereanalyzed. Moreover, no publication bias was found.No high risk of bias was found in the selectedstudies regarding losses, incomplete publication ofthe expected results, or randomization sequence inthe case of RCTs. When the risk of bias was found(blinded outcome measurement), the sensitivityanalysis revealed that the combined effect scarcelyvaried when excluding such studies.

On the other hand, it may be necessary to in-crease the number and quality of the studies thatinvestigate the effects of GPR on different healthconditions related to the spine (e.g., RCTs withhighmethodological quality and large sample size).No controlled trials were found focused on otherpathologic findings related to the spine, such asdisk herniation or spondylolisthesis. It may be ad-visable therefore to test the effect of GPR on theseother conditions in which nonexperimental studiesmay show promising findings. The studies shouldalso include other relevant outcome variablessuch as health status, quality of life, effect on drugsin take, use of surgery, or effect on work activity,among others.

In conclusion, this meta-analysis provides re-liable evidence that GPR may be an effective tech-nique for the treatment of spinal disorders bydecreasing pain and improving function. Thus,GPR may be recommended for the treatment

of certain spinal disorders, including AS, LBP,and NP.

Supplementary ChecklistPRISMAChecklist: http://links.lww.com/PHM/A301

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