Motor control exercise for chronic non-specific low-back pain

Therapeutic ultrasound for chronic low back pain

BACKGROUND

This is an update of a Cochrane Review published in 2014. Chronic non-specific low back pain (LBP) has become one of the main causes of disability in the adult population around the world. Although therapeutic ultrasound is not recommended in recent clinical guidelines, it is frequently used by physiotherapists in the treatment of chronic LBP.

OBJECTIVES

The objective of this review was to determine the effectiveness of therapeutic ultrasound in the management of chronic non-specific LBP. A secondary objective was to determine the most effective dosage and intensity of therapeutic ultrasound for chronic LBP.

SEARCH METHODS

We performed electronic searches in CENTRAL, MEDLINE, Embase, CINAHL, PEDro, Index to Chiropractic Literature, and two trials registers to 7 January 2020. We checked the reference lists of eligible studies and relevant systematic reviews and performed forward citation searching.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on therapeutic ultrasound for chronic non-specific LBP. We compared ultrasound (either alone or in combination with another treatment) with placebo or other interventions for chronic LBP.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of each trial and extracted the data. We performed a meta-analysis when sufficient clinical and statistical homogeneity existed. We determined the certainty of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

We included 10 RCTs involving a total of 1025 participants with chronic LBP. The included studies were carried out in secondary care settings in Turkey, Iran, Saudi Arabia, Croatia, the UK, and the USA, and most applied therapeutic ultrasound in addition to another treatment, for six to 18 treatment sessions. The risk of bias was unclear in most studies. Eight studies (80%) had unclear or high risk of selection bias; no studies blinded care providers to the intervention; and only five studies (50%) blinded participants. There was a risk of selective reporting in eight studies (80%), and no studies adequately assessed compliance with the intervention. There was very low-certainty evidence (downgraded for imprecision, inconsistency, and limitations in design) of little to no difference between therapeutic ultrasound and placebo for short-term pain improvement (mean difference (MD) -7.12, 95% confidence interval (CI) -17.99 to 3.75; n = 121, 3 RCTs; 0-to-100-point visual analogue scale (VAS)). There was also moderate-certainty evidence (downgraded for imprecision) of little to no difference in the number of participants achieving a 30% reduction in pain in the short term (risk ratio 1.08, 95% CI 0.81 to 1.44; n = 225, 1 RCT). There was low-certainty evidence (downgraded for imprecision and limitations in design) that therapeutic ultrasound has a small effect on back-specific function compared with placebo in the short term (standardised mean difference -0.29, 95% CI -0.51 to -0.07 (MD -1.07, 95% CI -1.89 to -0.26; Roland Morris Disability Questionnaire); n = 325; 4 RCTs), but this effect does not appear to be clinically important. There was moderate-certainty evidence (downgraded for imprecision) of little to no difference between therapeutic ultrasound and placebo on well-being (MD -2.71, 95% CI -9.85 to 4.44; n = 267, 2 RCTs; general health subscale of the 36-item Short Form Health Survey (SF-36)). Two studies (n = 486) reported on overall improvement and satisfaction between groups, and both reported little to no difference between groups (low-certainty evidence, downgraded for serious imprecision). One study (n = 225) reported on adverse events and did not identify any adverse events related to the intervention (low-certainty evidence, downgraded for serious imprecision). No study reported on disability for this comparison. We do not know whether therapeutic ultrasound in addition to exercise results in better outcomes than exercise alone because the certainty of the evidence for all outcomes was very low (downgraded for imprecision and serious limitations in design). The estimate effect for pain was in favour of the ultrasound plus exercise group (MD -21.1, 95% CI -27.6 to -14.5; n = 70, 2 RCTs; 0-to-100-point VAS) at short term. Regarding back-specific function (MD - 0.41, 95% CI -3.14 to 2.32; n = 79, 2 RCTs; Oswestry Disability Questionnaire) and well-being (MD -2.50, 95% CI -9.53 to 4.53; n = 79, 2 RCTs; general health subscale of the SF-36), there was little to no difference between groups at short term. No studies reported on the number of participants achieving a 30% reduction in pain, patient satisfaction, disability, or adverse events for this comparison.

AUTHORS' CONCLUSIONS

The evidence from this systematic review is uncertain regarding the effect of therapeutic ultrasound on pain in individuals with chronic non-specific LBP. Whilst there is some evidence that therapeutic ultrasound may have a small effect on improving low back function in the short term compared to placebo, the certainty of evidence is very low. The true effect is likely to be substantially different. There are few high-quality randomised trials, and the available trials were very small. The current evidence does not support the use of therapeutic ultrasound in the management of chronic LBP.

Effectiveness of Proprioceptive Neuromuscular Facilitation on Pain Intensity and Functional Disability in Patients with Low Back Pain: A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review aimed to investigate the effectiveness of proprioceptive neuromuscular facilitation (PNF) training on back pain intensity and functional disability in people with low back pain (LBP).

METHODS

Totally, five electronic databases, including PubMed/Medline (NLM), Scopus, Google Scholar, PEDro, and Cochrane Central Register of Controlled Clinical Trials were searched up to October 31, 2018. Clinical trials with a concurrent comparison group (s) that compared the effectiveness of PNF training with any other physical therapy intervention were selected. Publication language was restricted to English language articles. Methodologic quality was assessed using the PEDro scale. The measures of continuous variables were summarized as Hedges's g.

RESULTS

In total, 20 eligible trials were identified with 965 LBP patients. A large effect size (standardized mean difference [SMD]=-2.14, 95% confidence interval [CI]=3.23 to -1.05) and significant effect were observed favoring the use of PNF training to alleviate back pain intensity in patients with LBP. Moreover, large effect size and the significant result were also determined for the effect of PNF training on functional disability improvement (SMD=-2.68, 95% CI=-3.36 to -2.00) in population with LBP. A qualitative synthesis of results indicated that PNF training can significantly improve sagittal spine ROM. Statistical heterogeneity analysis showed that there was considerable statistical heterogeneity among the selected trials for the primary outcomes (I2 ≥ 86.6%).

CONCLUSION

There is a low quality of evidence and weak strength of recommendation that PNF training has positive effects on back pain and disability in LBP people. Further high-quality randomized clinical trials regarding long-term effects of PNF training versus validated control intervention in a clinical setting is recommendable.

Randomized Trial of General Strength and Conditioning Versus Motor Control and Manual Therapy for Chronic Low Back Pain on Physical and Self-Report Outcomes

Exercise and spinal manipulative therapy are commonly used for the treatment of chronic low back pain (CLBP) in Australia. Reduction in pain intensity is a common outcome; however, it is only one measure of intervention efficacy in clinical practice. Therefore, we evaluated the effectiveness of two common clinical interventions on physical and self-report measures in CLBP. Participants were randomized to a 6-month intervention of general strength and conditioning (GSC; n = 20; up to 52 sessions) or motor control exercise plus manual therapy (MCMT; n = 20; up to 12 sessions). Pain intensity was measured at baseline and fortnightly throughout the intervention. Trunk extension and flexion endurance, leg muscle strength and endurance, paraspinal muscle volume, cardio-respiratory fitness and self-report measures of kinesiophobia, disability and quality of life were assessed at baseline and 3- and 6-month follow-up. Pain intensity differed favoring MCMT between-groups at week 14 and 16 of treatment (both, p = 0.003), but not at 6-month follow-up. Both GSC (mean change (95%CI): −10.7 (−18.7, −2.8) mm; p = 0.008) and MCMT (−19.2 (−28.1, −10.3) mm; p < 0.001) had within-group reductions in pain intensity at six months, but did not achieve clinically meaningful thresholds (20mm) within- or between-group. At 6-month follow-up, GSC increased trunk extension (mean difference (95% CI): 81.8 (34.8, 128.8) s; p = 0.004) and flexion endurance (51.5 (20.5, 82.6) s; p = 0.004), as well as leg muscle strength (24.7 (3.4, 46.0) kg; p = 0.001) and endurance (9.1 (1.7, 16.4) reps; p = 0.015) compared to MCMT. GSC reduced disability (−5.7 (−11.2, −0.2) pts; p = 0.041) and kinesiophobia (−6.6 (−9.9, −3.2) pts; p < 0.001) compared to MCMT at 6-month follow-up. Multifidus volume increased within-group for GSC (p = 0.003), but not MCMT or between-groups. No other between-group changes were observed at six months. Overall, GSC improved trunk endurance, leg muscle strength and endurance, self-report disability and kinesiophobia compared to MCMT at six months. These results show that GSC may provide a more diverse range of treatment effects compared to MCMT.

Effectiveness of communicative and educative strategies in chronic low back pain patients: A systematic review

OBJECTIVE

To investigate the effectiveness of communicative and educative strategies on 1) patient's low back pain awareness/knowledge, 2) maladaptive behavior modification and 3) compliance with exercise in patients with chronic low back pain.

METHODS

A systematic review was conducted. Searches were performed on 13 databases. Only randomized controlled trials enrolling patients ≥ 18 years of age were included. Risk of bias was assessed with the Cochrane Collaboration's tool and interrater agreement between authors for full-texts selection was evaluated with Cohen's Kappa. No meta-analysis was performed and qualitative analysis was conducted.

RESULTS

24 randomized controlled trials which intervention included communicative and educative strategies were selected. Most of the studies were judged as low risk of bias and Cohen's Kappa was excellent ( = 0.822). Interventions addressed were cognitive behavioral therapy as unique treatment or combined with other treatments (multimodal interventions), coaching, mindfulness, pain science education, self-management, graded activity and graded exposure.

CONCLUSIONS, PRACTICE IMPLICATION

Patient's low back pain awareness/knowledge is still a grey area of literature. Pain science education, graded exposure and multimodal interventions are the most effective for behavior modification and compliance with exercise with benefits also in the long-term, while self-management, graded activity and coaching provide only short-term or no benefits.

Personalized Treatment Suggestions: The Validity and Applicability of the Risk-Prevention-Index Social in Low Back Pain Exercise Treatments

Background: The back pain screening tool Risk-Prevention-Index Social (RPI-S) identifies the individual psychosocial risk for low back pain chronification and supports the allocation of patients at risk in additional multidisciplinary treatments. The study objectives were to evaluate (1) the prognostic validity of the RPI-S for a 6-month time frame and (2) the clinical benefit of the RPI-S. Methods: In a multicenter single-blind 3-armed randomized controlled trial, n = 660 persons (age 18–65 years) were randomly assigned to a twelve-week uni- or multidisciplinary exercise intervention or control group. Psychosocial risk was assessed by the RPI-S domain social environment (RPI-S_SE) and the outcome pain by the Chronic Pain Grade Questionnaire (baseline M1, 12-weeks M4, 24-weeks M5). Prognostic validity was quantified by the root mean squared error (RMSE) within the control group. The clinical benefit of RPI-S_SE was calculated by repeated measures ANOVA in intervention groups. Results: A subsample of n = 274 participants (mean = 38.0 years, SD 13.1) was analyzed, of which 30% were classified at risk in their psychosocial profile. The half-year prognostic validity was good (RMSE for disability of 9.04 at M4 and of 9.73 at M5; RMSE for pain intensity of 12.45 at M4 and of 14.49 at M5). People at risk showed significantly stronger reduction in pain disability and intensity at M4/M5, if participating in a multidisciplinary exercise treatment. Subjects at no risk showed a smaller reduction in pain disability in both interventions and no group differences for pain intensity. Regarding disability due to pain, around 41% of the sample would gain an unfitted treatment without the back pain screening. Conclusion: The RPI-S_SE prognostic validity demonstrated good applicability and a clinical benefit confirmed by a clear advantage of an individualized treatment possibility.

Examination of a Subgroup of Patients With Chronic Low Back Pain Likely to Benefit More From Pilates-Based Exercises Compared to an Educational Booklet

OBJECTIVE

To investigate whether 2 previously published classification approaches, the updated treatment-based classification system and a Pilates subgroup defined by a preliminary clinical prediction rule, could identify patients with chronic low back pain who would benefit more from Pilates exercises compared to an educational booklet.

DESIGN

Secondary analysis of a randomized controlled trial.

METHODS

Two hundred twenty-two patients received advice and were randomly allocated to a group that received an educational booklet with no additional treatment (n = 74) or a group that received Pilates-based exercise treatment (n = 148) 2 or 3 times a week. At baseline, using a treatment-based classification system, patients were classified as having a good prognosis (positive movement control) or a poor prognosis. Similarly, using the Pilates clinical prediction rule, patients were classified as having a good prognosis (positive) or a poor prognosis (negative). The analysis was conducted using linear regression models to analyze the interaction between subgroup characteristics and treatment effect size, with changes in pain and disability from baseline to 6 weeks after randomization as dependent variables.

RESULTS

None of the interaction terms for pain and disability were statistically significant. The treatment effect of Pilates versus an educational booklet was similar in all subgroups.

CONCLUSION

The treatment-based classification system and the Pilates clinical prediction rule did not differentiate subgroups of patients with chronic low back pain who were more or less likely to benefit more from Pilates compared to an educational booklet. J Orthop Sports Phys Ther 2020;50(4):189-197. Epub 23 Aug 2019. doi:10.2519/jospt.2019.8839.

Clinical reasoning framework for thoracic spine exercise prescription in sport: a systematic review and narrative synthesis

BACKGROUND

The thoracic spine is critical for athletic kinetic chain functioning yet widely overlooked in terms of specific evidenced-based exercise prescription. Thoracic mobility, motor control and strength are required to optimise performance in sport and minimise excessive load/stress on other components of the kinetic chain.

OBJECTIVE

To identify and evaluate mobility, motor control, work capacity and strength thoracic exercises for use in athletes.

DESIGN

Systematic review involving expert reviewers at key stages: searches and screening (n=1), eligibility, evaluation, data extraction and evaluation (n=3). Key databases and social media sources were searched to 16 August 2019. Eligible exercises were thoracic exercises to promote mobility, motor control, work capacity and strength. A narrative synthesis enabled an outcome-based classification of exercises, with level of evidence of individual sources informing overall level of evidence for each outcome (Oxford Centre for Evidence-based Medicine).

RESULTS

From 2348 sources (social media, database searches and other sources), 38 exercises were included. Sources included images, video clips and written descriptions of exercises. Exercises targeting all planes of motion were evaluated and classified according to outcome. Exercises comprised functional and non-functional exercises for mobility (n=9), work capacity (n=15), motor control (n=7) and strength (n=7). Overall level of evidence for each outcome was level 5.

CONCLUSION

This synthesis and evaluation of exercises has captured the scope of thoracic exercises used in 'practice'. Evaluation against an expert-derived outcome-based classification provides practitioners with a framework to facilitate exercise prescription. Evaluation of validity and effectiveness of exercises on outcomes is now required.

Sustainability effects of motor control stabilisation exercises on pain and function in chronic nonspecific low back pain patients: A systematic review with meta-analysis and meta-regression

Study design

Systematic review with meta-analysis and meta-regression.

Background and objectives

We systematically reviewed and delineated the existing evidence on sustainability effects of motor control exercises on pain intensity and disability in chronic low back pain patients when compared with an inactive or passive control group or with other exercises. Secondary aims were to reveal whether moderating factors like the time after intervention completion, the study quality, and the training characteristics affect the potential sustainability effects.

Methods

Relevant scientific databases (Medline, Web of Knowledge, Cochrane) were screened. Eligibility criteria for selecting studies: All RCTs und CTs on chronic (≥ 12/13 weeks) nonspecific low back pain, written in English or German and adopting a longitudinal core-specific/stabilizing sensorimotor control exercise intervention with at least one pain intensity and disability outcome assessment at a follow-up (sustainability) timepoint of ≥ 4 weeks after exercise intervention completion.

Results and conclusions

From the 3,415 studies that were initially retrieved, 10 (2 CTs & 8 RCTs) on N = 1081 patients were included in the review and analyses. Low to moderate quality evidence shows a sustainable positive effect of motor control exercise on pain (SMD = -.46, Z = 2.9, p < .001) and disability (SMD = -.44, Z = 2.5, p < .001) in low back pain patients when compared to any control. The subgroups’ effects are less conclusive and no clear direction of the sustainability effect at short versus mid versus long-term, of the type of the comparator, or of the dose of the training is given. Low quality studies overestimated the effect of motor control exercises.

The Feasibility and Effectiveness of a New Practical Multidisciplinary Treatment for Low-Back Pain: A Randomized Controlled Trial

Low-back pain is a major health problem exacerbated by the fact that most treatments are not suitable for self-management in everyday life. Particularly, interdisciplinary programs consist of intensive therapy lasting several weeks. Additionally, therapy components are rarely coordinated regarding reinforcing effects, which would improve complaints in persons with higher pain. This study assesses the effectiveness of a self-management program, firstly for persons suffering from higher pain and secondly compared to regular routines. Study objectives were treated in a single-blind multicenter controlled trial. A total of n = 439 volunteers (age 18-65 years) were randomly assigned to a twelve-week multidisciplinary sensorimotor training (3-weeks-center- and 9-weeks-homebased) or control group. The primary outcome pain (Chronic-Pain-Grade) as well as mental health were assessed by questionnaires at baseline and follow-up (3/6/12/24 weeks, M2-M5). For statistical analysis, multiple linear regression models were used. N = 291 (age 39.7 ± 12.7 years, female = 61.1%, 77% CPG = 1) completed training (M1/M4/M5), showing a significantly stronger reduction of mental health complaints (anxiety, vital exhaustion) in people with higher than those with lower pain in multidisciplinary treatment. Compared to regular routines, the self-management-multidisciplinary treatment led to a clinically relevant reduction of pain-disability and significant mental health improvements. Low-cost exercise programs may provide enormous relief for therapeutic processes, rehabilitation aftercare, and thus, cost savings for the health system.

Psychological and physical factors related to disability in chronic low back pain

BACKGROUND

Chronic low back pain (CLBP) is a public health problem that causes high levels of disability. Psychological and physical factors could play a critical role in the disability perception of patients.

OBJECTIVE

The objective was to identify the psychological and physical factors associated with CLBP disability in patients and assess differences between asymptomatic subjects and CLBP patients through physical tests and psychological self-reports.

METHODS

A cross-sectional study was performed. Total sample of 80 participants were classified into two groups: patients with CLBP (n= 49) and asymptomatic subjects (i.e. the control group) (n= 31). The physical tests included lower back range of motion (LBROM), postural stability, lower back strength (LBS), and lumbopelvic motor control tests. The psychological self-reports included low back disability (Roland Morris Disability Questionnaire), self-efficacy, pain catastrophizing, and pain-related fear.

RESULTS

Self-efficacy and LBS displayed moderate negative correlations with disability in patients with CLBP (R=-0.47 and -0.40, respectively). Disability was predicted by self-efficacy and LBROM (β=-0.45 and -033 respectively, p< 0.01), explaining 30% of the variance in these patients. The comparative analysis showed statistically significant differences between groups in the physical/psychological variables (p< 0.01); however, the effect-sizes were small for all these variables.

CONCLUSIONS

The results of this study highlight the relevance of psychological and physical factors in CLBP patient disability. Evaluation and treatment in CLBP patients should take these factors into account.

Can Kinesio Taping® influence the electromyographic signal intensity of trunk extensor muscles in patients with chronic low back pain? A randomized controlled trial

BACKGROUND

The evidence of the influence of Kinesio Taping® in changing electromyographic signal intensity of the lumbar musculature in patients with chronic non-specific low back pain (LBP) is very sparse.

OBJECTIVES

To evaluate if Kinesio Taping® changes the electromyographic signal intensity of the longissimus and iliocostalis muscles in patients with chronic non-specific LBP.

METHODS

Prospectively registered, three-arm randomized controlled trial with a blinded assessor. Patients were randomly allocated to the following interventions: 1) Kinesio Taping® Group (n=21), where patients received the tape according to the manufacturer's manual; 2) Placebo Group (i.e. normal surgical tape) (n=21); and 3) Non-treatment control Group (n=21). Assessments were performed at baseline, immediately after, and 30min after the intervention. The primary outcome was muscle activity of the iliocostalis and longissimus muscles as measured by surface electromyography. The secondary outcome was pain intensity (measured with a 0-10 Numerical Rating Scale). The effects of treatment were calculated using linear mixed models.

RESULTS

A total of 63 patients were recruited. Follow up rate was high (98.4%). Patients were mostly women with moderate levels of pain and disability. Kinesio Taping® was better than the control and placebo groups in only 4 of 96 statistical comparisons, likely reflective of type I error due to multiple comparisons. No statistically significant differences were identified for the immediate reduction in pain intensity between groups.

CONCLUSION

Kinesio Taping® did not change the electromyographic signal intensity of the longissimus and iliocostalis muscles or reduce pain intensity in patients with chronic low back pain. Clinicaltrials.gov: NCT02759757 (https://clinicaltrials.gov/ct2/show/NCT02759757).

Validity of increasing the number of motor control tests within a test battery for discrimination of low back pain conditions in people attending a physiotherapy clinic: a case-control study

OBJECTIVES

To develop a time-efficient motor control (MC) test battery while maximising diagnostic accuracy of both a two-level and three-level classification system for patients with non-specific low back pain (LBP).

DESIGN

Case-control study.

SETTING

Four private physiotherapy practices in northern Germany.

PARTICIPANTS

Consecutive males and females presenting to a physiotherapy clinic with non-specific LBP (n=65) were compared with 66 healthy-matched controls.

PRIMARY OUTCOME MEASURES

Accuracy (sensitivity, specificity, Youden index, positive/negative likelihood ratio, area under the curve (AUC)) of a clinically driven consensus-based test battery including the ideal number of test items as well as threshold values and most accurate items.

RESULTS

For both the two and three-level categorisation system, the ideal number of test items was 10. With increasing number of failed tests, the probability of having LBP increases. The overall discrimination potential for the two-level categorisation system of the test is good (AUC=0.85) with an optimal cut-off of three failed tests. The overall discrimination potential of the three-level categorisation system is fair (volume under the surface=0.52). The optimal cut-off for the 10-item test battery for categorisation into none, mild/moderate and severe MC impairment is three and six failed tests, respectively.

CONCLUSION

A 10-item test battery is recommended for both the two-level (impairment or not) and three-level (none, mild, moderate/severe) categorisation of patients with non-specific LBP.

Effectiveness of dry needling for improving pain and disability in adults with tension-type, cervicogenic, or migraine headaches: protocol for a systematic review

Background

Headache is the most common neurological symptoms worldwide, as over 90% of people have noted at least one headache during their lifetime. Tension-type headaches, cervicogenic headaches, and migraines are common types of headache which can have a significant impact on social, physical, and occupational functioning. Therapeutic management of headaches mainly includes physical therapy and pharmacological interventions. Dry needling is a relatively new therapeutic approach that uses a thin filiform needle without injectate to penetrate the skin and stimulate underlying tissues for the management of neuromusculoskeletal pain and movement impairments.

The main objective of this systematic review and meta-analysis is to evaluate the effectiveness of dry needling in comparison to other interventions on pain and disability in patients with tension-type headache, cervicogenic headache, and migraine.

Methods/design

We will focus on clinical trials with concurrent control group(s) and comparative observational studies assessing the effect of dry needling in patients with tension-type headache, cervicogenic headache, and migraine. Electronic databases from relevant fields of research (PubMed/ Medline, Scopus, Embase®, PEDro, Web of Science, Ovid, AMED, CENTRAL, and Google Scholar) will be searched from inception to June 2019 using defined search terms. No restrictions for language of publication or geographic location will be applied. Moreover, grey literature, citation tracking, and reference lists scanning of the selected studies will be searched manually. Primary outcomes of this study are pain intensity and disability, and secondary outcomes are cervical spine ROM, frequency of headaches, health-related quality of life, and TrPs tenderness. Studies will be selected by three independent reviewers based on prespecified eligibility criteria. Three reviewers will independently extract data in each eligible study using a pre-piloted Microsoft Excel data extraction form. The assessment of risk of bias will be implemented using the Cochrane Back and Neck Review Group 13-item criteria and NOS. Direct meta-analysis will be performed using a fixed or random effects model to estimate effect size such as standardized mean difference (Morris’s d_ppc) and 95% confidence intervals. Statistical heterogeneity will also be evaluated using the I² statistic and the χ² test. All meta-analyses will be performed using Stata V.11 and V.14 softwares. The overall quality of the evidence for the primary outcomes will be assessed using GRADE.

Discussion

All analyses in this study will be based on the previous published papers. Therefore, ethical approval and patient consent are not required. The findings of this study will provide important information on the value of dry needling for the management of tension-type headache, cervicogenic headache, and migraine.

Trial registration

PROSPERO registration number: CRD42019124125.

Electronic supplementary material

The online version of this article (10.1186/s12998-019-0266-7) contains supplementary material, which is available to authorized users.

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

Effects of lumbar extensor muscle strengthening and neuromuscular control retraining on disability in patients with chronic low back pain: a protocol for a randomised controlled trial

INTRODUCTION

Chronic low back pain (CLBP) is the leading cause of disability worldwide. However, there is no consensus in the literature regarding optimal management. Exercise intervention is the most widely used treatment as it likely influences contributing factors such as physical and psychological. Literature evaluating the effects of exercise on CLBP is often generalised, non-specific and employs inconsistent outcome measures. Moreover, the mechanisms behind exercise-related improvements are poorly understood. Recently, research has emerged identifying associations between neuromuscular-biomechanical impairments and CLBP-related disability. This information can be used as the basis for more specific and, potentially more efficacious exercise interventions for CLBP patients.

METHODS AND ANALYSIS

Ninety-four participants (including both males and females) with CLBP aged 18-65 who present for treatment to a Melbourne-based private physiotherapy practice will be recruited and randomised into one of two treatment groups. Following baseline assessment, participants will be randomly allocated to receive either: (i) strengthening exercises in combination with lumbar force accuracy training exercises or (ii) strengthening exercises alone. Participants will attend exercise sessions twice a week for 12 weeks, with assessments conducted at baseline, midway (ie, 6 weeks into the trial) and at trial completion. All exercise interventions will be supervised by a qualified physiotherapist trained in the intervention protocol. The primary outcome will be functional disability measured using the Oswestry Disability Index. Other psychosocial and mechanistic parameters will also be measured.

ETHICS AND DISSEMINATION

This study was given approval by the University of Melbourne Behavioural and Social Sciences Human Ethics Sub-Committee on 8 August 2017, reference number 1 749 845. Results of the randomised controlled trial will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12618000894291.

RESTORE-Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain: study protocol for a randomised controlled trial

INTRODUCTION

Low back pain (LBP) is the leading cause of disability globally and its costs exceed those of cancer and diabetes combined. Recent evidence suggests that individualised cognitive and movement rehabilitation combined with lifestyle advice (cognitive functional therapy (CFT)) may produce larger and more sustained effects than traditional approaches, and movement sensor biofeedback may enhance outcomes. Therefore, this three-arm randomised controlled trial (RCT) aims to compare the clinical effectiveness and economic efficiency of individualised CFT delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling LBP.

METHODS AND ANALYSIS

Pragmatic, three-arm, randomised, parallel group, superiority RCT comparing usual care (n=164) with CFT (n=164) and CFT-plus-movement-sensor-biofeedback (n=164). Inclusion criteria include: adults with a current episode of LBP >3 months; sought primary care ≥6 weeks ago for this episode of LBP; average LBP intensity of ≥4 (0-10 scale); at least moderate pain-related interference with work or daily activities. The CFT-only and CFT-plus-movement-sensor-biofeedback participants will receive seven treatment sessions over 12 weeks plus a 'booster' session at 26 weeks. All participants will be assessed at baseline, 3, 6, 13, 26, 40 and 52 weeks. The primary outcome is pain-related physical activity limitation (Roland Morris Disability Questionnaire). Linear mixed models will be used to assess the effect of treatment on physical activity limitation across all time points, with the primary comparison being a formal test of adjusted mean differences between groups at 13 weeks. For the economic (cost-utility) analysis, the primary outcome of clinical effect will be quality-adjusted life years measured across the 12-month follow-up using the EuroQol EQ-5D-5L .

ETHICS AND DISSEMINATION

Approved by Curtin University Human Research Ethics Committee (HRE2018-0062, 6 Feb 2018). Study findings will be disseminated through publication in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12618001396213).

A Critical Analysis of the Exercise Prescription and Return to Activity Advice That Is Provided in Patient Information Leaflets Following Lumbar Spine Surgery

Background and objectives: Lumbar spine surgery may be considered if pharmacologic, rehabilitation and interventional approaches cannot provide sufficient recovery from low back-related pain. Postoperative physiotherapy treatment in England is often accompanied by patient information leaflets, which contain important rehabilitation advice. However, in order to be an effective instrument for patients, the information provided in these leaflets must be up to date and based on the best available evidence and clinical practice. This study aims to critically analyse the current postoperative aspects of rehabilitation (exercise prescription and return to normal activity) that are provided in patient information leaflets in England as part of an evaluation of current practice following lumbar spine surgery. Materials and Methods: Patient information leaflets from English National Health Service (NHS) hospitals performing lumbar spine surgery were sourced online. A content analysis was conducted to collect data on postoperative exercise prescription and return to normal activities. Results: Thirty-two patient information leaflets on lumbar surgery were sourced (fusion, n = 11; decompression, n = 15; all lumbar procedures, n = 6). Many of the exercises prescribed within the leaflets were not based on evidence of clinical best practice and lacked a relationship to functional activity. Return to normal activity advice was also wide ranging, with considerable variation in the recommendations and definitions provided. Conclusions: This study highlights a clear variation in the recommendations of exercise prescription, dosage and returning to normal activities following lumbar spine surgery. Future work should focus on providing a consistent and patient-centred approach to recovery.

State-of-the-Art Exercise Concepts for Lumbopelvic and Spinal Muscles - Transferability to Microgravity

Low back pain (LBP) is the leading cause of disability worldwide. Over the last three decades, changes to key recommendations in clinical practice guidelines for management of LBP have placed greater emphasis on self-management and utilization of exercise programs targeting improvements in function. Recommendations have also suggested that physical treatments for persistent LBP should be tailored to the individual. This mini review will draw parallels between changes, which occur to the neuromuscular system in microgravity and conditions such as LBP which occur on Earth. Prolonged exposure to microgravity is associated with both LBP and muscle atrophy of the intrinsic muscles of the spine, including the lumbar multifidus. The finding of atrophy of spinal muscles has also commonly been reported in terrestrial LBP sufferers. Studying astronauts provides a unique perspective and valuable model for testing the effectiveness of exercise interventions, which have been developed on Earth. One such approach is motor control training, which is a broad term that can include all the sensory and motor aspects of spinal motor function. There is evidence to support the use of this exercise approach, but unlike changes seen in muscles of LBP sufferers on Earth, the changes induced by exposure to microgravity are rapid, and are relatively consistent in nature. Drawing parallels between changes which occur to the neuromuscular system in the absence of gravity and which exercises best restore size and function could help health professionals tailor improved interventions for terrestrial populations.

Effects of pulsed low-frequency magnetic field therapy on pain intensity in patients with musculoskeletal chronic low back pain: study protocol for a randomised double-blind placebo-controlled trial

INTRODUCTION

The aim of the present study is to investigate the effectiveness of pulsed low-frequency magnetic field (PLFMF) on the management of chronic low back pain (CLBP).

METHODS AND ANALYSIS

A randomised double-blinded controlled clinical trial will be conducted, involving 200 patients with CLBP. Participants will be randomised in a 1:1 ratio to receive either active PLFMF (experimental arm) or sham treatment (control arm) using a permuted-block design which will be stratified according to three subtypes of musculoskeletal CLBP (nociceptive, peripheral neuropathic or central sanitisation). The intervention consists of three sessions/week for 6 weeks. The primary outcome is the percentage change in Numerical Rating Scale (NRS) pain at week 24 after treatment completion with respect to the baseline. Secondary outcomes include percentage NRS pain during treatment and early after treatment completion, short form 36 quality of life, Roland and Morris Disability Questionnaire; Depression Anxiety Stress Scale 21, Patient Specific Functional Scale, Global perceived effect of condition change, Pittsburgh Sleep Quality Index and Modified Fatigue Impact Scale. Measures will be taken at baseline, 3 and 6 weeks during the intervention and 6, 12 and 24 weeks after completing the intervention. Adverse events between arms will be evaluated. Data will be analysed on an intention-to-treat basis.

ETHICS AND DISSEMINATION

The study is funded by Imam Abdulrahman Bin Faisal University (IAU). It has been approved by the institutional review board of IAU (IRB- 2017-03-129). The study will be conducted at King Fahd Hospital of the University and will be monitored by the Hospital monitoring office for research and research ethics. The trial is scheduled to begin in September 2018. Results obtained will be presented in international conferences and will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12618000921280, prospectively.

Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate

SYNOPSIS

Although biomechanics plays a role in the development and perhaps the persistent or recurrent nature of low back pain (LBP), whether biomechanics alone can provide the basis for intervention is debated. Biomechanics, which refers to the mechanics of the body, including its neuromuscular control, has been studied extensively in LBP. But, can gains be made in understanding LBP by research focused on this component of biology in the multifactorial biopsychosocial problem of LBP? This commentary considers whether biomechanics research has the potential to advance treatment of LBP, and how likely it is that this research will lead to better treatment strategies. A point-counterpoint format is taken to present both sides of the argument. First, the challenges faced by an approach that considers biomechanics in isolation are presented. Next, we describe 3 models that place substantial emphasis on biomechanical factors. Finally, reactions to each point are presented as a foundation for further research and clinical practice to progress understanding of the place for biomechanics in guiding treatment of LBP. J Orthop Sports Phys Ther 2019;49(6):425-436. Epub 15 May 2019. doi:10.2519/jospt.2019.8825.

Active Visceral Manipulation Associated With Conventional Physiotherapy in People With Chronic Low Back Pain and Visceral Dysfunction: A Preliminary, Randomized, Controlled, Double-Blind Clinical Trial

OBJECTIVE

The purpose of this study was to generate data for conduction of a power analysis to investigate short-term effects of visceral manipulation associated with conventional physical therapy on pain intensity, lumbar mobility, and functionality of people with chronic low back pain and visceral dysfunctions.

METHODS

This was a double-blinded, randomized, controlled, clinical trial preliminary study. A blinded evaluation was conducted involving 20 people with chronic low back pain with visceral dysfunction. Pain perception, lumbar mobility, and functionality were assessed in 3 moments: evaluation 1 (1 week before the intervention), evaluation 2 (immediately after the last intervention), and evaluation 3 (1 week after the last intervention). The protocol consisted of 50-minute session of conventional physical therapy and visceral manipulation. The participants were randomly allocated to 2 groups: 10 for the experimental group (conventional physical therapy and visceral manipulation) and 10 for the control group (conventional physical therapy and placebo visceral manipulation).

RESULTS

Significant reductions were found in the experimental group for lumbar mobility and specific functionality in comparison with the control group (P < .05). There were no significant differences for pain perception and global functionality.

CONCLUSION

The combination of visceral manipulation and conventional physical therapy program demonstrated significant between-groups differences over time for lumbar spine mobility and specific functionality. These gains occurred after 5 sessions, once a week, and were maintained 1 week after the end of the treatment. This study generated data for conduction of a power analysis to inform the design for future clinical research in this line of inquiry.

Model Simulations Challenge Reductionist Research Approaches to Studying Chronic Low Back Pain

BACKGROUND

Traditionally, low back pain (LBP) is studied using a reductionist approach, in which the factors contributing to the clinical presentation of LBP are studied in isolation to identify the primary pathology or condition linked to LBP. We argue that reductionism may not be suitable for studying LBP, considering the complex, multifactorial nature of this condition.

OBJECTIVES

To quantify the likelihood of successfully subclassifying patients with LBP and effectively targeting treatment based on a single dominant factor contributing to LBP.

METHODS

Both analytical and numerical simulations (Monte Carlo) of 1 million patients with LBP were performed. Several factors contributing to LBP were randomly assigned to each individual. The following outcome measures were computed, as a function of the number of factors: the percentage of individuals who could be subclassified by identifying a single factor exceeding a certain threshold, and the average reduction in LBP when treatment eliminates the largest contributing factor versus a multimodal treatment that eliminates a number of the randomly selected factors.

RESULTS

With an increasing number of factors, the probability of subclassifying an individual to a subgroup based on a single factor tends toward zero. A multimodal treatment arbitrarily addressing any 2 or more factors was more effective than diagnosing and treating a single factor that maximally contributed to LBP.

CONCLUSION

Results suggest that reductionism is not appropriate for subclassifying patients with LBP or for targeting treatment. The use of reductionist approaches may explain some of the challenges when creating LBP classification systems and designing effective treatment interventions. J Orthop Sports Phys Ther 2019;49(6):477-481. Epub 15 May 2019. doi:10.2519/jospt.2019.8791.

Analysis of Motor Control in Patients With Low Back Pain: A Key to Personalized Care?

SYNOPSIS

Motor control exercise has been shown to be effective in the management of low back pain (LBP). However, the effect sizes for motor control exercise are modest, possibly because studies have used a one-size-fits-all approach, while the literature suggests that patients may differ in presence or type of motor control issues. In this commentary, we address the question of whether consideration of such variation in motor control issues might contribute to more personalized motor control exercise for patients with LBP. Such an approach is plausible, because motor control changes may play a role in persistence of pain through effects on tissue loading that may cause nociceptive afference, particularly in the case of peripheral sensitization. Subgrouping systems used in clinical practice, which comprise motor control aspects, allow reliable classification that is, in part, aligned with findings in studies on motor control in patients with LBP. Motor control issues may have heuristic value for treatment allocation, as the different presentations observed suggest different targets for motor control exercise, but this remains to be proven. Finally, clinical assessment of patients with LBP should take into account more aspects than motor control alone, including pain mechanisms, musculoskeletal health, and psychosocial factors, and may need to be embedded in a stratification approach based on prognosis to avoid undue diagnostic procedures. J Orthop Sports Phys Ther 2019;49(6):380-388. Epub 12 Jun 2018. doi:10.2519/jospt.2019.7916.

Overall confidence in the results of systematic reviews on exercise therapy for chronic low back pain: a cross-sectional analysis using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) 2 tool

OBJECTIVE

To evaluate the overall confidence in the results of systematic reviews of exercise therapy for chronic non-specific low back pain using the AMSTAR 2 tool.

METHODS

PubMed, Embase, Cochrane Database of Systematic Reviews, PEDro and CINAHL was searched up to February 2017. Two independent reviewers selected systematic reviews of randomized controlled trials that investigated exercise therapy in patients with low back pain. AMSTAR 2 assessment was performed by pairs of reviewers, and the overall confidence in the results of the systematic reviews were rated as 'High', 'Moderate', 'Low' and 'Critically low'. Descriptive analysis was used to summarize the characteristics of included systematic reviews. The percentage of systematic reviews achieving each item from the AMSTAR 2 and the overall confidence in the results were tabulated.

RESULTS

The search identified 38 systematic reviews. Most of the reviews included a median of 10 clinical trials and total sample size of 813 participants per review. Five of 38 (13%) reviews were Cochrane reviews, and 8 (21%) systematic reviews had a protocol published or registered prospectively. The overall confidence in the results of 28 reviews (74%) was rated as 'Critically low', 6 (16%) as 'Low', 1 (2%) as Moderate, while 3 of 38 reviews (8%) were rated as 'High'.

CONCLUSION

The results demonstrate very low confidence in the results of most systematic reviews of exercise in chronic non-specific low back pain. Clinicians are more likely to deliver the most efficacious interventions to patients by critically appraising systematic reviews using AMSTAR 2 before making their decisions.

Non-specific Low Back Pain and Postural Control During Quiet Standing-A Systematic Review

Background: There is a great number of people who require treatment for non-specific low back pain (LBP) yet the causes are still unclear. One proposed cause for LBP is impaired motor control and more specific an impaired postural control.

Objective: The purpose of this review is to provide an overview of postural control parameter differences in persons with and without non-specific LBP during quite standing.

Methods: A literature search in five databases from January 2000 until January 2018 was performed and was followed by a hand search. Twenty-one articles comparing healthy adults and adults with non-specific LBP in neuromuscular and/or biomechanical parameters during bipedal stance without external perturbation in lab studies were examined. Data extraction and quality assessment were independently performed by two persons. Factors such as study population, outcome measures, and results were extracted from the articles and included in this analysis.

Results: The results show that persons with and without non-specific LBP differed in several parameters of postural control such as the center of pressure displacement, postural control strategy, and muscle activation patterns.

Conclusion: While the results show that none of the parameters alone lead to significant effects, the combination of neuromuscular and biomechanical parameters was associated with the impairment of postural control in individuals with LBP during standing. Since the studies included in this analysis used different methodological procedures a replication of these studies with standardized procedures is imperative for the acquisition of more conclusive evidence on the differences in postural control during standing.

Evidence of stabilizing exercises for low back- and pelvic girdle pain - a critical review

BACKGROUND

Pregnancy-related low back pain (LBP) and pelvic girdle pain (PGP) have been associated with an alteration in the strategy for lumbopelvic stabilization. Different core stabilization approaches exist, the evidence is however controversial.

METHODS

This paper discusses how to improve the evidence of exercises for women suffering from LBP and PGP during and after pregnancy. Exercises should be understood in a context, where the bio-psycho-social perspective directs the prescription of exercises, targeting both psychological and physical factors. The type of exercise probably should be individually tailored to the needs and capability of the individual and it is not only about the most appropriate exercise, it is about dosage and delivery of the exercises, and it is about performance. To promote adherence the use of patient preferences, with self-defined movement goals, may be a motivational basis for behavior change. Communication skills may facilitate positive beliefs and provide a motivational foundation for empowerment, self-efficacy and for self-management. To learn by discovery where the patient learns through their own experiences, might motivate the patients to active engagement and to behavioral change. Adherence probably will increase when the patients understand the aim and the rationale behind the exercises they are prescribed. However, with high adherence to exercises that maintains an inappropriate motor pattern, LBP and PGP possibly could proceed into chronicity.

CONCLUSION

Exercises need to be meaningful to the patient, relevant for daily activities, individualized according to patient preferences, guided and supervised to secure performance and quality.

Effects of motor control exercise and patient education program in the management of chronic low back pain among community-dwelling adults in rural Nigeria: a study protocol for a randomized clinical trial

Background

The impact of chronic low back pain (CLBP) is disproportionally higher in rural Nigeria than in urban areas but lack access to rehabilitation. While exercise and education are commonly advocated interventions for the rehabilitation of CLBP, there is a paucity of community-based randomized clinical trials assessing their benefits among adults with CLBP in rural Nigeria. The purpose of this study is to investigate the effects of motor control exercise (MCE) and patient education (PE) in the management of CLBP among community-dwelling adults in rural Nigeria.

Methods

This is an assessor-blind, three-arm parallel randomized clinical trial and will be conducted at Tsakuwa Primary Health Care Center in Kano, Northwestern Nigeria. One hundred and twenty adults with CLBP will be recruited and randomized to one of three intervention arms; MCE plus PE, MCE, or PE groups. The MCE will be administered twice a week for 8 weeks while the PE will be provided once a week for 8 weeks. Participants will be assessed pre-intervention, immediately post-intervention and at 3-month post-intervention. Primary outcomes will be pain intensity and functional disability. Secondary outcomes will be quality of life, fear-avoidance beliefs, pain catastrophizing, back beliefs, global perceived recovery, and physical performance.

Discussion

This will be the first community-based trial to assess the benefits of exercise and education in the management of CLBP among adults in rural Nigeria. The study may provide a relatively inexpensive, assessable, and effective alternative intervention for reducing CLBP disability in a low-resource rural Nigerian community. Trial registration:This study is registered at ClinicalTrial.gov and the trial registration number is NCT03393104.

Exercise-induced hypoalgesia: A meta-analysis of exercise dosing for the treatment of chronic pain

OBJECTIVE

Increasing evidence purports exercise as a first-line therapeutic for the treatment of nearly all forms of chronic pain. However, knowledge of efficacious dosing respective to treatment modality and pain condition is virtually absent in the literature. The purpose of this analysis was to calculate the extent to which exercise treatment shows dose-dependent effects similar to what is seen with pharmacological treatments.

METHODS

A recently published comprehensive review of exercise and physical activity for chronic pain in adults was identified in May 2017. This report reviewed different physical activity and exercise interventions and their effectiveness in reducing pain severity and found overall modest effects of exercise in the treatment of pain. We analyzed this existing data set, focusing specifically on the dose of exercise intervention in these studies. We re-analyzed data from 75 studies looking at benefits of time of exercising per week, frequency of exercise per week, duration of intervention (in weeks), and estimated intensity of exercise.

RESULTS

Analysis revealed a significant positive correlation with exercise duration and analgesic effect on neck pain. Multiple linear regression modeling of these data predicted that increasing the frequency of exercise sessions per week is most likely to have a positive effect on chronic pain patients.

DISCUSSION

Modest effects were observed with one significant correlation between duration and pain effect for neck pain. Overall, these results provide insufficient evidence to conclude the presence of a strong dose effect of exercise in pain, but our modeling data provide tes predictions that can be used to design future studies to explicitly test the question of dose in specific patient populations.

Effects of Massage as a Combination Therapy with Lumbopelvic Stability Exercises as Compared to Standard Massage Therapy in Low Back Pain: a Randomized Cross-Over Study

BACKGROUND

Little is known about the effects of providing massage as a combination therapy (CT) with lumbopelvic stability training (LPST) in management of chronic nonspecific low back pain (CLBP) among elite female weight lifters. It is unclear whether massage therapy (MT) together with LPST has any additional clinical benefits for individuals with CLBP.

PURPOSE

The current study compares the therapeutic effects of CT against MT as a stand-alone intervention on pain intensity (PI), pain pressure threshold (PPT), tissue blood flow (TBF), and lumbopelvic stability (LPS) among elite weight lifters with CLBP.

SETTING

The study was conducted at the campus for National Olympic weight lifting training camp.

PARTICIPANTS

A total of 16 professional female elite weight lifting athletes who were training for Olympic weight lifting competition participated in the study.

RESEARCH DESIGN

A within-subject, repeated measures, crossover, single-blinded, randomized allocation study.

INTERVENTION

The athletes were randomized into three sessions of CT and MT with a time interval of 24 hrs within sessions and a wash out period of four weeks between the sessions.

MAIN OUTCOME MEASURES

The PI, PPT, TBF, and LPS were measured before and after each session repeatedly in both groups of intervention. The changes in the PI, PPT, TBF, and LPS were analyzed using repeated measures analysis of variance (ANOVA).

RESULTS

The results showed that the CT significantly demonstrated greater effects in reducing pain perception (45%-51%), improving pain pressure threshold (15% up to 25%), and increasing tissue blood flow (131%-152%) than MT (p < .001).

CONCLUSION

The combination therapy of massage therapy and LPST is likely to provide more clinical benefits in terms of PI, PPT, and TBF when compared to massage as a stand-alone therapy among individuals with chronic nonspecific low back pain.

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence

BACKGROUND

Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain.

METHODS

GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created.

RESULTS

Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions.

CONCLUSION

From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

The Perceived Benefits of an Artificial Intelligence-Embedded Mobile App Implementing Evidence-Based Guidelines for the Self-Management of Chronic Neck and Back Pain: Observational Study

Background

Chronic musculoskeletal neck and back pain are disabling conditions among adults. Use of technology has been suggested as an alternative way to increase adherence to exercise therapy, which may improve clinical outcomes.

Objective

The aim was to investigate the self-perceived benefits of an artificial intelligence (AI)–embedded mobile app to self-manage chronic neck and back pain.

Methods

A total of 161 participants responded to the invitation. The evaluation questionnaire included 14 questions that were intended to explore if using the AI rehabilitation system may (1) increase time spent on therapeutic exercise, (2) affect pain level (assessed by the 0-10 Numerical Pain Rating Scale), and (3) reduce the need for other interventions.

Results

An increase in time spent on therapeutic exercise per day was observed. The median Numerical Pain Rating Scale scores were 6 (interquartile range [IQR] 5-8) before and 4 (IQR 3-6) after using the AI-embedded mobile app (95% CI 1.18-1.81). A 3-point reduction was reported by the participants who used the AI-embedded mobile app for more than 6 months. Reduction in the usage of other interventions while using the AI-embedded mobile app was also reported.

Conclusions

This study demonstrated the positive self-perceived beneficiary effect of using the AI-embedded mobile app to provide a personalized therapeutic exercise program. The positive results suggest that it at least warrants further study to investigate the physiological effect of the AI-embedded mobile app and how it compares with routine clinical care.

Chronic Non-specific Low Back Pain and Motor Control During Gait

Background: Chronic non-specific low back pain (LBP) poses a major socioeconomic problem, although the mechanisms are not yet clear. Impaired motor control is one of the mechanisms being discussed. Objectives: The purpose of this review is to provide an overview of motor control parameter differences between individuals with and without non-specific LBP during gait. Methods: A literature search on Medline, SportDiscus, PsychInfo, PsychArticels, EMBASE, and Scopus was performed. Twenty-nine articles comparing healthy adults and adults with chronic non-specific LBP in neuromuscular and/or biomechanical parameters during walking or running were examined. Data extraction and quality assessment were independently performed by two persons. Among others, we extracted population, conditions, outcome measures, and results. Results: The results showed that persons with and without non-specific LBP differed in several parameters of motor control, which was indicated by a lower movement amplitude of the pelvis, more in-phase coordination, lower ground reaction forces, higher stride-to-stride variability and a higher activity in ES in the LBP group. Conclusion: Despite no strong evidence for any of the parameters, a combination of biomechanical and neuromuscular parameters provides a conclusive explanation. Impaired motor control during walking is reflected in higher activity of the erector spinae, which leads to a stiffened lumbar-pelvic region. Different acquisition and processing of data renders making comparisons difficult, whereby standards for future research are necessary.

General group exercise in low back pain management in a military population, a comparison with specific spine group exercise: a service evaluation

Objective

To investigate whether general group exercise (GGE) offers the same outcomes compared with a specific spinal group exercise (SSGE) for chronic low back pain (CLBP) in a military population.

Design

Retrospective service evaluation using routine service activity data.

Setting

A UK military rehabilitation centre.

Participants

A total of 106 patients with CLBP.

Interventions

Three-week intensive (5 days per week, 15-day intervention) rehabilitation course for patients with CLBP. Six SSGE groups (n=64); CLBP only. Six GGE groups (n=42); CLBP patients grouped with chronic lower limb (LL) injuries.

Outcome measures

Oswestry Disability Index (ODI), Numerical Pain-Rating Scores and the Modified Multi-Stage Fitness Test (Mod-MSFT). Long-term effects were measured by Medical Employment Standard (MES) status and physiotherapy follow-up at 3 and 12 months.

Results

A between-group analysis showed no significant difference in GGE compared with SSGE. Mean changes (SD) in pain were −2.71±2.35 and −1.20±1.99 (p=0.018), ODI were −3.6±5.7 and −4±8.5 respectively (p=0.649) and Mod-MSFT 28.4±30.8 and 29.7±31.7 respectively (p=0.792). At 3 months, a greater proportion of the GGE were having ongoing physiotherapy; GGE=50%, SSGE=30.2%, (p=0.016) although some differences were evident across MES with 32.5 % of GGE compared with 20.6 % of SSGE being medically fit with no restrictions. At 12 months, groups were largely comparable for follow-up physiotherapy and MES; 22.5% of GGE and 20.6% of SSGE continued to have physiotherapy input; 47.5% of GGE and 50.8% of SSGE were medically fit with no restrictions.

Conclusion

Patients with CLBP who completed a 3-week rehabilitation programme had comparable outcomes when grouped with patients with LL, although only improvements in pain in the GGE group achieved a meaningful change. Further evaluation of potential costs and savings to service costs is now required.

Management of Functional Somatic Syndromes and Bodily Distress

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.

Relationships between muscle electrical activity and the control of inter-vertebral motion during a forward bending task

Muscle strengthening exercises are commonly used in primary care for the treatment of chronic, non-specific low back pain (CNSLBP) as it has been theorised that increased muscle activity contributes to the stabilisation of inter-vertebral motion segments during bending and other spinal movements, however this has never been demonstrated in vivo. This study used contemporaneous quantitative fluoroscopy (QF) and surface electromyography (sEMG) to investigate relationships between continuous inter-vertebral motion variables and muscle electrical activity in the lumbar multifidus (LMU), lumbar and thoracic erector spinae (LES and TES) during standardised lumbar flexion and return in 18 healthy male human subjects. Our results demonstrated that the variability in the sharing of angular motion (i.e. Motion Share Variability MSV) and motion segment laxity during a bending task were significantly (p < 0.05) negatively correlated (Spearman) with muscle electrical activity throughout the participant bend for both locally and globally acting muscle groups. MSV was also strongly correlated with L2-3 laxity. The former suggests a damping mechanism reducing irregular displacements (i.e. less variability in the sharing of segmental motion) during bending and an action of spinal stabilisation by muscles at segmental levels, and the latter a synergy between laxity at L2-3 and MSV. While this has previously been theorised, it has never been shown in vivo at the inter-vertebral level. These assessments may be considered for use in validation studies of exercise programs for CNSLBP, however further replication is required.

Pain education for patients with non-specific low back pain in Nepal: protocol of a feasibility randomised clinical trial (PEN-LBP Trial)

INTRODUCTION

Low back pain (LBP) is the leading cause of years lived with disability in Nepal and elsewhere. Management of LBP that is evidence-based, easily accessible, cost-effective and culturally appropriate is desirable. The primary aim of this feasibility study is to determine if it is feasible to conduct a full randomised clinical trial evaluating the effectiveness of pain education as an intervention for individuals with LBP in Nepal, relative to guideline-based physiotherapy treatment. The findings of the study will inform the planning of a full clinical trial and if any modifications are required to the protocol before undertaking a full trial.

METHODS/ANALYSIS

This protocol describes an assessor-blinded feasibility clinical trial investigating feasibility of the pain education intervention in patients with non-specific LBP in a physiotherapy hospital in Kathmandu, Nepal. Forty patients with LBP will be randomly allocated to either pain education or guideline-based physiotherapy treatment (control). Outcomes will be assessed at baseline and at a 1 week post-treatment. The primary outcomes are related to feasibility, including: (1) participant willingness to participate in a randomised clinical trial, (2) feasibility of assessor blinding, (3) eligibility and recruitment rates, (4) acceptability of screening procedures and random allocation, (5) possible contamination between the groups, (6) intervention credibility, (7) intervention adherence, (8) treatment satisfaction and (9) difficulty in understanding the interventions being provided.

ETHICS/DISSEMINATION

The protocol was approved by Nepal Health Research Council (NHRC; registration number: 422/2017) and University of Otago Human Ethics Committee for Health (registration number: H17/157). The results of the study will be presented at national and international conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03387228; Pre-results.

Dose-response relationship of core-specific sensorimotor interventions in healthy, well-trained participants: study protocol for a (MiSpEx) randomized controlled trial

BACKGROUND

Core-specific sensorimotor exercises are proven to enhance neuromuscular activity of the trunk, improve athletic performance and prevent back pain. However, the dose-response relationship and, therefore, the dose required to improve trunk function is still under debate. The purpose of the present trial will be to compare four different intervention strategies of sensorimotor exercises that will result in improved trunk function.

METHODS/DESIGN

A single-blind, four-armed, randomized controlled trial with a 3-week (home-based) intervention phase and two measurement days pre and post intervention (M1/M2) is designed. Experimental procedures on both measurement days will include evaluation of maximum isokinetic and isometric trunk strength (extension/flexion, rotation) including perturbations, as well as neuromuscular trunk activity while performing strength testing. The primary outcome is trunk strength (peak torque). Neuromuscular activity (amplitude, latencies as a response to perturbation) serves as secondary outcome. The control group will perform a standardized exercise program of four sensorimotor exercises (three sets of 10 repetitions) in each of six training sessions (30 min duration) over 3 weeks. The intervention groups' programs differ in the number of exercises, sets per exercise and, therefore, overall training amount (group I: six sessions, three exercises, two sets; group II: six sessions, two exercises, two sets; group III: six sessions, one exercise, three sets). The intervention programs of groups I, II and III include additional perturbations for all exercises to increase both the difficulty and the efficacy of the exercises performed. Statistical analysis will be performed after examining the underlying assumptions for parametric and non-parametric testing.

DISCUSSION

The results of the study will be clinically relevant, not only for researchers but also for (sports) therapists, physicians, coaches, athletes and the general population who have the aim of improving trunk function.

TRIAL REGISTRATION

German Clinical Trials Register, ID: DRKS00012917 . Registered on 22 August 2017.

Aberrant intervertebral motion in patients with treatment-resistant nonspecific low back pain: a retrospective cohort study and control comparison

PURPOSE

Intervertebral kinematic assessments have been used to investigate mechanical causes when back pain is resistant to treatment, and recent studies have identified intervertebral motion markers that discriminate patients from controls. However, such patients are a heterogeneous group, some of whom have structural disruption, but the effects of this on intervertebral kinematics are unknown.

METHODS

Thirty-seven patients with treatment-resistant back pain referred for quantitative fluoroscopy were matched to an equal number of pain-free controls for age and sex. All received passive recumbent flexion assessments for intervertebral motion sharing inequality (MSI), variability (MSV), laxity and translation. Comparisons were made between patient subgroups, between patients and controls and against normative levels from a separate group of controls.

RESULTS

Eleven patients had had surgical or interventional procedures, and ten had spondylolisthesis or pars defects. Sixteen had no disruption. Patients had significantly higher median MSI values (0.30) than controls (0.27, p = 0.010), but not MSV (patients 0.08 vs controls 0.08, p = 0.791). Patients who received invasive procedures had higher median MSI values (0.37) than those with bony defects (0.30, p = 0.018) or no disruption (0.28, p = 0.0007). Laxity and translation above reference limits were not more prevalent in patients.

CONCLUSION

Patients with treatment-resistant nonspecific back pain have greater MSI values than controls, especially if the former have received spinal surgery. However, excessive laxity, translation and MSV are not more prevalent in these patients. Thus, MSI should be investigated as a pain mechanism and for its possible value as a prognostic factor and/or target for treatment in larger patient populations. These slides can be retrieved under Electronic Supplementary Material.

Stress and Alterations in the Pain Matrix: A Biopsychosocial Perspective on Back Pain and Its Prevention and Treatment

The genesis of chronic pain is explained by a biopsychosocial model. It hypothesizes an interdependency between environmental and genetic factors provoking aberrant long-term changes in biological and psychological regulatory systems. Physiological effects of psychological and physical stressors may play a crucial role in these maladaptive processes. Specifically, long-term demands on the stress response system may moderate central pain processing and influence descending serotonergic and noradrenergic signals from the brainstem, regulating nociceptive processing at the spinal level. However, the underlying mechanisms of this pathophysiological interplay still remain unclear. This paper aims to shed light on possible pathways between physical (exercise) and psychological stress and the potential neurobiological consequences in the genesis and treatment of chronic pain, highlighting evolving concepts and promising research directions in the treatment of chronic pain. Two treatment forms (exercise and mindfulness-based stress reduction as exemplary therapies), their interaction, and the dose-response will be discussed in more detail, which might pave the way to a better understanding of alterations in the pain matrix and help to develop future prevention and therapeutic concepts.

Clinical classification criteria for nonspecific low back pain: A Delphi-survey of clinical experts

BACKGROUND

Nonspecific low back pain (NSLBP) is a common problem. Attempts have been made to classify NSLBP patients into homogenous subgroups. Classification systems based on identifying the underlying mechanism(s) driving the disorder are clinically useful to guide specific interventions.

OBJECTIVE

To establish consensus among experts regarding clinical criteria suggestive of a dominance of 'articular', 'myofascial', 'neural', 'central', and 'sensorimotor control' dysfunction patterns (DPs) in NSLBP patients.

STUDY DESIGN

A 2-phase sequential design of a focus group and Delphi-study.

METHODS

A focus group with 10 academic experts was organized to elaborate on the different DPs discernible in LBP patients. Consecutively, a 3-round online Delphi-survey was designed to obtain consensual symptoms and physical examination findings for the 5 DPs resulting from the focus group.

RESULTS

Fifteen musculoskeletal physical therapists from Belgium and the Netherlands experienced in assessing and treating LBP patients completed the Delphi-survey. Respectively, 34 (response rate, 100.0%), 20 (58.8%) and 15 (44.12%) respondents replied to rounds 1, 2 and 3. Twenty-two 'articular', 20 'myofascial', 21 'neural', 18 'central' and 11 'sensorimotor control' criteria reached a predefined ≥80% consensus level. For example, after round 2, 85.0% of the Delphi-experts agreed to identify 'referred pain below the knee' as a subjective examination criterion suggestive for a predominant 'neural DP'.

CONCLUSION

These indicators suggestive of a clinical dominance of the proposed DPs could help clinicians to assess and diagnose NSLBP patients. Future reliability and validity testing is needed to determine how these criteria may help to improve physical therapy outcome for NSLBP patients.

Management of pain in patients with temporomandibular disorder (TMD): challenges and solutions

Thanks to advances in neuroscience, biopsychosocial models for diagnostics and treatment (including physical, psychological, and pharmacological therapies) currently have more clinical support and scientific growth. At present, a conservative treatment approach prevails over surgery, given it is less aggressive and usually results in satisfactory clinical outcomes in mild–moderate temporomandibular disorder (TMD). The aim of this review is to evaluate the recent evidence, identify challenges, and propose solutions from a clinical point of view for patients with craniofacial pain and TMD. The treatment we propose is structured in a multi-modal approach based on a biobehavioral approach that includes medical, physiotherapeutic, psychological, and dental treatments. We also propose a new biobehavioral model regarding pain perception and motor behavior for the diagnosis and treatment of patients with painful TMD.

Postural sensorimotor training versus sham exercise in physiotherapy of patients with chronic non-specific low back pain: An exploratory randomised controlled trial

Sensorimotor training (SMT) is popularly applied as exercise in rehabilitation settings, particularly for musculoskeletal pain. With insufficient evidence on its effect on pain and function, this exploratory randomised controlled trial investigated the potential effects of SMT in rehabilitation of chronic non-specific low back pain. Two arms received 9x30 minutes physiotherapy with added interventions: The experimental arm received 15 minutes of postural SMT while the comparator arm performed 15 minutes of added sub-effective low-intensity training. A treatment blinded tester assessed outcomes at baseline 2-4 days prior to intervention, pre- and post-intervention, and at 4-week follow-up. Main outcomes were pain and functional status assessed with a 0-100mm visual analogue scale and the Oswestry Disability Questionnaire. Additionally, postural control was analysed using a video-based tracking system and a pressure plate during perturbed stance. Robust, nonparametric multivariate hypothesis testing was performed. 22 patients (11 females, aged 32 to 75 years) with mild to moderate chronic pain and functional limitations were included for analysis (11 per arm). At post-intervention, average values of primary outcomes improved slightly, but not to a clinically relevant or statistically significant extent. At 4-week follow-up, there was a significant improvement by 12 percentage points (pp) on the functional status questionnaire in the SMT-group (95% confidence intervall (CI) = 5.3pp to 17.7pp, p < 0.001) but not in the control group (4 pp improvement, CI = 11.8pp to 19.2pp). However, group-by-time interaction effects for functional status (Q = 3.3, 19 p = 0.07) and pain (Q = 0.84, p = 0.51) were non-significant. Secondary kinematic outcomes did not change over time in either of the groups. Despite significant improvement of functional status after SMT, overall findings of this exploratory study suggest that SMT provides no added benefit for pain reduction or functional improvement in patients with moderate chronic non-specific low back pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02304120 and related study protocol, DOI: 10.1186/1471-2474-15-382.

Effects of Qigong practice in office workers with chronic non-specific low back pain: A randomized control trial

OBJECTIVE

To investigate the effects of Qigong practice, Guan Yin Zi Zai Gong level 1, compared with a waiting list control group among office workers with chronic nonspecific low back pain (CNLBP).

METHODS

A randomized controlled trial was conducted at offices in the Bangkok Metropolitan Region. Seventy-two office workers with CNLBP were screened for inclusion/exclusion criteria (age 20-40 years; sitting period more than 4 h per day) and were allocated randomly into two groups: the Qigong and waiting list groups (n = 36 each). The participants in the Qigong group took a Qigong practice class (Guan Yin Zi Zai Gong level 1) for one hour per week for six weeks at their workstation. The participants were encouraged to conduct the Qigong exercise at home every day. The waiting list group received general advice regarding low back pain management. The primary outcomes were pain intensity, measured by the visual analog scale, and back functional disability, measured by the Roland and Morris Disability Questionnaire. The secondary outcomes were back range of motion, core stability performance index, heart rate, respiratory rate, the Srithanya Stress Scale (ST-5), and the global perceived effect (GPE) questionnaire.

RESULTS

Compared to the baseline, participants in the Qigong group experienced significantly decreased pain intensity and back functional disability. No statistically significant difference in these parameters was found in the waiting list group. Comparing the two groups, Qigong exercise significantly improved pain intensity, back functional impairment, range of motion, core muscle strength, heart rate, respiratory rate, and mental status. The Qigong group also had a significantly higher global outcome satisfaction than the waiting list group.

CONCLUSION

Qigong practice is an option for treatment of CNLBP in office workers.

Experiences and attitudes about physical activity and exercise in patients with chronic pain: a qualitative interview study

Purpose

The purpose of this study was to describe how patients with chronic pain experience physical activity and exercise (PA&E).

Method

This qualitative interview study included 16 women and two men suffering from chronic pain and referred to a multimodal pain rehabilitation program. Semi-structured interviews were conducted and qualitative content analysis was used to analyze the interviews.

Results

One main theme emerged: "To overcome obstacles and to seize opportunities to be physically active despite chronic pain." This main theme was abstracted from five themes: "Valuing a life with physical activity," "Physical activity and exercise - before and after pain," "A struggle - difficulties and challenges," "The enabling of physical activity," and "In need of continuous and active support."

Conclusion

Although these participants valued PA&E, they seldom achieved desirable levels, and performance of PA&E was undermined by difficulties and failure. The discrepancy between the intention to perform physical activity and the physical activity accomplished could be related to motivation, self-efficacy, and action control. The participants desired high-quality interaction with healthcare providers. The findings can be applied to chronic pain rehabilitation that uses PA&E as treatment.

Trunk muscle activation levels during eight stabilization exercises used in the functional kinetics concept: A controlled laboratory study

BACKGROUND

To ensure accurate implementation of stabilization exercises in rehabilitation, physical therapists need to understand the muscle activation patterns of prescribed exercise.

OBJECTIVE

Compare muscle activity during eight trunk and lumbar spine stabilization exercises of the Functional Kinetics concept by Klein-Vogelbach.

METHODS

A controlled laboratory study with a single-group repeated-measures design was utilized to analyze surface electromyographic intensities of 14 female and 6 male young healthy participants performing eight exercises. Data were captured from the rectus abdominis, external/internal oblique and lumbar paraspinalis. The normalized muscle activation levels (maximum voluntary isometric contraction, MVIC) for three repetitions during each exercise and muscle were analyzed.

RESULTS

Side bridging (28 ± 20%MVIC) and advanced planking (29 ± 20%MVIC) reached the highest activity in the rectus abdominis. For external and internal oblique muscles, side bridging also showed the greatest activity of 99 ± 36%MVIC and 52 ± 25%MVIC, respectively. Apart from side bridging (52 ± 14%MVIC), the supine roll-out (31 ± 12%MVIC) and prone roll-out (31 ± 9%MVIC) showed the greatest activity for the paraspinalis. The advanced quadruped, seated back extension and flexion on chair/Swiss Ball, prone roll-out and advanced one-leg back bridging only yielded negligible muscle activities for the rectus abdominis (< 5%MVIC).

CONCLUSION

Based on the data obtained, recommendations for selective trunk muscle activation during eight stabilization exercises were established, which will guide physical therapists in the development of exercises tailored to the needs of their patients.