The efficacy of active rehabilitation in chronic low back pain. Effect on pain intensity, self-experienced disability, and lumbar fatigability

The relationship between active and neural measures in patients with nonspecific low back pain

STUDY DESIGN

Cross-sectional study of 50 individuals with nonspecific low back pain (LBP).

OBJECTIVE

To evaluate the relationship between active and neural measurements in individuals with nonspecific LBP.

SUMMARY OF BACKGROUND DATA

The Panjabi model for spinal stability consists of 3 interacting subsystems. Specific musculoskeletal measurements can be identified within the active and neural systems. The relationships among measures within this model have not been identified.

METHODS

A total of 50 individuals with nonspecific LBP were evaluated for measures of the active and neural stability systems, and analyzed using a canonical correlation analysis, which is used to measure the relationship between 2 multidimensional variables.

RESULTS

There were 2 significant relationships identified. The first identified a relationship among fatigue, flexion relation, and the feedforward abdominal response (r = 0.764, P < 0.001). The second relationship was between the Sorenson endurance test and feedforward abdominal response (r = 0.697, P = 0.006).

CONCLUSION

Identification of relationships between back pain measurements may allow discrimination between individuals with different histology and pain levels. This process may assist the specificity of treatment programs prescribed for patients with back pain.

Sex differences in predictors of outcome in selected physical therapy interventions for acute low back pain

STUDY DESIGN

Secondary analysis of pooled data from 3 randomized trials.

OBJECTIVE

This study investigated sex differences in response to physical therapy intervention for acute low back pain.

BACKGROUND

Sex differences in experimental pain sensitivity have been consistently described in the literature. However, clinical consequences of these sex differences have not been widely reported.

METHODS AND MEASURES

Subjects (n=165) were participants in 3 randomized trials of physical therapy interventions from outpatient physical therapy clinics in the general and military communities. Subjects were randomly assigned spinal manipulation with range-of-motion exercise, lumbar stabilization exercise, or directional-preference exercise. Outcomes were measured at 4 weeks through self-report of pain intensity and pain-related disability. Sex differences were investigated with independent t tests (baseline data), 2 x 3 analysis of variance (4-week reductions in pain and pain-related disability), and regression models (predictors of outcome).

RESULTS

Men and women had similar reductions of pain intensity (raw mean difference, 0.5; 95% Cl, -1.4 to 0.4) and pain-related disability (raw mean difference, 5.3; 95% CI, -0.1 to 10.7) over 4 weeks. Baseline pain intensity, duration of symptoms, and baseline pain-related disability significantly predicted change in pain intensity for women (r2 = 26%, P < .01). Baseline pain intensity and stabilization exercise predicted change in pain intensity for men (r2 = 33%, P<.01). Baseline pain-related disability, duration of pain, and pain intensity predicted change in disability for women (r2 = 24%, P < .01). Baseline pain-related disability, fear-avoidance beliefs, stabilization exercise, and leg pain predicted change in disability for men (r2 = 32%, P < .01).

CONCLUSION

For patients with acute low back pain, men and women had similar physical therapy outcomes for reductions in pain intensity and pain-related disability. However, men and women had different factors that predicted treatment outcome.

A Geriatrician's Guide to the Use of the Physical Modalities in the Treatment of Pain and Dysfunction

The use of the physical modalities in the treatment of musculoskeletal conditions has a long and rich history. This article explores the various physical modalities and their indications, precautions, and contraindications, especially in their applied use in pain management. It also highlights the role of the physical modalities as agents for the management of pain in the geriatric population.

Superficial heat or cold for low back pain

BACKGROUND

Heat and cold are commonly utilised in the treatment of low-back pain by both health care professionals and people with low-back pain.

OBJECTIVES

To assess the effects of superficial heat and cold therapy for low-back pain in adults.

SEARCH STRATEGY

We searched the Cochrane Back Review Group Specialised register, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to October 2005), EMBASE (1980 to October 2005) and other relevant databases.

SELECTION CRITERIA

We included randomised controlled trials and non-randomised controlled trials that examined superficial heat or cold therapies in people with low-back pain.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed methodological quality and extracted data, using the criteria recommended by the Cochrane Back Review Group.

MAIN RESULTS

Nine trials involving 1117 participants were included. In two trials of 258 participants with a mix of acute and sub-acute low-back pain, heat wrap therapy significantly reduced pain after five days (weighted mean difference (WMD) 1.06, 95% confidence interval (CI) 0.68 to 1.45, scale range 0 to 5) compared to oral placebo. One trial of 90 participants with acute low-back pain found that a heated blanket significantly decreased acute low-back pain immediately after application (WMD -32.20, 95%CI -38.69 to -25.71, scale range 0 to 100). One trial of 100 participants with a mix of acute and sub-acute low-back pain examined the additional effects of adding exercise to heat wrap, and found that it reduced pain after seven days. There is insufficient evidence to evaluate the effects of cold for low-back pain, and conflicting evidence for any differences between heat and cold for low-back pain.

AUTHORS' CONCLUSIONS

The evidence base to support the common practice of superficial heat and cold for low back pain is limited and there is a need for future higher-quality randomised controlled trials. There is moderate evidence in a small number of trials that heat wrap therapy provides a small short-term reduction in pain and disability in a population with a mix of acute and sub-acute low-back pain, and that the addition of exercise further reduces pain and improves function. The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain. There is conflicting evidence to determine the differences between heat and cold for low-back pain.

Outcome of non-invasive treatment modalities on back pain: an evidence-based review

At present, there is an increasing international trend towards evidence-based health care. The field of low back pain (LBP) research in primary care is an excellent example of evidence-based health care because there is a huge body of evidence from randomized trials. These trials have been summarized in a large number of systematic reviews. This paper summarizes the best available evidence from systematic reviews conducted within the framework of the Cochrane Back Review Group on non-invasive treatments for non-specific LBP. Data were gathered from the latest Cochrane Database of Systematic Reviews 2005, Issue 2. The Cochrane reviews were updated with additional trials, if available. Traditional NSAIDs, muscle relaxants, and advice to stay active are effective for short-term pain relief in acute LBP. Advice to stay active is also effective for long-term improvement of function in acute LBP. In chronic LBP, various interventions are effective for short-term pain relief, i.e. antidepressants, COX2 inhibitors, back schools, progressive relaxation, cognitive-respondent treatment, exercise therapy, and intensive multidisciplinary treatment. Several treatments are also effective for short-term improvement of function in chronic LBP, namely COX2 inhibitors, back schools, progressive relaxation, exercise therapy, and multidisciplinary treatment. There is no evidence that any of these interventions provides long-term effects on pain and function. Also, many trials showed methodological weaknesses, effects are compared to placebo, no treatment or waiting list controls, and effect sizes are small. Future trials should meet current quality standards and have adequate sample size.

The effect of motor control exercise versus placebo in patients with chronic low back pain [ACTRN012605000262606]

BACKGROUND

While one in ten Australians suffer from chronic low back pain this condition remains extremely difficult to treat. Many contemporary treatments are of unknown value. One potentially useful therapy is the use of motor control exercise. This therapy has a biologically plausible effect, is readily available in primary care and it is of modest cost. However, to date, the efficacy of motor control exercise has not been established.

METHODS

This paper describes the protocol for a clinical trial comparing the effects of motor control exercise versus placebo in the treatment of chronic non-specific low back pain. One hundred and fifty-four participants will be randomly allocated to receive an 8-week program of motor control exercise or placebo (detuned short wave and detuned ultrasound). Measures of outcomes will be obtained at follow-up appointments at 2, 6 and 12 months after randomisation. The primary outcomes are: pain, global perceived effect and patient-generated measure of disability at 2 months and recurrence at 12 months.

DISCUSSION

This trial will be the first placebo-controlled trial of motor control exercise. The results will inform best practice for treating chronic low back pain and prevent its occurrence.

Progressive Resistance Exercise in Physical Therapy: A Summary of Systematic Reviews

Progressive resistance exercise (PRE) is a method of increasing the ability of muscles to generate force. However, the effectiveness and safety of PRE for clients of physical therapists are not well known. The purpose of this article is to review the evidence on positive and negative effects of PRE as a physical therapy intervention. Electronic databases were searched for systematic reviews on PRE and any relevant randomized trials published after the last available review. The search yielded 18 systematic reviews under major areas of physical therapy: cardiopulmonary, musculoskeletal, neuromuscular, and gerontology. Across conditions, PRE was shown to improve the ability to generate force, with moderate to large effect sizes that may carry over into an improved ability to perform daily activities. Further research is needed to determine the potential negative effects of PRE, how to maximize carryover into everyday activities, and what effect, if any, PRE has on societal participation.

A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction

Clinical reports and research studies have documented the behavior of chronic low back and neck pain patients. A few hypotheses have attempted to explain these varied clinical and research findings. A new hypothesis, based upon the concept that subfailure injuries of ligaments (spinal ligaments, disc annulus and facet capsules) may cause chronic back pain due to muscle control dysfunction, is presented. The hypothesis has the following sequential steps. Single trauma or cumulative microtrauma causes subfailure injuries of the ligaments and embedded mechanoreceptors. The injured mechanoreceptors generate corrupted transducer signals, which lead to corrupted muscle response pattern produced by the neuromuscular control unit. Muscle coordination and individual muscle force characteristics, i.e. onset, magnitude, and shut-off, are disrupted. This results in abnormal stresses and strains in the ligaments, mechanoreceptors and muscles, and excessive loading of the facet joints. Due to inherently poor healing of spinal ligaments, accelerated degeneration of disc and facet joints may occur. The abnormal conditions may persist, and, over time, may lead to chronic back pain via inflammation of neural tissues. The hypothesis explains many of the clinical observations and research findings about the back pain patients. The hypothesis may help in a better understanding of chronic low back and neck pain patients, and in improved clinical management.

Exercise therapy for treatment of non-specific low back pain

BACKGROUND

Exercise therapy is widely used as an intervention in low-back pain.

OBJECTIVES

To evaluate the effectiveness of exercise therapy in adult non-specific acute, subacute and chronic low-back pain versus no treatment and other conservative treatments.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (Issue 3, 2004), MEDLINE, EMBASE, PsychInfo, CINAHL databases to October 2004; citation searches and bibliographic reviews of previous systematic reviews.

SELECTION CRITERIA

Randomized controlled trials evaluating exercise therapy for adult non-specific low-back pain and measuring pain, function, return-to-work/absenteeism, and/or global improvement outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short, intermediate, and long-term follow-up.

MAIN RESULTS

Sixty-one randomized controlled trials (6390 participants) met inclusion criteria: acute (11), subacute (6) and chronic (43) low-back pain (1 unclear). Evidence was found of effectiveness in chronic populations relative to comparisons at all follow-up periods; pooled mean improvement was 7.3 points (95% CI, 3.7 to 10.9) for pain (out of 100), 2.5 points (1.0 to 3.9) for function (out of 100) at earliest follow-up. In studies investigating patients (i.e. presenting to healthcare providers) mean improvement was 13.3 points (5.5 to 21.1) for pain, 6.9 (2.2 to 11.7) for function, representing significantly greater improvement over studies where participants included those recruited from a general population (e.g. with advertisements). There is some evidence of effectiveness of graded-activity exercise program in subacute low-back pain in occupational settings, though the evidence for other types of exercise therapy in other populations is inconsistent. There was evidence of equal effectiveness relative to comparisons in acute populations [pain: 0.03 points (95% CI, -1.3 to 1.4)].

LIMITATIONS

This review largely reflects limitations of the literature, including low quality studies with heterogeneous outcome measures, inconsistent and poor reporting, and possibility of publication bias.

AUTHORS' CONCLUSIONS

Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in healthcare populations. In subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.

Patient education in physiotherapy of low back pain: acute outcomes of group instruction

BACKGROUND

Adults with recalcitrant mechanical low back pain of more than six weeks duration can encounter unacceptable waiting periods for specialised care.

AIM

To evaluate the effectiveness of rapid treatment by means of group sessions.

METHODS

We instituted a rapidly accessed patient education programme in physiotherapy for low back pain. Pain and disability were assessed before and after the programme. The programme included four sessions of group instruction for self-actuated physiotherapy There were six to 10 patients per group.

RESULTS

In eight months, 160 patients were admitted to the programme. The average waiting time was 16 business days for the first appointment. Seventy-three per cent of the patients who attended some portion of the programme completed all sessions. At least 30% of the incompletions were ascribable to rapid improvement. Of patients completing the programme, 80% reported significant resolution of the pain and improvement in function. Twenty per cent reported no significant response, but no patients worsened during participation. Of the 20% with no subjective improvement, 50% were pursuing medico-legal claims. In comparison, 9% of those reporting a successful response were pursuing litigation.

CONCLUSIONS

Group instruction in physiotherapy for low back pain is safe, generally successful, and highly acceptable to patients.

Effect of Iyengar yoga therapy for chronic low back pain

Low back pain is a significant public health problem and one of the most commonly reported reasons for the use of Complementary Alternative Medicine. A randomized control trial was conducted in subjects with non-specific chronic low back pain comparing Iyengar yoga therapy to an educational control group. Both programs were 16 weeks long. Subjects were primarily self-referred and screened by primary care physicians for study of inclusion/exclusion criteria. The primary outcome for the study was functional disability. Secondary outcomes including present pain intensity, pain medication usage, pain-related attitudes and behaviors, and spinal range of motion were measured before and after the interventions. Subjects had low back pain for 11.2+/-1.54 years and 48% used pain medication. Overall, subjects presented with less pain and lower functional disability than subjects in other published intervention studies for chronic low back pain. Of the 60 subjects enrolled, 42 (70%) completed the study. Multivariate analyses of outcomes in the categories of medical, functional, psychological and behavioral factors indicated that significant differences between groups existed in functional and medical outcomes but not for the psychological or behavioral outcomes. Univariate analyses of medical and functional outcomes revealed significant reductions in pain intensity (64%), functional disability (77%) and pain medication usage (88%) in the yoga group at the post and 3-month follow-up assessments. These preliminary data indicate that the majority of self-referred persons with mild chronic low back pain will comply to and report improvement on medical and functional pain-related outcomes from Iyengar yoga therapy.

Supplementation of general endurance exercise with stabilisation training versus general exercise only. Physiological and functional outcomes of a randomised controlled trial of patients with recurrent low back pain

BACKGROUND

Determination of the mode of action of new exercise techniques in different back pain populations is lacking. The effectiveness of supplementing an exercise programme with stabilisation exercises concerning physiological and functional parameters in non-specific back pain patients is unknown.

METHODS

Randomised controlled trial, comparing a general trunk muscle endurance exercise approach enhanced with specific muscle stabilisation exercises (S&G group) with a general exercise approach only (G group). 55 patients with recurrent back pain were randomised in S&G group (n=29) and G group (n=26). Both groups received an 8-week exercise intervention and written advice. Paraspinal muscle strength and electromyographic fatigue of the erector spinae and multifidus were measured. Additionally, 3 functional speed tests were assessed. Outcomes were collected pre- and post-intervention.

FINDINGS

No differences were detected for any of the paraspinal fatigue characteristics either within or between groups, apart from a significant decrease in normalised median frequency slope of the erector spinae for the G group. Paraspinal muscle strength and all functional tests have demonstrated significant within-group improvements for both groups, without any between-group differences.

INTERPRETATION

An 8-week stabilisation exercise-enhanced approach presented equal benefits to a general endurance-based exercise programme for patients with recurrent non-specific back pain. A slightly steeper slope for the erector spinae in the G group was the only electromyographic fatigue alteration noted. Concomitant strength improvement probably reflects neural input changes rather than histochemical muscle changes. Physical exercise alone and not the exercise type was the key determinant for improvement in this patient group.

Device-assisted muscle strengthening in the rehabilitation of patients after surgically stabilized vertebral fractures

OBJECTIVES

To investigate the effects of a device-assisted muscle strengthening exercise program on the surgically traumatized multifidus musculature and on the intact longissimus and iliocostal muscles and to assess the possible relationship between patients' reported pain symptoms and changes in muscle strength or changes in cross-sectional area (CSA) of the musculature.

DESIGN

Open, prospective noncontrolled prepost intervention study.

SETTING

University-affiliated center for ambulant physiotherapy.

PARTICIPANTS

Fifteen patients who had undergone dorsal osteosynthesis for treatment of thoracolumbar vertebral fracture and who complained of persistent back pain.

INTERVENTION

Twelve-week device-assisted training exercise program.

MAIN OUTCOME MEASURES

Patients' pain score, muscle strength, and the CSA of the paravertebral musculature determined by magnetic resonance imaging (MRI) were assessed before and after the exercise program.

RESULTS

MRI findings revealed no increase in the CSA of the multifidus muscle in any patient (median change, -.27 cm 2 ). All patients, however, exhibited hypertrophy of both the longissimus and iliocostal muscles (median change, 1.39 cm 2 ). Significant increase in muscle strength was observed in 14 of 16 patients (median increase, 56%; range, 0.7%-126.4%). The median overall pain score improved from 19 (range, 7-24) to 16 (range, 5-27). The change in muscle strength and muscle CSA, however, showed no correlation. There was also no correlation between increase in muscle strength and changes in pain scores.

CONCLUSIONS

The device-assisted training program resulted in hypertrophy of the iliocostal and longissimus muscles and an increase in muscle strength in patients with surgically stabilized vertebral fractures. About half of the patients reported relief of pain. No correlation was found between hypertrophy, increase in muscle strength, and relief of pain. The surgically damaged multifidus musculature, however, did not show any change in CSA and was not accessible to rehabilitative measures.

Long-term effects of supervised physical training in secondary prevention of low back pain

BACKGROUND AND OBJECTIVES

In the last few years, several studies have focused on short-term treatment effects of exercise therapy. However, there is a lack of knowledge concerning the long-term treatment effects recorded after several years. Hence, this study was performed to investigate the short- and long-term effects of supervised physical training on functional ability, self-rated pain and disability in secondary prevention of low back pain.

METHODS

One hundred and eighty-three hospital employees with chronic low back pain were randomly assigned either to back school (comparison group), or three-months supervised physical training including a back school (exercise group). Various measurements of functional ability were performed and subjects completed questionnaires on self-rated pain, disability, and general well-being before treatment, immediately after intervention, and at six-months follow-up. At one-year and at ten-years follow-up participants evaluated treatment effectiveness.

RESULTS

Out of 183 employees, 148 completed the program. Participation at follow-ups ranged from 66 to 96%. Supervised physical training significantly improved muscular endurance and isokinetic strength during a six-months follow-up, and effectively decreased self-rated pain and disability during a one-year follow-up. At ten-years follow-up the subjects' assessment of the effectiveness of treatment was significantly better in the exercise group.

CONCLUSIONS

Supervised physical training effectively improved functional capacity and decreased LBP and disability up to one-year follow-up. The subjects' positive evaluation of the treatment effect at ten-years follow-up suggests a long-term benefit of training.

Rationale and design of a multicenter randomized controlled trial on a 'minimal intervention' in Dutch army personnel with nonspecific low back pain [ISRCTN19334317]

Background

Researchers from the Royal Netherlands Army are studying the potential of isolated lumbar extensor training in low back pain in their working population. Currently, a randomized controlled trial is carried out in five military health centers in The Netherlands and Germany, in which a 10-week program of not more than 2 training sessions (10–15 minutes) per week is studied in soldiers with nonspecific low back pain for more than 4 weeks. The purpose of the study is to investigate the efficacy of this 'minimal intervention program', compared to usual care. Moreover, attempts are made to identify subgroups of different responders to the intervention.

Methods

Besides a baseline measurement, follow-up data are gathered at two short-term intervals (5 and 10 weeks after randomization) and two long-term intervals (6 months and one year after the end of the intervention), respectively. At every test moment, participants fill out a compound questionnaire on a stand-alone PC, and they undergo an isometric back strength measurement on a lower back machine.

Primary outcome measures in this study are: self-assessed degree of complaints and degree of handicap in daily activities due to back pain. In addition, our secondary measurements focus on: fear of movement/(re-) injury, mental and social health perception, individual back extension strength, and satisfaction of the patient with the treatment perceived. Finally, we assess a number of potential prognostic factors: demographic and job characteristics, overall health, the degree of physical activity, and the attitudes and beliefs of the physiotherapist towards chronic low back pain.

Discussion

Although a substantial number of trials have been conducted that included lumbar extension training in low back pain patients, hardly any study has emphasized a minimal intervention approach comparable to ours. For reasons of time efficiency and patient preferences, this minimal sports medicine approach of low back pain management is interesting for the population under study, and possibly for comparable working populations with physical demanding job activities.

The effect of spinal steroid injections for degenerative disc disease

BACKGROUND

No conclusive evidence exists to determine that spinal steroid injections give lasting improvement in patients with predominantly axial low back pain resulting from lumbar degenerative disc disease (DDD).

PURPOSE

The objectives of the study were to determine the effect of epidural steroid injections (ESIs) and intradiscal steroid injections (ISIs) in patients who exhibit DDD symptoms for more than 1 year and to determine whether patients with inflammatory end-plate changes are a unique subgroup of DDD patients in terms of treatment response.

STUDY DESIGN

Pain and function in patients with DDD were prospectively assessed by an outcomes questionnaire before and after various spinal injections. Further correlation was made with end-plate inflammatory (Modic Type 1) changes identified on magnetic resonance imaging (MRI).

PATIENT SAMPLE

ESI was performed in 232 patients who were referred for treatment of DDD, and discography with or without intradiscal steroid was performed in 171 patients who were possible spinal arthrodesis candidates.

OUTCOME MEASURES

Pain and function were determined by a self-administered outcomes questionnaire that consisted of a visual analog pain scale, pain drawing, Oswestry Disability Index, use of pain medication and opinion of treatment success.

METHODS

ESI was performed in 93 patients with DDD and inflammatory end-plate changes and in 139 patients without inflammatory end-plate changes. Patients with inflammatory end-plate changes (n=78) or without inflammatory end-plate changes (n=93), all of whom were considered fusion candidates, underwent discography with or without intradiscal steroid in a randomized fashion. Pain and function were prospectively determined by a self-administered outcomes survey (VAS pain, Oswestry Disability index [ODI], pain diagram [PD] and opinion of success) before and after the patients' injection for a 2-year follow-up period. MRI and discography results were correlated with patient outcomes scores.

RESULTS

ESI was effective in improving pain and function, as assessed by outcomes scores at short-term follow-up. However, at 2 years, less than one-third had not had additional invasive treatment. Patients with inflammatory end-plate changes had greater improvement in ODI and PD scores in the first 6 months than did those patients without the end-plate changes. Intradiscal steroid injections into discs with concordant pain at the time of discography led to significant improvement in patients with inflammatory end-plate changes in all outcomes scales, but only minimal temporary improvement in patients without the end-plate changes. Disc pressure manometry at the time of discography found that discs with adjacent inflammatory end-plate changes reproduced symptoms at pressures significantly lower than those in other types of discs.

CONCLUSIONS

Spinal steroid injections, both ESI and ISI, are beneficial for a small number of patients with advanced DDD and chronic low back pain. For those patients in whom a beneficial effect is found, spinal steroid injection is a low-risk and rapid treatment option. Spinal steroid injections are more effective in patients with MRI findings of discogenic inflammation, specifically adjacent inflammatory end-plate changes.

Activation of lumbar paraspinal and abdominal muscles during therapeutic exercises in chronic low back pain patients11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To assess the activities of paraspinal and abdominal muscles during therapeutic exercises for the treatment of patients with nonspecific chronic low back pain (CLBP), and to study the effects of active physical rehabilitation on these activities.

DESIGN

A cross-sectional study comparing muscle activities during 18 stabilization exercises, and a prospective follow-up of patients with CLBP during rehabilitation.

SETTING

Rehabilitation clinic in university hospital in Finland.

PARTICIPANTS

Nine volunteers (5 men, 4 women) aged 27 to 58 years.

INTERVENTION

Three months of active outpatient rehabilitation (4 to 6 times in a rehabilitation clinic, supplemented with self-motivated exercise at home) supervised by a physiotherapist.

MAIN OUTCOME MEASURES

Surface electromyography was recorded bilaterally from L5 level paraspinal, rectus abdominis, and obliquus externus abdominis muscles. The recorded signal was averaged and normalized to the maximal electromyographic amplitude obtained during the maximal voluntary contraction. The measurements were taken before and after the exercise treatment period.

RESULTS

CLBP patients showed variable trunk muscle activity patterns during the different therapeutic exercises, similar to those that we reported earlier in healthy subjects. The maximal trunk isometric extension (pre, 147.3+/-75.9Nm; post, 170.1+/-72.3Nm) and flexion (pre, 72.0+/-37.9Nm; post, 93.5+/-42.5Nm) torques did not show a significant changes during the exercise period. However, trunk rotation-flexion torque (pre, 52.9+/-26.5Nm; post, 82.4+/-65.8Nm) increased significantly (35.8%) after the exercise period (P<.05). The corresponding maximal electromyographic amplitudes of back and abdominal muscles remained unchanged. Disability, as assessed by visual analog scale and Oswestry Disability Index, did not change.

CONCLUSIONS

The CLBP patients performed therapeutic exercises with similar abdominal and back extensor muscle activities in the same way as the healthy subjects in our earlier studies. In this study, active physical rehabilitation had no effect on the abdominal and back muscle activities or on pain and functional disability indices.

The preoperative and postoperative assessment and care of patients with back pain

Changing health care regulations and funding have led healthcare providers to develop new ways of providing care for patients who have back pain, while consuming fewer hospital resources. As no consensus exists for a transcendent model of preoperative and postoperative assessment and care, clinicians must define their objectives clearly for effective patient care. These include, but are not limited to, acquiring pertinent medical information, consultations, and laboratory testing necessary to assess perioperative risk; optimizing the patient's condition and developing an appropriate perioperative care plan; and educating the patient about intraoperative care and postoperative management to reduce preoperative anxiety. Clinical circumstances and specific tests for patients who have back pain meet the criteria for good screening opportunities and should be used effectively for pre- and postoperative care.

Chronic low back pain-associated paraspinal muscle dysfunction is not the result of a constitutionally determined "adverse" fiber-type composition

STUDY DESIGN

Investigative case control study.

OBJECTIVES

To determine whether excessive paraspinal muscle fatigue in chronic low back pain results from a paucity of muscle type I fiber content.

SUMMARY OF BACKGROUND DATA

Paraspinal muscle function is vital for spinal protection. Prospective studies suggest that excessive paraspinal muscle fatigability may increase risk of first-time low back pain. As contractile performance of the paraspinal muscles is governed by their constitutionally determined fiber composition, the question arises whether a constitutionally determined "adverse" composition could predispose to low back pain through impaired spinal protection.

METHODS

Thirty-five male patients with chronic low back pain were compared with 32 male control patients of similar age and anthropometry. During Sorensen and 60% of maximum voluntary isometric contraction fatigue tests, median frequency declines in the paraspinal muscle surface electromyograph signal were monitored and correlated with muscle histomorphometry.

RESULTS

Patients were weaker than controls during maximum voluntary isometric contractions (84.47 [28.44]vs. 98.74 [18.11] kg, respectively; P = 0.02) and more fatigable during their Sorensen tests (endurance time 105.29 [28.53]vs. 137.50 [40.38] sec, respectively; P < 0.01). There were no between-group differences in median frequency declines during the Sorensen (-0.37 [0.16]vs. -0.36 [0.12]%.sec) or 60% maximum voluntary isometric contraction (-0.42 [0.31]vs. -0.51 [0.29]%.sec) tests, for patients and controls, respectively. There were no between-group differences in the percent number of paraspinal muscle type I fibers (64 [11]vs. 64 [9]%) or the percent area occupied by type I fibers (67 [11]vs. 69 [9]%), for patients and controls, respectively. Type I and II muscle fiber narrow diameters were similar for both groups.

CONCLUSION

In the patients with chronic low back pain tested, their associated paraspinal muscle dysfunction was not the result of a constitutionally determined "adverse" fiber type composition.

The influence of intense exercise-based physical therapy program on back pain anticipated before and induced by physical activities

BACKGROUND CONTEXT

Pain anticipated before and induced by physical activities has been shown to influence the physical performance of patients with chronic back pain. Limited data exist as to the influence of treatment on this component of pain.

PURPOSE

This study attempted to determine if pain anticipated before and induced by physical activities was altered during an exercise-oriented physical therapy program for chronic back pain.

STUDY DESIGN/SETTING

Subjects were recruited from three physical therapy sites with similar spine rehabilitation programs that used intense exercise delivered in a group format. During the recruitment period, 70 subjects with chronic low back pain and disability agreed to participate and complied with recommended treatments. The primary outcome measures were anticipated and induced pain as assessed by visual analog scales (VAS) during six tests of back flexibility and strength. Additional outcome measures included the performance levels of these six tests (trunk flexion, extension, straight leg raising, back strength, lifting from floor to waist and waist to shoulder height), global back and leg VAS and Oswestry Low Back Pain Disability Questionnaire scores.

METHODS

At evaluation for the spine rehabilitation programs, we recorded the anticipated and induced pain levels associated with the six tests of back function, the performance levels on each test and global pain and disability scores. Subjects then participated in the spine rehabilitation program that consisted of intense exercise delivered up to three times per week, for 2 hours over a period of 6 weeks. All outcome measures were reassessed at discharge. Pre- and posttreatment outcome scores were statistically compared using paired sample t tests and chi-squared test. Spearman correlation coefficients were used to compare anticipated and induced pain results with global back and leg pain VAS scores, Oswestry scores and physical performance levels for each physical test.

RESULTS

Most measures of anticipated and induced pain improved between evaluation and discharge. Improvements were noted for global back pain (p<.001), leg pain (p=.001), disability (p<.001) and performance on each physical testing (p<.001) after treatment. Performances on all physical testing correlated with anticipated and induced pain for all tests at evaluation but only for measures of flexibility at discharge. Improvements in global pain and disability correlated with improvements in anticipated and induced pain with physical testing.

CONCLUSION

Anticipated and induced pain with physical activities was lessened after physical therapy using exercise. Anticipated and induced pain with physical activities related to physical performance levels, global pain and disability ratings. These findings may help explain how exercise exerts a positive influence on chronic back pain and disability.

Assessment of lumbar spine kinematics using dynamic MRI: a proposed mechanism of sagittal plane motion induced by manual posterior-to-anterior mobilization

STUDY DESIGN

Descriptive study.

OBJECTIVE

The purpose of this study was to describe the segmental motion of the lumbar spine during a posterior-to-anterior (PA) mobilization procedure using dynamic magnetic resonance imaging and to propose a mechanism of the lumbar spine's motion as a result of a PA force to a lumbar spinous process.

BACKGROUND

Studies reporting kinematic descriptions of PA mobilization are in agreement that motion takes place at all lumbar vertebrae. However, these studies differ in the reported direction of motion.

METHODS AND MEASURES

Twenty asymptomatic subjects (mean age +/- SD, 31.1 +/- 7.0 years) participated in this study. For each subject, a PA mobilization force was manually applied at each lumbar spinous process while sagittal plane magnetic resonance images were simultaneously obtained. Intervertebral motion was defined as the change in the intervertebral angle between the resting and end range vertebral positions imparted by the PA pressure.

RESULTS

PA force applied at 1 spinous process caused motion at the target vertebra and this motion was propagated caudally and cranially. Motion at the target segment was always into extension.

CONCLUSIONS

A PA force applied at a single lumbar spinous process caused motion of the entire lumbar region. The magnitude and direction of intervertebral motions varied with the segment at which the PA force was applied. We postulated that the intervertebral motion induced by a PA force on a spinous process could be in part explained by the morphology of the lumbar spine.

Effective physical treatment for chronic low back pain

It is now feasible to adopt an evidence-based approach when providing physical treatment for patients with chronic LBP. A summary of the efficacy of a range of physical treatments is provided in Table 1. The evidence-based primary care options are exercise, laser, massage, and spinal manipulation; however, the latter three have small or transient effects that limit their value as therapies for chronic LBP. In contrast, exercise produces large reductions in pain and disability, a feature that suggests that exercise should play a major role in the management of chronic LBP. Physical treatments, such as acupuncture, backschool, hydrotherapy, lumbar supports, magnets, TENS, traction, ultrasound, Pilates therapy, Feldenkrais therapy, Alexander technique, and craniosacral therapy are either of unknown value or ineffective and so should not be considered. Outside of primary care, multidisciplinary treatment or functional restoration is effective; however, the high cost probably means that these programs should be reserved for patients who do not respond to cheaper treatment options for chronic LBP. Although there are now effective treatment options for chronic LBP, it needs to be acknowledged that the problem of chronic LBP is far from solved. Though treatments can provide marked improvements in the patient's condition, the available evidence suggests that the typical chronic LBP patient is left with some residual pain and disability. Developing new, more powerful treatments and refining the current group of known effective treatments is the challenge for the future.

Exercise as a treatment for chronic low back pain

BACKGROUND CONTEXT

Exercise is a widely prescribed treatment for chronic low back pain, with demonstrated effectiveness for improving function and work.

PURPOSE

The goal of this article is to review several key aspects about the safety and efficacy of exercise that may help clinicians understand its utility in treating chronic back pain.

STUDY DESIGN/SETTING

A computerized literature search of MEDLINE was conducted using "exercise," "fitness," "back pain," "backache" and "rehabilitation" as search words. Identified abstracts were scanned, and useful articles were acquired for further review. Additional references were acquired through the personal collections of research papers possessed by the authors and by reviewing prior review articles on this subject. These final papers were scrutinized for data relevant to the key aspects about exercise covered in this article.

RESULTS

For people with acute, subacute or chronic low back pain, there is no evidence that exercise increases the risk of additional back problems or work disability. To the contrary, current medical literature suggests that exercise has either a neutral effect or may slightly reduce risk of future back injuries. Exercise can be prescribed for patients with chronic low back pain with three distinct goals. The first and most obvious goal is to improve or eliminate impairments in back flexibility and strength, and improve performance of endurance activities. There is a large body of evidence confirming that this goal can be accomplished for a majority of patients with chronic low back pain. The second goal of exercise is to reduce the intensity of back pain. Most studies of exercise have noted overall reduction in back pain intensity that ranges from 10% to 50% after exercise treatment. The third goal of exercise is to reduce back pain-related disability through a process of desensitization of fears and concerns, altering pain attitudes and beliefs and improving affect. The mechanisms through which exercise can accomplish this goal have been the subject of substantial research.

CONCLUSIONS

Exercise is safe for individuals with back pain, because it does not increase the risk of future back injuries or work absence. Substantial evidence exists supporting the use of exercise as a therapeutic tool to improve impairments in back flexibility and strength. Most studies have observed improvements in global pain ratings after exercise programs, and many have observed that exercise can lessen the behavioral, cognitive, affect and disability aspects of back pain syndromes.

Lumbar muscle fatigue and recovery in patients with long-term low-back trouble--electromyography and health-related factors

OBJECTIVE

The aim was to explore the validity and reliability of EMG for assessing lumbar muscle fatigue.

DESIGN

Patients with long-term low-back trouble (n=57) were compared to a healthy reference group (n=55). Back muscle fatigue and recovery were studied in relation to health-related factors.

BACKGROUND

EMG spectral variables are important tools in the assessment of patients with low-back trouble. The influence of disability on these variables needs further investigation.

METHODS

EMG from the lower back muscles was recorded during a 45 s trunk extension at 80% of maximal voluntary contraction torque and during recovery. Disability was studied using questionnaires.

RESULTS

The reliability was high for maximal voluntary contraction torque and EMG initial median frequency, lower for the median frequency slope, and insufficient for median frequency recovery half-time. The patients had lower maximal voluntary contraction torque, higher initial median frequency at L5 level, flatter slope, and longer recovery half-time than the healthy subjects did. However, for subjects with significantly negative slope, indicating fatigue, there was no significant difference in slope between patients and healthy subjects, while, for subjects without such fatigue, patients showed significantly flatter slopes at L5. The sensitivity/specificity of the test was 86%/78%. The most significant variables selected with logistic regression were maximal voluntary contraction torque and initial median frequency at L5. Patients without significantly negative slopes during contraction and/or not exponential-like EMG recovery scored worse on several items concerning disability and self-efficacy.

CONCLUSIONS

EMG spectral variables in combination with torque might be used for classification. For patients with long-term low-back trouble, the ability to fatigue the lumbar muscles sufficiently to obtain a significantly negative slope during an 80% maximal voluntary contraction may be a sign of better functioning.

RELEVANCE

The ability to fatigue the back muscles during a test requiring a high force output might be achieved with back muscle training focused on increasing strength and self-efficacy.

[Rehabilitation treatment in lumbar canal stenosis. Intermediate results of a prospective study (Télemar)]

STUDY DESIGN

Lumbar spine stenosis is a common cause of lower back pain and lower extremity pain especially in people over 60-years-old. Treatment can be surgical or non-surgical. The efficacy of these treatments remains unclear. The purpose of this study was to assess the result of a medical management in a prospective study. Preliminary results are presented.

PATIENTS AND METHODS

Patients following the clinical and the radiological criteria of inclusion were included in the study. Pain was assessed by visual analogic scale (VAS) and Oswestry scale. Sixty patients meeting inclusion criteria underwent non-surgical intervention including therapeutic exercises and 2 epidural injections. Patients were followed up at 3 and 6 months.

RESULTS

The main score on VAS was 5.2 for lumbar pain, 5.8 for radicular pain and 21/50 on the Oswestry scale. Three months later an improvement was noticed in 12 cases. Thirty-seven patients remained unchanged and surgery was decided for 11 patients. At 6 months an improvement was reported by 47% of the patients who have been managed by conservative treatment. No predictive factor except VAS was noticed.

DISCUSSION

Our results are inferior to those previously reported. Most of previous studies are retrospective and criteria of assessment are not based on functional scale as we done. The fact that the treatment management was ambulatory without supervision is probably the main explanation.

CONCLUSION

Conservative treatment for spinal lumbar stenosis remains a reasonable option.

Musculoskeletal fitness: the keystone in overall well-being and injury prevention

Musculoskeletal fitness is an important and inadequately appreciated component of overall health and well-being. Wellness as it applies to strength and conditioning has numerous benefits. It allows maintenance of functional independence for longer periods in older adults. It impacts the metabolic capabilities of children and adults affecting the ability to maintain an ideal body weight. It has been shown to influence the prevalence and possibly the prevention of many musculoskeletal disorders such as muscle sprains, low back pain, osteoarthritis, osteoporosis, shoulder instability, and knee stability and pain. The current author summarizes the most recent recommendations for achievement and maintenance of musculoskeletal fitness for children and adults.

Paraspinal muscle denervation, paradoxically good lumbar endurance, and an abnormal flexion-extension cycle in lumbar spinal stenosis

STUDY DESIGN

A descriptive study was conducted to investigate the paraspinal muscle function in patients with lumbar spinal stenosis.

OBJECTIVE

To evaluate paraspinal muscle innervation and endurance in lumbar spinal stenosis.

SUMMARY OF BACKGROUND DATA

Abnormal lumbar paraspinal muscle function is associated with chronic low back pain. Abnormal neurophysiologic findings of the lower limbs often are observed in lumbar spinal stenosis, and abnormal lumbar function also can be expected. However, paraspinal muscle function and innervation have not been studied in lumbar spinal stenosis.

METHODS

The study evaluated 25 patients with clinically and radiologically diagnosed lumbar spinal stenosis. Electromyography of the paraspinal muscles was performed from L3 to S1 bilaterally using a concentric needle. At least 20 insertions were analyzed from each muscle. The aim of the examination was to detect abnormal spontaneous activity associated with axonal damage (fibrillation potentials, positive sharp waves, and complex repetitive discharges). Paraspinal muscle activity during trunk flexion-extension movement and muscle endurance during the dynamic isoinertial back endurance test were assessed by surface electromyography. Muscle fatigue was calculated using mean power frequency analysis.

RESULTS

Abnormal findings in needle electromyography of the paraspinal muscles were observed in 18 of the 22 (81.8%) examined patients. Abnormal flexion-extension activation of the paraspinal muscles was observed in all the examined patients. The change in mean power frequency was significantly smaller than in previously evaluated healthy subjects and patients with nonspecific chronic low back pain (P < 0.001) who were not experiencing symptoms of lumbar spinal stenosis. Paraspinal muscle fatigability was not associated with the denervation of the muscles. CONCLUSIONS Denervation and abnormal activation of lumbar paraspinal muscles are frequent findings in patients with lumbar spinal stenosis who have not undergone surgery. The paraspinal muscle endurance of the patients was unexpectedly good.

The effect of massage on localized lumbar muscle fatigue

BACKGROUND

There is not enough evidence to support the efficacy of massage for muscle fatigue despite wide utilization of the modality in various clinical settings. This study investigated the influence of massage application on localized back muscle fatigue.

METHODS

Twenty-nine healthy subjects participated in two experimental sessions (massage and rest conditions). On each test day, subjects were asked to lie in the prone position on a treatment table and perform sustained back extension for 90 seconds. Subjects then either received massage on the lumbar region or rested for a 5 minute duration, then repeated the back extension movement. The median frequency (MDF), mean power frequency (MNF), and root mean square (RMS) amplitude of electromyographic signals during the 90 second sustained lumbar muscle contraction were analyzed. The subjective feeling of fatigue was then evaluated using the Visual Analogue Scale (VAS).

RESULTS

MDF and MNF significantly declined with time under all conditions. There was no significant difference in MDF, MNF or RMS value change between before and after massage, or between rest and massage conditions. There was a significant increase in fatigue VAS at the end of the 2nd back extension with rest condition. There was a significant difference in fatigue VAS change between massage and rest condition.

CONCLUSIONS

A significant difference was observed between massage and rest condition on VAS for muscle fatigue. On EMG analysis, there were no significant differences to conclude that massage stimulation influenced the myoelectrical muscle fatigue, which is associated with metabolic and electrical changes.

Massage for low-back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group

BACKGROUND

Low back pain (LBP) is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability and speed return-to-normal function.

OBJECTIVES

To assess the effects of massage therapy for nonspecific LBP.

SEARCH STRATEGY

We searched MEDLINE, Embase, Cochrane Controlled Trials Register, HealthSTAR, CINAHL, and dissertation abstracts through May 2001 with no language restrictions. References in the included studies and in reviews of the literature were screened. Contact with content experts and massage associations was also made.

SELECTION CRITERIA

The studies had to be randomized or quasirandomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific LBP.

DATA COLLECTION AND ANALYSIS

Two reviewers blinded to authors, journals, and institutions selected the studies, assessed the methodologic quality using the criteria recommended by the Cochrane Collaboration Back Review Group, and extracted the data using standardized forms. The studies were analyzed in a qualitative way because of heterogeneity of population, massage technique, comparison groups, timing, and type of outcome measured.

RESULTS

Nine publications reporting on eight randomized trials were included. Three had low and five had high methodologic quality scores. One study was published in German, and the rest, in English. Massage was compared with an inert treatment (sham laser) in one study that showed that massage was superior, especially if given in combination with exercises and education. In the other seven studies, massage was compared with different active treatments. They showed that massage was inferior to manipulation and transcutaneous electrical nerve stimulation; massage was equal to corsets and exercises; and massage was superior to relaxation therapy, acupuncture, and self-care education. The beneficial effects of massage in patients with chronic LBP lasted at least 1 year after the end of the treatment. One study comparing two different techniques of massage concluded in favor of acupuncture massage over classic (Swedish) massage.

CONCLUSIONS

Massage might be beneficial for patients with subacute and chronic nonspecific LBP, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this needs confirmation. More studies are needed to confirm these conclusions, to assess the effect of massage on return-to-work, and to measure longer term effects to determine cost-effectiveness of massage as an intervention for LBP.

Contribution of individual spa therapies in the treatment of chronic pain

OBJECTIVES

The aim of the present study was to evaluate the contribution of individual spa therapies administered during a period of 3 weeks on measures of well being and pain in a sample of patients with chronic back pain.

DESIGN

One hundred fifty-three patients with chronic back pain undergoing inpatient spa therapy in Bad Tatzmannsdorf, Austria, participated in the study. According to the prescription of their spa physician, patients underwent two or more of the following treatments: mud packs, carbon dioxide baths, massages, exercise therapies, spinal traction, and electrotherapy. The outcome measures were general pain, back pain, negative mood, and health satisfaction. Regression analyses were conducted to predict the 4 outcome measures at the end of spa therapy and at 6 weeks' follow-up for all therapies applied. The pretreatment outcome measure, age, and sex were controlled for by entering them into the analysis.

RESULTS

Patients showed significant improvements in all 4 outcome measures. The prediction of improvement was generally small: only 1% to 11% of the change of the outcome measures could be explained by the type and number of therapies received. On a short-term basis, mud packs and exercise were found to be associated with a greater improvement in mood, whereas a greater frequency of massage therapy and carbon dioxide baths was associated with a smaller improvement in health satisfaction. On a long-term basis, exercise therapy and spinal traction were associated with a greater reduction in back pain.

CONCLUSIONS

The results indicate that, in addition to the individual therapies, other factors relating to spa therapy as a whole must contribute to overall treatment outcome. In addition, the results support the efficacy of exercise therapy for chronic back pain.

Activation of paraspinal and abdominal muscles during manually assisted and nonassisted therapeutic exercise

OBJECTIVE

To assess the activities of the paraspinal and abdominal muscles during manually assisted therapeutic exercises (MATEs) and nonassisted therapeutic exercises (NATEs) that are used in the initial phases of the progressive exercise programs designed for the treatment of low back pain.

DESIGN

Thirteen healthy subjects volunteered in the study. Surface electromyography (EMG) was recorded. The recorded EMG signal was averaged and normalized to the maximal EMG amplitude obtained during the maximal voluntary contraction (%EMGmax).

RESULTS

In general, the %EMGmax values were higher during NATEs than during MATEs. Sitting seemed to activate lumbar L5 level paraspinal muscles to the same extent as MATEs.

CONCLUSION

MATEs require only minimal trunk muscle activities, and thus, they may not be sufficiently intense to improve the trunk muscle performance. NATEs require high trunk muscle activities that are adequate for improving the trunk muscle performance, but they may cause high compressive loading of the lumbar spine, and if unchecked, this can aggravate low back pain.

Interexaminer reliability of low back pain assessment using the McKenzie method

STUDY DESIGN

A test-retest design was used.

OBJECTIVE

To assess interexaminer reliability of the McKenzie method for performing clinical tests and classifying patients with low back pain.

SUMMARY OF BACKGROUND DATA

Clinical methods and tests classifying patients with nonspecific low back pain have been based mainly on symptom duration or extent of pain referral. The McKenzie mechanical diagnostic and classification approach is a widely used noninvasive, low-technology method of assessing patients with low back pain. However, little is known about the interexaminer reliability of the method, previous studies having yielded conflicting results.

METHODS

For this study, 39 volunteers with low back pain, mean age 40 years (range, 24-55 years), were blindly assessed by two physical therapists trained in the McKenzie method. The variability of two examiners for binary decisions was expressed by the kappa coefficient, and by the proportion of observed agreement, as calculated from a 2 x 2 contingency table of concordance.

RESULTS

On the basis of pure observation alone, agreement among clinical tests on the presence and direction of lateral shift was 77% (kappa = 0.2; P < 0.248) and 79% (kappa = 0.4; P < 0.003), respectively. Agreement on the relevance of lateral shift and the lateral component according to symptom responses was 85% (kappa = 0.7; P < 0.000) and 92% (kappa= 0.4; P < 0.021), respectively. Using the repeated movements and static end-range loading strategy to define the centralization phenomenon and directional preference, agreement was 95% (kappa = 0.7; P < 0.002) and 90% (kappa = 0.9; P < 0.000), respectively. When patients with low back pain were classified into the McKenzie main syndromes and into specific subgroups, agreement was 95% (kappa = 0.6; P < 0.000) and 74% (kappa = 0.7; P < 0.000), respectively.

CONCLUSIONS

Interexaminer reliability of the McKenzie lumbar spine assessment in performing clinical tests and classifying patients with low back pain into syndromes were good and statistically significant when the examiners had been trained in the McKenzie method.

Massage for low back pain

BACKGROUND

Low-back pain is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function.

OBJECTIVES

To assess the effects of massage therapy for non-specific low-back pain.

SEARCH STRATEGY

We searched Medline, Embase, Cochrane Controlled Trials Register, HealthSTAR, CINAHL and Dissertation abstracts from their beginning to May 2001 with no language restrictions. References in the included studies and in reviews of the literature were screened. Contact with content experts and massage associations was also made.

SELECTION CRITERIA

The studies had to be randomized or quasi-randomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for non-specific low-back pain.

DATA COLLECTION AND ANALYSIS

Two reviewers blinded to authors, journal and institutions selected the studies, assessed the methodological quality using the criteria recommended by the Cochrane Back Review Group, and extracted the data using standardized forms. The studies were analysed in a qualitative way due to heterogeneity of population, massage technique, comparison groups, timing and type of outcome measured.

MAIN RESULTS

Nine publications reporting on eight randomized trials were included. Three had low and five had high methodological quality scores. One study was published in German and the rest in English. Massage was compared to an inert treatment (sham laser) in one study that showed that massage was superior, especially if given in combination with exercises and education. In the other seven studies, massage was compared to different active treatments. They showed that massage was inferior to manipulation and TENS; massage was equal to corsets and exercises; and massage was superior to relaxation therapy, acupuncture and self-care education. The beneficial effects of massage in patients with chronic low-back pain lasted at least one year after the end of the treatment. One study comparing two different techniques of massage concluded in favour of acupuncture massage over classic (Swedish) massage.

REVIEWER'S CONCLUSIONS

Massage might be beneficial for patients with subacute and chronic non-specific low-back pain, especially when combined with exercises and education. The evidence suggest that acupuncture massage is more effective than classic massage, but this need confirmation. More studies are needed to confirm these conclusions and to assess the impact of massage on return-to-work, and to measure longer term effects to determine cost-effectiveness of massage as an intervention for low-back pain.

Working with low back pain: workplace and individual psychosocial determinants of limited duty and lost time

BACKGROUND

Few studies have identified the risk factors associated with lost time in employees working with occupational low back pain (OLBP) despite the presence of pain. Such data could assist in the development of evidenced-based secondary prevention programs.

METHODS

The present investigation was a case-control study (n = 421) of demographic, health behavior, ergonomic, workplace and individual psychosocial factors hypothesized to be associated with lost time in young, full-time employees (i.e., soldiers) with OLBP. Analyses of the burden of OLBP in terms of the number of days on limited duty and lost time status were also computed.

RESULTS

Logistic regression analysis indicated that female gender, education beyond HS/GED, longer time working in military, higher levels of daily life worries, no support from others, higher levels of ergonomic exposure, stressful work, increased peer cohesion, and greater perceived effort at work placed a worker at a greater likelihood for OLBP-related lost work time. Lower levels of innovation, involvement, and supervisor support were also associated with lost time. Linear regression indicated that the number of days of lost time and limited duty was associated with lower levels of physical health and higher levels of symptom severity.

CONCLUSIONS

The results support the potential utility of interventions targeting ergonomic, workplace and individual psychosocial risk factors in secondary prevention.

Back and abdominal muscle function during stabilization exercises

OBJECTIVES

To assess the paraspinal and abdominal muscle activities during different therapeutic exercises and to study how load increment produced by varying limb movements and trunk positions could affect these muscle activities.

DESIGN

A cross-sectional study comparing muscle activities between men and women.

SETTING

Rehabilitation clinic in university hospital.

PARTICIPANTS

Twenty-four healthy volunteers (14 women, 10 men) aged 21 to 39 years.

INTERVENTIONS

Subjects performed 16 different therapeutic exercises commonly used to treat low back pain.

MAIN OUTCOME MEASURES

Surface electromyography was recorded from the paraspinal (T9, L5) and abdominal (rectus abdominis, obliquus externus) muscles during these exercises. Average electromyographic amplitudes obtained during the exercises were normalized to the amplitude in maximal voluntary contraction (% MVC) to produce interindividually comparable muscle activity assessments.

RESULTS

Mean average normalized electromyographic amplitudes (% MVC) of the exercises were below 50% MVC. At L5 level, the multifidus muscle activities were significantly higher (p <.05) in women than in men, whereas no significant difference was found at T9 level. Similarly, rectus abdominis and obliquus externus activities were significantly higher (p <.001, p <.05) in women than in men. Load increment in hands or unbalanced trunk and limb movements produced higher paraspinal and abdominal muscle activities (p <.05).

CONCLUSIONS

Simple therapeutic exercises are effective in activating both abdominal and paraspinal muscles. By changing limb and trunk positions or unbalancing trunk movements, it is possible to increase trunk muscle activities. Women were better able to activate their stabilizing trunk muscles than men; but it is also possible that men, having a much higher degree of strength on maximal contraction, only need to activate a smaller amount of that maximum to perform a similar activity.

Comparison of three active therapies for chronic low back pain: results of a randomized clinical trial with one-year follow-up

OBJECTIVES

To examine the relative efficacy of three active therapies for patients with chronic low back pain.

METHODS

One hundred and forty-eight subjects with chronic low back pain were randomized to receive, twice weekly for 3 months, (i) active physiotherapy, (ii) muscle reconditioning on training devices, or (ii) low-impact aerobics. Questionnaires were administered to assess pain intensity, pain frequency and disability before and after therapy and at 6 and 12 months of follow-up.

RESULTS

One hundred and thirty-two of the 148 patients (89%) completed the therapy programmes and 127 of the 148 (86%) returned a questionnaire at all four time-points. The three treatments were equally efficacious in significantly reducing pain intensity and frequency for up to 1 yr after therapy. However, the groups differed with respect to the temporal changes in self-rated disability over the study period (P=0.03): all groups showed a similar reduction after therapy, but for the physiotherapy group disability increased again during the first 6 months of follow-up whilst the other two groups showed a further decline. In all groups the values then remained stable up to the 12-month follow-up. The larger group size and minimal infrastructure required for low-impact aerobics rendered it considerably less expensive to administer than the other two programmes.

CONCLUSIONS

The introduction of low-impact aerobic exercise programmes for patients with chronic low back pain may reduce the enormous costs associated with its treatment.

Dose-response of physical activity and low back pain, osteoarthritis, and osteoporosis

PURPOSE

The purpose of this study was to examine the evidence for causal relationships between physical activity (PA) and low back pain (LBP), osteoarthritis (OA), and osteoporosis (OP), and for dose-response relations involved.

METHODS

Computer database searches and personal retrieval systems were used to locate relevant literature.

RESULTS

PA can be effective in preventing LBP (Category A) but prolonged, heavy loading can lead to LBP (Category C). Specific exercises have not been found effective in treatment of acute LBP (Category A), but PA can be effective in chronic LBP (Category B), especially for diminishing the effects of deconditioning. No evidence indicates that PA directly prevents OA. Large amounts of intensive PA involving high impacts or torsional loadings or causing injuries increases risk of OA (Category C). Light or moderate PA does not increase the risk of OA (Category C). PA can be effective in the treatment and rehabilitation of OA (Category B). High-intensity loading is osteogenic and possibly useful in prevention of OP (Category A) at the loaded site, but low to moderate loading is not osteogenic (Category D). Static efforts and slow movements are ineffective or less effective than fast application of force (Category B). The types of PA to attain the effects mentioned above are known except in the case of prevention of LBP, but dose-response relationships are poorly known; at best, semiquantitatively on the basis of just a few studies.

CONCLUSION

Given the shown primary and/or secondary preventative effectiveness of PA regarding LBP, OA, and OP, research to elucidate the inadequately known dose-response relations should be given high priority.

Intermittent isometric fatigue study of the lumbar multifidus muscle in four-point kneeling: an intra-rater reliability investigation

Back muscle endurance is considered important in low back pain (LBP) rehabilitation. Specific training of multifidus may also be necessary to restore normal low back function. The reliability of surface electromyogram (EMG) to assess endurance of the multifidus muscle during intermittent isometric exercise was evaluated. Multifidus endurance was monitored in the four-point kneeling exercise position using the power spectral analysis method. Twenty healthy volunteers were tested on three separate occasions. Subjects performed repeat 10 s high-intensity voluntary contractions of multifidus for 3 min. The median frequency (MF) and the integrated-rectified (I-R) EMG signal displayed the fatigue pattern of multifidus. Intraclass correlation coefficients indicated fair-good reproducibility for MF (0.48-0.67) but poor reliability for IR-EMG. In conclusion, problems concerning functional testing protocols for the back muscles remain and careful development is necessary for more realistic rehabilitation monitoring.

Active therapy for chronic low back pain: part 2. Effects on paraspinal muscle cross-sectional area, fiber type size, and distribution

DESIGN

Randomized prospective study to compare the effects of three types of active therapy on the back muscle structure of chronic low back pain patients.

OBJECTIVES

To analyze the effects of 3 months active therapy on gross back muscle size and muscle fiber type characteristics and their relationship to changes in muscle function.

SUMMARY OF BACKGROUND DATA

Many studies have documented a diminished muscular performance capacity in cLBP patients, but few have supported this with evidence of alterations in either the macro- or microscopic structure of the paraspinal muscles. Investigations of the changes in muscle structure following active rehabilitation are even rarer.

METHODS

Assessments of trunk muscle cross-sectional area (using MRI), erector spinae fiber size/type distribution and pathology (percutaneous biopsy), and muscle function (see Part 1) were made in a group of 59 individuals with cLBP, who were participating in a randomized trial of active therapies for cLBP (physiotherapy, muscle training on devices, aerobics).

RESULTS

Fifty-three out of 59 patients (90%) completed the therapy. At baseline, significant correlations were observed between the size of the paraspinal muscles and isometric back extension strength (P=0.0001), and between the proportional area of the muscle occupied by each fiber type and the fatigability of the muscle (P=0.012). Following therapy, there were small (few percent) increases in trunk muscle size in the aerobics and physiotherapy groups and a similarly slight decrease in the devices group. Changes in erector spine size correlated only weakly and nonsignificantly with changes in back extension strength. There were no major changes in fiber type proportion or fiber size in any group following therapy.

CONCLUSION

Three months active therapy is not sufficient to reverse the typical "glycolytic" profile of the muscles of cLBP patients or to effect major changes in backmuscle size. The alterations in muscle performance observed (increased strength and endurance; Part 1) werenot explainable on the basis of structural changes within the muscle.

Active therapy for chronic low back pain part 1. Effects on back muscle activation, fatigability, and strength

DESIGN

Randomized prospective study of the effects of three types of active therapy on back muscle function in chronic low back pain patients.

OBJECTIVES

To quantify the effects of 3 months active therapy on strength, endurance, activation, and fatigability of the back entensor muscles.

SUMMARY OF BACKGROUND DATA

Many studies have documented an association between chronic low back pain and diminished muscular performance capacity. Few studies have quantified the changes in these measures following interventions using objective measurement techniques or related them to changes in clinical outcome.

METHODS

A total of 148 individuals (57% women) with chronic low back pain (age, 45.0 +/- 10.0 years; duration of low back pain, 10.9 +/- 9.5 years) were randomized to a treatment that they attended for 3 months: active physiotherapy, muscle reconditioning on devices, or low-impact aerobics. Before and after therapy, assessments were made of the following: trunk muscle strength (in flexion, extension, lateral bending, and axial rotation), erector spinae activation (maximal, and during forward bending movements), back extensor endurance (Biering-Sørensen test), and erector spinae fatigability (determined from changes in the median frequency of the surface electromyographic signal) during isometric and dynamic tests.

RESULTS

A total of 132 of 148 patients (89%) completed the therapy. Isometric strength in each movement direction increased in all groups post-therapy (P < 0.0008), most notably in the devices group. Activation of the erector spinae during the extension tests also increased significantly in all groups and showed a weak, but significant, relationship with increased maximal strength (P = 0.01). Pretherapy 55% of the subjects showed no relaxation of the back muscles at L5 when in the fully flexed position; no changes were observed in any group post-therapy. Endurance time during the Biering-Sørensen test increased significantly post-therapy in all groups (P = 0.0001), but there were no significant changes in EMG-determined fatigability. Fatigability of the lumbar muscles at L5 (EMG median frequency changes) during the dynamic test increased post-therapy (P = 0.0001) without group differences.

CONCLUSION

Significant changes in muscle performance were observed in all three active therapy groups post-therapy, which appeared to be mainly due to changes in neural activation of the lumbar muscles and psychological changes concerning, for example, motivation or pain tolerance.

Active therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy

DESIGN

Cross-sectional analysis of the factors influencing self-rated disability associated with chronic low back pain and prospective study of the relationship between changes in each of these factors and in disability following active therapy.

OBJECTIVES

To examine the relative influences of pain, psychological factors, and physiological factors on self-rated disability.

SUMMARY OF BACKGROUND DATA

In chronic LBP, the interrelationship between physical impairment, pain, and disability is particularly complicated, due to the influence of various psychological factors and the lack of unequivocal methods for assessing impairment. Investigations using new "belief" questionnaires and "sophisticated" performance tests, which have shown promise as discriminating measures of impairment, may assist in clarifying the situation. Previous studies have rarely investigated all these factors simultaneously.

METHODS

One hundred forty-eight patients with cLBP completed questionnaires and underwent tests of mobility, strength, muscle activation, and fatigability, and (in a subgroup) erector spinae size and fiber size/type distribution. All measures were repeated after 3 months active therapy. Relationships between each factor and self-rated disability (Roland and Morris questionnaire) at baseline, and between the changes in each factor and changes in disability following therapy, were examined.

RESULTS

Stepwise linear regression showed that the most significant predictors of disability at baseline were, in decreasing order of importance: pain; psychological distress; fear-avoidance beliefs; muscle activation levels; lumbar range of motion; gender. Only changes in pain, psychological distress, and fear-avoidance beliefs significantly accounted for the changes in disability following therapy.

CONCLUSION

A combination of pain, psychological and physiological factors was best able to predict baseline disability, although its decrease following therapy was determined only by reductions in pain and psychological variables. The active therapy program-in addition to improving physical function-appeared capable of modifying important psychological factors, possibly as a result of the positive experience of completing the prescribed exercises without undue harm.

Paraspinal muscle EMG fatigue testing with two methods in healthy volunteers. Reliability in the context of clinical applications

OBJECTIVE

Comparison of the accuracy of surface electromyogram for back muscle endurance assessment with two different tests.

DESIGN

Test-retest measurements in 16 healthy volunteers on two separate occasions for each test under controlled conditions.

BACKGROUND

Back muscle endurance is considered important in low back pain rehabilitation. Reliability of paraspinal muscle endurance assessment is a pre-requisite for accurate and meaningful clinical applications of the technique.

METHODS

All participants performed each test twice. A direct comparison was made between two popular fatigue testing methods, the modified Biering-Sørensen and a 60% maximum voluntary isometric contraction in the upright position during which time fatigue was assessed from the electromyogram spectral and amplitude analysis.

RESULTS

Reproducibility of initial median frequency was excellent for both tests. Normalised median frequency slope values were more reliable with the 60% maximum voluntary contraction upright test. The clinical applicability of these measures in detecting significant differences after patient rehabilitation is recommended. Root mean square had very large between-day error for both tests.

The effects of common medical interventions on pain, back function, and work resumption in patients with chronic low back pain: A prospective 2-year cohort study in six countries

STUDY DESIGN

A prospective cohort study with identical questionnaires and inclusion criteria was performed.

OBJECTIVES

To compare in six different countries the frequencies and effects of the common medical interventions used for patients with low back pain who are work incapacitated.

SUMMARY OF BACKGROUND DATA

Low back pain is a huge problem with increasing costs for health care, industry, and society.

METHODS

Cohorts of employed men and women ages 18 to 59 years who had been sick-listed (100%) for a minimum of 90 days because of low back pain were recruited in Denmark, Germany, Israel, Sweden, the Netherlands, and the United States. The subjects received three separate questionnaires with identical questions after 90 days, 1 year, and 2 years. The questionnaires included separate questions about background factors, treatment, and the like, as well as validated scales such as the Hannover Activities of Daily Living, von Korff pain score, Short Form-36, and Karasek-Theorell. Working status was obtained from registers. Main outcome measures were working/not working, back function, and pain.

RESULTS

All three questionnaires were completed by 2080 subjects in the six countries. With few exceptions, there were great similarities in the appointments, examinations, and treatments in the different countries. Considerable differences were found between the back surgery rates, which ranged from 6% in Sweden to 32% in the United States during the first 90 days of the study. Very few of the interventions had any noticeable positive effects on work resumption, pain, or back function. Back surgery in Sweden was a striking exception, positively affecting all three outcome measures. The frequencies of work resumption within the first year ranged from 73% in the Netherlands to 32% in Denmark.

CONCLUSIONS

Almost none of the commonly occurring and frequently practiced medical interventions for patients who are sick-listed because of low back pain had any positive effects on either the recorded health measures or work resumption.

The role of physical exercise and inactivity in pain recurrence and absenteeism from work after active outpatient rehabilitation for recurrent or chronic low back pain: a follow-up study

STUDY DESIGN

An observational follow-up.

OBJECTIVES

To analyze the role of physical exercise and inactivity on the long-term outcome after active outpatient low back rehabilitation.

SUMMARY OF BACKGROUND DATA

There is considerable evidence documenting the efficacy of exercise in the conservative treatment of chronic low back pain, but the role of exercises after the guided treatment period on the long-term success and maintenance of the results is not known.

METHODS

One hundred twenty-five patients with low back pain, who had participated in a 12-week active low back rehabilitation program, were asked about subjective pain and disability on the average of 14 months after the treatment. The outcomes were defined as a recurrence of persistent pain and work absenteeism, and a survival or failure analysis was performed between those who had continued exercising and who had been physically inactive.

RESULTS

Recurrences of persistent pain during the follow-up period were fewer (P = 0.03) among those who had maintained regular exercise habits after the treatment than among those who had been physically inactive. Similarly, work absenteeism was less (P < 0.01) among physically active than among physically inactive persons. However, patients with good outcome in pain reduction after low back pain rehabilitation were more likely to participate in physical exercise.

CONCLUSIONS

Exercises are beneficial after guided treatment in the maintenance of the results of active treatment for recurrent chronic low back pain in the long term, but those with less favorable outcome in rehabilitation are less likely to participate in exercises afterward. In active treatment programs, it is recommended that exercises be incorporated after the guided treatment.

Can exercise therapy improve the outcome of microdiscectomy?

STUDY DESIGN

A prospective randomized controlled trial of exercise therapy in patients who underwent microdiscectomy for prolapsed lumbar intervertebral disc. Results of a pilot study are presented.

OBJECTIVE

To determine the effects of a postoperative exercise program on pain, disability, psychological status, and spinal function.

SUMMARY OF BACKGROUND DATA

Microdiscectomy is often used successfully to treat prolapsed lumbar intervertebral disc. However, some patients do not have a good outcome and many continue to have low back pain. The reasons for this are unclear but impairment of back muscle function due to months of inactivity before surgery may be a contributing factor. A postoperative exercise program may improve outcome in such patients.

METHODS

Twenty patients who underwent lumbar microdiscectomy were randomized into EXERCISE and CONTROL groups. After surgery, all patients received normal postoperative care that included advice from a physiotherapist about exercise and a return to normal activities. Six weeks after surgery, patients in the EXERCISE group undertook a 4-week exercise program that concentrated on improving strength and endurance of the back and abdominal muscles and mobility of the spine and hips. Assessments of spinal function were performed in all patients during the week before surgery and at 6, 10, 26, and 52 weeks after. The assessment included measures of posture, hip and lumbar mobility, back muscle endurance capacity and electromyographic measures of back muscle fatigue. On each occasion, patients completed questionnaires inquiring about pain, disability and psychological status.

RESULTS

Surgery improved pain, disability, back muscle endurance capacity and hip and lumbar mobility in both groups of patients. After the exercise program, the EXERCISE group showed further improvements in these measures and also in electromyographic measures of back muscle fatigability. All these improvements were maintained 12 months after surgery. The only further improvement showed by the CONTROL group between 6 and 52 weeks was an increase in back muscle endurance capacity.

CONCLUSION

A 4-week postoperative exercise program can improve pain, disability, and spinal function inpatients who undergo microdiscectomy. [Key words: electromyogram median frequency, exercise therapy, intervertebral disc prolapse, microdiscectomy, randomized controlled trial, spinal function.