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Landim C, Dias CMCC, Nascimento C, Goes ALB, Araújo THA, Ribeiro A, Oliveira FTD, Castro-Lima H, Boa-Sorte N, Galvão-Castro B. Impaired flexibility in patients with tropical spastic paraparesis/HTLV-associated myelopathy: evaluation via pendulum fleximeter. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:271-283. [PMID: 37059437 PMCID: PMC10104761 DOI: 10.1055/s-0043-1764417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Flexibility is crucial to the harmonious execution of joint movements. While skeletal muscle dysfunction in patients with HTLV-1 can interfere with mobility, it is unclear whether these patients experience reduced flexibility. OBJECTIVE To evaluate the differences in flexibility between HTLV-1-infected individuals with and without myelopathy compared with uninfected controls. We also investigated whether age, sex, body mass index (BMI), physical activity level, or lower back pain influence flexibility in HTLV-1-infected individuals. METHODS The sample consisted of 56 adults, of which 15 did not have HTLV-1, 15 had HTLV-1 without myelopathy, and 26 had TSP/HAM. Their flexibility was assessed using the sit-and-reach test and a pendulum fleximeter. RESULTS No differences in flexibility were observed between the groups with and without myelopathy and controls without HTLV-1 infection using the sit-and-reach test. The pendulum fleximeter results of individuals with TSP/HAM presented the lowest flexibility among the groups with respect to trunk flexion, hip flexion and extension, knee flexion, and ankle dorsiflexion, even after adjusting for age, sex, BMI, level of physical activity, and lower back pain using multiple linear regression models. Additionally, HTLV-1-infected individuals without myelopathy demonstrated reduced flexibility in movements: knee flexion, dorsiflexion, and ankle plantar flexion. CONCLUSIONS Individuals with TSP/HAM demonstrated reduced flexibility in most of the movements evaluated by the pendulum fleximeter. Additionally, HTLV-1-infected individuals without myelopathy demonstrated reduced knee and ankle flexibility, potentially representing a marker of myelopathic development.
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Affiliation(s)
- Caroline Landim
- Escola Bahiana de Medicina e Saúde Pública, Salvador BA, Brazil
| | | | | | | | | | - Adriele Ribeiro
- Escola Bahiana de Medicina e Saúde Pública, Salvador BA, Brazil
| | | | | | - Ney Boa-Sorte
- Escola Bahiana de Medicina e Saúde Pública, Salvador BA, Brazil
- Universidade Federal da Bahia, Salvador BA, Brazil
| | - Bernardo Galvão-Castro
- Escola Bahiana de Medicina e Saúde Pública, Salvador BA, Brazil
- Fundação Oswaldo Cruz, Instituto Gonçalo Moniz, Laboratório Avançado de Saúde Pública, Salvador BA, Brazil
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Nokariya S, Kotani T, Sakuma T, Iijima Y, Okumura T, Katogi T, Okuwaki S, Miyagi M, Inoue G, Akazawa T, Shiga Y, Minami S, Ohtori S, Takaso M. Trunk flexibility using a sit-and-reach test after surgery for adolescent idiopathic scoliosis. Spine Deform 2023; 11:297-303. [PMID: 36331800 DOI: 10.1007/s43390-022-00608-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Spinal fusion reduces flexibility, but we do not have detailed knowledge that accounts for growth or sex differences. We sought to determine trunk flexibility pre- and postoperatively in patients with adolescent idiopathic scoliosis (AIS). METHODS We included data from 109 patients with AIS in this retrospective, single-center observational study. Patients had performed a sit-and-reach (SR) test preoperatively, and 1 and 2 years postoperatively, and measurements were standardized to Z scores according to age and sex. The patient data were divided into three groups according to the level of lower instrumented vertebra (LIV): (1) Group A (fusion above L2); (2) Group B (fusion to L2), and (3) Group C (fusion to L3 or L4). The change in the Z score for various levels was determined and compared. RESULTS The preoperative Z score for all patients was -0.622. At 2 years postoperatively, the Z score in Groups A and B was not significantly different from the preoperative score; in Group C, the Z score decreased by 1 year postoperatively, improved during the second year, but remained significantly lower than the preoperative score. Our study was the first to assess trunk flexibility using the SR test in patients with scoliosis. CONCLUSIONS Preoperatively, patients with AIS had lower SR test Z-scores than the general population, indicating a lower trunk flexibility in these patients. At 2 years after surgery in these patients, trunk flexibility had returned to preoperative levels when LIV was at L2 or above, but when LIV was at L3 or L4, trunk flexibility was less than it was preoperatively. LEVEL OF EVIDENCE Prognostic Level II: retrospective study.
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Affiliation(s)
- Shun Nokariya
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, 2-36-2 Ebaradai Sakura-Shi, Sakura, Chiba, 285-8765, Japan
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Toshiaki Kotani
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, 2-36-2 Ebaradai Sakura-Shi, Sakura, Chiba, 285-8765, Japan.
| | - Tsuyoshi Sakuma
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, 2-36-2 Ebaradai Sakura-Shi, Sakura, Chiba, 285-8765, Japan
| | - Yasushi Iijima
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, 2-36-2 Ebaradai Sakura-Shi, Sakura, Chiba, 285-8765, Japan
| | - Taro Okumura
- Department of Physical Therapy, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Takehide Katogi
- Department of Physical Therapy, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Shun Okuwaki
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, 2-36-2 Ebaradai Sakura-Shi, Sakura, Chiba, 285-8765, Japan
| | - Masayuki Miyagi
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Gen Inoue
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tsutomu Akazawa
- Department of Orthopedic Surgery, School of Medicine, St. Marianna University, Kawasaki, Japan
| | - Yasuhiro Shiga
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shohei Minami
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, 2-36-2 Ebaradai Sakura-Shi, Sakura, Chiba, 285-8765, Japan
| | - Seiji Ohtori
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masashi Takaso
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
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Systematic analysis of different low-pass filter cut-off frequencies on lumbar spine kinematics data and the impact on the agreement between accelerometers and an optoelectronic system. J Biomech 2022; 145:111395. [PMID: 36442430 DOI: 10.1016/j.jbiomech.2022.111395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/18/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
A necessary step in the validation of accelerometers for the measurement of spine angles is to determine the levels of agreement with current gold standard methods. However, agreement may be a function of filtering parameters. We aimed to (1) systematically determine the effect of different filter frequency cut-offs on the peak range of motion (ROM) during forward bending as measured by accelerometers and an optoelectronic (OE) system, (2) explore the influence of filtering on agreement between systems, and (3) determine the difference in peak ROM measurement between these systems. Accelerometers and OE sensors were attached at L2, L4, and S1 of 20 asymptomatic female participants for a guided flexion trial. Signals were then iteratively low-pass filtered with cut-off frequencies ranging from 14 Hz to 1 Hz and peak range of motion outcome measures were compared between systems. Peak ROM was minimally affected by filter cut-off frequency for both accelerometer and OE system. The difference in peak ROM between difference cut-off frequencies were maximum 0.66°, median 0.18° and minimum 0.06° for accelerometer derived values and maximum 0.23°, median 0.08° and minimum 0.03° for the OE system. The maximum difference across the filtering frequencies was 0.62° and the largest difference between the two systems (with outliers removed) was 0.82°. Cut-off frequencies ranging from 14 to 1 Hz had little effect of peak lumbar spine ROM during low velocity (6°/s) forward bending, regardless of motion capture method. Filtering cut-off frequency had little effect on the differences between the accelerometer and OE system and similar measurements can be achieved using accelerometers compared to OE systems.
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The Effect of Hamstring Relaxation Program on Headache, Pressure Pain Threshold, and Range of Motion in Patients with Tension Headache: A Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910137. [PMID: 34639438 PMCID: PMC8508316 DOI: 10.3390/ijerph181910137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to determine if the severity of headache is reduced by decreasing hamstring tension in patients with tension headache. Thirty patients participated in this study. The participants were randomly allocated to two groups: hamstring relaxation program (HR) group (n = 15) and control group (n = 15). The participants in the HR group participated in a HR program for 25 min per day, three times per week, for a period of 4 weeks, and the control group participated in an electrotherapy for 25 min per day, three times per week, for a period of 4 weeks. Both groups participated in a self-myofacial release for 5 min per day, three times per week, for a period of 4 weeks. Headache was evaluated using the headache impact test (HIT-6) and visual analog scale (VAS). The pain pressure threshold (PPT) was evaluated using a digital pressure algometer. The range of motion (ROM) was evaluated using a goniometer and two special tests: straight leg raise test (SLRT) and popliteal angle test (PAT). The two groups showed no significant differences in terms of age, sex, height, and weight. The VAS and HIT-6 scores (p < 0.05) and neck and hamstring PPT showed significant improvements (p < 0.05). Neck flexion ROM and SLRT and PAT scores showed significant improvements (p < 0.05) in both groups, and the HR group showed significantly more improvements than the control group. This study confirmed that the HR program has positive effects on tension headache and is a good intervention for alleviating headaches in patients with tension headache.
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Shin SS, Yoo WG. Differences in regional and global lumbar angle during slumped sitting and upright sitting among global three subgroups. J Back Musculoskelet Rehabil 2021; 34:877-885. [PMID: 34057131 DOI: 10.3233/bmr-200087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate differences in regional lumbar lordosis (RLL) and global lumbar lordosis (GLL) angle during slumped sitting and upright sitting among three global subgroups. METHODS A total of 48 young asymptomatic volunteers stood in a comfortable posture, sat upright, and sat in a slumped position for 5 seconds, with inertial measurement units attached to the T10, L3, and S2 vertebrae. According to standing measurement, the participants were categorized into flat-back (GLL < 20∘), normal lordosis (20∘⩽ GLL < 30∘), and hyper-lordosis (30∘⩽ GLL < 40∘) groups. RESULTS Both the GLL and RLL in the flat-back group were reduced lumbar lordosis in the upright sitting posture and increased lumbar kyphosis in the slumped sitting postures compared to the other groups (p< 0.05), but the range of motion during the transition from upright sitting to slumped sitting was lower than that of the normal and hyper-lordosis groups (p< 0.05). GLL in standing was a moderate correlation with GLL and RLL during upright sitting (p< 0.05). However, there was a strong correlation between GLL and RLL kinematics during upright and slumped sitting (p< 0.05). CONCLUSIONS Flat-back posture is a potential source of low back pain during both upright and slumped sitting compared to the normal and hyper-lordosis groups. Posture measurements in a standing and sitting position conducted to assess lordosis should consider the relationship between GLL and RLL.
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Sheldon BL, DiMarzio M, Chung SH, Tram J, Khazen O, Staudt MD, Bondoc M, Pilitsis JG. Association of Outcomes of Spinal Cord Stimulation for Chronic Low Back Pain and Psoas Measurements Based on Size of Iliopsoas Muscles. Neuromodulation 2021; 25:121-127. [PMID: 33616289 DOI: 10.1111/ner.13375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/02/2021] [Accepted: 02/02/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Patients experience variable long-term improvement in chronic back pain despite successful spinal cord stimulation (SCS) trials. Iliopsoas (IP) size has been shown to differ between patients with low back pain and healthy controls. In this study, we examine whether IP muscle cross-sectional area (CSA) is associated with SCS outcomes. MATERIALS AND METHODS We examined patients for whom we had lumbar MRIs 6.3 years prior to SCS and had baseline and one-year outcome data. Percent change from baseline to one year was calculated for Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), Pain Catastrophizing Scale (PCS), and McGill Pain Questionnaire (MPQ). Correlations between IP muscle CSA, ratio of iliopsoas muscle size to the vertebral body area (P/VBA), and the ratio of iliopsoas muscle size to BMI (P/BMI) were examined. Sex differences were considered. RESULTS A total of 73 subjects were included in this study including 30 females and 43 males. Males had significantly larger IP (males 15.70 ± 0.58, females 9.72 ± 0.43; p < 0.001), P/VBA (males 1.00 ± 0.04, females 0.76 ± 0.03, p < 0.001) and P/BMI ratio (males 0.51 ± 0.02, females 0.32 ± 0.01; p < 0.001) than females. In females, P/VBA predicted NRS worst pain scores (β = 0.82, p = 0.004, r2 = 0.55) and BDI (β = 0.59, p = 0.02, r2 = 0.24). In males, P/BMI was a significant predictor of BDI outcomes scores (β = 0.45, p = 0.03, r2 = 0.16). Males who had more muscle mass measured by iliopsoas size had more depression as measured using BDI (p = 0.03, r = 0.61). Females with less muscle mass measured by P/VBA also experienced more depression (p = 0.02, r = 0.74). CONCLUSIONS Our study showed that psoas measurements correlated with various pain outcomes specifically. P/VBA was most predictive in females and P/BMI in males. Depression correlated with P/BMI, reinforcing the complex relationship between depression and constant chronic pain. Tertile analyses further showed a relationship between iliopsoas CSA and depression in males and females. We provide preliminary data of sex-specific psoas measurements as a risk factor for worse SCS outcomes.
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Affiliation(s)
- Breanna L Sheldon
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | - Marisa DiMarzio
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | - Sung Hwan Chung
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | - Justin Tram
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | - Olga Khazen
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | - Michael D Staudt
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Melanie Bondoc
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | - Julie G Pilitsis
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA.,Department of Neurosurgery, Albany Medical College, Albany, NY, USA
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Mendes Tozim B, Thomaz de Aquino Nava G, Zuliani Stroppa Marques AE, Tavella Navega M. Efficacy of the Pilates versus general exercises versus educational workshops on neuromuscular parameters: A randomized controlled trial. J Bodyw Mov Ther 2020; 26:420-427. [PMID: 33992277 DOI: 10.1016/j.jbmt.2020.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 06/30/2020] [Accepted: 08/28/2020] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Muscle strength, flexibility and changes in muscle recruitment patterns are usually associated to low back pain (LBP). Physical exercises can reverse the adverse changes associated to LBP. OBJECTIVES Compare Pilates, general exercises and educational workshop on muscle flexibility, strength and recruitment of the trunk extensor muscles in women with LBP. METHODS Forty-six women were randomly divided into Pilates group (PG, n = 16), general exercise group (GEG, n = 15), and educational group (EG, n = 15). This study sought to determine flexibility, muscle strength, and muscle recruitment of right (RIL), left (LIL) iliocostalis lumbar; right (RMU) and left (LMU) lumbar multifidus muscles. Both PG and GEG performed 16 exercise sessions, while EG attended 4 workshops. Statistical analysis used data sample from Shapiro-Wilk test, Pearson's correlation, multivariate analysis, mixed variance analysis, and Cohen's index. RESULTS Flexibility showed no differences (p > 0.05). Muscle strength increased in the intragroup analysis for PG (p = 0.003) and GEG (p = 0.002); however, the intergroup analysis presented no difference. Intergroup showed statistically significant differences for the recruitment of RMU in PG (p < 0.001). Intragroup analysis presented differences after interventions in PG for RIL (p = 0.001); in GEG for LIL (p = 0.005); and in EG for RIL (p = 0.007), LIL (p = 0.002) and RMU (p < 0.001). CONCLUSIONS None of the groups showed flexibility improvements. PG and GEG increased muscle strength through intragroup analysis. Intergroup analysis showed an increase in recruitment of the RMU muscle in PG and all groups demonstrated significant improvements in the intragroup analysis.
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Affiliation(s)
- Beatriz Mendes Tozim
- Faculty of Philosophy and Sciences, São Paulo State University (UNESP), Marília, São Paulo, Brazil.
| | - Guilherme Thomaz de Aquino Nava
- Department of Physical Education, Institute of Biosciences, São Paulo State University (UNESP), Rio Claro, São Paulo, Brazil
| | | | - Marcelo Tavella Navega
- Faculty of Philosophy and Sciences, São Paulo State University (UNESP), Marília, São Paulo, Brazil; Department of Physical Education, Institute of Biosciences, São Paulo State University (UNESP), Rio Claro, São Paulo, Brazil
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What is the best way to collect maximum forward lumbar spine flexion values for normalizing posture to range of motion? J Biomech 2020; 103:109706. [PMID: 32164962 DOI: 10.1016/j.jbiomech.2020.109706] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 02/19/2020] [Accepted: 02/23/2020] [Indexed: 11/22/2022]
Abstract
Spine angles are an important measure in biomechanics research and are commonly normalized to a percentage of range of motion. However, standardized methods to collect the reference posture trials for this normalization do not exist. The purpose of this study was to determine posture (seated or standing) and number of trials that should be collected and how to calculate the angle that best represents the maximum range. Forty healthy adults (22 females, 18 males) completed 12 reference trials: 1 upright standing, 5 standing flexion, and 5 seated flexion trials. The maximum lumbar angle was found for each flexion trial. Additionally, different methods to calculate the maximum were applied by taking the maximum of the 5 standing, 5 seated, and all 10 flexion trials. An interaction was found between posture, order, and trial number. 42.5% and 57.5% of participants reached their maximum angle during seated and standing flexion respectively which may be due to back- vs hip-dominant movement strategies. 85% of participants achieved their maximum at some point during the first six flexion trials. The maximum angle of all 10 flexion trials was significantly greater than the angle of the first standing or seated trial only but not significantly greater than the maximum of all seated or standing flexion trials respectively. Secondarily, no differences in the maximum lumbar angle were found between sexes. This study suggests that 6 flexion trials, involving both standing and seated flexion, should be collected to best represent the maximum end range of spine flexion.
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Ozsoy G, Ilcin N, Ozsoy I, Gurpinar B, Buyukturan O, Buyukturan B, Kararti C, Sas S. The Effects Of Myofascial Release Technique Combined With Core Stabilization Exercise In Elderly With Non-Specific Low Back Pain: A Randomized Controlled, Single-Blind Study. Clin Interv Aging 2019; 14:1729-1740. [PMID: 31631992 PMCID: PMC6790630 DOI: 10.2147/cia.s223905] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 09/18/2019] [Indexed: 01/10/2023] Open
Abstract
Purpose To evaluate the effects of Myofascial Release Technique (MRT) with a roller massager combined with core stabilization exercises (CSE) in elderly with non-specific low back pain (NSLBP). Patients and methods A total of forty-five participants were randomly divided into two groups (CSE and CSE+MRT). A core stabilization exercise program was applied for the participants in the CSE group for 3 days per week for a total of 6 weeks. In addition to the core stabilization exercises, myofascial relaxation technique with a roller massager was performed for 3 days per week for 6 weeks for the participants in the CSE+MRT group. Participants were assessed in terms of pain, low back disability, lower body flexibility, kinesiophobia, core stability endurance, spinal mobility, gait characteristics and quality of life both pre- and post-treatment. Results It was found that the improvement in core stability endurance (p=0.031) and spinal mobility (in the sagittal plane) (p=0.022) was greater in the CSE+MRT group compared to the CSE group. There was no significant difference between the two groups in terms of pain, low back disability, lower body flexibility, kinesiophobia, gait characteristics and quality of life (p>0.05). Conclusion The current study suggests that myofascial release technique with a roller massager combined with core stabilization exercises can be a better choice in the treatment of NSLBP in elderly. ClinicalTrials.gov Identifier NCT03898089.
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Affiliation(s)
- Gulsah Ozsoy
- School of Physical Therapy and Rehabilitation, Kırsehir Ahi Evran University, Kırsehir, Turkey
| | - Nursen Ilcin
- School of Physical Therapy and Rehabilitation, Dokuz Eylül University, Izmir, Turkey
| | - Ismail Ozsoy
- School of Physical Therapy and Rehabilitation, Kırsehir Ahi Evran University, Kırsehir, Turkey
| | - Barış Gurpinar
- School of Physical Therapy and Rehabilitation, Dokuz Eylül University, Izmir, Turkey
| | - Oznur Buyukturan
- School of Physical Therapy and Rehabilitation, Kırsehir Ahi Evran University, Kırsehir, Turkey
| | - Buket Buyukturan
- School of Physical Therapy and Rehabilitation, Kırsehir Ahi Evran University, Kırsehir, Turkey
| | - Caner Kararti
- School of Physical Therapy and Rehabilitation, Kırsehir Ahi Evran University, Kırsehir, Turkey
| | - Senem Sas
- Department of Physical Medicine and Rehabilitation, Kırsehir Ahi Evran University Training and Research Hospital, Kırşehir, Turkey
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