Correlations between core muscle geometry, pain intensity, functional disability and postural balance in patients with nonspecific mechanical low back pain

Effects of unstable load and unstable surface ontrunk muscles activation and postural control in healthy subjects

Exercise with an unstable load is considered a new training method to activate the core muscles. Research has shown consistency regarding an unstable surface but has not provided comprehensive findings about the effect of an unstable load. The study aimed to examine the impact of an unstable load and unstable surfaces on core muscle activation and postural control during lifting. Thirty-eight participants lifted a load equivalent to 10 % of their body weight under three conditions: a stable load on an unstable surface, a stable load on a stable surface, and an unstable load on a stable surface. The center of pressure (COP) displacement and electromyography activity of abdominal and back extensor muscles were measured during lifting. The results indicated that lifting on an unstable surface activated the lumbar erector spinae and multifidus muscles more than in a stable condition (P<0.05). However, there was no significant difference in the level of thoracic erector spinae muscle activity between the unstable load and unstable surface conditions. The stable condition increased activity in the internal oblique muscle (1.37 times) compared to the unstable conditions. The analysis of postural control revealed that lifting the load on an unstable surface significantly decreased COP displacement in the anteroposterior direction (P<0.05), while holding the load on the unstable surface significantly increased COP displacement in the anteroposterior direction compared to the other conditions. These findings could be valuable for future rehabilitation research, learning appropriate lifting techniques, and setting specific training goals in sports.

Spinal degeneration and lumbar multifidus muscle quality may independently affect clinical outcomes in patients conservatively managed for low back or leg pain

Few non-surgical, longitudinal studies have evaluated the relations between spinal degeneration, lumbar multifidus muscle (LMM) quality, and clinical outcomes. None have assessed the potential mediating role of the LMM between degenerative pathology and 12-month clinical outcomes. This prospective cohort study used baseline and 12-month follow-up data from 569 patients conservatively managed for low back or back-related leg pain to estimate the effects of aggregate degenerative lumbar MRI findings and LMM quality on 12-month low back and leg pain intensity (0-10) and disability (0-23) outcomes, and explored the mediating role of LMM quality between degenerative findings and 12-month clinical outcomes. Adjusted mixed effects generalized linear models separately estimated the effect of aggregate spinal pathology and LMM quality. Mediation models estimated the direct and indirect effects of pathology on leg pain, and pathology and LMM quality on leg pain, respectively. Multivariable analysis identified a leg pain rating change of 0.99 [0.14; 1.84] (unstandardized beta coefficients [95% CI]) in the presence of ≥ 4 pathologies, and a disability rating change of - 0.65 [- 0.14; - 1.16] for each 10% increase in muscle quality, but no effect on back pain intensity. Muscle quality had a non-significant mediating role (13.4%) between pathology and leg pain intensity. The number of different pathologies present demonstrated a small effect on 12-month leg pain intensity outcomes, while higher LMM quality had a direct effect on 12-month disability ratings but no mediating effect between pathology and leg pain. The relations between degenerative pathology, LMM quality, and pain-related outcomes appear complex and may include independent pathways.

An Integrated Approach to Chronic Low Back Pain: Evaluating the Impact of Consecutive Loop TheraBand Training Combined With Proprioceptive Neuromuscular Facilitation and Conventional Physiotherapy

Chronic low back pain (CLBP) is a prevalent musculoskeletal condition characterized by persistent discomfort in the lumbosacral region lasting beyond 12 weeks. Individuals with CLBP often experience limitations in range of motion and compromised performance of affected body parts. Core muscle weakness/delayed activation and impaired lumbar proprioception are established contributors to CLBP. And influence balance dysfunction in CLBP patients. Exercise therapy is a cornerstone in the management of CLBP, aimed at enhancing muscular endurance, strength, and flexibility of the back muscles and soft tissues. However, the efficacy of exercise interventions depends on various factors including the type, intensity, frequency, and duration of exercises. This case report presents the rehabilitation of a corporate employee with a non-specific CLBP. The rehabilitation goals focused on improving balance, reducing disability, and alleviating pain. An integrated approach combining proprioceptive neuromuscular facilitation (PNF) with Consecutive Loop TheraBand (CLX) (The Hygenic Corporation, Akron, USA) along with traditional physical therapy techniques was implemented. PNF, a well-established technique, was chosen for its effectiveness in reducing disability and LBP while enhancing balance. The integration of PNF alongside conventional physiotherapy resulted in notable improvements, including increased lumbar flexion range following the rehabilitation period. This case underscores the importance of early initiation of comprehensive rehabilitation in CLBP patients to preserve strength, alleviate pain, reduce functional disability, and enhance balance. By addressing both the muscular and proprioceptive aspects of CLBP, this integrated approach aims to optimize outcomes in CLBP management.

Unveiling the Efficacy of Physiotherapy Strategies in Alleviating Low Back Pain: A Comprehensive Review of Interventions and Outcomes

Low back pain (LBP) presents a significant burden globally, affecting individuals of all ages, but it is more common in adults aged 30-60 years old and demographics including race, ethnicity, and socioeconomic status. Physiotherapy interventions are commonly employed to manage LBP due to their non-invasive nature and potential for addressing underlying biomechanical dysfunctions. This comprehensive review aims to evaluate the efficacy of various physiotherapy strategies in alleviating LBP, considering a range of interventions and their associated outcomes. Through a thorough examination of existing literature from January 2017 to October 2023, this review synthesises evidence on the effectiveness of interventions such as manual therapy, exercise therapy, electrotherapy modalities, and education-based approaches. The review also scrutinizes the comparative effectiveness of different physiotherapy modalities and their suitability for specific patient populations, considering factors such as chronicity, severity, and underlying pathology. By critically evaluating the evidence base, this review aims to provide insights into the most effective physiotherapy strategies for alleviating LBP, chronic low back pain (CLBP) and chronic nonspecific low back pain (CNLBP) and guiding clinical practice toward evidence-based interventions. The Visual Analogue Scale and Numerical Pain Rating Scale for pain, Oswestry Disability Index and Roland-Morris Disability Questionnaire for disability, Modified-Modified Schober Test for measurement of lumbar flexion and extension and static and dynamic balance for assessing postural stability and balance were among the measures used to foresee enhancements in pain, disability, balance, and LBP symptoms. Twenty-one studies that fulfilled the criteria for inclusion (aged 20 to 50 years and of both genders) were added to the review. Exercises for core stability, strengthening, orthosis (a medical device designed to support, align, stabilise, or correct musculoskeletal structures and functions), transcutaneous electrical nerve stimulation, heat massage therapy, interferential current (a form of electrical stimulation used in physical therapy), Mulligan's mobilization (a manual therapy technique), low-level laser therapy, and McGill stabilization exercises (core exercises) were among the therapeutic strategies. The McKenzie method (back exercises), ultrasound, sensory-motor training, Swiss ball exercises, and other techniques reduced pain and enhanced strength, balance, and ease of daily activities. Every therapeutic approach has an impact on recovery rates ranging from minimal to maximal. Conventional physical therapy is less effective than most recent advanced techniques like mobilisation and exercises. In summary, the integration of manual techniques, orthoses and alternative intervention strategies with conservative therapeutic approaches can effectively alleviate pain, enhance function and yield better overall outcomes. To get more information about the optimal dosage, therapeutic modalities and long-term effects of these treatments, more admirable research is required. This paper aims to expand the scientific discourse by exploring non-traditional physiotherapy interventions and assessing their efficacy in light of the rigorous standards set forth by the latest WHO guidelines.

Comparing the effectiveness of flexi-bar and stability exercises on postural control in chronic nonspecific low back pain: A randomized controlled study

Objectives

This study aimed to compare the effect of flexi-bar and stabilization exercises on static and dynamic postural control in patients with chronic nonspecific low back pain.

Patients and methods

In this randomized controlled study conducted between November 2019 and March 2020, 38 patients (19 males, 19 females; mean age: 33.8±6.2 years; range, 20 to 45 years) were randomly assigned into flexi-bar (n=19) and stabilization (n=19) groups. Both groups received general physiotherapy for three sessions per week, a total of 10 sessions. Besides, the flexi-bar group received flexi-bar exercises, and the stabilization group received stabilization exercises. Postural sway was assessed with a force platform in three difficult conditions, including open eye, close eye, and one-leg standing and dynamic posture with the modified Star Excursion Balance Test.

Results

After the intervention, both groups showed a significant improvement in static and dynamic postural control (p<0.05). However, no significant differences were found between groups after treatment, while only the phase-plane portrait of opened eyes condition was significantly improved (p=0.03), in the flexi-bar group compared to the stabilization group.

Conclusion

Both flexi-bar and stabilization exercises effectively improved static and dynamic postural control, but none of the exercises was superior to the other. Flexi-bar is recommended as an effective tool in low back pain rehabilitation.

Functional Alterations of the Basal Ganglia Are Associated with Voluntary Activation of the Core Stabilizing Muscles in Patients with Chronic Low Back Pain: A Cross-Sectional Study

Purpose

Deficits in voluntary activation of the core stabilizing muscles are consistently observed in patients with chronic low back pain (CLBP); however, the underlying neural mechanism remains unclear. This cross-sectional study aimed at testing the hypothesis that the impaired voluntary activation of core stabilizing muscles is associated with structural and functional alterations in the basal ganglia, thalamus, and cortex in patients with CLBP.

Methods

We obtained structural and resting-state functional magnetic resonance imaging (rs-fMRI) data from 53 patients with CLBP and 67 healthy controls and estimated the alterations in grey matter volume (GMV) and functional and effective connectivity (EC) of regions with altered GMV via whole brain analysis. The voluntary activation of the multifidus (MF) and transversus abdominis (TrA) was evaluated by ultrasound imaging in these patients.

Results

Compared with the HCs, they displayed a significant decrease in GMV in the bilateral thalamus and caudate nucleus, a significant increase in GMV in the left middle frontal gyrus, and increased resting-state functional connectivity between the right caudate nucleus and the bilateral precuneus (voxel-level p < 0.005, Gaussian random field-corrected p < 0.05). The patients also showed increased EC from the right caudate nucleus to the bilateral precuneus, which was significantly correlated with voluntary activation of the bilateral MF and TrA (all p < 0.050).

Conclusions

Grey matter alterations may be confined to regions responsible for perception, motor control, and emotion regulation in patients with CLBP. The interrupted EC from the basal ganglia to the default mode network might be involved in the impairment of voluntary activation of the core stabilizing muscles.

Shoulder Proprioception and Its Correlation with Pain Intensity and Functional Disability in Individuals with Subacromial Impingement Syndrome-A Cross-Sectional Study

Subacromial Impingement Syndrome (SAIS) is a common shoulder condition characterized by pain and functional impairment. Proprioception, the sense of joint position and movement, is crucial in maintaining joint stability and coordinating movements. The relationship between shoulder proprioception, pain intensity, and functional disability in individuals with SAIS remains unclear, with conflicting findings in the literature. This cross-sectional study aimed to evaluate shoulder proprioception, examine its correlation with pain intensity and functional disability, and contribute to our understanding of the clinical implications of proprioceptive deficits in individuals with SAIS. Forty-two individuals were diagnosed with SAIS, and an equal number of asymptomatic controls were recruited. Shoulder proprioception was assessed using a digital inclinometer, measuring joint position sense at various angles of flexion and rotation. Pain intensity was measured using the Visual Analog Scale (VAS), and functional disability was assessed using the Shoulder Pain and Disability Index (SPADI). Results: Individuals with SAIS exhibited significantly higher joint position error (JPE) values compared to asymptomatic controls in all measured angles of flexion and rotation (p < 0.001). Strong positive correlations were observed between JPE and pain intensity (r = 0.61 to 0.71, p < 0.01) and disability (r = 0.56 to 0.68, p < 0.01). These findings suggest impaired shoulder proprioception is associated with higher pain intensity and functional disability in SAIS. This study provides evidence of impaired shoulder proprioception in individuals with SAIS and its correlation with pain intensity and functional disability. The results highlight the clinical relevance of proprioceptive deficits in SAIS and emphasize the importance of incorporating proprioceptive assessment and targeted rehabilitation interventions into managing this condition. Future research should focus on longitudinal studies with larger and more diverse samples to further understand the underlying mechanisms and evaluate the effectiveness of proprioceptive interventions in improving outcomes for individuals with SAIS.

Lumbar multifidus muscle morphology is associated with low back-related pain duration, disability, and leg pain: A cross-sectional study in secondary care

BACKGROUND

Systematic reviews and studies exploring associations between morphologic change of paraspinal muscles and low back pain or related outcomes such as disability, radiculopathy, and physical workload, have reported conflicting results. This study explores the associations between lumbar multifidus muscle quality and clinical outcomes relating to low back pain.

METHODS

Cross-sectional study of spinal clinic outpatients presenting with a primary complaint of low back and/or leg symptoms. Univariable and multivariable regression models were used to investigate associations between MRI-based multifidus muscle cross-sectional area at L4 and L5 and clinical outcomes for low back pain, leg pain, disability, restricted motion, and strenuous nature of work. Results were reported with β-coefficients, odds ratios (OR), or incidence rate ratios (IRR) and their corresponding 95% confidence intervals, based on a 10% difference in muscle quality for each clinical variable. Multivariable analyses were adjusted for age, sex, and BMI.

RESULTS

875 patients [487 females; mean (SD) age: 43.6 (10.2) years] were included. In the multivariable analyses, muscle quality was significantly associated with disability (0-23 scale) [β: -0.74, 95% CI: -1.14, -0.34], leg pain intensity (0-10 scale) [β: -0.25, 95% CI: -0.46, -0.03], and current pain duration of more than 12 months [OR: 1.27, 95% CI: 1.03, 1.55]. No associations were found for low back pain intensity, morning stiffness, painful active range of motion, or work nature.

CONCLUSIONS

Patients with higher lumbar multifidus muscle quality reported lower levels of low back pain-related disability and leg pain intensity, indicating that muscle quality may play a role in the etiology of lumbar spine disorders. However, the clinical importance of these associations is uncertain due to the low magnitude of identified associations. Future longitudinal studies are needed to understand the effect of lumbar multifidus muscle quality on lumbar-related pain and disability.

Association between functional disability with postural balance among patients with chronic low back pain

Introduction

Postural balance is impaired in patients with chronic low back pain (CLBP). In addition, the swaying velocity can be affected by low back pain (LBP) dysfunction. However, the extent to which the dysfunction affects postural balance in CLBP patients remains unclear. Therefore, this study aimed to investigate the effect of LBP-related disability on postural balance among CLBP patients and determine factors associated with postural balance impairments.

Methods

Participants with CLBP were recruited and instructed to complete the one-leg stance and Y-balance test. Moreover, they were divided into two subgroups (i.e., low and medium to high LBP-related disability groups) to compare the difference in postural balance based on the degree of LBP-related disability measured by the Roland Morris Disability Questionnaire. The relationships between postural balance and negative emotions as well as LBP characteristics were determined using the Spearman correlations.

Results

A total of 49 participants with low LBP-related disabilities and 33 participants with medium to high LBP-related disabilities participated in the study. Compared to the medium to high LBP-related disability group, patients in the low LBP-related disability group performed better in one-leg stance on the left leg (z = -2.081, p = 0.037). For Y-balance test, patients in the low LBP-related disability group also had greater normalized values of left leg reach in posteromedial (t = 2.108, p = 0.038) direction and composite score (t = 2.261, p = 0.026) and of right leg reach in posteromedial (t = 2.185, p = 0.032), and posterolateral (t = 2.137, p = 0.036) directions as well as composite score (t = 2.258, p = 0.027). Factors associated with postural balance impairments were also revealed, such as anxiety, depression, and fear avoidance belief.

Discussion

The greater the dysfunction degree, the worse the CLBP patient's postural balance impairment. Negative emotions could also be considered contributing factors for postural balance impairments.

Changes in cortical activation during upright stance in individuals with chronic low back pain: An fNIRS study

Introduction

Postural control deficits are a potential cause of persistent and recurrent pain in patients with chronic low back pain (CLBP). Although some studies have confirmed that the dorsolateral prefrontal cortex (DLPFC) contributes to pain regulation in CLBP, its role in the postural control of patients with CLBP remains unclear. Therefore, this study aimed to investigate the DLPFC activation of patients with CLBP and healthy controls under different upright stance task conditions.

Methods

Twenty patients with CLBP (26.50 ± 2.48 years) and 20 healthy controls (25.75 ± 3.57 years) performed upright stance tasks under three conditions: Task-1 was static balance with eyes open; Task-2 was static balance with eyes closed; Task-3 involved dynamic balance on an unstable surface with eyes open. A wireless functional near-infrared spectroscopy (fNIRS) system measured cortical activity, including the bilateral DLPFC, pre-motor cortex (PMC) and supplementary motor area (SMA), the primary motor cortex (M1), the primary somatosensory cortex (S1), and a force platform measured balance parameters during upright stance.

Results

The two-way repeated measures ANOVA results showed significant interaction in bilateral PMC/SMA activation. Moreover, patients with CLBP had significantly increased right DLPFC activation and higher sway 32 area and velocity than healthy controls during upright stance.

Discussion

Our results imply that PMC/SMA and DLPFC maintain standing balance. The patients with CLBP have higher cortical activity and upright stance control deficits, which may indicate that the patients with CLBP have low neural efficiency and need more motor resources to maintain balance.

Activation of Anterolateral Abdominal Muscles During Sling Bridge Exercises: Comparison of Different Pelvic Positions

CONTEXT

Inappropriate activation of the anterolateral abdominal muscles affects the stability of the lumbopelvic zone and increases the appearance of pain and lesion in the area. Therefore, ways to improve its effective contraction are crucial in rehabilitation. The aim of this study was to compare the activation of the transverse abdominis (TrA), internal oblique (IO), and external oblique (EO) muscles in 3 different pelvic positions (down pelvis [DP], horizontal pelvis [HP], and up pelvis [UP]) during sling bridge exercise (SBE) to determinate which position is more effective to promote a correct contraction of the anterolateral abdominal muscles.

DESIGN

Cross-sectional study.

METHODS

Fifteen participants performed 3 variations (DP, HP, and UP) of a one-legged exercise called "supine pelvic lift" on a sling device. The thicknesses of the TrA, IO, and EO were recorded at rest and at the 3 positions using ultrasound imaging. Thickness, change ratio, lateral slide of TrA, and preferential and contraction activation ratio of TrA, IO, and EO were analyzed.

RESULTS

TrA and IO showed greater activation (P = .01) in the UP position than the other pelvic positions. In addition, UP position decreased the activation of the EO (P = .01).

CONCLUSION

Based on the results of this study, SBE in the UP position has the potential to improve normal contraction patterns of the musculature and can be used in future intervention of the lumbopelvic zone.

Ultrasonography Comparison of Diaphragm Morphological Structure and Function in Young and Middle-Aged Subjects with and without Non-Specific Chronic Low Back Pain: A Case-Control Study

Background

It is reported that impaired postural control in patients with non-specific chronic low back pain (NCLBP) was associated with "core" trunk muscle incoordination. However, as the diaphragm is an important component of the "core" deep trunk muscle group, we still know little about the potential relationship between diaphragm dysfunction and NCLBP.

Objectives

This case-control study is intended to investigate the changes of diaphragm morphological structure and function in young and middle-aged subjects with and without NCLBP by ultrasound evaluation and its possible validity in predicating the occurrence of NCLBP.

Methods

31 subjects with NCLBP (NCLBP group) and 32 matched healthy controls (HC group) were enrolled in this study. The diaphragm thickness at the end of inspiration (T ^ins) or expiration (T ^exp) during deep breathing was measured through B-mode ultrasound, and the diaphragm excursion (T ^exc) was estimated at deep breathing through M-mode ultrasound. The diaphragm thickness change rate (T ^rate) was calculated by the formula: T ^rate=(T ^ins - T ^exp)/T ^exp × 100%.

Results

Compared with the HC group, the NCLBP group had a significant smaller degree of T^ins (t = -3.90, P < 0.001), T ^exp (Z = -2.79, P=0.005), and T ^rate (t = -2.03, P=0.047). However, there was no statistical difference in T ^exc between the two groups (t = -1.42, P=0.161). The binary logistic regression analysis indicated that T ^rate (OR = 16.038, P=0.014) and T ^exp (OR = 7.714, P=0.004) were potential risk factors for the occurrence of NCLBP.

Conclusions

The diaphragm morphological structure and function were changed in young and middle-aged subjects with NCLBP, while the diaphragm thickness change rate (T ^rate) and diaphragm thickness at the end of expiration (T ^exp) may be conductive to the occurrence of NCLBP. Furthermore, these findings may suggest that abnormal diaphragm reeducation is necessary for the rehabilitation of patients with NCLBP.

Tai Chi for spatiotemporal gait features and dynamic balancing capacity in elderly female patients with non-specific low back pain: A six-week randomized controlled trial

BACKGROUND

Non-specific low back pain (NS-LBP) is a serious public health problem. Tai Chi is promising in reducing the risk of falls and alleviating symptoms in this population.

OBJECTIVE

To investigate the effect of Tai Chi on gait and dynamic balance in elderly women with NS-LBP.

METHODS

20 women (age > 65 yr.) with NS-LBP were randomly assigned to a Tai Chi group (n= 10) or a control group (n= 10). The Tai Chi group practiced Tai Chi exercise 3 times a week for 6 weeks. Each session lasted 60 minutes. Pain, spatiotemporal gait features and dynamic balancing capacity were assessed at 0 and 6 weeks.

RESULTS

Compared to the control group at 6 weeks, the Tai Chi group had a significant decrease in VAS (p= 0.027) and stride width (p= 0.019), significant improvement in gait velocity, stride length (p< 0.001). Regarding dynamic balance capacity, the Tai Chi group had significant improvements in anterior (Left: p= 0.001; Right: p= 0.038), postero-lateral (Left: p< 0.001; Right: p= 0.038), and postero-medial (Left: p= 0.015; Right: p= 0.018).

CONCLUSION

6-week Tai Chi can relieve pain and improve gait and dynamic balance in elderly women with NS-LBP, which suggests Tai Chi could be a promising rehabilitation intervention to reduce the risk of falls in this population.

Differences in pain, disability, and psychological function in low back pain patients with and without anxiety

Objectives: Non-specific low back pain affects people of all ages and is a leading contributor to disease burden worldwide. Chronic low back pain (LBP) reduces working hours, increases comorbidities, and increases rehabilitation needs. The aim of this study was to evaluate whether there were differences in pain, dysfunction, and psychological factors between two groups. The supplementary demonstrated the relationship between these influencing factors and anxiety.

Methods: A cross-sectional study was designed to analyze the differences in pain, disability, and psychological function in non-specific LBP patients with and without anxiety. In total, 60 subjects were divided into two groups based on self-rated anxiety scores: 30 patients with SAS score ≥50 were in the low back pain with anxiety group, and 30 for the LBP without anxiety group with SAS score &lt;50. The pain intensity was assessed using the Visual Analog Scale; psychological function, using the Pain Anxiety Symptoms Scale, the Tampa Scale for Kinesiophobia, and the Fear Avoidance Beliefs Questionnaire; functional disability, using the Oswestry Disability Index and the Roland–Morris Disability Questionnaire; quality of life using 36-Item Short-Form Health Survey questionnaire; and the quality of sleep using Pittsburgh Sleep Quality Index, and the relationships between variables and anxiety scores were estimated using Spearman correlation analysis.

Results: A total of 60 participants were enrolled after self-rated anxiety was assessed and the full investigation was finished. The analyses showed significant differences of pain intensity (p = 0.034, disability (ODI, p = 0.007; RMDQ, p = 0.012) and psychological function (TSK, p = 0.000; PASS, p = 0.009; FABQ, p = 0.000; SF-36, p = 0.000; and PSQI, p = 0.000) between the two groups. Spearman correlation analysis showed that the anxiety score had significant positive correlations with functional disability (ODI, p = 0.004 and 95% CI = 0.112–0.573; RMDQ, p = 0.003, 95% CI = 0.135–0.586) and psychological function (TSK, p = 0.001, 95% CI = 0.174–0.612), excellent positive correlation with quality of sleep (PASS, p = 0.025, 95% CI = 0.031–0.512), and strongly negative correlations with the quality of life (SF-36, p = 0.000, 95% CI = 0.761–0.433).

Conclusion: We recognized that anxiety in low back pain patients was mainly due to interaction with the intensity of pain, disability level, and a mass of psychological function. The future research direction could be to alleviate the anxiety on the comprehensive efficacy of patients with low back pain.

Pain Neuroscience Education and Motor Control Exercises versus Core Stability Exercises on Pain, Disability, and Balance in Women with Chronic Low Back Pain

Background: Several interventions have been used to relieve chronic low back pain (CLBP). This study aimed to compare the effects of pain neuroscience education (PNE) followed by motor control exercises (MCEs) with core stability training (CST) on pain, disability, and balance in women with CLBP. Methods: Thirty-seven women with CLBP were randomly divided into two groups of PNE/MCE (n = 18, 55.2 ± 2.6 years) or CST (n = 19, 54.6 ± 2.4 years). Eight weeks of PNE/MCE or CST were prescribed for each group, independently. Pain intensity (VAS scale), disability (Roland Morris Disability Questionnaire), unipodal static balance, and dynamic balance (time up and go test) were measured at the beginning and 8 weeks after the intervention. Two-way mixed ANOVA was used to analyze the results with alpha of 5%. Results: After 8 weeks, there was a significant difference in VAS scale between groups (p = 0.024), with both PNE/MCE and CST showing 58% and 42% reductions, respectively. There were no differences for all other variables between groups. Regarding pre- to post-comparisons, both groups showed improvements in all dependent variables (p < 0.001). Conclusion: The treatment with PNE/MCE was more effective in improving pain disability and unipodal static and dynamic balance than treatment with CST. Even so, both treatments were shown to be valid and safe in improving all dependent variables analyzed in women with CLBP.

Chronic low back pain is associated with impaired bed turning ability: Evaluation by a mobility detection system

BACKGROUND

We aimed to assess and compare kinetics and kinematic variables of bed turning ability using a mobility detection system in patients with and without chronic low back pain and to observe the impacts of the disease on bed turning kinetics and kinematics.

METHODS

Thirty-five patients with chronic low back pain were enrolled and compared to healthy controls (n = 34). Pain scores and disability level were assessed by Numeric Pain Rating Scale and the function questionnaires including Oswestry Disability Index and Roland Morris Disability Questionnaire. Bed turning ability was tested using the Mobile Detection System. Univariate and multivariate regression analysis were applied to compare the differences between groups.

FINDINGS

Patients with chronic low back pain had significantly lower turning over and back force/weight ratio (p < 0.001) than those healthy controls. Turning over time was significantly longer in patients with Numeric Rating Scale score 3 than in those with Numeric Rating Scale score 2 (p = 0.015). Turning over and back force were significantly higher in male patients and patients with higher BMI after adjusting BMI and sex, respectively (all p < 0.001). When turning back, chronic low back pain patients with Numeric Rating Scale scores of 3 had lower turning back force/weight ratio than those with Numeric Rating Scale scores of 2 (p = 0.014). Male patients had higher turning back force/weight ratio after adjusting pain score (p = 0.001).

INTERPRETATION

The novel Mobility Detection System can provide more objective assessments of bed turning kinetics and kinematics in patients with chronic low back pain.

Impaired static postural control correlates to the contraction ability of trunk muscle in young adults with chronic non-specific low back pain: A cross-sectional study

INTRODUCTION

Patients with chronic non-specific low back pain (CNSLBP) were found with impaired postural control in previous studies. Since the trunk muscle take important efforts on core stability, the study aimed to examine the relationships of postural control during stance tasks and the contractility of trunk muscle in young adults with CNSLBP and without.

METHODS

Healthy individuals (n = 25) and individuals with CNSLBP (n = 30) were included. The thickness of the bilateral transversus abdominis (TrA) and lumbar multifidus (MF) was measured during rest and maximal voluntary contraction, and the change percentages (TrA%, MF%) were calculated. Regarding postural control, COP path length and sway area during the stance tasks were measured thrice in each group.

RESULTS

The bilateral TrA% of the CNSLBP group was less than that of the HC group (p < 0.05). The bilateral TrA% of the CNSLBP group was less than that of the HC group (p < 0.05). The bilateral MF% showed no significantly different(p > 0.05) between the two groups. Compared with healthy controls, CNSLBP patients resulted larger path length and sway area of COP during most of static stance tasks. During the EO task in the CNSLBP group, TrA% was found correlate to COP path length (p < 0.05); the right MF% was correlated with COP sway area (p < 0.05). No significant correlations appeared in the healthy controls (p > 0.05).

CONCLUSIONS

Compared with healthy individuals, impaired postural control during static stance with eyes open in patients with CNSLBP was likely to be related to the poor contraction ability of bilateral transversus abdominis and correlated to the normal contraction ability of right lumbar multifidus.

Supervised Physical Therapy Versus Video-Assisted Technique for Chronic Mechanical Low Back Pain: A Comparative Study

Objective To compare the effect of supervised physical therapy versus video-assisted technique in patients with chronic mechanical low back pain.

Materials and Methods This is a comparative study. Forty-two patients were recruited in the study where they were randomized by simple random sampling. Group A (n = 21) received supervised physical therapy, and Group B (n = 21) received the video-assisted technique. The intervention was given 45 minutes per day for 15 days. The measures of visual analog scale (VAS) and Roland–Morris Disability Questionnaire (RMQ) were taken both at baseline and after 15 days of intervention.

Results Comparison between the two groups using Mann–Whitney U test, supervised physiotherapy group showed significant improvement in VAS on activity, RMQ, and RMQ percentage (p < 0.005). However, Group A, VAS on rest was not significant (p > 0.005).

Conclusion Supervised physical therapy is effective in reducing pain on activity and improved the disability of patients with chronic mechanical low back pain than the video-assisted technique.

Pain Is Associated With Poor Balance in Community-Dwelling Older Adults: A Systematic Review and Meta-analysis

OBJECTIVES

Pain is a risk factor for falls in older adults, but the mechanisms are not well understood, limiting our ability to implement effective preventive strategies. The aim of this study was to systematically review and synthesize the literature that has examined the impact of pain on static, dynamic, multicomponent, and reactive balance in community-dwelling older adults.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Studies from inception to March 2019 were identified from electronic databases (MEDLINE, EMBASE, PsycINFO, CINAHL), contact with the primary authors, and reference lists of included articles.

METHODS

Cross-sectional and case-control studies that compared objective balance measures between older (minimum age 60 years) adults with and without pain were included.

RESULTS

Thirty-nine eligible studies (n = 17,626) were identified. All balance modalities (static, dynamic, multicomponent, and reactive) were significantly poorer in participants with pain compared to those without pain. Subgroup analyses revealed that chronic pain (pain persisting ≥3 months) impaired balance more than pain of unspecified duration. The effects of pain at specific sites (neck, lower back, hip, knee, and foot) on balance were not significantly different.

CONCLUSIONS AND IMPLICATIONS

Pain is associated with poor static, dynamic, multicomponent, and reactive balance in community-dwelling older adults. Pain in the neck, lower back, hip, knee, and foot all contribute to poor balance, and this is even more pronounced for chronic pain. Comprehensive balance and pain characteristic assessments may reveal mechanisms underlying the contribution of pain to instability and increased fall risk in older people.

Lateral Abdominal Muscles Shear Modulus and Thickness Measurements under Controlled Ultrasound Probe Compression by External Force Sensor: A Comparison and Reliability Study

The aim of this study was to perform a reliability and agreement analysis and to compare lateral abdominal muscles (LAMs) thickness and elasticity results obtained by an experienced operator, by a non-experienced operator, and in an ultrasound imaging probe compression controlled (PCC) condition with minimal force necessary to obtain a proper ultrasound image. The sample consisted of 39 adolescents. An Aixplorer ultrasound scanner was used to evaluate the LAM. The probe in PCC condition was positioned in a prepared probe holder coupled with a pressure sensor. The LAM thickness and elasticity measurements were significantly (p < 0.05) different in the ultrasound PCC condition, compared to results obtained by both examiners. The abdominal oblique external and internal muscle thickness measurements were underestimated and all LAM shear moduli were overestimated during measurements without controlling the probe compression by an external sensor. The intra-class correlation coefficient was excellent in all conditions, but the smallest detectable differences were approximately 43–60% lower during the measurements collected in PCC condition. Differences in LAM measurements between PCC and ‘on-hand’ conditions may be clinically irrelevant when the force applied by the probe is consciously controlled by the examiner. However, during ultrasound measurements of the LAM morphology, the potential under/over estimation should always be considered when measurements are performed without controlling probe compression by an external sensor.

The Effects of Abdominal Hypopressive Training on Postural Control and Deep Trunk Muscle Activation: A Randomized Controlled Trial

BACKGROUND

Abdominal Hypopressive Training (AHT) provides postural improvement, and enhances deep trunk muscle activation. However, until recently, there was a lack of scientific literature supporting these statements. The major purpose of this study was to investigate the effect of AHT on posture control and deep trunk muscle function.

METHODS

125 female participants aged 18-60 were randomly allocated to the Experimental Group (EG), consisting of two sessions of 30 min per week for 8 weeks of AHT, or the Control Group (CG), who did not receive any treatment. Postural control was measured with a stabilometric platform to assess the static balance and the activation of deep trunk muscles (specifically the Transverse Abdominal muscle (TrA)), which was measured by real-time ultrasound imaging.

RESULTS

The groups were homogeneous at baseline. Statistical differences were identified between both groups after intervention in the Surface of the Center of Pressure (CoP) Open-Eyes (S-OE) (p = 0.001, Cohen's d = 0.60) and the Velocity of CoP under both conditions; Open-Eyes (V-OE) (p = 0.001, Cohen´s d = 0.63) and Close-Eyes (V-CE) (p = 0.016, Cohen´s d = 0.016), with the EG achieving substantial improvements. Likewise, there were statistically significant differences between measurements over time for the EG on S-OE (p < 0.001, Cohen´s d = 0.99); V-OE (p = 0.038, Cohen´s d = 0.27); V-CE (p = 0.006, Cohen´s d = 0.39), anteroposterior movements of CoP with Open-Eyes (RMSY-OE) (p = 0.038, Cohen´s d = 0.60) and activity of TrA under contraction conditions (p < 0.001, Cohen´s d = 0.53).

CONCLUSIONS

The application of eight weeks of AHT leads to positive outcomes in posture control, as well as an improvement in the deep trunk muscle contraction in the female population.

Is the pain pressure threshold linked to the transversus abdominis in women with chronic neck pain?: a preliminary report

PURPOSE

The present study aimed to investigate the relationship between the ultrasonography parameters of transversus abdominis and neck pain manifestations in women with chronic neck pain.

MATERIALS AND METHODS

Thirty women (mean age: 38.44 ± 9.56 years, BMI: 25.57 ± 3.32 kg/m²) with chronic neck pain were included in the study. The pain severity, disability scores, and bilateral pain pressure threshold of upper trapezius were assessed. The thickness of transversus abdominis in-rest and abdominal draw-in conditions were evaluated by two-dimensional ultrasonography. Pearson's correlation coefficients and linear regression statistics were determined.

RESULTS

We found a moderate correlation between the thickness of transversus abdominis in abdominal draw-in and the pain pressure threshold of right (r = 0.636, p < 0.001), and left upper trapezius (r = 0.403, p = 0.03). Moreover, there was a moderate correlation between the pain pressure threshold of the right upper trapezius and the thickness of transversus abdominis in-rest (r = 0.498, p = 0.006). No significant correlation was found between pain intensity, disability scores, and ultrasonography parameters of transversus abdominis. There was also a significant total effect of transversus abdominis' thickness on abdominal draw-in manoeuvre on predicting pain pressure threshold of right upper trapezius (B = 0.636, SE = 0.765, p < 0.001) and pain pressure threshold of left upper trapezius (B = 0.403, SE = 0.840, p = 0.03).

CONCLUSIONS

Our results revealed that upper trapezius muscle tenderness may associated with decreased muscle thickness of transversus abdominis. Addressing new exercise methodologies including transversus abdominis training in the management of chronic neck pain may be helpful to improve neck pain symptoms.

Application of ultrasound for muscle assessment in sarcopenia: 2020 SARCUS update

PURPOSE

In 2018, the SARCUS working group published a first article on the standardization of the use of ultrasound to assess muscle. Recommendations were made for patient positioning, system settings and components to be measured. Also, shortcomings in knowledge were mentioned. An important issue that still required standardization was the definition of anatomical landmarks for many muscles.

METHODS

A systematic search was performed in Medline, SCOPUS and Web of Sciences looking for all articles describing the use of ultrasound in the assessment of muscle not described in the first recommendations, published from 01/01/2018 until 31/01/2020. All relevant terms used for older people, ultrasound and muscles were used.

RESULTS

For 39 muscles, different approaches for ultrasound assessment were found that likely impact the values measured. Standardized anatomical landmarks and measuring points were proposed for all muscles/muscle groups. Besides the five already known muscle parameters (muscle thickness, cross-section area, pennation angle, fascicle length and echo-intensity), four new parameters are discussed (muscle volume, stiffness, contraction potential and microcirculation). The former SARCUS article recommendations are updated with this new information that includes new muscle groups.

CONCLUSIONS

The emerging field of ultrasound assessment of muscle mass only highlights the need for a standardization of measurement technique. In this article, guidelines are updated and broadened to provide standardization instructions for a large number of muscles.

Determination of Biodex Balance System Cutoff Scores in Older People With Nonspecific Back Pain: A Cross-sectional Study

OBJECTIVE

The purpose of this study was to determine cutoff scores for the Biodex Balance System (BBS) and verify if they could be used to discriminate older people with nonspecific low back pain (NSLBP) with poor postural performance from those with good postural performance.

METHODS

This cross-sectional study included 52 participants with NSLBP older than 65 years. One level of stability (level 5; intraclass correlation ≥0.70) and 2 conditions (eyes open and eyes closed) were selected for the testing procedure. Anterior-posterior stability index (APSI), medial-lateral stability index (MLSI), and overall stability index (OSI) scores were calculated. The participants were classified into 2 groups: high risk of falling and low risk of falling. Both the receiver operating characteristic and the area under the curve were used to determine the best BBS cutoff values. Binary logistic regression analysis was used to investigate the ability of BBS scores to predict risk of falling.

RESULTS

BBS cutoff scores in the eyes-open condition (APSI = 2.60, MLSI = 1.95, OSI = 2.95) and eyes-closed condition (APSI = 3.05, MLSI = 2.17, OSI = 3.25) were found to be sensitive and specific in determining postural performance. Participants with index values lower than the cutoff scores had, respectively, 6.42, 4.20, and 3.72 times lower risk of falling in the eyes-open condition and 3.33, 5.50, and 3.00 times lower risk of falling in the eyes-closed condition. The predictive characteristics of the models for risk analysis were excellent and good to excellent.

CONCLUSION

Our study shows that BBS cutoff scores are sensitive and specific in distinguishing between poor and good postural performance in older people with NSLBP.

Pain Catastrophizing Is Related to Static Postural Control Impairment in Patients with Nonspecific Chronic Low Back Pain: A Cross-Sectional Study

Purpose

Pain catastrophizing may contribute to the altered trunk muscle activity in patients with nonspecific chronic low back pain (NSCLBP). It is unclear if pain catastrophizing influences static postural control in patients with NSCLBP. This study aimed to investigate the relationship between pain catastrophizing and static postural control in NSCLBP patients.

Methods

Sixty-eight participants with NSCLBP and 40 healthy participants were recruited. Postural control was assessed by the sway area and the sway length of the center of pressure (COP) during balance tests. Pain catastrophizing in participants with NSCLBP was assessed by the Pain Catastrophizing Scale (PCS). Bilateral transversus abdominis (TrA) activation was evaluated by ultrasound imaging-measured percent change in muscle thickness. Associations between COP parameter and PCS/subscales of PCS were examined by multiple linear regression (MLR).

Results

Our results observed a larger COP sway area in NSCLBP group under eyes-closed condition (p < 0.001) and a lower level of voluntary activation of the bilateral TrA (p < 0.001), compared with the healthy control group. The MLR analyses revealed that the COP area sway under eyes-closed condition was significantly associated with the PCS score/helplessness score of PCS, voluntary activation of the left TrA, and age in participants with NSCLBP (β = 0.222/0.236, 0.341/0.344, and 0.328/0.325; p=0.045/0.033, 0.002, and 0.004, resp.).

Conclusions

Static postural control was associated with pain catastrophizing, voluntary activation of TrA, and age in participants with NSCLBP. This indicated that pain catastrophizing may affect postural control and should be considered when interpreting balance test results and managing NSCLBP.

Modification of Pronated Foot Posture after a Program of Therapeutic Exercises

Working on the intrinsic musculature of the foot has been shown to be effective in controlling pronation. However, the potential coadjuvant effect that involving other muscle groups might have on foot posture remains unknown. The aim was, therefore, to assess whether a 9-week intrinsic and extrinsic foot and core muscle strength program influenced foot posture in pronated subjects. The participants were 36 healthy adults with pronated feet that were randomly assigned to two groups. The experimental group (n = 18) performed a strengthening exercise protocol for 9 weeks (two sessions of 40 min per week), while the control group (n = 18) did not do these exercises. After 9 weeks, the foot posture index (FPI) scores of the two groups were analyzed to detect possible changes. The FPI at the baseline was 8.0 ± 1.5. After the 9 weeks, the experimental group showed significantly reduced FPI from 8.1 ± 1.7 to 6.4 ± 2.1 (p = 0.001), while the control group had the same score as pre-intervention (FPI 8 ± 1.2, p = 1.0). The FPI scores showed no significant differences by sex. Strengthening of the intrinsic and extrinsic foot and core muscles contributed to improving foot posture in adults, reducing their FPI by 1.66 points.

Core muscles thickness is not associated with knee frontal plane projection angle during single-leg squat in healthy people

BACKGROUND

Core muscles play an important role in lower limb stability and alignment, with their weakness being associated with poor alignment and, consequently, with injuries. Despite muscle structure being critical to muscle strength production, we did not find studies associating the morphology of the core muscles and lower limb alignment during functional tasks.

RESEARCH QUESTION

Is there association between thickness of core muscles (external oblique - EO, internal oblique - IO, transversus abdominis - TrA and gluteus medius - GMed) and lower limb alignment during the single-leg squat in healthy subjects?

METHODS

Forty-six healthy participants (27 male and 19 female) performed the following evaluations: (i) measurements of muscle thickness of the EO, IO, TrA and GMed using ultrasound and (ii) measurements of lower limb alignment using the knee frontal plane projection angle (FPPA) during the single-leg squat. A Spearman rank correlation coefficient (r_s) was performed between the thickness of selected core muscles (OE, OI, TrA and GMed) and the knee FPPA. In addition, a partial correlation (r) was performed, using sex, physical activity level and body mass index as control variables.

RESULTS

We did not observe significant correlations between the knee FPPA and the thickness of the EO (r_s = 0.194; p = 0.197), IO (r_s = 0.182; p = 0.225), TrA (r_s = 0.073; p = 0.627) and GMed (r_s = -0.092; p = 0.542). When controlling for sex, physical activity level and body mass index, similar results were observed [EO (r = 0.157; p = 0.316), IO (r = 0.261; p = 0.092), TrA (r = 0.030; p = 0.850) and GMed (r = -0.144; p = 0.356)] SIGNIFICANCE: Our results demonstrated that core muscles' thickness is not associated with lower limb alignment during the single-leg squat in healthy people.

Does Plantar Pressure Distribution Influence the Lumbar Multifidus Muscle Thickness in Asymptomatic Individuals? A Preliminary Study

BACKGROUND

Atrophy can occur in the lumbar multifidus (LM) muscle quickly as a result of various musculoskeletal problems. Knowing factors influencing muscle thickness of the LM will provide important clues about lumbopelvic stability.

OBJECTIVES

Although there are several studies in the literature investigating the adverse effects of foot-ankle postural disorders on the lumbopelvic region, to our knowledge there has been no investigation of plantar pressure distribution (PPD) as a factor influencing muscle thickness of the LM. The aim of this study was to determine whether PPD could affect LM muscle thickness.

METHODS

This observational study consisted of 25 asymptomatic individuals. Ultrasonographic imaging was used to determine the thickness of the LM. All participants were subjected to PPD analysis using the Digital Biometry Scanning System and Milletrix software in 9 different plantar pressure zones. The Pearson product-moment correlation coefficients were used to examine the correlations between the LM muscle thickness and other variables. Stepwise multiple linear regression analysis was used to determine the variables with the greatest influence on LM muscle thickness.

RESULTS

Peak pressures of medial and lateral zones of the heel were the significant and independent factors influencing static LM thickness, with 39.5% of the variance; moreover, the peak pressures of heel medial and fourth metatarsal bone were the significant and independent factors influencing dynamic LM thickness, with 38.7% of the variance.

CONCLUSIONS

Plantar pressure distribution could be an important factor influencing LM thickness, although further research is required. Examining foot-ankle biomechanics may provide information about the stability of the LM.

Inconsistent descriptions of lumbar multifidus morphology: A scoping review

Background

Lumbar multifidus (LM) is regarded as the major stabilizing muscle of the spine. The effects of exercise therapy in low back pain (LBP) are attributed to this muscle. A current literature review is warranted, however, given the complexity of LM morphology and the inconsistency of anatomical descriptions in the literature.

Methods

Scoping review of studies on LM morphology including major anatomy atlases. All relevant studies were searched in PubMed (Medline) and EMBASE until June 2019. Anatomy atlases were retrieved from multiple university libraries and online. All studies and atlases were screened for the following LM parameters: location, imaging methods, spine levels, muscle trajectory, muscle thickness, cross-sectional area, and diameter. The quality of the studies and atlases was also assessed using a five-item evaluation system.

Results

In all, 303 studies and 19 anatomy atlases were included in this review. In most studies, LM morphology was determined by MRI, ultrasound imaging, or drawings – particularly for levels L4–S1. In 153 studies, LM is described as a superficial muscle only, in 72 studies as a deep muscle only, and in 35 studies as both superficial and deep. Anatomy atlases predominantly depict LM as a deep muscle covered by the erector spinae and thoracolumbar fascia. About 42% of the studies had high quality scores, with 39% having moderate scores and 19% having low scores. The quality of figures in anatomy atlases was ranked as high in one atlas, moderate in 15 atlases, and low in 3 atlases.

Discussion

Anatomical studies of LM exhibit inconsistent findings, describing its location as superficial (50%), deep (25%), or both (12%). This is in sharp contrast to anatomy atlases, which depict LM predominantly as deep muscle. Within the limitations of the self-developed quality-assessment tool, high-quality scores were identified in a majority of studies (42%), but in only one anatomy atlas.

Conclusions

We identified a lack of standardization in the depiction and description of LM morphology. This could affect the precise understanding of its role in background and therapy in LBP patients. Standardization of research methodology on LM morphology is recommended. Anatomy atlases should be updated on LM morphology.

Relationship Between Postural Stability and Paraspinal Muscle Adaptation in Lame Horses Undergoing Rehabilitation

Postural stability maintains balance, protects the spinal column, and allows accurate responses to destabilizing forces. The musculus multifidus (m. multifidus) is the major postural muscle located adjacent to the vertebrae along the length of the spinal column. Increased cross-sectional area (CSA) of the m. multifidus has been demonstrated in horses after a rehabilitation strengthening exercise program; however, correlation with functional postural stability has not been shown. The objective of the present study is to evaluate the relationship of the thoracolumbar m. multifidus CSA and measures of postural sway performance in lame horses undergoing rehabilitation exercises in clinical cases. Seven client-owned horses admitted to the equine rehabilitation service were included in the study. M. multifidus CSA was measured via ultrasonography at the start of a rehabilitation program (initial evaluation) and after 12 weeks of rehabilitation exercises (final evaluation). Postural sway data were also measured at initial and final evaluation. A significant increase in m. multifidus CSA was seen from initial to final evaluation. A moderate to strong correlation was present between m. multifidus CSA and postural sway variables. These results suggest that there is an association between postural stability and m. multifidus hypertrophy in lame horses undergoing individualized rehabilitation programs. However, more research is needed to provide a definitive answer on the nature of this relationship. Ideally, specific performance tests would better define and examine the relationship in which to guide clinicians in rehabilitation protocol development.

Supersonic Shear Imaging for Quantification of Lateral Abdominal Muscle Shear Modulus in Pediatric Population with Scoliosis: A Reliability and Agreement Study

The aim of this study was to assess the intra- and inter-rater reliability/agreement of the lateral abdominal muscle (LAM) stiffness and thickness measurements at rest and during contraction and to determine the relationship between the superficial fat thickness and the LAM stiffness measurements. LAM stiffness and thickness were measured using supersonic shear wave elastography (SSI) in pediatric participants. The reliability of LAM stiffness and thickness measurements ranged from moderate to excellent. There was an inverse correlation between fat thickness and between-rater difference in the resting external oblique stiffness (r > -0.37) and the contracted external and internal oblique stiffness (r > -0.40). SSI is a reliable method for assessing LAM stiffness and thickness in pediatric populations. To remove potential systematic errors: (i) the first round of measurements should be performed to familiarize patients with procedures; (ii) the examiner should pay more attention while performing LAM measurements on the opposite side of the body.