Reliability of a test measuring transversus abdominis muscle recruitment with a pressure biofeedback unit

The Role of Dynamic Neuromuscular Stabilization Exercises in Stress Urinary Incontinence Among Females Aged 18-40 Years

BACKGROUND AND OBJECTIVE

Stress urinary incontinence (SUI) is prevalent among females across various age groups, yet societal taboos and unawareness contribute to under-reporting and hinder effective management strategies. This study aimed to evaluate the efficacy of dynamic neuromuscular stabilization (DNS) compared to traditional Kegel exercises in females with stress urinary incontinence, focusing on assessing the impact of DNS on pelvic floor strength and core musculature activation to provide valuable insights into urinary continence management.

METHODOLOGY

This is a single-blinded, randomized trial with 90 females aged 18-40 years assessed perineometer readings, pelvic floor electromyography (EMG), and transverse abdominis activation via pressure biofeedback.

RESULTS

Significant improvements in pelvic floor strength and core musculature activation were observed in the DNS group compared to the Kegel exercise group. Perineometer values, EMG measurements, and pressure biofeedback unit readings demonstrated substantial enhancements post-intervention in both groups. Effect sizes, including Cohen's D and point biserial correlation coefficient, indicated medium to large effects favoring the DNS intervention.

CONCLUSION

DNS is superior to Kegel exercises for SUI management, emphasizing the importance of targeting core musculature. Future research should explore long-term outcomes and patient-reported measures for a comprehensive understanding.

Measuring transversus abdominis activity using pressure biofeedback unit-A technical report

BACKGROUND AND PURPOSE

Pressure biofeedback is a tool that can detect the movement of a structure and may be used as an indicator of muscle function. It's widely used to measure the transversus abdominis (TrA) muscle activity. Pressure biofeedback (PBU) monitors the abdominal wall movement by measuring the pressure change during abdominal hollowing and can indirectly evaluate the TrA muscle function, which is considered as a valuable tool. The evaluation of the training of core muscles, including the transversus abdominis, requires a reliable outcome. Various methods using different positions are used to evaluate the transversus abdominis muscle function. However, it is noted that a standard way of evaluation and training still needs to be improved in research and clinical practice. This technical report discusses the optimal position and technique to measure the TrA muscle activity using PBU, with discussions on the merits and demerits of the body positions.

METHODS

The technical report is presented with a literature review of the PBU measurement of TrA and through observation in the clinical practice. The evaluation methods of TrA, including the position to activate and isolate, are discussed in detail.

RESULTS

Training core muscles does not imply TrA activation, and evaluating isolated TrA and multifidus is essential before intervention. The abdominal drawing-in maneuver effectively activates TrA in various evaluation positions of the body, but when using PBUs, it would be valid in a prone position.

DISCUSSION

Different body positions are practiced to train TrA and core muscles using PBU, commonly adopted by practice are in supine. It's noted that most of the studies lack in establishing the effectiveness of the position in evaluating the TrA muscle activity using PBU. The need for insight into an appropriate technique for evaluating TrA activity is addressed in this technical report. This report presents key points on the complete technique and concludes that the prone position is superior to other positions and recommended for measuring and recording the TrA activity using a PBU.

Effects of "Taking the Waist as the Axis" Therapy on trunk postural control disorder after stroke: A randomized controlled trial

Background

Sufficient attention to trunk rehabilitation after stroke is still lacking. Loss of trunk selective activity is considered to be the leading cause of trunk postural control disorder after stroke. "Taking the Waist as the Axis" Therapy (WAT) was developed as a combination of the concept of "Taking the Waist as the Axis" from Tai Chi and the rehabilitation of trunk dysfunction after stroke. The present clinical trial examined and assessed the effects of WAT on stroke patients.

Methods

A total of 43 stroke hemiplegic patients with trunk postural control disorder, whose Trunk Impairment Scale (TIS) scoring between 8 and 18, participated in the present study and were allocated randomly to the experimental (n = 23) or control groups (n = 20). The experimental group received WAT plus conventional therapy, and the control group received "Trunk Selective Activity" Therapy (TSAT) plus conventional therapy. Both groups received treatment once daily and 5 times per week for 3 weeks. The Trunk Impairment Scale (TIS), Fugl-Meyer Assessment (FMA), Berg Balance Scale (BBS), change of Intra-abdominal Pressure (IAP), static balance ability assessment, rapid ventilation lung function test and the Modified Barthel Index (MBI) were evaluated before and after intervention for both groups.

Results

The experimental group was superior to the control group in TIS [4 (2, 5) vs. 3 (1.25, 4), p = 0.030], change of IAP [-3 (-8, -1.33) vs. -0.02 (-3.08, 6), p = 0.011], FMA-upper extremity [10 (6, 18) vs. 1 (0, 3), p = 0.002], FMA-lower extremity [2 (1, 4) vs. 1 (0, 2), p = 0.009] and FMA [14 (7, 21) vs. 2 (0.25, 3.75), p = 0.001]. Within experimental group, forced vital capacity (FVC) [81.35 (63.30, 94.88) vs. 91.75 (79.40, 97.90), p = 0.02] was significantly improved.

Conclusion

WAT was an effective trunk treatment after stroke, which significantly improved the patients' trunk posture control ability, motor function and forced vital capacity. However, the results still need to be interpreted with caution for the intervention only lasted for 3 weeks.

Comparison of the Effects of Myofascial Meridian Stretching Exercises and Acupuncture in Patients with Low Back Pain

Background

Acupuncture and myofascial meridians show great anatomical and clinical compatibility.

Objectives

We aimed to compare the effects of myofascial meridian stretching exercises and acupuncture in patients with low back pain.

Methods

We randomized 81 subjects with acute/subacute low back pain into three groups: an acupuncture (A) group, a myofascial meridian stretching (MMS) group, and a control (C) group. We recorded the Numerical Rating Scale (NRS) and Roland- Morris Disability Questionnaire (RMQ) scores at baseline and weeks two and six. We evaluated posterior pelvic tilt and transversus abdominis muscle strenghth with a pressure biofeedback unit, back extensor muscle strength by the Sorenson test, and lumbar range of motion (ROM) with an inclinometer. Group A received acupuncture (BL 57 and BL 62 acupoints) and stretching exercises according to the posterior superficial line were applied to the MMS group.

Results

Improvements in the NRS score were more prominent in group A than in group C (p = 0.004). The RMQ score improvement between baseline and weeks two and six was more prominent in groups A and MMS (p < 0.001, p = 0.001, respectively). The Sorenson test showed significant improvement between the baseline and week two in groups A and MMS (p = 0.004, p < 0.001, respectively). The increase in lumbar ROM measurement in the MMS group between baseline and week two was significantly higher than in groups A and C (p = 0.009, p < 0.001, respectively).

Conclusion

Stretching exercises according to the myofascial meridian system and acupuncture contributed to improved symptoms in the first two weeks in patients with acute/subacute low-back pain.

Prevalence and Potential Risk Factors for Occupational Low Back Pain Among Male Military Pilots: A Study Based on Questionnaire and Physical Function Assessment

Objectives: Low back pain (LBP) has negative implications for the military's combat effectiveness. This study was conducted to determine the prevalence and risk factors of LBP among pilots through a questionnaire and physical function assessments.

Methods: Data on the demographic and occupational characteristics, health habits, physical activity, and musculoskeletal injuries of 217 male pilots (114 fighter, 48 helicopter, and 55 transport pilots) were collected using a self-reported questionnaire and physical function assessments.

Results: LBP prevalence was 37.8% in the total cohort and 36.0, 45.8, and 34.5% among fighter, helicopter, and transport pilots, respectively. Multivariate regression analysis revealed that the risk factors significantly associated with LBP were neck pain [odds ratio (OR): 3.559, 95% confidence interval (CI): 1.827–6.934], transversus abdominis activation (OR: 0.346, 95% CI: 0.172–0.698), and hip external rotator strength (OR: 0.001, 95% CI: 0.000–0.563) in the total cohort; neck pain (OR: 3.586, 95% CI: 1.365–9.418), transversus abdominis activation (OR: 0.268, 95% CI: 0.094–0.765), hip external rotator strength (OR: 0.000, 95% CI: 0.000–0.949), and weekly flying hours (OR: 3.889, 95% CI: 1.490–10.149) in fighter pilots; irregular strength training (OR: 0.036, 95% CI: 0.003–0.507) and hip external rotator strength (OR: 0.000, 95% CI: 0.000–0.042) in helicopter pilots; and neck pain (OR: 6.417, 95% CI: 1.424–28.909) in transport pilots.

Conclusions: High volume flight schedules and weak core muscle functions have significant negative effects on pilots' back health. LBP is commonly associated with high weekly flying hours, worsening neck pain, transversus abdominis insufficient activation, and reduced hip extensor/rotator strength. Risk factors vary among pilots of different aircraft. Thus, specific core muscle training would be especially important for military pilots.

DIFFERENTIAL EFFECTS OF THE ABDOMINAL DRAW-IN MANEUVER IN DIFFERENT POSITIONS ON MUSCLE THICKNESS AND BALANCE RATIO IN NONSYMPTOMATIC ADULTS

Core stability mediated by the abdominal draw-in maneuver (ADIM) has been proven to be an important component of neuromuscular motor control before movement. However, no previous research has investigated which position is best for performing ADIM to achieve optimal core stability. This study aimed to define the effectiveness of performing ADIM in three different positions (prone, supine, and hook lying) on abdominal muscle thickness in nonsymptomatic participants. In total, 30 nonsymptomatic participants (mean age: [Formula: see text] years) were randomly assigned to a trial sequence using the random sequence method. The clinical outcomes were transverse abdominis (TrA), external oblique (EO), and internal oblique (IO) muscle thicknesses, which were evaluated using ultrasonography (US) and muscle thickness balance ratio. One-way repeated-measures analysis of variance (ANOVA) was used to evaluate the US data to determine if the resulting TrA, IO, and EO muscle thicknesses from the three different positions were statistically significant. Bonferroni correction was used as a post hoc test if statistical significance was found. The [Formula: see text] value was set to 0.013. One-way ANOVA showed a significant difference in the thickness of the TrA, IO, and EO muscles resulting from the different positions ([Formula: see text]). Post hoc analysis using Bonferroni correction revealed that the prone position resulted in greater changes than the supine and hook-lying positions ([Formula: see text], respectively). ANOVA did not show a significant change in the TrA, IO, and EO muscle thickness balance ratios ([Formula: see text], 0.44, and 0.59, respectively). The results provide innovative clinical evidence that performing ADIM in different positions (prone, supine, and hook lying) has different effects on abdominal muscle thickness in nonsymptomatic participants.

Correlation between palpatory assessment and pressure sensors in response to postural trunk tests

BACKGROUND: The evaluation of postural trunk muscle function is a critical component of clinical assessment in patients with musculoskeletal pain and dysfunction. Postural activation of the trunk muscles has been evaluated by various methods. This study evaluates the correlation between subjective assessment of postural trunk muscle function with an objective measurement of abdominal wall expansion. METHODS: Twenty-five healthy participants (16 women, 9 men, age 22.4 years) were assessed. The subjective assessment was performed by two experienced Dynamic Neuromuscular Stabilization (DNS) clinicians evaluating the quality of trunk stabilization using five postural stability tests through palpation and observation. Interrater reliability was determined using an intraclass correlation coefficients (ICC). Objective measurement was performed using a new device (DNS Brace) which externally measures abdominal wall pressure. Spearman rank correlations were calculated for both palpation and observation measures with DNS Brace data. RESULTS: The interrater reliability (ICC2,k) estimates demonstrated moderate reliability in palpation measures for three DNS tests: Hip flexion test, Diaphragm test, & Intra-abdominal pressure regulation test (IAPRT) (ICC = 0.645–0.707). For observation measures, good reliability was found in IAPRT (ICC = 0.835), and three tests demonstrated moderate reliability: Hip flexion test, Diaphragm test, & Breathing Stereotype (ICC = 0.577–0.695). Correlation analysis demonstrated several moderate to strong correlations between palpation and DNS brace values (Assessor 1): IAPRT, rs= 0.580, p= 0.002, Diaphragm test, rs= 0.543, p= 0.005, (Assessor 2): IAPRT, rs= 0.776, p< 0.001, Breathing Stereotype, rs= 0.625, p= 0.001, Diaphragm test, rs= 0.519, p= 0.008, Hip Flexion test, rs= 0.536, p= 0.006, and Arm Elevation test, rs= 0.460, p= 0.021. For observation, several moderate correlations were demonstrated with DNS brace values (Assessor 1): Arm Elevation test, rs= 0.472, p= 0.017, (Assessor 2) Diaphragm test, rs= 0.540, p= 0.005, IAPRT rs= 0.475, p= 0.016, Hip Flexion test, rs= 0.485, p= 0.014, and Arm Elevation, rs= 0.451, p= 0.024. CONCLUSION: Based on inter-rater reliability and DNS brace correlations with trained DNS professionals, the IAPRT, Diaphragm test, and Hip Flexion test may prove useful when assessing asymptomatic individuals. More research is needed in order to establish the utility of DNS brace and clinical testing both in asymptomatic and back pain populations. DNS tests must be supplemented by further examinations for definitive clinical decision making.

Effect of Transversus abdominis muscle training on pressure-pain threshold in patients with chronic low Back pain

Background

Therapeutic training is the most commonly used treatment methods for chronic low back pain (CLBP), and the use of a pressure biofeedback unit for transversus abdominis muscle (TrA) training is one of the core muscle training methods. The study aim of this research is to explore the effects of different intensities (sham training, low-intensity and high-intensity) of TrA muscle training on people with CLBP in pressure-pain threshold (PPT).

Methods

A total of 45 patients with CLBP were recruited, of whom 44 were included in the analysis. Fifteen, 14, and 15 were included in the sham training group, the low-intensity group, and the high-intensity group, respectively. A pressure biofeedback unit was used in performing a one-time TrA training intervention involving 30 times of 180 mmHg TrA contraction training at high intensity for 10 min and 15 times of 100 mmHg TrA contraction training at low intensity for 5 min. The sham training group completed comfort exercises and did not undergo training. The evaluation indicators were as follows: PPT, short-form McGill pain questionnaire, and body surface pain radiation.

Results

High-intensity training could activate more waist core muscles than low-intensity training. Significant changes on PPT (units: kgf) were observed in the following four muscles immediately after high-intensity training: iliopsoas [0.69 (0.13–1.25) 95% CI, p = 0.020]; quadratus lumborum [0.84 (0.23–1.45) 95% CI, p = 0.012]; erector spinae [0.66 (0.18–1.15) 95% CI, p = 0.011]; transversus abdominis [0.70 (0.26–1.14) 95% CI, p = 0.004], and in three muscles after low-intensity training: quadratus lumborum [0.61 (0.17–1.05) 95% CI, p = 0.009]; transversus abdominis [0.14 (from − 0.15 to 0.43) 95% CI, p = 0.022]; piriformis [0.55 (0.13–0.98) 95% CI, p = 0.014]. The change in body surface pain radiation immediately after exercise was [− 10.87 (from − 17.51 to − 4.22) 95% CI, p = 0.003] for high-intensity training and [− 5.21 (from − 9.40 to − 1.03) 95% CI, p = 0.019] for low-intensity training.

Conclusions

TrA training could increase the PPT of the waist core muscles and reduce the radiation range of waist pain. The benefits of high-intensity training are higher than those of low-intensity training.

Trial registration

ChiCTR-TRC-13003701. Registered 18 October 2013.

Code of ethical approval: 2018069.

Comparison of the Pressure Biofeedback Unit and Real-Time Ultrasound Imaging as Feedback Tools to Contract the Transversus Abdominis Muscle: A Randomized Controlled Trial in Healthy Older Adults

BACKGROUND AND PURPOSE

The transversus abdominis (TrA) is a key muscle for lumbar stabilization and is often retrained in physical therapy. Feedback tools, such as the pressure biofeedback unit (PBU) and rehabilitative ultrasound imaging (RUSI), are frequently used by physical therapists to train their patients and improve their patients' ability to contract this muscle. However, the effect of these tools in rehabilitating the TrA in older adults remains to be demonstrated, as is their efficiency in transferring the skill of recruiting the TrA from a supine position to a standing position.The objective of the study was to compare the immediate effectiveness of the PBU and RUSI to reeducate the TrA muscle in a population of asymptomatic older adults (without pain).

METHODS

Forty participants were randomized into 2 groups (RUSI or PBU). The intervention included a training session involving 15 TrA contractions held for 10 seconds with the corresponding feedback device. The dependent variable, TrA thickness (a muscle activation indicator), was measured using ultrasound images before and after the intervention in a supine and standing position. Nonparametric analyses were used for inter- and intragroup comparisons.

RESULTS AND DISCUSSION

The results showed no between-group differences in TrA activation ratio (AR) in the supine or standing position (supine AR: TrA RUSI thickness change P = .53 vs PBU thickness change P = .73, comparison between groups P = .51; standing AR: TrA RUSI thickness change P = .003 vs PBU thickness change P = .10; comparison between groups P = .61). However, the change in TrA thickness compared to the other abdominal wall muscles in a standing position was significantly less post-intervention for the RUSI group only (RUSI P = .006 vs PBU P = .72). Both groups remained similar post-intervention for this outcome (P = .20).

CONCLUSIONS

Neither the RUSI nor the PBU seems to have the desired effect on the activation of TrA in asymptomatic older adults.

Influence of Abdominal Hollowing Maneuver on the Core Musculature Activation during the Prone Plank Exercise

This cross-sectional study of repeated measures investigated whether integrating the abdominal hollowing maneuver (AHM) into the prone plank performance is an effective strategy for increasing both the activation of the deep and superficial core musculature. Electromyographical (EMG) responses of rectus abdominis (RA), external oblique (EO), internal oblique (IO), and lumbar erector spinae (LES), and ratings of perceived exertion (RPE) of 20 participants (13 male, 7 female; mean ± standard deviation (SD) age: 24.25 ± 3.54 years; body mass: 66.42 ± 8.40 kg; height: 1.70 ± 9.51 m) were compared across two experimental conditions: the traditional prone plank (STANDARD); and a variation including the AHM (HOLLOWING). Regarding Total Intensity, HOLLOWING resulted in significantly greater EMG response than STANDARD (p < 0.001; Effect size (ES) = 3.01). Specifically, RA showed no significant differences between STANDARD and HOLLOWING (p = 0.056; ES = 0.285). However, for the remaining analyzed muscles, HOLLOWING significantly provided higher EMG activation compared to STANDARD (LES: p = 0.004; ES = 0.619; left EO: p < 0.001; ES = 1.031; right EO: p < 0.001; ES = 1.419; left IO: p < 0.001; ES = 2.021; right IO: p < 0.001; ES = 2.269). Regarding RPE, HOLLOWING reported values significantly greater than STANDARD (p < 0.001; ES = 2.94). In conclusion, integrating the AHM into the prone plank exercise enhances overall abdominal activity, particularly in both obliques. These findings provide updated guidelines for lumbar stabilization and core strengthening in health-related physical fitness programs.

Intrasession Real-time Ultrasonography Feedback Improves the Quality of Transverse Abdominis Contraction

OBJECTIVE

The purpose of this study was to compare changes in thickness of the transverse abdominis during performance of the hollowing exercise guided by feedback using ultrasonography images together with verbal guidance and using verbal guidance alone. We also determined the minimal detectable change and agreement between normalized pressures and muscle thickness.

METHODS

Twenty participants without lumbar pain performed the hollowing exercises with or without ultrasonography feedback: 7 men and 13 women, mean (SD) age = 25 (5) years, height = 166 (10) cm, body mass = 64 (6) kg, body mass index = 22.2 (5.8) kg/m². The thickness of the transverse abdominis was quantified during the exercise using musculoskeletal ultrasonography. Basal and 3 repetitions guided by an evaluator were performed. Pressure was determined using a lumbar cushion. Data were compared with a mixed-model analysis of variance and Bonferroni post hoc test (P < .05). Minimal detectable changes were identified and Bland-Altman analysis performed considering normalized thickness and pressure.

RESULTS

Ultrasonography feedback resulted in larger thickness changes (P < .05). The lowest minimal detectable changes were achieved using ultrasonography feedback. Nonagreement was found between normalized thickness and pressure.

CONCLUSION

Contraction of the transverse abdominis is improved using real-time ultrasonography together with verbal feedback. Low changes in muscle contraction estimated by thickness showed nonagreement with a pressure cushion.

Comparison of Hip and Lumbopelvic Performance Between Chronic Low Back Pain Patients Suited for the Functional Optimization Approach and Healthy Controls

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

We explored the differences between chronic low back pain (CLBP) patients suited for the functional optimization approach and healthy controls in isometric hip-strength and lumbar-endurance tests and determined classificatory cutoff values for strength and endurance tests and ratios.

SUMMARY OF BACKGROUND DATA

To optimize the treatment effect for CLBP, some approaches have classified patients into homogeneous subgroups matched to specific treatments. We evaluated CLBP patients suited for the functional optimization approach, who seek care because they experience symptoms during activities with high physical demands, although they are relatively asymptomatic.

METHODS

Three hundred fifty subjects (healthy controls, 170; CLBP patients, 180) were stratified by age (18-40 and 41-65 yrs), sex, and physical activity level. The CLBP patients had an Oswestry Disability Index score < 20% and a Numeric Pain Rating Scale score < 3. The subjects underwent hip abductor, extensor, and flexor isometric strength tests; a deep abdominal function test; and lateral/frontal bridge and lumbar flexor/extensor endurance tests.

RESULTS

Relative to the healthy controls, the CLBP patients showed significantly (P > 0.05) higher strength scores in the hip flexor and deep abdominal function tests but lower endurance in the lateral and frontal bridge and lumbar flexor and extensor tests. The cutoff values of the lumbar flexor test and the lumbar flexor/extensor, lateral bridge/lumbar flexor, frontal bridge/lumbar flexor, and hip extensor/flexor test ratios showed acceptable accuracy (AUC = 0.84, 0.82, 0.79, 0.75, and 0.73, respectively).

CONCLUSION

In lumbopelvic and hip-performance tests, CLBP patients suited for the functional optimization approach showed differences from healthy controls. These patients could be discriminated from healthy controls on the basis of accurate cutoff values for strength and endurance tests and ratios, which should be considered in treatment decision-making when patients need to return to activities with higher physical demands.

LEVEL OF EVIDENCE

2.

Diagnostic accuracy of lumbopelvic motor control tests using pressure biofeedback unit in professional swimmers: A cross-sectional study

Hypothesis

To determine the effect of receiving the visual feedback of the sphygmomanometer on lumbopelvic motor control (LPMC) tests in professional swimmers.

Method

31 professional swimmers to participate in the study. The outcome was maximum absolute mmHg variation in the pressure biofeedback unit's manometer with and without visual feedback on four LPMC tests.

Results

Test scores were significantly affected by visual feedback F = 10.07, p = 0.002, η² _p = 0.117 and the type of test F = 32.53, p < 0.001, η² _p = 0.300.

Conclusion

Visual feedback has a positive effect on the Active Straight Leg Raise Test (ASLR), the Knee Lift Abdominal Test (KLAT) scores completed by professional swimmers.

Abnormal performance of cervical stabilizer muscles in individuals with low back pain

Objectives: To compare the performance of cervical stabilizer muscles using the craniocervical flexion test (CCFT) among individuals with subacute, chronic, and asymptomatic low back pain (LBP) conditions. Methods: Individuals with subacute (N = 23) and chronic LBP (N = 23) with their age- and gender-matched controls (N = 30) participated in this study. All recruited participants were required to perform the CCFT. The activation score (AS) and the performance index (PI) were recorded by an assessor who was blinded to the group of participants. Results: Approximately, 74% of subacute LBP participants and 60-65% of chronic LBP participants obtained abnormal AS and PI. AS was significantly lower in participants with subacute (P = 0.0002) and chronic LBP (P = 0.0009) than the control group. Likewise, the PI was significantly lower in participants with subacute (P = 0.0002) and chronic LBP (P = 0.0036) than the control group. Participants in the subacute LBP group showed significantly greater percentages of abnormal responses on the AS (P < 0.0001) and the PI (P = 0.0001) than the control. Discussion: Abnormal performance of cervical stabilizer muscles using the CCFT was demonstrated in a high proportion of participants with LBP. The findings highlight the plausible association in muscle control between cervical and lumbar stabilizers. Level of Evidence: 2b.

Factors predisposing to work-related lower back pain in automobile industry workers

Objective. This study aimed to assess the presence of lower back pain (LBP) in automobile industrial workers and correlate it with the factors known to be contributing to the development of work-related LBP. Method. Post ethical approval, an analytical cross-sectional assessment was conducted for a correlation study on 317 workers from different automobile industries, garages and service centres, who were then assessed by Nordic musculoskeletal questionnaire for the presence of LBP. Their pain intensity was assessed using a numerical rating scale, their core strength with a pressure biofeedback unit, their flexibility via the sitting and reach test and their work posture with the rapid entire body assessment tool. Pain intensity was correlated with core strength, flexibility and posture in all of the workers using Spearman's correlation coefficient r with α set at p ≤ 0.05 at a 95% confidence interval. Results. There was no significant correlation of the pain intensity with the core strength (r = 0.052, p = 0.424), flexibility (r = 0.020, p = 0.755) or posture (r = 0.002, p = 0.974). Conclusion. The present study indicates that internal factors like core strength and flexibility, and work postures have no correlation with intensity and severity of LBP in automobile industry workers.

The validity and reliability of a dynamic neuromuscular stabilization-heel sliding test for core stability

BACKGROUND

Core stabilization plays an important role in the regulation of postural stability. To overcome shortcomings associated with pain and severe core instability during conventional core stabilization tests, we recently developed the dynamic neuromuscular stabilization-based heel sliding (DNS-HS) test.

OBJECTIVE

The purpose of this study was to establish the criterion validity and test-retest reliability of the novel DNS-HS test.

METHOD

Twenty young adults with core instability completed both the bilateral straight leg lowering test (BSLLT) and DNS-HS test for the criterion validity study and repeated the DNS-HS test for the test-retest reliability study. Criterion validity was determined by comparing hip joint angle data that were obtained from BSLLT and DNS-HS measures. The test-retest reliability was determined by comparing hip joint angle data.

RESULTS

Criterion validity was (ICC2,3) = 0.700 (p< 0.05), suggesting a good relationship between the two core stability measures. Test-retest reliability was (ICC3,3) = 0.953 (p< 0.05), indicating excellent consistency between the repeated DNS-HS measurements.

CONCLUSIONS

Criterion validity data demonstrated a good relationship between the gold standard BSLLT and DNS-HS core stability measures. Test-retest reliability data suggests that DNS-HS core stability was a reliable test for core stability. Clinically, the DNS-HS test is useful to objectively quantify core instability and allow early detection and evaluation.

Comparison of lumbopelvic and dynamic stability between dancers and non-dancers

OBJECTIVE

To compare lumbopelvic stability between dancers and non-dancers by assessing lumbopelvic motor control, abdominal muscles automatic-activation, lumbar range of motion and dynamic stability.

DESIGN

Cross-sectional.

SETTING

University/superior-dance-conservatory.

PARTICIPANTS

Twenty-two dancers and 22 non-dancers.

MAIN OUTCOME MEASUREMENTS

The active straight leg raise test (ASLR) was used to test lumbopelvic motor control with pressure feedback (mmHg). Transversus, rectus anterior and internal oblique muscles thicknesses were measured at rest and ASLR. For dynamic stability, the modified Star Excursion Balance Test (mSEBT) was employed.

RESULTS

Significant differences were revealed in lumbopelvic motor control between groups (p < 0.001). Abdominal muscles automatic-activation showed no differences between the groups. There were significant differences in the mSEBT for most of the test's directions, with dancers performing better than the non-dancers (p < 0.05). For the dancers, there were positive associations between motor control and dynamic stability, and between abdominal muscle thickness and mSEBT. For non-dancers, the rectus anterior activation correlated with the mSEBT.

CONCLUSIONS

The dancers had better lumbopelvic motor control, dynamic stability and lumbar movements except in terms of extension, as compared with non-dancers. Therefore, this novel study could stimulate a new line of research to determine the influence of these outcomes on sports performance, prevention and injury rehabilitation.

Kinesiophobia, Pain, Muscle Functions, and Functional Performances among Older Persons with Low Back Pain

Objectives

This study aims (1) to determine the association between kinesiophobia and pain, muscle functions, and functional performances and (2) to determine whether kinesiophobia predicts pain, muscle functions, and functional performance among older persons with low back pain (LBP).

Methods

This is a correlational study, involving 63 institutionalized older persons (age = 70.98 ± 7.90 years) diagnosed with LBP. Anthropometric characteristics (BMI) and functional performances (lower limb function, balance and mobility, and hand grip strength) were measured. Muscle strength (abdominal and back muscle strength) was assessed using the Baseline® Mechanical Push/Pull Dynamometer, while muscle control (transverse abdominus and multifidus) was measured by using the Pressure Biofeedback Unit. The pain intensity and the level of kinesiophobia were measured using Numerical Rating Scale and Tampa Scale of Kinesiophobia, respectively. Data were analyzed using Pearson's correlation coefficients and multivariate linear regressions.

Results

No significant correlations were found between kinesiophobia and pain and muscle functions (all p > 0.05). Kinesiophobia was significantly correlated with mobility and balance (p = 0.038, r = 0.263). Regressions analysis showed that kinesiophobia was a significant predictor of mobility and balance (p = 0.038).

Conclusion

We can conclude that kinesiophobia predicted mobility and balance in older persons with LBP. Kinesiophobia should be continuously assessed in clinical settings to recognize the obstacles that may affect patient's compliance towards a rehabilitation program in older persons with LBP.

Comparison of abdominal muscle thickness according to feedback method used during abdominal hollowing exercise

[Purpose] This study was intended to examine the most effective feedback method for contracting the musculus transversus abdominis muscle by using basic training, a pressure biofeedback unit, and real-time ultrasonographic imaging during abdominal hollowing exercise training. [Subjects and Methods] The subjects in this study were 30 healthy young students in their twenties. Thirty subjects were divided randomly and equally into the basic training, the pressure biofeedback unit, and real-time ultrasonographic imaging groups. All of the subjects received abdominal hollowing exercise training for 15 minutes. The subjects in the pressure biofeedback unit group were trained by using a pressure biofeedback unit. Those in the real-time ultrasonographic imaging group received training with monitoring of possible contraction of their musculus transversus abdominis muscles on ultrasonography. [Results] In all the three groups, the musculus transversus abdominis became significantly thicker, but more significantly in the real-time ultrasonographic imaging group than in the basic training group. [Conclusion] The feedback method using real-time ultrasonographic imaging may be more effective in thickening the musculus transversus abdominis muscle during exercise than the traditional feedback method with manual contact only. However, it is insufficient in terms of overall qualitative improvement of exercise outcome.

Does decrease of the thoracic kyphosis influence decrease knee adduction moment during gait? A preliminary study of a healthy population

[Purpose] The purpose of this study was to investigate the influence of a decrease in thoracic kyphosis angle on the knee adduction moment during gait in healthy young individuals. [Subjects and Methods] Twenty-nine healthy adults, consisting of 15 males and 14 females (21.6 ± 1.1 years old), participated. The draw-in maneuver was used to decrease thoracic kyphosis, and thoracic kyphosis was measured using a SpinalMouse during normal standing and standing with the draw-in maneuver. The participants were required to maintain the draw-in maneuver during gait. A 3-D motion analysis system and a force plate were used to obtain knee adduction moment. [Results] Thoracic kyphosis angles during the draw-in maneuver (41.0 ± 7.4 degrees) were significantly decreased compared with the angles during normal standing (43.0 ± 7.9 degrees). Although the knee adduction moment during gait with the draw-in maneuver was not significantly decreased compared with that during level gait, in the 20 subjects who had decreased kyphosis due to the draw-in maneuver, the 1st peak knee adduction moment (55.7 ± 24.3 × 10⁻³) with the draw-in maneuver was significantly decreased compared with the knee adduction moment (57.0 ± 16.3 × 10⁻³) during level gait. [Conclusion] Knee adduction moment in the case of a decreased thoracic kyphosis angle due to the draw-in maneuver was decreased compared with that during level gait.

Effects of selective exercise for the deep abdominal muscles and lumbar stabilization exercise on the thickness of the transversus abdominis and postural maintenance

[Purpose] The purpose of this study was to examine the effects of selective exercise for the deep abdominal muscles (SEDA) and lumbar stabilization exercise (LSE) on the thickness of the transversus abdominis and postural maintenance on an unstable base of support. [Subjects and Methods] The subjects of this study were 20 male and 10 female adults in their 20s without lumbar pain. They were equally and randomly assigned to a SEDA group and a LSE group. The thickness of the transversus abdominis was measured using ultrasound imaging during rest and drawing-in. The thickness of the transversus abdominis was measured when subjects raised their right and left legs while lying on a Swiss ball. [Results] Initially, there were no differences between the two groups. After the intervention, significant differences were observed in all parameters. A significant interaction between group and period was not found for any parameters. [Conclusion] In conclusion, both SEDA and LSE thickened the transversus abdominis, which is a deep abdominal muscle, thereby adjusting posture, and stabilizing the trunk. These exercises increased the thickness of the deep abdominal muscles. They are important exercises for improving the stability of athletes or patients who need postural adjustment.

Unipedal postural stability in nonathletes with core instability after intensive abdominal drawing-in maneuver

CONTEXT

The exact neuromechanical nature and relative contribution of the abdominal drawing-in maneuver (ADIM) to postural instability warrants further investigation in uninjured and injured populations.

OBJECTIVE

To determine the effects of the ADIM on static core and unipedal postural stability in nonathletes with core instability.

DESIGN

Controlled laboratory study.

SETTING

University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 19 nonathletes (4 women: age = 22.3 ± 1.3 years, height = 164.0 ± 1.7 cm, mass = 56.0 ± 4.6 kg; 15 men: age = 24.6 ± 2.8 years, height = 172.6 ± 4.7 cm, mass = 66.8 ± 7.6 kg) with core instability.

INTERVENTION(S)

Participants received ADIM training with visual feedback 20 minutes each day for 7 days each week over a 2-week period.

MAIN OUTCOME MEASURES(S)

Core instability was determined using a prone formal test and measured by a pressure biofeedback unit. Unipedal postural stability was determined by measuring the center-of-pressure sway and associated changes in the abdominal muscle-thickness ratios. Electromyographic activity was measured concurrently in the external oblique, erector spinae, gluteus medius, vastus medialis oblique, tibialis anterior, and medial gastrocnemius muscles.

RESULTS

All participants initially were unable to complete the formal test. However, after the 2-week ADIM training period, all participants were able to reduce the pressure biofeedback unit by a range of 4 to 10 mm Hg from an initial 70 mm Hg and maintain it at 60 to 66 mm Hg with minimal activation of the external oblique (t(18) = 3.691, P = .002) and erector spinae (t(18) = 2.823, P = .01) muscles. Monitoring of the pressure biofeedback unit and other muscle activations confirmed that the correct muscle contraction defining the ADIM was accomplished. This core stabilization was well maintained in the unipedal-stance position, as evidenced by a decrease in the center-of-pressure sway measures (t(18) range, 3.953-5.775, P < .001), an increased muscle-thickness ratio for the transverse abdominis (t(18) = -2.327, P = .03), and a reduction in external oblique muscle activity (t(18) = 3.172, P = .005).

CONCLUSIONS

We provide the first evidence to highlight the positive effects of ADIM training on core and postural stability in nonathletes with core instability.

The preferential contraction ratios of transversus abdominis on the variations of knee angles during abdominal drawing-in maneuver in wall support standing

The objective of this study was to determine appropriate knee angles for the abdominal drawing-in maneuver (ADIM) through evaluation of changes in contraction ratios of the abdominal muscles and activity of quadriceps muscle in relation to changes in knee angles occurring while the ADIM is performed in the wall support standing (WSS). 20 subjects performed the ADIM at different knee angles (0°, 20°, 40°, 60°) in random order, standing at a point 6 inches away from the wall with the spine maintained in the neutral position. The WSS with knee flexion at 20° showed significantly higher preferential contraction ratio (PCR) of transversus abdominis (TrA) compared to other positions (0°, 40°, 60°). Therefore, performing the ADIM in the WSS with knee flexion at 20° appears to be the most appropriate position for TrA PCR.

Evaluation of the lumbar multifidus in rowers during spinal stabilization exercise

Lumbar stabilization is important in high performance rowing due to the high incidence of low back pain. The purpose of this study was to evaluate the lumbar stabilizers muscles performance during an exercise of spinal segmental stabilization and in lumbar multifidus muscle thickness in rowing athletes trained and untrained for this exercise. Nine rowers trained with lumbar stabilization (TLS) and eight rowers without training (CON) participated in the study. Lumbar stabilization performance and multifidus muscle thickness were measured during a maximal voluntary isometric contraction. Lumbar stabilization performance was higher (p=0.015) in the TLS (mean 18.38 ± 8.00 mmHg) compared to the CON (9.31 ± 4.91 mmHg) group. Muscle thickness variation was higher (p=0.023) in the TLS (6.92% ± 3.98) compared to the CON (2.81% ± 1.40) group. Lumbar stabilization training is an efficient clinical tool to strengthen lumbar muscles and may help to prevent low back pain in rowers.

Effect of head and limb orientation on trunk muscle activation during abdominal hollowing in chronic low back pain

Background

Individuals with chronic low back pain (CLBP) have altered activations patterns of the anterior trunk musculature when performing the abdominal hollowing manœuvre (attempt to pull umbilicus inward and upward towards the spine). There is a subgroup of individuals with CLBP who have high neurocognitive and sensory motor deficits with associated primitive reflexes (PR). The objective of the study was to determine if orienting the head and extremities to positions, which mimic PR patterns would alter anterior trunk musculature activation during the hollowing manoeuvre.

Methods

This study compared surface electromyography (EMG) of bilateral rectus abdominis (RA), external oblique (EO), and internal obliques (IO) of 11 individuals with CLBP and evident PR to 9 healthy controls during the hollowing manoeuvre in seven positions of the upper quarter.

Results

Using magnitude based inferences it was likely (>75%) that controls had a higher ratio of left IO:RA activation with supine (cervical neutral), asymmetrical tonic neck reflex (ATNR) left and right, right cervical rotation and cervical extension positions. A higher ratio of right IO:RA was detected in the cervical neutral and ATNR left position for the control group. The CLBP group were more likely to show higher activation of the left RA in the cervical neutral, ATNR left and right, right cervical rotation and cervical flexion positions as well as in the cervical neutral and cervical flexion position for the right RA.

Conclusions

Individuals with CLBP and PR manifested altered activation patterns during the hollowing maneuver compared to healthy controls and that altering cervical and upper extremity position can diminish the group differences. Altered cervical and limb positions can change the activation levels of the IO and EO in both groups.

The effect of a novel core stabilization technique on managing patients with chronic low back pain: a randomized, controlled, experimenter-blinded study

Objective:

To identify the effect of a novel augmented core stabilization exercise technique on physical function, pain and core stability in patients with chronic low back pain.

Design:

A block randomized controlled trial with two groups.

Setting:

A sports rehabilitation clinic.

Participants:

Forty patients with low back pain (20 experimental, mean (SD) age 50.35 (9.26) years and 20 control, 51.30 (7.01)), 19 men and 21 women.

Interventions:

In the experimental group ankle dorsiflexion was used in addition to drawing in the abdominal wall; the control group involved drawing in the abdominal wall alone. Both groups received the same conventional physical therapy training three days a week for eight weeks.

Main outcome measures:

Physical disability instruments; Oswestry Disability Index and Roland Morris Disability Questionnaire; pain intensity assessments; visual analogue scale, Pain Disability Index, and a pain rating scale; and core stability measures, such as the active straight leg raise, were determined at pretest, posttest and two-month follow-up.

Results:

After the intervention, the experimental group showed significant greater improvement at two months compared with the control group. Physical disability results included Oswestry Disability Index ( P = 0.001, from 24.25 (7.08) to 13.35 (4.17)) and Roland Morris Disability Questionnaire ( P = 0.001, from 15.55 (1.99) to 8.15 (1.69)), pain intensity including visual analogue scale ( P = 0.001, from 6.30 (1.03) to 3.35 (0.59)), Pain Disability Index ( P = 0.001, 31.25 (5.44) to 19.00 (3.58)) and pain rating scale ( P = 0.001, from 72.25 (18.73) to 50.10 (15.47)), and the core stability test such as active straight leg raise ( P = 0.001, from 7.40 (0.75) to 2.15 (0.49)).

Conclusions:

This study provides the clinical evidence that adding ankle dorsiflexion to drawing in the abdominal wall gave increased benefit in terms of physical disability, pain and core stability in patients with chronic low back pain.

What is a Suitable Pressure for the Abdominal Drawing-in Maneuver in the Supine Position Using a Pressure Biofeedback Unit?

[Purpose] The aim of this study was to determine the appropriate pressure variation for performing a successful abdominal drawing-in maneuver (ADIM). The abdominal muscle thickness variations and contraction ratios were examined in relation to pressure variations using a Pressure Biofeedback Unit (PBU) during an ADIM in the supine position. [Methods] The PBU was placed identically between the lumbar lordosis of 20 healthy subjects (12 males and 8 females) and the pressure of the PBU was maintained at 40 mmHg. Then, while the subjects performed ADIM at four random pressure variations (0, 2, 4, or 6 mmHg), the thicknesses of the transversus abdominis (TrA), the internal oblique abdominal muscle (IO), and the external oblique abdominal muscle (EO) were measured using ultrasonography. [Results] Pressure increases of 0-2 mmHg resulted in significant decreases in IO and EO thicknesses compared to pressure increases of 6 mmHg. Increases of 0-2 mmHg also resulted in significant decreases in IO+EO and EO contraction ratios compared to pressure increases of 6 mmHg, while the preferential activation ratio of the TrA was significantly increased. [Conclusion] Compared to the other pressure increases, an increase of 0-2 mmHg effectively regulated the thicknesses and contraction ratios of superficial muscles such as IO and EO, rather than the thickness and contraction ratio of the TrA, showing high and indirect preferential activation ratios for TrA. Therefore, for successful ADIM, rather than using large PBU pressure increases, exercises that promote slight increases of around 0-2 mmHg from a baseline of 40 mmHg are desirable.

The influence of varying hip angle and pelvis position on muscle recruitment patterns of the hip abductor muscles during the clam exercise

STUDY DESIGN

Within-subject, repeated-measures design.

OBJECTIVES

To determine the influence of pelvis position and hip angle on activation of the hip abductors while performing the clam exercise.

BACKGROUND

Therapeutic exercises are regularly employed to strengthen the hip abductors to improve lower-limb and pelvis stability. While previous studies primarily have compared the activity of hip abductor muscles between various exercises, few studies have examined the influence of varying the techniques of particular exercises on the relative activation of hip abductor muscles. Such information could be used to facilitate appropriate exercise instruction.

METHODS

Muscle activation in 17 healthy, asymptomatic volunteers during 6 variations of the clam exercise was analyzed with surface electromyography. Electromyographic signals were recorded from the gluteus maximus, gluteus medius, and tensor fasciae latae. Normalized data were examined using 2-way, repeated-measures analyses of variance.

RESULTS

The magnitude of gluteus maximus and gluteus medius activation was significantly greater when the pelvis was in neutral rather than reclined. Furthermore, gluteus medius activation was greatest when the hip was flexed to 60°. Activation of the tensor fasciae latae was not influenced by pelvis position or hip angle.

CONCLUSION

A neutral pelvis position is advocated to optimize recruitment of the gluteus maximus and gluteus medius during the clam exercise. Increasing the hip flexion angle increases activation of the gluteus medius. Tensor fasciae latae activity was relatively low and generally unaffected by variations of the clam exercise.

Clinimetric analysis of pressure biofeedback and transversus abdominis function in individuals with stabilization classification low back pain

STUDY DESIGN

Descriptive laboratory study.

OBJECTIVE

To determine if a proposed clinical test (pressure biofeedback) could detect changes in transversus abdominis (TrA) muscle thickness during an abdominal drawing-in maneuver.

BACKGROUND

Pressure biofeedback may be used to assess abdominal muscle function and TrA activation during an abdominal drawing-in maneuver but has not been validated.

METHODS

Forty-nine individuals (18 men, 31 women) with low back pain who met stabilization classification criteria underwent ultrasound imaging to quantify changes in TrA muscle thickness while a pressure transducer was used to measure pelvic and spine position during an abdominal drawing-in maneuver. A paired t test was used to compare differences in TrA activation ratios between groups (able or unable to maintain pressure of 40 ± 5 mmHg). The groups were further dichotomized based on TrA activation ratio (high, greater than 1.5; low, less than 1.5). Sensitivity, specificity, and likelihood ratios were calculated.

RESULTS

There was not a significant difference (P = .57) in TrA activation ratios (able to maintain pressure, 1.59 ± 0.28; unable to maintain pressure, 1.54 ± 0.24) between groups. The pressure biofeedback test had low sensitivity of 0.22 (95% confidence interval [CI]: 0.10, 0.42) but moderate specificity of 0.77 (95% CI: 0.58, 0.89), a positive likelihood ratio of 0.94 (95% CI: 0.33, 2.68), and a negative likelihood ratio of 1.02 (95% CI: 0.75, 1.38).

CONCLUSION

Successful completion on pressure biofeedback does not indicate high TrA activation. Unsuccessful completion on pressure biofeedback may be more indicative of low TrA activation, but the correlation and likelihood coefficients indicate that the pressure test is likely of minimal value to detect TrA activation. This study was registered with ClinicalTrials.gov (NCT01015846).J Orthop Sports Phys Ther 2013;43(3):184-193. Epub 16 November 2012. doi:10.2519/jospt.2013.4397.

Alongamento muscular na dor lombar crônica inespecífica: uma estratégia do método GDS

O objetivo deste estudo foi verificar a eficácia do alongamento muscular, usando uma sequência proposta pelo Método Godelieve Denys-Struyf (GDS) na redução da dor, na incapacidade funcional, no aumento da flexibilidade global e na capacidade de contração do músculo transverso do abdome (TrA), em indivíduos com dor lombar crônica inespecífica. Participaram 55 pacientes, de 18 a 60 anos, divididos em dois grupos: Grupo Alongamento (n=30) submetido a exercícios de alongamento, duas vezes por semana, e Grupo Controle (n=25) que não realizou tratamento. A dor foi avaliada pela escala visual analógica; a incapacidade funcional, pelo Índice de Oswestry; a flexibilidade global, pelo terceiro dedo ao solo; e a capacidade de contração do TrA, pela unidade de biofeedback pressórico. Foram realizadas três avaliações, inicial, após 8 e 16 semanas da inicial. Foi considerado nível de significância de α<0,05. Os resultados mostram que o Grupo Alongamento apresentou diminuição na dor, incapacidade funcional e aumentou a flexibilidade global (p<0,001) após 8 e 16 semanas (p<0,05), porém não melhorou a capacidade de contração do TrA (p=0,13). A sequência de alongamentos usada no método GDS mostra-se eficaz na redução da dor, incapacidade funcional e melhora da flexibilidade global em pacientes com dor lombar crônica inespecífica.

Ultrasound assessment of transversus abdominis muscle contraction ratio during abdominal hollowing: a useful tool to distinguish between patients with chronic low back pain and healthy controls?

Spine stabilisation exercises, in which patients are taught to preferentially activate the transversus abdominus (TrA) during "abdominal hollowing" (AH), are a popular treatment for chronic low back pain (cLBP). The present study investigated whether performance during AH differed between cLBP patients and controls to an extent that would render it useful diagnostic tool. 50 patients with cLBP (46.3 ± 12.5 years) and 50 healthy controls (43.6 ± 12.7 years) participated in this case-control study. They performed AH in hook-lying. Using M-mode ultrasound, thicknesses of TrA, and obliquus internus and externus were determined at rest and during 5 s AH (5 measures each body side). The TrA contraction-ratio (TrA-CR) (TrA contracted/rest) and the ability to sustain the contraction [standard deviation (SD) of TrA thickness during the stable phase of the hold] were investigated. There were no significant group differences for the absolute muscle thicknesses at rest or during AH, or for the SD of TrA thickness. There was a small but significant difference between the groups for TrA-CR: cLBP 1.35 ± 0.14, controls 1.44 ± 0.24 (p < 0.05). However, Receiver Operator Characteristics (ROC) analysis revealed a poor and non-significant ability of TrA-CR to discriminate between cLBP patients and controls on an individual basis (ROC area under the curve, 0.60 [95% CI 0.495; 0.695], p = 0.08). In the patient group, TrA-CR showed a low but significant correlation with Roland Morris score (Spearman Rho = 0.328; p = 0.02). In conclusion, the difference in group mean values for TrA-CR was small and of uncertain clinical relevance. Moreover, TrA-CR showed a poor ability to discriminate between control and cLBP subjects on an individual basis. We conclude that the TrA-CR during abdominal hollowing does not distinguish well between patients with chronic low back pain and healthy controls.

A rationale for the provision of extrinsic feedback towards management of low back pain

Low back pain (LBP) is associated with dysfunction of global and local muscle systems, feedback and feedforward postural control mechanisms. Physiotherapists include the use of feedback as part of treatment protocols. Such feedback can focus on a variety of neuromuscular impairments, although the literature related to feedback on the management of LBP has focused mainly on local muscle system impairments. Furthermore, there are various characteristics of feedback that can lead to motor control enhancement or deterioration. The aim of this manuscript is to present a rationale for feedback provision as a rehabilitation tool on the management of LBP. Feedback provision should focus on the main neuromuscular impairment presented by the patient. The suggested rationale describes decision-making stages for the use and progress of feedback interventions. Local muscle system impairment might benefit more from parameter feedback provision, while global muscle system and feedback mechanism impairments may benefit better from program feedback. The described rationale has the potential to help clinicians select the appropriate feedback for the treatment of their patients. Additionally, the presented rationale could be used by researchers to assess how different forms of feedback provision impact on clinical outcomes.

Practical use of the HOAC II for clinical decision making and subsequent therapeutic interventions in an elite athlete with low back pain

STUDY DESIGN

Resident's case problem.

BACKGROUND

This case report describes the diagnostic process, based on the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II), and subsequent interventions in an elite athlete with subacute low back pain. It also demonstrates the clinical application of the HOAC II and shows how disablement terms, as used in the World Health Organization's International Classification of Functioning, Disability and Health model, can be integrated into patient management in a manner that we believe enhances clinical practice. It also demonstrates the practical use of validated questionnaires and how these can be used to gather necessary information for the algorithm.

DIAGNOSIS

A structured, evidence-based assessment led to a multifaceted, activity limitation-based diagnosis of being unable to (1) remain in a deep squat position during speed skating, (2) accelerate in turns while speed skating, and (3) rise from a slouched position without pain. We believed that these dysfunctions were due to local limited lumbar segmental mobility, concurrent with an inability to properly and functionally stabilize the lumbopelvic area.

DISCUSSION

The HOAC II requires the therapist to develop an evidence-based strategy for the examination that is based on initial hypotheses developed from the medical history and other data obtained prior to the examination. The examination was tailored to identify and quantify activity limitations and participation restrictions that we believed could help to explain why this patient had his health problem. The case demonstrates how all elements of the HOAC II can be used for what we consider to be relatively common types of patients. We believe that by applying the HOAC II on an individual-patient basis, therapists will be ideally positioned to apply evidence to patient care and to defend their interventions to colleagues and third-party payers.

LEVEL OF EVIDENCE

Differential diagnosis, level 4.

The effect of core stability training on balance and mobility in ambulant individuals with multiple sclerosis: a multi-centre series of single case studies

BACKGROUND

Core stability training is popular in the management of people with multiple sclerosis (MS); however, scientific evidence to support its effectiveness is scarce.

OBJECTIVE

To explore the effectiveness of core stability training on balance and mobility.

METHOD

A multi-centre series of eight single case studies was undertaken. Eight ambulant individuals with stable MS participated in 16 face-to-face core stability training sessions, delivered by a neurophysiotherapist, plus a daily home exercise programme. A range of outcomes were measured: 10-m timed walk, 12-item MS walking scale, timed get up and go, functional reach tests, timed single leg stance, visual analogue scales of two activities, and the Activities-specific Balance Confidence Scale.

RESULTS

Visual analysis of trend, level and slope demonstrated improvement in five subjects (62%) in seven measures. This was confirmed by the two standard deviation band method of analysis for six measures. Analysis of group data (repeated measures within subjects analysis of variance) indicated significant improvement between baseline and intervention phases for timed walk (p = 0.019), MSWS-12 Scale (p = 0.041), forward (p = 0.015) and lateral reach (p = 0.012). In general, no further improvements were made following withdrawal of the intervention.

CONCLUSIONS

This study provides preliminary evidence of the effectiveness of an 8-week core stability training programme in improving balance and mobility in ambulant people with MS. Variations in response to intervention are evident. Assessor-blinded randomized controlled studies are required to confirm these findings and determine patient characteristics which identify those who benefit most from this intervention.

Effect of the abdominal draw-in manoeuvre in combination with ankle dorsiflexion in strengthening the transverse abdominal muscle in healthy young adults: a preliminary, randomised, controlled study

OBJECTIVES

To compare the effect of the abdominal draw-in manoeuvre with the abdominal draw-in manoeuvre in combination with ankle dorsiflexion on changes in muscle thickness and associated muscle activity in abdominal muscles.

DESIGN

A preliminary, randomised, controlled study.

SETTING

University laboratory.

PARTICIPANTS

Forty healthy adults (18 males, 22 females) were allocated at random to the experimental group [mean age (SD) 24 (1.6) years, n=20] or the control group [mean age (SD) 24 (1.9) years, n=20]. The experimental group performed the abdominal draw-in manoeuvre in combination with ankle dorsiflexion, and the control group performed the abdominal draw-in manoeuvre alone, five times a day.

MAIN OUTCOME MEASURES

Ultrasonography and electromyography were used to determine the intervention-related changes in muscle activity and the thickness of abdominal muscles during the abdominal draw-in manoeuvre or the abdominal draw-in manoeuvre in combination with ankle dorsiflexion.

RESULTS

A significant difference was found in the thickness of the transverse abdominal muscle between the groups [mean difference 0.24 cm, 95% confidence interval (CI) 0.08 to 0.40, P=0.005. On electromyography, a significant difference was demonstrated in the amplitude of the transverse abdominal muscle contraction between the two techniques in the experimental group (mean difference 68.76 mV, 95% CI 53.16 to 84.36, P=0.000. The intra-class correlation coefficient (ICC(2,1)) showed excellent test-retest reliability of ultrasound measurement of the abdominal muscles: 0.96 (95% CI 0.85 to 0.99) for the transverse abdominal muscle, 0.87 (95% CI 0.62 to 0.98) for the internal oblique muscle and 0.77 (95% CI 0.44 to 0.96) for the external oblique muscle.

CONCLUSIONS

This is the first study to demonstrate the additive effect of ankle dorsiflexion on deep core muscle thickness and activity, thus contributing to existing knowledge about therapeutic exercise for the effective management of low back pain.