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

Surgical vs. Conservative Management of Chronic Sciatica (>3 Months) Due to Lumbar Disc Herniation: Systematic Review and Meta-Analysis

Sciatica, characterized by leg or back symptoms along the sciatic nerve pathway, often manifests as a chronic condition lasting over 12 weeks. Decision-making between nonoperative treatment and immediate microdiscectomy for chronic sciatica remains challenging, due to the complex relationship between symptom duration, severity, and lumbar discectomy outcomes. In this systematic review, we conducted a comprehensive search across Scopus, PubMed, Web of Science, and the Cochrane Library, identifying relevant two-arm clinical trials up to September 2023. Rigorous screening and data extraction were performed by two independent reviewers, with study quality evaluated using the risk of bias 2 (RoB) tool. This meta-analysis incorporated four studies comprising 352 participants. Our analysis revealed that conservative treatment was associated with a significant reduction in leg pain and improvement in, SF mental, and physical scores compared to surgical intervention. However surgical treatment demonstrated significant improvement in back pain. In conclusion, our findings suggest that surgical intervention may be more effective than non-surgical treatment for chronic sciatica-related back pain. Conservative treatment significantly reduces leg pain while improving mental and physical health outcomes. Ultimately, our findings support conservative as the initial approach unless surgery is warranted, particularly in cases with neurological deficits or cauda equina syndrome.

Effect of Hip Muscle Strengthening Exercises on Pain and Disability in Patients with Non-Specific Low Back Pain-A Systematic Review

Low back pain (LBP) is a health problem that affects 70-80% of the population in Western countries. Because of the biomechanical relationship between the lumbar region and the hip, it is thought that strengthening the muscles of this joint could improve the symptoms of people with LBP. The objective of this study is to evaluate the current evidence on the efficacy of hip strengthening exercises to reduce pain and disability in people with LBP. Clinical trials were collected from the PubMed, PEDro, and Scopus databases published up to September 2022. Based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and using CASP and PEDro tools for methodological quality assessment, we selected studies that included hip strengthening exercises as part of LBP treatment and measured pain and/or disability parameters. Among the 966 records identified in the search, a total of 7 studies met the established selection criteria. Overall, participants who performed hip strengthening exercises had significantly improved in pain and disability. The methodological quality of the included studies was assessed as "good". In conclusion, the addition of hip muscle strengthening exercises iterating interacted with LBP, effectively improving pain and disability.

The Relationship Between Pain-Related Psychological Factors and Maximal Physical Performance in Low Back Pain: A Systematic Review and Meta-Analysis

Theoretical frameworks explain how pain-related psychological factors may influence the physical performance. In this systematic review and meta-analysis, we evaluated the evidence regarding the relationship between the pain-related psychological factors and the maximal physical performance in patients with low back pain (LBP). Pubmed, Embase, CINAHL and Web of Science databases were searched from inception to May 2022. Cross-sectional or longitudinal studies reporting cross-sectional measures of association between at least one pain-related psychological factor and a quantitatively measured outcome of maximal physical performance in patients with LBP were eligible for inclusion. Thirty-eight studies (n = 2,490; 27 cross-sectional studies, n = 1,647 (66%); 11 longitudinal studies, n = 843 (34%)) were included, with 92% of participants (n = 2,284) having chronic LBP. Results showed that pain-related fear, pain catastrophizing, and anticipated pain were consistently and negatively associated with the maximal physical performance in chronic LBP, whereas pain-self efficacy showed positive correlations. Overall, magnitudes of absolute pooled r-values were small (r ≤ 0.25), except for anticipated pain, which was moderately associated with maximal physical performance (r = -0.34 to -0.37). Subanalyses and sensitivity analyses yielded similar pooled correlation coefficients. Certainty of evidence using the GRADE recommendations was very low to moderate for pain-related fear, and very low to low for the other pain-related psychological factors. Prospero registration: CRD42021227486. PERSPECTIVE: Overall, small pooled correlation coefficients were shown between pain-related psychological factors and maximal physical performance in chronic LBP. Certainty of evidence was very low to low for all pain-related psychological factors other than pain-related fear. Future studies taking into account limitations of the current literature may therefore change these conclusions.

Headache Attributed to Temporomandibular Disorder and Primary Cough Headache

Orofacial pain is a frequent chief complaint of many systemic disorders. A primary cough headache may mimic the clinical symptoms of a temporomandibular disorder (TMD) or may be associated with TMDs. Case report: A 52-year-old man presented with a 1-year history of TMD symptoms with clicking. He presented with the chief complaint of a sudden and severe headache when coughing, sneezing, or crouching. Comprehensive intra- and extra-oral examinations were performed, which revealed myofascial pain involving the right masseter and temporalis muscles, disc displacement with reduction in the right temporomandibular joint, and headache attributed to TMD, but no severe headaches appeared in the cough-induced test at the first visit. Initially, we advised the patient to minimize activities that require jaw function (e.g., chewing), avoid jaw parafunction (e.g., bruxism), and to perform at-home jaw exercises to stretch the jaw muscles. The patient’s symptoms reduced by more than half after the TMD home care and physiotherapy. He was then treated with 75 mg of indomethacin per day, which eliminated his headache. The patient was then referred to a headache specialist, who diagnosed primary cough headache.

Differential activation of psoas major and rectus femoris during active straight leg raise to end range

The purpose of this study was to investigate the activation of the hip flexor and abdominal muscles during an active straight leg raise (ASLR) to end range of hip flexion. Data were recorded from nine healthy men. Fine-wire electromyography (EMG) electrodes were inserted into psoas major (PM), and surface electrodes were placed over rectus femoris (RF), rectus abdominis, obliquus externus abdominis (OE), and obliquus internus abdominis/transversus abdominis (OI/TrA). EMG and kinematic data were obtained during concentric, hold (at end range) and eccentric phases of an ASLR. Concentric and eccentric movements were divided into three phases (early, mid, and late). Onsets of EMG relative to the onset of the ALSR movement and EMG amplitudes in each phase were compared between muscles. Onsets of the PM (-33 ± 245 ms) and RF (-3 ± 119 ms) EMG prior to leg elevation were significantly earlier than those of the OE and OI/TrA. PM EMG showed highest activation in the late concentric, hold, early eccentric phase, and was significantly higher than RF EMG. OI/TrA EMG was significantly greater in mid and late concentric, hold, and early eccentric phase than other phases. During the ASLR, unlike RF, PM EMG continues to increase towards the end range of hip flexion. Activation of OI/TrA muscle may be involved in control trunk and pelvic movement.

Association between headache and temporomandibular disorder

Headaches are one of the most common conditions associated with temporomandibular disorder (TMD). In the present paper, we evaluated the relationship between headache and TMD, determined whether headache influences the symptoms of TMD, and reported two cases of TMD accompanied by headache. Our practical experience and a review of the literature suggested that headache increases the frequency and intensity of pain parameters, thus complicating dysfunctional diseases in both diagnostic and treatment phases. Therefore, early and multidisciplinary treatment of TMD is necessary to avoid the overlap of painful events that could result in pain chronicity.

Graded group exercise and fear avoidance behavior modification in the treatment of chronic low back pain

BACKGROUND

Approaches in the treatment of general chronic low back pain (CLBP) are multifaceted relative to specific interventions. In the past, passive interventions have commonly been employed with little evidence to support their effectiveness. Recent reviews suggest a focus on active exercises programs that includes pain education and cognitive behavioral therapy.

OBJECTIVE

To investigate the outcomes of CLBP patients and describe the approach in persons undergoing a group spinal rehabilitation program using graded exercise, and operant conditioning.

METHODS

Adult patients with CLBP participated in a twice weekly 90 minute exercise sessions for 8-weeks (n= 201). The program consisted of behavioral education, stretching, aerobic exercises, graded progressive resistance exercise, MedX isotonic strengthening, and functional bending lifting task exercises.

RESULTS

A total of 201 patient records were evaluated where the overall ODI improvement was 13.2% (± 14.0) (p< 0.001). There were significant and clinically meaningful improvements in flexibility, VAS, functional lifting tasks (p< 0.001), and lumbar extension strength (p= 0.01) at 8-week follow-up. Questionnaires were delivered via mail with a 21% return rate revealed sustained improvements.

CONCLUSION

CLBP patients undergoing an 8-week intensive exercise approach incorporating both behavioral and physical conditioning principles showed both significant and clinically significant improvements in this observational case series. Long-term benefits were also seen in both the 6 and 12 month follow-up questionnaires although further investigation is warranted due to limited survey return rate and study design.

Effect of two different exercise regimens on trunk muscle morphometry and endurance in soldiers in training

BACKGROUND

Limited evidence exists on how strength and endurance exercises commonly used to prevent low back pain affect muscle morphometry and endurance.

OBJECTIVE

The purpose of this study was to analyze the effects of 2 exercise regimens on the morphometry and endurance of key trunk musculature in a healthy population.

DESIGN

The study was designed as a randomized controlled trial.

SETTING

The study was conducted in a military training setting.

PARTICIPANTS

A random subsample (n=340; 72% men, 28% women; mean [±SD] age=21.9±4.2 years; mean [±SD] body mass index=24.8±2.8 kg/m2) from the larger Prevention of Low Back Pain in the Military trial (N=4,325) was included.

INTERVENTION

The core stabilization exercise program (CSEP) included low-load/low-repetition motor control exercises, whereas the traditional exercise program (TEP) included exercises conducted at a fast pace, with the use of high-load, high-repetition trunk strengthening exercises.

MEASUREMENTS

Baseline and follow-up examinations included ultrasound imaging of the trunk muscles and endurance tests. Linear mixed models were fitted to study the group and time effect and their interactions, accounting for the clustering effect.

RESULTS

Symmetry generally improved in the rest and contracted states, but there were no differences suggestive of muscle hypertrophy or improved ability to contract the trunk muscles between soldiers receiving the CSEP or the TEP. Total trunk endurance time decreased over the 12-week period, but endurance performance favored soldiers in the CSEP group. Endurance time was not associated with future episodes of low back pain.

LIMITATIONS

The lack of morphological changes may not be detectable in an already-active cohort, or a more intensive dose was needed.

CONCLUSIONS

Although improved symmetry was noted, neither the CSEP nor the TEP resulted in muscle hypertrophy. Longer endurance times were noted in individuals who completed the CSEP but were not strongly predictive of future low back pain episodes.

Manual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: a randomized controlled trial

BACKGROUND

Recent clinical recommendations still propose active exercises (AE) for CNSLBP. However, acceptance of exercises by patients may be limited by pain-related manifestations. Current evidences suggest that manual therapy (MT) induces an immediate analgesic effect through neurophysiologic mechanisms at peripheral, spinal and cortical levels. The aim of this pilot study was first, to assess whether MT has an immediate analgesic effect, and second, to compare the lasting effect on functional disability of MT plus AE to sham therapy (ST) plus AE.

METHODS

Forty-two CNSLBP patients without co-morbidities, randomly distributed into 2 treatment groups, received either spinal manipulation/mobilization (first intervention) plus AE (MT group; n = 22), or detuned ultrasound (first intervention) plus AE (ST group; n = 20). Eight therapeutic sessions were delivered over 4 to 8 weeks. Immediate analgesic effect was obtained by measuring pain intensity (Visual Analogue Scale) before and immediately after the first intervention of each therapeutic session. Pain intensity, disability (Oswestry Disability Index), fear-avoidance beliefs (Fear-Avoidance Beliefs Questionnaire), erector spinae and abdominal muscles endurance (Sorensen and Shirado tests) were assessed before treatment, after the 8th therapeutic session, and at 3- and 6-month follow-ups.

RESULTS

Thirty-seven subjects completed the study. MT intervention induced a better immediate analgesic effect that was independent from the therapeutic session (VAS mean difference between interventions: -0.8; 95% CI: -1.2 to -0.3). Independently from time after treatment, MT + AE induced lower disability (ODI mean group difference: -7.1; 95% CI: -12.8 to -1.5) and a trend to lower pain (VAS mean group difference: -1.2; 95% CI: -2.4 to -0.30). Six months after treatment, Shirado test was better for the ST group (Shirado mean group difference: -61.6; 95% CI: -117.5 to -5.7). Insufficient evidence for group differences was found in remaining outcomes.

CONCLUSIONS

This study confirmed the immediate analgesic effect of MT over ST. Followed by specific active exercises, it reduces significantly functional disability and tends to induce a larger decrease in pain intensity, compared to a control group. These results confirm the clinical relevance of MT as an appropriate treatment for CNSLBP. Its neurophysiologic mechanisms at cortical level should be investigated more thoroughly.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

NCT01496144.

Changes in lateral abdominal muscle thickness during an abdominal drawing-in maneuver in individuals with and without low back pain

The purpose of this study was to compare lateral abdominal muscle thickness changes in individuals with and without low back pain (LBP) during an abdominal drawing-in maneuver (ADIM) using ultrasound imaging. Twenty individuals (13 females and 7 males, average age 40.1 ± 13.4) with stabilization classification LBP and 19 controls (10 females and 9 males, average age 30.3 ± 8.7) participated in this study. Bilateral measurements were made using ultrasound imaging to determine changes in thickness of the transversus abdominus (TrA) and external and internal oblique (EO+IO) muscles during an ADIM. There were no significant differences in relaxed muscle thickness values or contraction ratios for the TrA or EO+IO between groups or side. Individuals with stabilization classification LBP demonstrated no difference in lateral abdominal muscle thickness during an ADIM when compared with controls without LBP when using a pressure biofeedback device to monitor stability.

Factors that predict discharge destination for patients in transitional care: a prospective observational cohort study

Objective. To investigate factors that predict discharge destination for patients making the transition from hospital to the community. Methods. Using a prospective cohort design, 696 patients from 11 Transition Care Programs were recruited. Baseline patient and program characteristics were considered for predicting discharge destination, functional status, and patient length of stay. Results. An increased physiotherapy staffing ratio in Transition Care Program was associated with an increased likelihood that a patient was discharged home, with an improved functional or mobility status, and after a shorter length of stay. The other factor that predicted discharge to home included having an Aged Care Assessment Service classification of low level care or home with a support package. An increased physiotherapy staffing level also reduced the likelihood of discharge to low level or high level care. The other factors that predicted discharge to low level care were having higher mobility status and older age; the other factor associated with increased likelihood of predicting discharge to high level care was having an Aged Care Assessment Service classification of high level care. Conclusions. Factors on admission that predicted discharge destination were program physiotherapy staffing ratios, Aged Care Assessment Service assessment, age and mobility status. What is known about the topic? In 2004/05 Australia introduced a program called the Transition Care Program (TCP), which targets older persons at the conclusion of an acute hospital episode who require more time and support in a non-acute setting to complete their restorative process and optimise their functional capacity. This program has a particular objective to prevent inappropriate admission to a residential aged care facility. To date, there are no published papers that report the factors that predict discharge destination for patients in the Transition Care Program. What does this paper add? This study provides evidence that program physiotherapy staffing ratios, Aged Care Assessment Service assessment, age and mobility status are predictive of an increased likelihood that a patient will be discharged home with an improved functional/mobility status, after a shorter length of stay. What are the implications for practitioners? Knowledge of factors that predict discharge destination may assist healthcare practitioners and health managers in managing TCP patients and planning services.

Fear-avoidance beliefs and pain avoidance in low back pain--translating research into clinical practice

BACKGROUND CONTEXT

For patients with low back pain, fear-avoidance beliefs (FABs) represent cognitions and emotions that underpin concerns and fears about the potential for physical activities to produce pain and further harm to the spine. Excessive FABs result in heightened disability and are an obstacle for recovery from acute, subacute, and chronic low back pain.

PURPOSE

This article summarizes past research concerning the etiology, impact, and assessment of FABs; reviews the results and relevance to clinical practice of trials that have addressed FAB as part of low back pain treatment; and lists areas in need of further study.

STUDY DESIGN

This article reports on a plenary presentation and discussion of an expert panel and workshop entitled "Addressing fear-avoidance beliefs in a fear-avoidant world--translating research into clinical practice" that was held at Forum X, Primary Care Research on Low Back Pain, during June 2009, at the Harvard School of Public Health in Boston, MA, USA.

METHODS

Important issues including the definition, etiology, impact, and treatment of FAB on low back pain outcomes were reviewed by six panelists with extensive experience in FAB-related research. This was followed by a group discussion among 40 attendees. Conclusion and recommendations were extracted by the workshop panelist and summarized in this article.

RESULTS

Fear-avoidance beliefs are derived from both emotionally based fears of pain and injury and information-based beliefs about the soundness of the spine, causes of spine degeneration, and importance of pain. Excessively elevated FABs, both in patients and treating health care providers, have a negative impact on low back pain outcomes as they delay recovery and heighten disability. Fear-avoidance beliefs may be best understood when patients are categorized into subgroups of misinformed avoiders, learned pain avoiders, and affective avoiders as these categories elucidate potential treatment strategies. These include FAB-reducing information for misinformed avoiders, pain desensitizing treatments for pain avoiders, and fear desensitization along with counseling to address the negative cognition in affective avoiders. Although mixed results have been noted, most clinical trials have documented improved outcomes when FAB is addressed as part of treatment. Deficiencies in knowledge about brief methods for assessing FAB during clinical encounters, the importance of medical explanations for back pain, usefulness of subgroup FABs, core points for information-based treatments, and efficient strategies for transferring FAB-reducing information to patients hamper the translation of FAB research into clinical practice.

CONCLUSIONS

By incorporating an understanding of FAB, clinicians may enhance their ability to assess the predicaments of their patients with low back pain and gain insight into potential value of corrective information that lessen fears and concerns on well-being of their patients.

The association of physical deconditioning and chronic low back pain: A hypothesis-oriented systematic review

PURPOSE

Does physical deconditioning (loss of cardiovascular capacity and strength/endurance of paraspinal muscles) exist in patients with chronic low back pain (CLBP) and are treatments specifically aimed to reduce these signs effective?

METHOD

Systematic literature search in PUBMED, MEDLINE, EMBASE and PsycINFO until December 2004 to identify observational studies regarding deconditioning signs and high quality RCTs regarding the effectiveness of cardiovascular and/or muscle strengthening exercises. Internal validity of the RCTs was assessed by using a checklist of nine methodology criteria in accordance with the Cochrane Collaboration.

RESULTS

There is conflicting evidence that cardiovascular deconditioning is present in CLBP and limited evidence for wasting of the multifidus muscle. No study examined the effectiveness of cardiovascular training specifically. General and lumbar muscle strengthening are equally effective as other active treatments. Only moderate evidence is available for the effectiveness of intensive low back extensor muscle strengthening compared to less intensive strengthening.

CONCLUSION

Probably reactivation caused by active treatment and not the reconditioning itself is the important factor in the reduction of disability. Further prospective and evaluative research into the role of physical deconditioning is necessary. It seems more promising to further explore the interplay between biological, social and psychological factors.

Physical capacity tasks in chronic low back pain: What is the contributing role of cardiovascular capacity, pain and psychological factors?

PURPOSE

To explore the association of personal and body functions with physical capacity tasks used in the evaluation of chronic low back pain (CLBP) treatment.

METHOD

Cross-sectional study in which 221 patients with non-specific CLBP participated. Physical capacity was assessed by six capacity tasks, and several personal and body functions were assessed by questionnaires (age, gender, pain intensity, duration of pain, radiating pain to leg, fear of injury/movement, depression, pain catastrophizing and internal control of pain). Cardiovascular capacity was measured by a modified Astrand submaximal bicycle test. The association of these hypothetically influential personal and body function factors with capacity tasks was examined with multiple linear regression analyses.

RESULTS

The total explained variance was low to moderate (9 - 19%), except for stair climbing for which the variance just reached 30%. Many putative factors did not contribute significantly to the level of outcome of several different tasks.

CONCLUSIONS

Cardiovascular capacity, pain intensity, fear of injury/movement, cognitions, and depression had statistically significant but clinically minor effects on several, but not all capacity tasks. Radiating pain, age and duration of complaints had no significant influence at all. Due to anthropometric differences men outperformed women on most tasks. Apparently the influence of many personal, physical but especially psychological factors on the selected capacity tasks is not high at all. This might indicate that these tasks are more objectively measuring physical capacity than expected.

Measurements and evaluations in low back pain patients

With the present review of literature, the authors intended to compare the definition terms, selection criteria, and measurement tools or methods used in different studies related to chronic low back pain (CLBP) patients. The relevance of including all the above information is that any health-care professional can use them to evaluate their treatment methods with CLBP patients or use them in study designs according to their objectives. These measurements concern pain measurements, measures that were used to describe the CLBP pain, questionnaires used to measure the CLBP patients' responses to pain, the pain effects on their living activities, and also measurements of the physical abilities and functional performance. A computerized literature search in English MEDLINE was conducted using "low back pain," and "flexibility, "strength,""evaluation,""functional level," and "measurements" as search words. Identified abstracts were scanned, and useful articles were acquired for further review. Interms of CLBP definitions, the authors concluded that is best defined as a lumbar, sacral, or lumbosacral spinal pain that is continuous or essentially continuous but low level punctuated by exacerbations of pain, each of which is characterized as "acute." In order to establish the criteria for selecting participants in a study design related to CLBP, pain characteristics and clinical diagnoses have to be taken into consideration for obtaining homogeneity of groups. Finally, the selection of measurement tools and evaluation methods is related to the study's goals, the specialization of the researchers, and their validity.

Long-term exercise adherence in the elderly with chronic low back pain

OBJECTIVE

Chronic back pain is common in the elderly population and can be treated with exercise. Long-term adherence to exercise recommendations has been documented in adults of <65 yrs of age but not for elderly adults. This study explored exercise behaviors of elderly adults with a history of chronic back pain before and 2 yrs after treatment in an exercise-oriented rehabilitation program.

DESIGN

This study utilized a case series design to survey 126 subjects >65 yrs old who underwent physical therapy during the year 2000 for complaints of chronic low back pain. Of these, 89 (70%) responded to the 2-yr questionnaire. Outcome measures included visual analog scale for pain, Oswestry disability questionnaires, back flexibility and strength, and a questionnaire exploring exercise behaviors. All subjects underwent a 6-wk physical therapy program that consisted of exercise coupled with advice to remain active.

RESULTS

Improvements in flexibility and strength occurred during treatment. Mean Oswestry disability scores (0-100 scale) improved from 32 to 20, and pain scores (0-10 scale) from 5.0 to 3.0 during treatment (P < 0.001) and were maintained at the 2-yr follow-up, regardless of exercise adherence. The percentage of patients who performed at least some exercise increased from 49% before treatment to 72% at the 2-yr follow-up. The changes in disability or pain observed during treatment did not influence exercise compliance. The most frequently stated reasons for nonadherence was that exercise did not help or aggravated pain (33%). For those who exercised regularly, 80% did so because of the health benefits from exercise.

CONCLUSIONS

The exercise behaviors of many elderly adults with chronic low back pain can increase after an exercise-oriented spine physical therapy program.

Health related quality of life outcome instruments

Health is the most significant part of quality of life. Generally, quality of life outcome instruments used in healthcare confine their attention to health related areas, assessing health related quality of life. The present study aims to describe some commonly used health profile instruments such as the generic measures SF-36, Nottingham Health Profile and Sickness Impact Profile; and the preference-based measures EuroQol and SF-6D. The latter preference-based instruments are increasingly used in outcome studies and obtained data might be used for calculating quality-adjusted life-years.