Back Pain and the Exercise Prescription

Comparison between the Ki-hap technique and verbal encouragement on activation of abdominal muscles in healthy participants

The aim of this study was to investigate the comparison between a Ki-hap, defined as a psyching-up technique, and verbal encouragement, defined as a verbal command by a third party, on abdominal muscle activation during performance of the crunch exercise in healthy participants. Ninety participants were randomly allocated to the following three groups: crunch only exercise group (CG, n₁ = 30), crunch exercise with Ki-hap group (CKG, n₂ = 30), and crunch exercise with Ki-hap and verbal encouragement group (CKVG, n₃ = 30). The interventions were conducted over three trials with each group, and measurements involving each participant, were performed by a single examiner. The activation of the rectus abdominis (RA), external oblique (EO), and internal oblique (IO) muscles were evaluated using electromyography (EMG) during performance of the crunch exercise by the CG, CKG, and CKVG. Our results showed a significantly greater increase in the EMG patterns of all muscles during performance of the crunch exercise in the CKG (p < 0.05) compared to those in the CG and CKVG. The results also showed that there was a significantly greater increase in the activation of the EO and IO muscles in the CKVG (p < 0.05) compared with that in the CG. These findings demonstrated that the addition of the Ki-hap technique and verbal encouragement, during performance of the crunch exercise, improves activation of the abdominal muscles.

Mechanical Low Back Pain in Elite Track and Field Athletes: An observational cohort study

OBJECTIVE

The aim of the study was to gain information about the incidence of mechanical Low Back Pain (MLBP) injuries etiology in elite track and field athletes and to assess the recurrence rate.

BACKGROUND

The prevalence and the etiology of Low Back Pain (LBP) in athletic populations at the elite level of competition lack of longitudinal studies focused on certain sport fields. The present study evaluates MLBP incidents in elite track and field athletes visiting National Track and Field Centre in Thessaloniki, Greece and classifies MLBP according to etiology.

METHODS

One hundred and thirty Elite Track and Field Athletes with MLBP injuries were included in a 20-year observational cohort study recording the initial MLBP etiology according to a classification system based on mechanical diagnosis. It was examined if age, gender and sport category predispose the incidence of the initial MLBP etiology and if they consist risk factors for MLBP recurrence.

RESULTS

Discogenic MLBP in elite track and field athletes was significantly higher at 46.9% (α= 0.05) compared with the other MLBP etiologies under consideration. Secondary findings of the present study regarding the incidence of MLBP etiology categories did not reveal significant associations with gender, age and contest categories (α= 0.05). Additionally, recurrence pathophysiology showed that discogenic MLBP obtained high recurrence rates at 0.48 (14 athletes from 29 athletes recurred) compared with other etiologies, followed by back elements injury recurrence rate at 0.24 (7 athletes out of 29).

CONCLUSIONS

The study provided us with evidence of higher incidence of discogenic etiology of MLBP in elite track and field athletes. Further research is suggested in the use of etiology related LBP classification system in order to evaluate causes, prevalence and epidemiology of MLBP in athletic populations of specific sport categories.

Multidisciplinary rehabilitation for chronic back pain in an outpatient setting: A controlled randomized trial

Based on existing models for pain chronicity and effective treatment strategies for patients with chronic low back pain, a multidisciplinary rehabilitation programme for an outpatient group setting was developed. The main treatment components address the patient's physical functional capacity (functional restoring), cognitive and affective processes (pain management strategies), and behavioural and ergonomical aspects (back school elements). Short-term (immediately after intervention) and long-term effects (at 6-months follow-up) of the intervention were assessed in a randomized controlled study. Dependent variables were pain measures, functional capacity, disability, muscular strength and endurance, pain and posture-related self-efficacy, attitudes, depression, well-being, behavioural habits and posture assessed by a standardized behavioural observation method. Immediately after the intervention, patients in the treatment group (n=36) showed significant improvement over patients in the control group (n=29) in all variables except depression and muscular strength and endurance. At 6-months follow-up, compared to pretreatment scores, patients continued to show beneficial effects in pain intensity and frequency, posture, posture-related self-efficacy and well-being. In contrast to post-treatment results, there were also significant improvements in strength and endurance. Overall results testify to the effectiveness of the intervention programme. Future studies (with larger sample sizes) should aim at a further improvement of functional capacity and disability perception, an analysis of differential treatment effects, and strategies for an improved long-term maintenance of the changes induced by the programme.

Comparison of four physiotherapy regimens in the treatment of long-term mechanical low back pain

OBJECTIVE

This study compared efficacy of combinations of Back Muscles Endurance Exercise (BMEE) and McKenzie Exercise (ME) and McKenzie Back Care Education (MBE) in the management of long term mechanical Low Back Pain (LBP).

SUBJECTS AND METHODS

A single-blind randomized controlled comparative trial was employed. Seventy three participants mean age 45.3 ± 8.1 years were recruited for the study but only 53 completed the study. Participants in group A were treated with a combination of BMEE, ME and MBE. Group B: A combination BMEE and MBE. Group C: A combination of ME and MBE. Group D: MBE only. Participants were seen thrice weekly for 8 weeks. They were measured for pain intensity, lumbar flexibility, activities limitation and self esteem. Data were analysed using descriptive and inferential statistics of F-test. Significance was set at 0.05 alpha-level.

RESULTS

At the end of the study, the four treatment groups had significant reduction in pain intensity p<0.05. Post hoc analysis showed groups A, B, and C had significantly greater reduction than D, and groups A and C had significantly greater reduction than B. Groups A, B and C also had significant improvement in activities limitation p<0.05. Post hoc analysis showed groups A, B and C had significantly greater improvement than D, and group B significantly greater improvement than C.

CONCLUSION

Combination physiotherapy regimens proved effective in the management of long- term mechanical LBP. Regimen A is recommended in managing long-term mechanical LBP.

The lumbar spine and low back pain in golf: a literature review of swing biomechanics and injury prevention

BACKGROUND CONTEXT

The golf swing imparts significant stress on the lumbar spine. Not surprisingly, low back pain (LBP) is one of the most common musculoskeletal complaints among golfers.

PURPOSE

This article provides a review of lumbar spine forces during the golf swing and other research available on swing biomechanics and muscle activity during trunk rotation.

STUDY DESIGN

The role of "modern" and "classic" swing styles in golf-associated LBP, as well as LBP causation theories, treatment, and prevention strategies, are reviewed.

METHODS

A PubMed literature search was performed using various permutations of the following keywords: lumbar, spine, low, back, therapy, pain, prevention, injuries, golf, swing, trunk, rotation, and biomechanics. Articles were screened and selected for relevance to injuries in golf, swing mechanics, and biomechanics of the trunk and lumbar spine. Articles addressing treatment of LBP with discussions on trunk rotation or golf were also selected. Primary references were included from the initial selection of articles where appropriate. General web searches were performed to identify articles for background information on the sport of golf and postsurgical return to play.

RESULTS

Prospective, randomized studies have shown that focus on the transversus abdominus (TA) and multifidi (MF) muscles is a necessary part of physical therapy for LBP. Some studies also suggest that the coaching of a "classic" golf swing and increasing trunk flexibility may provide additional benefit.

CONCLUSIONS

There is a notable lack of studies separating the effects of swing modification from physical rehabilitation, and controlled trials are necessary to identify the true effectiveness of specific swing modifications for reducing LBP in golf. Although the establishment of a commonly used regimen to address all golf-associated LBP would be ideal, it may be more practical to apply basic principles mentioned in this article to the tailoring of a unique regimen for the patient. Guidelines for returning to golf after spine surgery are also discussed.

Sensitivity, specificity and predictive value of the clinical trunk muscle endurance tests in low back pain

OBJECTIVE

To describe the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of five clinical tests used to measure trunk muscle endurance in low back pain.

DESIGN

A cross-sectional non-experimental design.

SETTING

Orthopaedic and physical therapy departments of four hospitals and outpatient physical therapy clinics, Tehran, Iran.

SUBJECTS

Convenience sample of 200 subjects participated in this study. Subjects were categorized into four groups: men without low back pain (N = 50, mean (SD) age = 38 (12) years), women without low back pain (N = 50, mean (SD) age = 43 (11) years), men with low back pain (N = 50, mean (SD) age = 39 (12) years) and women with low back pain (N = 50, mean (SD) age = 43 (12) years).

MAIN MEASURES

Five clinical static endurance tests of trunk muscles such as: Sorensen test, prone isometric chest raise test, prone double straight-leg raise test, supine isometric chest raise test and supine double straight-leg raise test were measured in each group.

RESULTS

The result of receiver operating characteristics (ROC) curve analysis revealed that in a separate analysis of data for men and women, among all tests, the prone double straight-leg raise test had the highest sensitivity, specificity and predictive value in low back pain compared with other performed tests.

CONCLUSIONS

It seems that the prone double straight-leg raise test has more sensitivity, specificity and predictive value in low back pain than other tests and could be used as a useful clinical method for testing the spinal muscle endurance to predict the probability of the occurrence of low back pain.

Estimated moments at L5/S1 level and muscular activation of back extensors for six prone back extension exercises in healthy individuals

The purpose of this study was to identify the prone back extension (PBE) exercises that offer the most resistance to the back extensor muscles. Twenty males with no previous history of low back injury performed two repetitions of eight exercises. These consisted of two maximal isometric voluntary activations (MVA) and six different PBE exercises. The participants, while lying prone on a bench, were asked to raise either their trunk or legs to the horizontal position and hold for one second (static phase) before returning to the original position. The exercises differed according to the particular segments that were raised into extension. To assess the PBE exercises, a biomechanical model was used to estimate the level of load resistance (%MVA) relative to the maximum voluntary activation strength (MVA). In addition, electromyography (EMG) was included to measure the level of muscle activity (%MVE) relative to the maximum voluntary activation EMG (MVE) value reached during the MVA. A significant relationship of 0.86 was found between the mass of the subject and the peak reaction moment during the MVA. Peak level of load resistance averaged around 50% MVA with the exception of exercise no. 5 where the subject had to raise in extension his trunk, legs and arms (65% MVA). The erector spinae (ES) activity level reached a peak value of 61% MVE for exercise no. 5. In the exercises where only the trunk was lifted, the peak level of ES was below 47% MVE and the average activity during the static phase reached approximately 26% MVE. For healthy individuals PBE exercises can be considered low intensity exercises (< 50% MVA; except exercise no. 5) and can be used to improve the endurance of the back muscles.

Epidemiology of back pain in the athlete

Back pain and injuries are common complaints of athletes. The nature of the sport involved with the specific stresses that it places on the athlete's spine may play a role in the injuries incurred. These injuries may limit an athlete's function and hinder performance; however, the majority of these insults are self-limiting and respond well to conservative measures. Based on the epidemiologic data, it appears that possibly the single most important step in reducing the back pain experienced by athletes would involve the performance of a structured back-strengthening program. Such a plan might reduce the most common diagnostic entities encountered by the athlete with back pain.

Psychometric properties of child- and teacher-reported curl-up scores in children ages 10-12 years

The purpose of this study was to examine the psychometric properties of child- and teacher-reported curl-up (CU) scores in children ages 10-12 years in both a norm-referenced (NR) and criterion-referenced (CR) framework. Eighty-four children, 36 boys and 48 girls, performed the FITNESSGRAM (Cooper Institute for Aerobics Research, 1992) CU test on 2 days separated by 48-72 hr. Two video cameras were used to record students' CU performances. Two students performed the CU at the same time, with each child's performance recorded by one camera. The test was terminated when the child stopped due to fatigue or after two form errors occurred. Teacher-reported scores were the average of two independent ratings of each video performance, while child-reported scores came from data collected and recorded by the children. Single trial norm-referenced reliability was R = .75 for girls and R = .80 for boys for teacher-reported CU and R = .69 and R = .70 for child-reported CU for girls and boys, respectively. CR reliability was examined using P, proportion of students who consistently passed or failed the test across 2 days, and km, defined as reliability with chance removed. For teacher-reported scores, P = .89 and km = .78 for boys and P = .81 and km = .62 for girls. For child-reported scores, P = .86 and km = .72 for boys, while P = .79 and km = .58 for girls. For teacher-reported data, 39% of boys passed and 50% failed the test on both days, while for girls the percentages were 27% pass and 54% fail. For child-reported data, 64% of boys passed and 22% failed on both days, while 54% of girls passed and 25% failed. NR validity was examined by correlating teacher and child-reported scores. The resultant coefficient was r = .42 (95% CI = .11-.66) for boys and r = .67 (95% CI = .58-.74) for girls. Additionally, child-reported scores were significantly higher than teacher-reported scores. CR validity was examined with a contingency coefficient, and results indicated C = .55 with 44% false master errors for boys and C = .65 with 29% false master errors for girls. The findings of this study suggest that while NR reliability estimates were moderate for teacher-reported scores, single trial estimates suggest that child-reported CU should be viewed with caution. In regard to CR reliability, both teacher-reported and child-reported reliability were moderate. However, there were marked differences between teacher- and child-reported scores, with children reporting higher percentages of students passing and lower percentage of student failing the test when compared with scores reported by teachers. Validity was rather moderate when viewed in either a NR and CR framework. It is suggested that problems with child-reported scores may be due to the need for additional practice or simplification of the testing protocol.

Pelvic mobility when bending forward in standing position: validity and reliability of 2 motion analysis devices

OBJECTIVE

To evaluate the validity and reliability of 2 measurement devices that assess pelvic mobility in persons bending forward while in a standing position.

DESIGN

Validity and reliability studies.

PATIENTS

The validity study included 10 patients (4 men, 6 women) aged 42 (range, 33--51yr). The reliability study included 50 subjects (25 men, 25 women) aged 30 (range, 18--49yr).

INTERVENTIONS

A 3-dimensional ultrasound motion analyzer (CMS 50) and a spine motion analyzer using potentiometers (Rachimètre).

METHODS

Two lateral radiographs of the patients' lumbosacral junction were taken, the first in neutral position, the second in full trunk flexion. Correlations between mobilities assessed by radiographs and both devices were evaluated by Spearman's rank correlation coefficient. Reliability was studied in healthy volunteers using the intraclass coefficient correlation (ICC) and the Bland and Altman plot.

RESULTS

Spearman's coefficient between radiographic measures and the Rachimètre and the CMS 50 evaluations were.89 and.81, respectively. For the Rachimètre, ICC was.65 and increased with a better standardization of the measurement procedures. For the CMS 50, ICC was.85, and the Bland and Altman plot revealed no systematic trend.

CONCLUSIONS

The Rachimètre and the CMS 50 have acceptable metric properties. Because few simple clinical measurements are available to evaluate pelvic mobility during trunk flexion in standing position, these 2 devices could be useful in the clinical evaluation of low back pain.

Predictors of occupational low back disability: implications for secondary prevention

Over the past decade, studies have identified a combination of demographic, physical/medical, ergonomic, and psychosocial factors in the development of work disability related to occupational low back pain. Using such data on disability risk factors, investigators have begun to develop risk identification and disability prevention programs. As part of an ongoing effort to develop a secondary prevention program, the present case-control study identified the relative contribution of demographic, physical demand, physical fitness, as well as occupational and individual psychosocial variables to back-related work disability in the US Army. Soldiers (n = 174) diagnosed with a lumbosacral strain and medically discharged from the Army were compared with non-disabled controls (n = 173). Dependent measures were obtained from the US Army Health Risk Appraisal (HRA). For cases, these data pre-dated disability determination by 1 to 3 years. For controls, the HRA was completed during the same time period. Significant predictors of low back disability were: age (odds ratio [OR] = 1.13 per year), lower rank (E2/E3) (OR = 4.08/OR = 3.02), infrequent aerobic exercise (OR = 2.2), higher work stress (OR = 2.71), worries (OR = 2.17), and lower social support (OR = 5.07). The model correctly classified 73.13% of all subjects. These results highlight the importance of considering age, status level in the organization, frequency of aerobic exercise, occupational stress, general worries, and social support for the early detection of soldiers at increased risk for back-related disability. Additionally, the findings support past research indicating the multivariate nature of work disability and emphasize the importance of considering such factors in future secondary prevention efforts.

Toward a better prescription of the prone back extension exercise to strengthen the back muscles

This study investigated the level of resistance and the level of muscle activation of the prone back exercise. Fifteen male subjects with no previous history of low back injury performed two repetitions of seven exercises. These consisted of four maximal isometric voluntary contractions (MVC) and three prone back extension (PBE) exercises. The subject was lying prone on a table, the upper body was suspended off the end of the table and the legs and thighs were secured to the table with straps. Three starting positions from the horizontal were investigated, 0 degree, 30 degrees and 60 degrees, and were compared with MVC to quantify the level of effort needed to perform the task. The results showed that the three PBE exercises require a level of resistance and a level of muscle activation generally under 40% of the maximum capacity of healthy subjects. Muscle activity of the erector spinae (ES) was slightly greater when the exercise started at 60 degrees, compared to 0 degree and 30 degrees. During the static phase of the PBE exercises, the level of resistance remained at 40% relative to the peak reaction moment of the MVC, but muscular activity of ES tended to work at a lower activity level. In conclusion, since for healthy subjects PBE exercises are low resistance exercises, they seem to be more specifically designed to develop muscular endurance of the back muscles.

Criterion-related validity of sit-and-reach tests in university men in Hong Kong

To examine the criterion-related validity of traditional, modified, and YMCA sit-and-reach tests and the relationships of these with abdominal muscular strength and endurance measured by the sit-up test, 52 university men of mean age 20.7 yr. were administered two trials of six measurements in counterbalanced order, including traditional, modified, and YMCA sit-and-reach tests, passive straight-leg raise, low-back flexibility evaluation, and 1-min. sit-up test. Pearson product-moment correlations were significant (p < .05) for traditional and modified sit-and-reach tests with hamstrings' flexibility (rs = .71 and .77, respectively). Also, the YMCA sit-and-reach test was significantly associated with hamstrings' flexibility (r = .64) and low-back flexibility (r = .47). Stepwise multiple regression indicated hamstrings' flexibility was the only significant predictor of traditional and modified sit-and-reach tests, explaining the variances of 59.1% and 49.8%, respectively. However, both hamstring and low-back flexibility were significant predictors for the YMCA sit-and-reach test, which in total accounted for 52.2% of explained variance. Traditional and modified sit-and-reach tests are valid in assessing hamstrings' flexibility only, whereas the YMCA sit-and-reach test is valid for measuring both the hamstring and low-back flexibility.

Abdominal Strengthening Exercises: A Comparative EMG Study

The purpose of this study was to compare electromyographic (EMG) activity of the abdominal muscles between the crunch exercise and five other popular abdominal exercises. Surface EMG recordings of four muscles (upper rectus, lower rectus, external oblique, and internal oblique) of the anterior abdominal wall were collected and analyzed on 20 healthy, male volunteers. EMG activity was recorded during execution of the abdominal crunch, the sit-up, and exercises performed with the Abflex machine, the AbRoller, the Nordic Track Ab Works, and the Nautilus crunch machine. The results indicate that the crunch exercise is comparable to the five other abdominal exercises with respect to muscle activation of the internal and external abdominal oblique muscles. Activation of the upper rectus abdominal muscles appears to be best achieved with the Abflex machine, whereas the crunch exercise is superior to the sit-up for activation of the upper and lower rectus abdominal muscles.

Strength and Flexibility Characteristics of Athletes with Chronic Low-Back Pain

The purpose of this study was to identify strength and flexibility deficits in subjects with chronic low-back pain (CLBP). Subjects were 16 female Division I athletes: 8 athletes who had experienced CLBP for at least 6 months prior to testing and a control group of 8 matched subjects. Athletes with neurological symptoms, previous back operations, and leg length discrepancies and those who were diagnosed with scoliosis, spondylolisthesis, or spondylolysis were excluded from this study. Variables assessed included abdominal strength, erector spinae endurance, hip flexion and extension endurance, torso lateral flexibility, and low-back flexibility. Strength and endurance were calculated as a function of time in seconds. Goniometric measurements were used to determine flexibility. Significant mean differences were found by using dependentttests for abdominal strength, erector Spinae endurance, hip extension, and right lateral flexion of the torso. The results validate the necessity for pelvic stabilization and indicate that strength and flexibility deficits vary among populations.

Outcome comparison of workers' compensation and noncompensation low back pain in a highly structured functional restoration program

Low back pain is both common and costly. A paucity of information exists within the literature comparing workers' compensation and noncompensation back-injured individuals. The intent of this study was to examine differences between the two groups--individuals injured and seeking compensation, and injured individuals not pursuing a compensation claim. Sixty subjects referred to a functional restoration facility were identified and evaluated, and their progress was tracked. Demographic and return-to-employment data were collected. Of the 35 workers' compensation subjects, 23 (65.71%) were not working during therapy, while only one of 25 noncompensation individuals was not working throughout treatment. Thirty-two compensation individuals (91%) and all of the noncompensation group members made successful returns to employment (p < or = .05). The authors conclude that while some differences existed between the two groups, a high return-to-work frequency was achieved (91%) (p < or = .05). Results indicate high success outcomes as measured by return-to-work, increased function, and reduced pain. These outcomes were obtained through highly structured, medically supervised functional restoration programs.

Exercise for the low back pain patient

As 90% of patients with acute LBP recover within a 2-month period, irrespective of the type of treatment received, exercise probably plays little role in facilitating recovery from an acute episode of LBP. It may be a very important factor in both symptomatic and functional recovery in chronic LBP, as well as an integral factor in preventing recurrent injury. The most efficacious exercise regimen for treating LBP is currently unknown. Similarly, little is known about the efficacy of individual exercises. In certain patients, flexion or extension exercises may be inappropriate. A careful history and physical examination, observing the movements that cause pain, will assist the physician in tailoring the exercise programme to the individual patient to achieve the greatest likelihood of success. Communication between the patient, physician and therapist is vital to allow continual adjustment of the programme to best meet the patient's needs. As improvement occurs, more stressful exercises can be added to improve strength, endurance and aerobic fitness. Individualizing the exercise programme to the patient's symptoms and communication between the patient, therapist and physician lead to greater compliance with the exercise programme and a greater likelihood of improved outcome.