Combined neuromuscular electrical stimulation with motor control exercise can improve lumbar multifidus activation in individuals with recurrent low back pain

Neuromuscular responses to combined neuromuscular electrical stimulation and motor control exercises in a patient with recurrent low back pain: A single subject research report

BACKGROUND

Previous studies have demonstrated changes in lumbar multifidus muscle (LM) contractility after motor control exercises (MCE), and it has been hypothesized that adding neuromuscular electrical stimulation (NMES) may help to re-activate motor units.

OBJECTIVE

To present the effects of combined NMES and MCE on LM contractility, spatial and temporal motor unit recruitment, and movement control in a patient with recurrent low back pain (rLBP).

METHODS

Motion tracking system was used to measure quality of movement (smoothness) during an active forward bend, while ultrasound imaging and decomposition electromyography were used to measure the LM contractility and motor unit recruitment during the Sorensen test. These data were collected pre and post intervention. Perceived improvement was also recorded.

RESULTS

Improved movement smoothness post intervention was found, with increases in LM contractility from 68.1% to 97.7%, and from 74.2% to 86.7% on the right and left sides, respectively. Number of motor unit increased from 14 to 18 units, while mean firing rate decreased from 10.9 to 7.1 pulses/second post intervention. The patient also reported a perceived improvement of +2 on the Global Rating of Change (GROC). However, this change was not greater than +3 to be considered as minimal clinically important difference.

CONCLUSION

These findings indicate improvements in movement control, LM contractility, and changes in spatial and temporal motor unit recruitment in the study patient, suggesting the potential clinical utility and the need for further research on combined NMES and MCE in the treatment of patients with rLBP.

Effects of MLS Laser on pain, function, and disability in chronic non-specific low back pain: A double-blind placebo randomized-controlled trial

BACKGROUND

Among non-pharmacological interventions, Multiwave Locked System (MLS) Laser therapy has been used in patients with several musculoskeletal pathologies and in combination with other therapeutical interventions. The effects of sole MLS therapy on pain and function in patients with chronic non-specific low-back pain are unknown.

OBJECTIVE

The objective of this study was to investigate the effects of MLS Laser therapy on pain, function, and disability in patients with chronic non-specific low back pain in comparison to a placebo treatment group.

METHODS

Forty-five patients were randomized into two groups: the MLS Laser group and the Sham Laser group, undergoing 8 sessions of either a MLS Laser therapy or a Sham Laser therapy, respectively. At the beginning of the therapy (T0), at the end of the therapy (T1), and 1 month after the end of therapy (T2) patients were assessed for low back pain (by means of a VAS scale), function (by means of kinematic and electromyographic assessment of a forward bending movement) and self-reported disability (by means of the Roland-Morris and Oswestry Disability questionnaires).

RESULTS

There was a significant reduction of pain and disability in both groups at T1 and T2 in comparison with T0. At T2 patients in the MLS group showed a significantly lower pain in comparison with patients in the Sham group (VAS = 2.2 ± 2 vs. 3.6 ± 2.4; p< 0.05). No differences between the two groups were found for function and disability.

CONCLUSION

Both MLS Laser and Sham Laser therapies lead to a significant and comparable reduction in pain and disability in patients with chronic non-specific low back pain. However, one month after treatment, MLS Laser therapy has been found to be significantly more effective in reducing pain as compared to sham treatment.

Multifidus dysfunction and restorative neurostimulation: a scoping review

OBJECTIVE

Chronic low back pain (CLBP) is multifactorial in nature, with recent research highlighting the role of multifidus dysfunction in a subset of nonspecific CLBP. This review aimed to provide a foundational reference that elucidates the pathophysiological cascade of multifidus dysfunction, how it contrasts with other CLBP etiologies and the role of restorative neurostimulation.

METHODS

A scoping review of the literature.

RESULTS

In total, 194 articles were included, and findings were presented to highlight emerging principles related to multifidus dysfunction and restorative neurostimulation. Multifidus dysfunction is diagnosed by a history of mechanical, axial, nociceptive CLBP and exam demonstrating functional lumbar instability, which differs from other structural etiologies. Diagnostic images may be used to grade multifidus atrophy and assess other structural pathologies. While various treatments exist for CLBP, restorative neurostimulation distinguishes itself from traditional neurostimulation in a way that treats a different etiology, targets a different anatomical site, and has a distinctive mechanism of action.

CONCLUSIONS

Multifidus dysfunction has been proposed to result from loss of neuromuscular control, which may manifest clinically as muscle inhibition resulting in altered movement patterns. Over time, this cycle may result in potential atrophy, degeneration and CLBP. Restorative neurostimulation, a novel implantable neurostimulator system, stimulates the efferent lumbar medial branch nerve to elicit repetitive multifidus contractions. This intervention aims to interrupt the cycle of dysfunction and normalize multifidus activity incrementally, potentially restoring neuromuscular control. Restorative neurostimulation has been shown to reduce pain and disability in CLBP, improve quality of life and reduce health care expenditures.

Telerehabilitation for the treatment in chronic low back pain: A randomized controlled trial

INTRODUCTION

Although there is growth in the approach to telerehabilitation (TLRH) in different pathologies, research on TLRH for the management of low back pain is scarce and controversial. Thus, the purpose of this study was to analyze whether a TLRH program is as effective as a clinical exercise program in improving pain and different functional variables in patients with nonspecific low back pain (NLBP).

METHOD

A single-blind, two-armed randomized controlled trial was carried out with 68 individuals with chronic NLBP. Participants were randomly allocated to either the TLRH group (TG) (n = 34) or the clinic group (CG) (n = 34). The TG received an exercise-based TLRH video and an educational program on the neurophysiology of pain. The CG received the same pain education and exercise program at the clinic facility supervised by a clinician. Both groups performed 2 weekly sessions for 8 weeks. Active movements of the lumbar spine, pain and range of motion, and kinesiophobia were assessed at baseline, at the end of 8 weeks of treatment, and at 3 months.

RESULTS

Statistically significant differences for time-by-group interaction were identified in range of motion of right (F = 11.668; p = 0.001) and left (F = 4.219; p = 0.042) legs when knee extended test is performed; as well as in pain intensity when the same test (F = 5.176; p = 0.043). Moreover, higher pain level during flexion (F = 5.133; p = 0.009) and extension movements (F = 6.335; p = 0.003) in patients with bilateral pain location than those with unilateral or central pain location has been appreciated.

CONCLUSION

A TLRH rehabilitation program via mobile app is as effective as the same exercise program supervised in a clinic.

Lumbar multifidus thickness changes during active leg raising with ultrasound imaging can detect patients with chronic non-specific low back pain

BACKGROUND

Altered lumbar multifidus (LM) activation has been found in populations with non-specific chronic low back pain (NSCLBP).

OBJECTIVE

To detect differences in LM muscle thickness at rest and during active manoeuvres between patients with NSCLBP and pain-free controls and to analyze the ability of LM thickness change during the active straight leg raise (ASLR) with rehabilitative ultrasound imaging to detect patients with NSCLBP.

DESIGN

Cross-sectional observational study.

METHODS

Seventy volunteers (50% patients NSCLBP) were recruited. 18 B-mode images of LM at L4-L5 or L5-S1 level selecting the most symptomatic level (both sides, six at rest and three during ASLR) were collected by a blinded assessor. Differences between patients and controls in LM muscle thickness at rest, during ASLR (holding 3sec), and 5 s after ASLR were calculated. In addition, discriminant validity was evaluated by calculating the area under the receiver operating characteristic curve (ROC), sensitivity, specificity and positive and negative likelihood ratio.

RESULTS

Significant LM thickness change differences during ASLR were found within and between groups: bilaterally, LM thickness change during ASLR was significantly higher in healthy controls than in NSCLBP patients. Ipsilateral LM muscle thickness change was sensitive to detect individuals with NSCLBP (ROC = 0.79-0.80).

CONCLUSION

Pain-free individuals exhibited significantly greater LM thickness changes bilaterally during the ASLR compared to patients with NSCLBP. LM thickness change during the ASLR has good validity for discriminating patients with NSCLBP. Further studies should assess benefits of LM training programs in the management of these patients.

Bilateral Asymmetrical Limb Proprioceptive Neuromuscular Facilitation Effects on Pain, Multifidus Activity, Range of Motion, and Disability in Low Back Pain: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to determine the effects of bilateral asymmetrical limb proprioceptive neuromuscular facilitation (PNF) pattern exercises on lumbar multifidus (LM) activity, pain, disability, and lumbar range of motions (ROMs) compared to Swiss ball exercises in patients with chronic low back pain (CLBP).

METHODS

A randomized controlled trial was conducted at the Sindh Institute of Physical Medicine and Rehabilitation, Karachi, Pakistan, between March 2020 and January 2021. A sample size of 150 patients with CLBP was randomized into 2 groups. Participants in the intervention group (n = 75) received bilateral asymmetrical limb PNF, while the comparison group (n = 75) received Swiss ball exercises. The scores of the visual analog scale, Oswestry Disability Index, Modified-Modified Schober's test, and percentage of the maximum voluntary contractions of LM (%MVC LM) through surface electromyography were recorded before and after 15 sessions of exercises. The Wilcoxon signed rank and Mann-Whitney U tests were employed for within-group and between-group comparisons of all outcomes, respectively. The considered level of significance was 0.05. The trial was registered with ClinicalTrials.gov (NCT04206137).

RESULTS

Pain (in sitting, standing, and walking), disability on the Oswestry Disability Index, and left side %MVC LM were significantly improved (P < .001) in the PNF group compared to the comparison group except for right side %MVC LM and ROMs on the Modified-Modified Schober's test (P > .05).

CONCLUSION

Bilateral asymmetrical limb PNF exercises showed improvement in pain, disability, and LM activity of patients with CLBP more than those who used Swiss ball exercises.

The effect of phasic versus combined neuromuscular electrical stimulation using the StimaWELL 120MTRS system on multifidus muscle morphology and function in patients with chronic low back pain: a randomized controlled trial protocol

Background

Neuromuscular electrical stimulation (NMES) is used to improve muscle strength clinically when rehabilitating various musculoskeletal disorders. However, the effects of NMES on muscle morphology and function in individuals with non-specific chronic low back pain (CLBP) have scarcely been investigated. Although research links deficits in the paraspinal musculature with subjective reports of pain and disability, it is unknown if treatment with NMES can help reverse these deficits. Therefore, the primary aim of this study is to compare the effects of two muscle therapy protocols with a medium-frequency electrotherapy device (the StimaWELL 120MTRS system) on multifidus muscle morphology and function in CLBP patients. The secondary aims are to determine the effects of these protocols subjective reports of pain intensity, pain interference, disability, and catastrophizing.

Methods

A total of 30 participants with non-specific CLBP, aged 18–60, will be recruited from local orthopedic clinics and databases. Participants will be randomized (1:1) to either the phasic or combined (phasic + tonic) muscle therapy protocols on the StimaWELL 120MTRS system. Participants will undergo 20 supervised electrotherapy treatments over a 10-week period. The primary outcomes will be multifidus morphology (e.g. cross-sectional area (CSA), fat infiltration) and function (e.g., contraction measured via %thickness change from a rested to contracted state, and stiffness at rest and during contraction). Secondary outcomes will include pain intensity, interference, disability, and catastrophizing. Both primary and secondary outcomes will be obtained at baseline and at 11-weeks; secondary outcomes measured via questionnaires will also be obtained at 6-weeks, while LBP intensity will be measured before and after each treatment. Paired t-tests will be used to assess within-group changes for all primary outcome measures. A two-way repeated-measures analysis of variance will be used to assess changes in secondary outcomes over time.

Discussion

The results of this trial will help clarify the role of medium-frequency NMES on lumbar multifidus morphology and function.

Trial Registration

NCT04891692, registered retrospectively on May 18, 2021.

Effectiveness of lumbar stabilization exercise with real-time ultrasound imaging biofeedback on lumbar multifidus muscle cross-sectional area in individuals with non-specific chronic low back pain: a study protocol for a randomized controlled trial

BACKGROUND

Structural impairment of the lumbar multifidus muscle, such as reduced cross-sectional area, is evident among individuals with chronic low back pain. Real-time ultrasound imaging (RUSI) biofeedback has been reported to improve preferential activation of as well as retention in the ability to activate the lumbar multifidus muscle during lumbar stabilization exercises (LSE). However, evidence of the effectiveness of this treatment approach in individuals with non-specific chronic low back pain (NCLBP) is still limited. The purpose of this study is, therefore, to determine the effectiveness of LSE with RUSI biofeedback on lumbar multifidus muscle cross-sectional area in individuals with NCLBP.

METHODS/DESIGN

This study is a prospective, single-center, assessor-blind, three-arm, parallel randomized controlled trial to be conducted at National Orthopedic Hospital, Kano State, Nigeria. Ninety individuals with NCLBP will be randomized in a 1:1:1: ratio to receive LSE, LSE with RUSI biofeedback, or minimal intervention. All participants will receive treatment twice weekly for 8 weeks. The primary outcome will be the lumbar multifidus muscle cross-sectional area. The secondary outcomes will include pain (Numerical Pain Rating Scale), functional disability (Roland-Morris Disability Questionnaire), and quality of life (12-Item Short-Form Health Survey). All outcomes will be assessed at baseline, 8 weeks post-intervention,  and 3 months follow-up.

DISCUSSION

To our knowledge, this study will be the first powered randomized controlled trial to compare the effectiveness of LSE training with and without RUSI biofeedback in individuals with NCLBP. The outcome of the study may provide evidence for the effectiveness of LSE with RUSI biofeedback on enhancing the recovery of the lumbar multifidus muscle in individuals with NCLBP.

TRIAL REGISTRATION

Pan African Clinical Trials Registry ( PACTR201801002980602) . Registered on January 16, 2018.