Modifying patterns of movement in people with low back pain -does it help? A systematic review

Use of Intervention Mapping to Adapt a Psychologically Informed Physical Therapy Telerehabilitation Intervention for Latino Persons With Chronic Spine Pain

The need for culturally tailored pain care is well-recognized, yet few studies report how existing interventions can be adapted to the needs of culturally and linguistically diverse populations. This report describes a formative mixed-methods approach using intervention mapping-adapt and the expanded framework for reporting adaptations and modifications to evidence-based interventions to adapt and report modifications of an existing physical therapy intervention for Latino persons with chronic spine pain in Federally Qualified Health clinics in the southwestern United States. Mixed methods included literature reviews, patient surveys, an Adaptation Advisory Panel, and sequential case series with semistructured interviews. Six steps of intervention mapping-adapt guided the adaptation process and adaptations were prospectively documented with framework for reporting adaptations and modifications to evidence-based interventions. A needs assessment revealed an absence of culturally tailored physical therapy interventions for Latino persons with chronic spine pain in the United States. An intervention logic model and review of the sociocultural context guided the selection of essential interventions, determinants of behavior change, and outcomes. An existing cognitive behavioral-based physical therapy telerehabilitation intervention was selected for adaptation based on accessibility and strong congruency with the logic model. An Adaptation Advisory Panel planned and evaluated iterative adaptations of the cognitive behavioral-based physical therapy intervention content, activities, delivery, materials, and design. The adapted Goal-Oriented Activity for Latino persons with Spine pain intervention aimed to reduce pain intensity and disability through patient-centered goal setting in physical and cognitive treatment domains. Sequential case series supported feasibility and acceptability of the adapted intervention in the target population. PERSPECTIVE: We describe adaptation and reporting of an evidence-based physical therapy intervention for a culturally and linguistically diverse population. Greater rigor and transparency using tools such as intervention mapping-adapt and framework for reporting adaptations and modifications to evidence-based interventions will accelerate efforts to reduce ethnic and racial disparities in pain rehabilitation.

Psychologically Informed Physical Therapy Management of Chronic Musculoskeletal Pain in Culturally Diverse Populations: An Intervention Logic Model

Culturally and linguistically diverse (CALD) individuals are underrepresented in pain research, including studies of psychologically informed physical therapy (PIPT) for musculoskeletal pain. This perspective describes a conceptual framework for PIPT management of chronic musculoskeletal pain that identifies essential elements that can be culturally tailored to meet the needs of different CALD populations. Essential interventions, determinants of behavior change, and clinical outcomes were identified from studies of existing PIPT interventions for chronic pain. PIPT approaches shared the following essential interventions: 1) cognitive skill training, 2) general aerobic activity, 3) impairment-based therapeutic exercises, and 4) graded functional movement training. An intervention logic model was developed to conceptualize how these interventions might promote active coping behaviors and greater engagement in physical activity, therapeutic exercise, and functional mobility. The model included physical and cognitive-emotional processes that may contribute to behavioral changes that ultimately reduce pain-related disability. To illustrate the cultural tailoring of model constructs, we describe how intervention delivery and assessments were customized for Latino persons with chronic spine pain at a health center located near the United States-Mexico border. A literature review of sociocultural influences on the pain experience of Latino persons was conducted, and essential elements of the model were operationalized to ensure that therapeutic goals, language, content, and processes were compatible with Latino cultural beliefs, values, and behaviors. Future research using the proposed model to adapt and test PIPT interventions for other CALD populations may help identify shared and divergent mechanisms of treatment response for culturally tailored pain management programs. PERSPECTIVE: A novel conceptual framework may help inform the cultural tailoring of PIPT management approaches for chronic musculoskeletal pain by maintaining fidelity to essential treatment elements while also leveraging the unique sociocultural context of different CALD communities to improve health outcomes.

How do people with chronic low back pain pick a pencil off the floor?

BACKGROUND

Picking objects off the floor is provocative for people with chronic low back pain (CLBP). There are no clinically applicable methods evaluating movement strategies for this task. The relationship between strategy and multidimensional profiles is unknown.

OBJECTIVE

Develop a movement evaluation tool (MET) to examine movement strategies in people with CLBP (n = 289) picking a pencil off the floor. Describe those movement strategies, and determine reliability of the MET. Explore differences across multidimensional profiles and movement strategies.

METHODS

An MET was developed using literature and iterative processes, and its inter-rater agreement determined. Latent class analysis (LCA) derived classes demonstrating different strategies using six movement parameters as indicator variables. Differences between classes across multidimensional profiles were investigated using analysis of variance, Kruskal-Wallis, or chi-squared tests.

RESULTS

Six movement parameters were evaluated. There was substantial inter-rater agreement (Cohen's Kappa = 0.39-0.79) across parameters. LCA derived three classes with different strategies: Class 1 (71.8%) intermediate trunk inclination/knee flexion; Class 2 (24.5%) greater forward trunk inclination, lower knee flexion; Class 3 (3.7%) lower forward trunk inclination, greater knee flexion. Pain duration differed across all classes (p ≤ .001). Time taken to complete forward bends differed between Class 3 and other classes (p = .024).

CONCLUSIONS

Movement strategies can be reliably assessed using the MET. Three strategies for picking lightweight objects off the floor were derived, which differed across pain duration and speed of movement.

People With Low Back Pain Exhibit Higher Trunk Muscle Activity and Impaired Postural Control During Static and Dynamic Functional Tasks: A Cross-Sectional Study

The study compared superficial trunk muscle activity and postural control among an active extension subgroup of people with nonspecific chronic low back pain (AE-NSCLBP) with painfree controls during functional tasks. Thirty-two people (17 people with low back pain [LBP] and 15 painfree controls) participated in this study. Muscle activity of 5 trunk muscles and postural control were investigated during both standing tasks (eyes open/closed; single/double-leg balance) and dynamic functional tasks (spinal forward flexion and return, and a sit to stand transfer). Results showed that during single-leg standing, people with AE-NSCLBP exhibit higher muscle activity than painfree controls for 3 trunk muscles, especially with their eyes closed. There were no significant differences in muscle activity between eye conditions during double-leg standing and sit to stand transfer, forward flexion, and return from flexion. The AE-NSCLBP subgroup also demonstrated significantly impaired postural control (lower time to boundary) in 4 of 8 conditions, especially during single-leg standing and with their eyes closed. These findings show people with LBP typically demonstrated greater trunk muscle activity and poorer postural control while maintaining standing posture. This pattern was most evident when the postural challenge was higher, such as single-leg standing or with eyes closed. While this study design cannot infer causality, these findings have implications for LBP rehabilitation, particularly regarding approaches which seek to alter muscle activation among people with LBP.

Effects of peak ankle dorsiflexion angle on lower extremity biomechanics and pelvic motion during walking and jogging

Objective

Ankle dorsiflexion during walking causes the tibia to roll forward relative to the foot to achieve body forward. Individuals with ankle dorsiflexion restriction may present altered movement patterns and cause a series of dysfunction. Therefore, the aim of this research was to clearly determine the effects of peak ankle dorsiflexion angle on lower extremity biomechanics and pelvic motion during walking and jogging.

Method

This study involved 51 subjects tested for both walking and jogging. The motion capture system and force measuring platforms were used to synchronously collect kinematics and kinetics parameters during these activities. Based on the peak ankle dorsiflexion angle during walking, the 51 subjects were divided into a restricted group (RADF group, angle <10°) and an ankle dorsiflexion-unrestricted group (un-RADF group, angle >10°). Independent-Sample T-tests were performed to compare the pelvic and lower limb biomechanics parameters between the groups during walking and jogging test on this cross-sectional study.

Results

The parameters that were significantly smaller in the RADF group than in the un-RADF group at the moment of peak ankle dorsiflexion in the walking test were: ankle plantar flexion moment (p < 0.05), hip extension angle (p < 0.05), internal ground reaction force (p < 0.05), anterior ground reaction force (p < 0.01), pelvic ipsilateral tilt angle (p < 0.05). In contrast, the external knee rotation angle was significantly greater in the RADF group than in the un-RADF group (p < 0.05). The parameters that were significantly smaller in the RADF group than in the un-RADF group at the moment of peak ankle dorsiflexion in the jogging test were: peak ankle dorsiflexion angle (p < 0.01); the anterior ground reaction force (p < 0.01), the angle of pelvic ipsilateral rotation (p < 0.05).

Conclusion

This study shows that individuals with limited ankle dorsiflexion experience varying degrees of altered kinematics and dynamics in the pelvis, hip, knee, and foot during walking and jogging. Limited ankle dorsiflexion alters the movement pattern of the lower extremity during walking and jogging, diminishing the body's ability to propel forward, which may lead to higher injury risks.

The C-Brace® microprocessor controlled stance and swing orthosis improves safety, mobility, and quality of life at one year: Interim results from a prospective registry

Introduction

The C-Brace microprocessor-controlled stance and swing control orthosis has been shown to improve function, mobility, and quality of life. A systematic registry to gather long-term, real-world safety and effectiveness data in patients fit with a C-Brace has not been performed.

Methods

International multicenter registry. Patients undergoing routine C-Brace fittings were assessed at baseline and 1 year after fitting. Primary outcomes were fast walking speed (FWS) measured by 25-foot or 10-meter walk test, Timed Up and Go (TUG) and the Activity-specific Balance Confidence (ABC) Scale. Secondary and exploratory outcomes included the Patient-specific Functional Scale (PSFS), falls, pain, PROMIS Pain Interference (PI), and quality of life.

Results

48 subjects with 1-year baseline and follow up data were analyzed. With the C-Brace, FWS improved by + 0.26 ± 0.33 m/s (p < .0001), TUG by -8.1 ± 14.6 sec (p < .0001), and ABC by + 24.9 ± 25.8% (p < .0001). Mean falls reduced from 33 ± 77 to 3.0 ± 5.6 (p = .0005). PSFS increased by 3.60 ± 2.34 points (p < .0001). Outcomes for pain, PI and quality of life showed significant improvements with the C-Brace.

Conclusion

The C-Brace is an effective option to improve safety, mobility, and quality of life for patients needing a KAFO for ambulation.

Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management

BACKGROUND

The biomedical understanding of chronic musculoskeletal pain endorses a linear relationship between noxious stimuli and pain, and is often dualist or reductionist. Although the biopsychosocial approach is an important advancement, it has a limited theoretical foundation. As such, it tends to be misinterpreted in manners that lead to artificial boundaries between the biological, psychological, and social, with fragmented and polarized clinical applications.

OBJECTIVE

We present an ecological-enactive approach to complement the biopsychosocial model. In this approach, the disabling aspect of chronic pain is characterized as an embodied, embedded, and enactive process of experiencing a closed-off field of affordances (i.e., shutting down of action possibilities). Pain is considered as a multi-dimensional, multicausal, and dynamic process, not locatable in any of the biopsychosocial component domains. Based on a person-centered reasoning approach and a dispositional view of causation, we present tools to reason about complex clinical problems in face of uncertainty and the absence of 'root causes' for pain. Interventions to open up the field of affordances include building ability and confidence, encouraging movement variability, carefully controlling contextual factors, and changing perceptions through action according to each patient's self-identified goals. A clinical case illustrates how reasoning based on an ecological-enactive approach leads to an expanded, multi-pronged, affordance-based intervention.

CONCLUSIONS

The ecological-enactive perspective can provide an overarching conceptual and practical framework for clinical practice, guiding and constraining clinicians to choose, combine, and integrate tools that are consistent with each other and with a true biopsychosocial approach.

Protocol for a Parallel Group Randomized Clinical Trial Comparing a Culturally Adapted Cognitive Behavioral Telerehabilitation Intervention to Usual Physical Therapy for Latino Patients With Chronic Spine Pain

OBJECTIVE

Disparities exist in health care access, diagnosis, and treatment of chronic pain in Latino populations and other minority populations. Cognitive behavioral-based physical therapy (CBPT) interventions have been shown to be effective in predominantly non-Hispanic white populations with chronic spine pain. However, there is a need for culturally adapted CBPT interventions that focus on the conservative management of chronic spine pain. The primary purpose of the study described in this protocol is to test the efficacy of an adapted cognitive behavioral-based hybrid telerehabilitation intervention for Latino patients with chronic spine pain.

METHODS

A single-blind, 2-arm parallel group, superiority randomized clinical trial is planned to compare an adapted CBPT intervention to Usual Care physical therapy. Goal Oriented Activity for Latinos with chronic Spine pain (GOALS/Metas) is an 8-week hybrid telerehabilitation intervention that integrates guideline-based physical therapy and pain management interventions using cognitive behavioral approaches and has been adapted for Latino patients with chronic spine pain. Usual Care physical therapy will be administered based on institutional standards at the referring health center. Outcome measures will be evaluated preintervention and at 1-week, 3-months, and 6-months postintervention. The primary outcome is pain-related disability 1-week postintervention using the Brief Pain Inventory Pain Interference subscale. Secondary outcome measures include behavioral measures of functional activity, social participation, physical activity, and sleep. Determinants of treatment effect, including pain-related psychological measures, posture and movement, self-efficacy, treatment expectancy, and therapeutic alliance, will be included in the secondary moderation and mediation analyses.

IMPACT

This clinical trial will provide information on the extent to which an adapted CBPT hybrid telerehabilitation intervention is effective in reducing pain-related disability for Latino patients with chronic spine pain. This information will be useful for clinicians to integrate in their practice, given the growing population of Latino patients who experience disparities in health care management of chronic pain.

The Role of Back Muscle Dysfunctions in Chronic Low Back Pain: State-of-the-Art and Clinical Implications

Changes in back muscle function and structure are highly prevalent in patients with chronic low back pain (CLBP). Since large heterogeneity in clinical presentation and back muscle dysfunctions exists within this population, the potential role of back muscle dysfunctions in the persistence of low back pain differs between individuals. Consequently, interventions should be tailored to the individual patient and be based on a thorough clinical examination taking into account the multidimensional nature of CLBP. Considering the complexity of this process, we will provide a state-of-the-art update on back muscle dysfunctions in patients with CLBP and their implications for treatment. To this end, we will first give an overview of (1) dysfunctions in back muscle structure and function, (2) the potential of exercise therapy to address these dysfunctions, and (3) the relationship between changes in back muscle dysfunctions and clinical parameters. In a second part, we will describe a framework for an individualised approach for back muscle training in patients with CLBP.

Anticipatory postural adjustments mediate the changes in fear-related behaviors in individuals with chronic low back pain

OBJECTIVES

The role(s) of anticipatory postural adjustments (APAs) in changes in subsequent motor and postural controls in response to movement perturbations are unclear in individuals with chronic low back pain (CLBP). This study aimed to clarify the relationships among kinesiophobia, APAs, lumbar kinematic output, and postural control associated with lumbar movement in individuals with CLBP.

METHODS

CLBP participants (n=48) and healthy controls (HCs) without CLBP (n=22) performed a bend-forward task using their lumbar region on a force platform and returned upright. Each participant's lumbar movements were recorded using an electrogoniometer. We calculated the APA duration, the duration of lumbar direction changes from forward to backward, and the center of pressure (COP) position after lumbar movement tasks completion.

RESULTS

Compared with the HCs, the duration of direction changes in lumbar movement and the APA duration in CLBP participants were prolonged, and the COP position was shifted forward. The mediation analysis revealed that the duration of lumbar direction changes in the CLBP group was subjected to a significant indirect effect of APAs and a direct effect of kinesiophobia, and the COP position was subjected to a significant indirect effect of kinesiophobia through APAs.

CONCLUSIONS

APAs partially mediate the relationship between kinesiophobia and changes in lumbar motor control and mediate the relationship between kinesiophobia and postural control in response to movement perturbations. These findings expand our understanding of APAs in altered subsequent movement and postural controls due to kinesiophobia in individuals with CLBP.

Delayed response in rectus abdominis muscle following a step perturbation in subjects with and without recurrent low back pain

BACKGROUND

Delayed trunk and lower limb muscle activation is associated with balance loss and fall injuries in subjects with recurrent low back pain (LBP).

PURPOSE

This study was conducted to compare differences in the onset of muscle contractions of the trunk and lower limb muscles following a treadmill-induced step perturbation between subjects with and without LBP.

METHODS

Eighty-three right limb dominant individuals (43 subjects with LBP and 40 control subjects) were exposed to the perturbation (0.31 m/s velocity for 0.2 m). The electromyography (EMG) reaction times were analyzed during the first step following the perturbation. The EMG electrodes were placed on both sides of the trunk and lower limbs, including the rectus abdominis (RA), erector spinae (ES), tibialis anterior (TA), and gastrocnemius (GA) muscles.

RESULTS

The group x muscle interaction was statistically significant (F = 9.44, p = 0.003). The TA muscle activation was significantly delayed compared to the RA, ES, and GA. There was a significant interaction on side x muscle (F = 4.14, p = 0.04). The RA muscles were significantly delayed on the non-dominant (t = - 3.35, p = 0.001) and dominant (t = - 2.53, p = 0.01) sides in the LBP group.

CONCLUSION

The LBP group demonstrated a delayed reaction time on the RA muscles, which indicated poor trunk control relative to the lower limbs. The delayed bilateral RA muscle might indicate possible coordination problems relative to the ES and lower limb muscles, which may lead to potential fall hazards.

Reduction in pain-related fear is not associated with improvement in spinal biomechanics but with decrease in movement-evoked pain in patients with chronic low back pain

BACKGROUND AND AIMS

While a causal relationship between pain-related fear and spinal movement avoidance in patients with chronic low back pain (CLBP) has frequently been postulated, evidence supporting this relationship is limited. This study aimed to test if decreases in pain-related fear or catastrophizing were associated with improvements in spinal biomechanics, accounting for possible changes in movement-evoked pain.

METHODS

Sixty-two patients with CLBP were assessed before and after an interdisciplinary rehabilitation program (IRP). Pain-related fear was assessed with general and task-specific measures. Lower and upper lumbar angular amplitude and velocity as well as paraspinal muscle activity were recorded during five daily-life tasks to evaluate spinal biomechanics. Relationships were tested with multivariable linear regression analyses.

RESULTS

The large decreases in pain-related fear and catastrophizing following the IRP were scarcely and inconsistently associated with changes in spinal biomechanics (< 3% of the models reported a statistically significant association). Results remained comparable for activities inducing more or less fear, for specific or general measures of pain-related fear, and for analyses performed on the entire population or limited to subgroups of patients with higher levels of task-specific fear. In contrast, reductions in task-specific pain-related fear were significantly associated with decreases in movement-evoked pain in all tasks (r = 0.26-0.62, p ≤ 0.02).

CONCLUSION

This study does not support an association between pain-related fear and spinal movement avoidance. However, it provides evidence supporting a direct relationship between decreased pain-related fear and decreased movement-evoked pain, possibly explaining some mechanisms of the rehabilitation programs.

Modelling brain dynamics by Boolean networks

Understanding the relationship between brain architecture and brain function is a central issue in neuroscience. We modeled realistic spatio-temporal patterns of brain activity on a human connectome with a Boolean networks model with the aim of computationally replicating certain cognitive functions as they emerge from the standardization of many fMRI studies, identified as patterns of human brain activity. Results from the analysis of simulation data, carried out for different parameters and initial conditions identified many possible paths in the space of parameters of these network models, with normal (ordered asymptotically constant patterns), chaotic (oscillating or disordered) but also highly organized configurations, with countless spatial–temporal patterns. We interpreted these results as routes to chaos, permanence of the systems in regimes of complexity, and ordered stationary behavior, associating these dynamics to cognitive processes. The most important result of this work is the study of emergent neural circuits, i.e., configurations of areas that synchronize over time, both locally and globally, determining the emergence of computational analogues of cognitive processes, which may or may not be similar to the functioning of biological brain. Furthermore, results put in evidence the creation of how the brain creates structures of remote communication. These structures have hierarchical organization, where each level allows for the emergence of brain organizations which behave at the next superior level. Taken together these results allow the interplay of dynamical and topological roots of the multifaceted brain dynamics to be understood.

Lumbar segment-dependent soft tissue artifacts of skin markers during in vivo weight-bearing forward–Backward bending

Traditional optical motion capture (OMC) with retroreflective markers is commonly used to measure joint kinematics but was also reported with unavoidable soft tissue artifacts (STAs) when quantifying the motion of the spine. Additionally, the patterns of the STA on the lumbar spine remain unclear. This study aimed to 1) quantify the in vivo STAs of the human lower back in three-dimensional directions during weight-bearing forward–backward bending and 2) determine the effects of the STAs on the calculated flexion angles between the upper and lower lumbar spines and adjacent vertebrae by comparing the skin marker (SM)- and virtual bone marker (VM)-based measurements. Six healthy volunteers were imaged using a biplanar radiographic system, and thirteen skin markers were mounted on every volunteer’s lower back while performing weight-bearing forward–backward bending. The STAs in the anterior/posterior (AP), medial/lateral (ML), and proximal/distal (PD) directions were investigated. The flexion angles between the upper and lower lumbar segments and adjacent intervertebral segments (L2–L5) throughout the cycle were calculated. For all the participants, STAs continuously increased in the AP direction and exhibited a reciprocal trend in the PD direction. During flexion, the STA at the lower lumbar region (L4–L5: 13.5 ± 6.5 mm) was significantly higher than that at the upper lumbar (L1–L3: 4.0 ± 1.5 mm) in the PD direction (p < 0.01). During extension, the lower lumbar (L4–L5: 2.7 ± 0.7 mm) exhibited significantly less STAs than that exhibited by the upper lumbar region (L1–L3: 6.1 ± 3.3 mm) (p < 0.05). The STA at the spinous process was significantly lower than that on both sides in the AP direction (p < 0.05). The present results on STAs, based on dual fluoroscopic measurements in healthy adult subjects, presented an anatomical direction, marker location, and anatomic segment dependency, which might help describe and quantify STAs for the lumbar spine kinematics and thus help develop location- and direction-specific weighting factors for use in global optimization algorithms aimed at minimizing the effects of STAs on the calculation of lumbar joint kinematics in the future.

Linking Pain and Motor Control: Conceptualization of Movement Deficits in Patients With Painful Conditions

When people experience or expect pain, they move differently. Pain-altered movement strategies, collectively described here as pain-related movement dysfunction (PRMD), may persist well after pain resolves and, ultimately, may result in altered kinematics and kinetics, future reinjury, and disability. Although PRMD may manifest as abnormal movements that are often evident in clinical assessment, the underlying mechanisms are complex, engaging sensory-perceptual, cognitive, psychological, and motor processes. Motor control theories provide a conceptual framework to determine, assess, and target processes that contribute to normal and abnormal movement and thus are important for physical therapy and rehabilitation practice. Contemporary understanding of motor control has evolved from reflex-based understanding to a more complex task-dependent interaction between cognitive and motor systems, each with distinct neuroanatomic substrates. Though experts have recognized the importance of motor control in the management of painful conditions, there is no comprehensive framework that explicates the processes engaged in the control of goal-directed actions, particularly in the presence of pain. This Perspective outlines sensory-perceptual, cognitive, psychological, and motor processes in the contemporary model of motor control, describing the neural substrates underlying each process and highlighting how pain and anticipation of pain influence motor control processes and consequently contribute to PRMD. Finally, potential lines of future inquiry-grounded in the contemporary model of motor control-are outlined to advance understanding and improve the assessment and treatment of PRMD.

IMPACT

This Perspective proposes that approaching PRMD from a contemporary motor control perspective will uncover key mechanisms, identify treatment targets, inform assessments, and innovate treatments across sensory-perceptual, cognitive, and motor domains, all of which have the potential to improve movement and functional outcomes in patients with painful conditions.

Wrist, but Not Back, Isometric Contraction Induced Widespread Hypoalgesia in Healthy Participants

Objective: Exercise may reduce pain sensitivity. This phenomenon called exercise-induced hypoalgesia is observed in different types of exercises and involves the activation of endogenous pain modulation systems. Although the effect of limb exercise on pain sensitivity has often been tested, few studies explored the impact of back exercises that are often used to treat low back pain. The main objective is to measure the effect of back-muscle exercise on pain sensitivity and compare it to the effect of a limb-muscle exercise.

Methods: Twenty-three participants who were pain-free performed a 4-min wrist flexion isometric contraction followed by a 4-min low back extension, separated by a 20-min break. Pressure pain thresholds were tested at two low back (S1 spinous process, lumbar erector spinae muscle) and two wrist (capitate bone, wrist flexor muscles) sites before and after each exercise. For each exercise, sites were considered as remote or local in relation to the muscles contracted during the exercise. An independent sample of 11 participants was recruited to confirm the influence of low back extension on pain sensitivity.

Results: Wrist exercise induced a larger increase in pain sensitivity than back exercise at the remote site. Only wrist exercise induced a hypoalgesia effect at both the local and the remote sites. Back exercise induced a similar effect in the independent sample.

Conclusions: This study showed that back and wrist exercises induced a distinct effect on pain sensitivity in participants who were pain-free. The wrist exercise induced a systemic reduction in pain sensitivity (locally and remotely), whereas the back exercise did not. This differential effect may be present because wrist exercise induced most fatigue compared with the back exercise.

Recovery of the lumbopelvic movement and muscle recruitment patterns using motor control exercise program in people with chronic nonspecific low back pain: A prospective study

This study aims to investigate the dysfunction and recovery of the lumbopelvic movement and motor control of people with chronic nonspecific low back pain after a structured rehabilitation which emphasizes on re-education and training of movement and motor control. The lumbopelvic movement and motor control pattern of 30 adults (15 with chronic low back pain, 15 healthy controls) were assessed using 3D motion and electromyographic analysis during the repeated forward bending test, in additional to the clinical outcome measures. Regional kinematics and muscle recruitment pattern of the symptomatic group was analysed before and after the 6-week rehabilitation, and compared to healthy controls. Significant improvement in back pain, functional capacity and self-efficacy of the symptomatic group was found after the rehabilitation. Patients with chronic nonspecific low back pain were capable to recover to a comparable level of the healthy controls in terms of their lumbopelvic movement and motor control pattern upon completion of a 6-week rehabilitation program, despite their dysfunction displayed at baseline. Phase specific motor control reorganization in which more profound and positive changes shown during the flexion phase. Our findings indicate that the recovery of the movement and motor control pattern in patients with chronic low back pain achieved to a comparable level of the healthy able-bodies. The improvement of both the physical outcome measures suggest that specific rehabilitation program which emphasizes on optimizing motor control during movements would help promoting the functional recovery of this specific low back pain subgroup.

The Relationship Between Changes in Movement and Activity Limitation or Pain in People With Knee Osteoarthritis: A Systematic Review

OBJECTIVE

To report whether changes in knee joint movement parameters recorded during functional activities relate to change in activity limitation or pain after an exercise intervention in people with knee osteoarthritis (OA).

DESIGN

Etiology systematic review.

LITERATURE SEARCH

Four databases (MEDLINE, Embase, CINAHL, and AMED) were searched up to January 22, 2021.

STUDY SELECTION CRITERIA

Randomized controlled trials or cohort studies of exercise interventions for people with knee OA that assessed change in knee joint movement parameters (moments, kinematics, or muscle activity) and clinical outcomes (activity limitation or pain).

DATA SYNTHESIS

A descriptive synthesis of functional activities, movement parameters, and clinical outcomes.

RESULTS

From 3182 articles, 22 studies met the inclusion criteria, and almost all were of low quality. Gait was the only investigated functional activity. After exercise, gait parameters changed 26% of the time, and clinical outcomes improved 90% of the time. A relationship between group-level changes in gait parameters and clinical outcomes occurred 24.5% of the time. Two studies directly investigated an individual-level relationship, reporting only 1 significant association out of 8 correlations tested.

CONCLUSION

Most studies reported no change in gait-related movement parameters despite improvement in clinical outcomes, challenging the belief that changing movement parameters is always clinically important in people with knee OA. J Orthop Sports Phys Ther 2021;51(10):492-502. doi:10.2519/jospt.2021.10418.

Validity and reliability of a sensor-based electronic spinal mobility index for axial spondyloarthritis

OBJECTIVE

To evaluate the validity and reliability of inertial measurement unit (IMU) sensors in the assessment of spinal mobility in axial spondyloarthritis (axSpA).

METHODS

A repeated measures study design involving 40 participants with axSpA was used. Pairs of IMU sensors were used to measure the maximum range of movement at the cervical (Cx) and lumbar (Lu) spine. A composite IMU score was defined by combining the IMU measures. Conventional metrology and physical function assessment were performed. Validation was assessed considering the agreement of IMU measures with conventional metrology and correlation with physical function. Reliability was assessed using intra-class correlation coefficients (ICCs).

RESULTS

The composite IMU score correlated closely (r = 0.88) with the BASMI. Conventional Cx rotation and lateral flexion tests correlated closely with IMU equivalents (r = 0.85, 0.84). All IMU movement tests correlated strongly with BASFI, while this was true for only some of the BASMI tests. The reliability of both conventional and IMU tests (except for chest expansion) ranged from good to excellent. Test-retest ICCs for individual conventional tests varied between 0.57 and 0.91, in comparison to a range from 0.74 to 0.98 for each of the IMU tests. Each of the composite regional IMU scores had excellent test-retest reliability (ICCs=0.94-0.97), comparable to the reliability of the BASMI (ICC=0.96).

CONCLUSION

Cx and Lu spinal mobility measured using wearable IMU sensors is a valid and reliable assessment in multiple planes (including rotation), in patients with a wide range of axSpA severity.

Does Movement Change When Low Back Pain Changes? A Systematic Review

OBJECTIVE

To investigate the relationship between changes in volitional spinal movement (including muscle activity) and changes in pain or activity limitation at the individual level in people with nonspecific low back pain.

DESIGN

Etiology systematic review.

LITERATURE SEARCH

MEDLINE, Embase, CINAHL, and AMED were searched from inception to January 2020.

STUDY SELECTION CRITERIA

The study included peer-reviewed articles that reported the relationship between changes in volitional spinal movement and changes in pain or activity limitation at the individual level in people with nonspecific low back pain.

DATA SYNTHESIS

The data were descriptively synthesized to identify a relationship between change in movement and improved pain or activity limitation.

RESULTS

We included 27 studies involving 2739 participants. There was low-quality evidence of a relationship between change in movement and change in pain or activity limitation at the individual level 31% of the time (20 of the 65 times investigated within the 27 studies). Increases in spinal range of motion, velocity, and flexion relaxation of the back extensors were consistently related to improved pain or activity limitation (93%, 18.5/20 relationships observed).

CONCLUSION

A relationship between changes in movement and changes in pain or activity limitation was infrequently observed at the individual level; however, a paucity of high-quality evidence precludes a definitive understanding of this relationship. J Orthop Sports Phys Ther 2020;50(12):664-680. Epub 28 Oct 2020. doi:10.2519/jospt.2020.9635.

Cognitive Behavioral Therapy With Stabilization Exercises Affects Transverse Abdominis Muscle Thickness in Patients With Chronic Low Back Pain: A Double-Blinded Randomized Trial Study

OBJECTIVE

Nonspecific chronic low back pain (NCLBP) is a major public health and global socioeconomic burden with a variety of symptoms, such as fear-avoidance behaviors. This study aimed to evaluate the effect of cognitive behavioral therapy (CBT) associated with stabilization exercise (SE) on thickness of transverse abdominis (TrA) muscle in patients with NCLBP.

METHODS

Forty patients with NCLBP were randomly assigned into experimental CBT associated with SE (n = 20) and control groups without SE (n = 20). Transverse abdominis muscle thickness was assessed during abdominal drawing in maneuver (ADIM) and active straight leg raise (ASLR) of the right lower limb using ultrasound imaging. Fear-avoidance belief and disability were evaluated using a fear-avoidance belief questionnaire (FABQ) and a Roland-Morris disability questionnaire (RMDQ) before and after intervention.

RESULTS

Mixed-model analysis of variance indicated that the effect of time was significant for the right and left TrA contraction thickness during ADIM and left TrA contraction thickness during ASLR (P < .05). However, the experimental group exhibited higher right and left TrA muscle thickness compared with the control group during ADIM (P = .001). Moreover, there were no significant differences between groups in the thickness of TrA muscle during ASLR (P > .05). The effect of time was significant for FABQ (P = .02) and RMDQ (P = .01); however, the effect of group was significant for the FABQ after intervention (P = .04).

CONCLUSIONS

Stabilization exercise associated with CBT is more effective than SE alone in improving fear avoidance belief and in increasing the thickness of the TrA muscle during ADIM task.

Movement, posture and low back pain. How do they relate? A replicated single-case design in 12 people with persistent, disabling low back pain

BACKGROUND

Movement and posture are commonly believed to relate to non-specific low back pain (NSLBP). While people with NSLBP appear to move and posture themselves differently from those without NSLBP, changes in movement and posture infrequently relate to improvements in NSLBP when analysed at a group-level. Additionally, little is known about how movement or posture change when clinical outcome improves.

METHODS

Within-person relationships were investigated using a replicated, repeated measures, single-case design in 12 people with persistent, disabling NSLBP. Individually relevant movement and posture were captured using wearable sensors on up to 20 occasions over a 22-week period (5-week baseline, 12-week physiotherapy-led intervention, 5-week follow-up), while pain and activity limitation were collected concomitantly. A series of cross-correlation analyses estimated the presence, strength, and direction of relationships.

RESULTS

Many participants (n = 10/12) had strong (e.g. r = 0.91, p = <0.001) relationships between changes in movement or posture and changes in pain and activity limitation, while some showed no strong association. Where relationships were observed, clinical improvement predominantly (93% or 57/61 relationships) related to increased spinal movement range and velocity during forward bending and lifting, reduced lumbar muscle EMG activity at maximum voluntary flexion, and increased posterior-pelvic-tilt during sitting and standing.

CONCLUSION

Within-person changes to individually relevant movement and posture appear to often relate to clinical outcome, but not always. When changes were related, movement and posture appear to return towards being 'less protective', however causal directions remain unknown. Important activities, movements, and postural parameters varied across the participants, highlighting the potential importance of individualized management.

SIGNIFICANCE

Changes to individually relevant movement and posture appear to often relate to clinical outcome, but not always. Patient-specific activities, and movement or postural parameters that related to improved pain and activity limitation, varied across the 12 participants, highlighting the potential importance of individualised management. Where clinical improvements were related to changes in movement or posture, participants consistently returned towards being 'less protective' (increased range and speed of movement, increased posterior-pelvic-tilt during sitting and standing). Mechanisms and generalizability remain unclear.

Measuring Spinal Mobility Using an Inertial Measurement Unit System: A Validation Study in Axial Spondyloarthritis

Portable inertial measurement units (IMUs) are beginning to be used in human motion analysis. These devices can be useful for the evaluation of spinal mobility in individuals with axial spondyloarthritis (axSpA). The objectives of this study were to assess (a) concurrent criterion validity in individuals with axSpA by comparing spinal mobility measured by an IMU sensor-based system vs. optical motion capture as the reference standard; (b) discriminant validity comparing mobility with healthy volunteers; (c) construct validity by comparing mobility results with relevant outcome measures. A total of 70 participants with axSpA and 20 healthy controls were included. Individuals with axSpA completed function and activity questionnaires, and their mobility was measured using conventional metrology for axSpA, an optical motion capture system, and an IMU sensor-based system. The UCOASMI, a metrology index based on measures obtained by motion capture, and the IUCOASMI, the same index using IMU measures, were also calculated. Descriptive and inferential analyses were conducted to show the relationships between outcome measures. There was excellent agreement (ICC > 0.90) between both systems and a significant correlation between the IUCOASMI and conventional metrology (r = 0.91), activity (r = 0.40), function (r = 0.62), quality of life (r = 0.55) and structural change (r = 0.76). This study demonstrates the validity of an IMU system to evaluate spinal mobility in axSpA. These systems are more feasible than optical motion capture systems, and they could be useful in clinical practice.

Assessment instruments of movement quality in patients with non-specific low back pain: A systematic review and selection of instruments

BACKGROUND

Observing and analyzing movement quality (MQ) in patients with non-specific low back pain (NS-LBP) is important in the clinical reasoning of primary care physiotherapists and exercise therapists. However, there is no standardized form of assessment.

RESEARCH QUESTION

which MQ domains are measured with which instruments, and which activities are relevant, appropriate and methodologically sound for assessing MQ in patients with NS-LBP?

METHODS

The study had three phases. In phase 1 we conducted a systematic review in PubMed, CINAHL and SPORTDiscus of literature published until October 2018. The selected studies measured MQ domains with instruments that enabled us to 1) compare MQ in self-paced dynamic activities of patients with NS-LBP and healthy controls, and/or 2) determine change over time of MQ in patients with NS-LBP. In phase 2 we established relevant dynamic activities to assess in patients with NS-LBP. In phase 3 we determined appropriateness and methodological qualities of the selected instruments.

RESULTS

Thirty cross-sectional and three pre-post-test studies were eligible. The instruments consisted of complex (n = 19) and simple (n = 7) instrumented motion analysis systems and standardized observational tests (n = 7). We identified three domains representative for MQ: range of motion (ROM), inter-segmental coordination, and whole-body movements. In these domains, patients with NS-LBP significantly differed from healthy controls, respectively 7/12, 12/13 and 13/20 studies. Moreover, ROM and whole-body movements significantly improved over time in patients with NS-LBP (3/3 studies). Based on phase 3, we concluded that none of the instruments are appropriate to assess MQ in patients with NS-LBP in primary care.

SIGNIFICANCE

Forward bending, lifting, and walking seem the most relevant activities to evaluate in patients with NS-LBP. However, we found no suitable instruments to measure ROM, inter-segmental coordination, or whole-body movements as determinants of MQ in these activities in daily practice. We therefore recommend such an instrument be developed.

The Effects of Stabilization Exercise on the Thickness of Lateral Abdominal Muscles During Standing Tasks in Women With Chronic Low Back Pain: A Randomized Triple-Blinded Clinical Trial Study

CONTEXT

Chronic low back pain (CLBP) often presents with a dysfunction in deep abdominal muscles activity during standing tasks. Although some studies indicated that deep abdominal muscle activity improved during some functional tasks following stabilization exercise (SE), there is no study to evaluate the effect of SE on lateral abdominal muscles thickness during standing postural tasks.

OBJECTIVE

The purpose of this study was (1) to evaluate the lateral abdominal muscles thickness in the participants with CLBP while standing on a balance board and (2) to compare the effects of SE and a general exercise (GE) program on the lateral muscles thickness changes.

METHODS

This was a between-groups, triple-blinded randomized controlled trial design. In total, 40 females with CLBP were randomly assigned into 2 groups:  GE (control group) and supervised progressive SE (experimental group). Diagnostic ultrasound imaging was used before and after the intervention to measure lateral abdominal muscles thickness during standing on 2 different levels of platform in the Biodex Balance System. Visual analog scale and Roland-Morris Disability Questionnaire were used to evaluate changes in pain intensity and disability.

RESULTS

The results indicated significant increases in transverse abdominis muscle thickness during all standing tasks (P = .02) and significant decreases in pain intensity and disability following SE intervention (P < .001). However, the lateral abdominal muscle thicknesses were not changed after GE intervention while standing postural tasks (P > .05). The GE group revealed only significant decreases in pain intensity after intervention (P = .03).

CONCLUSION

Supervised progressive SE improved the activity of deep abdominal muscles in standing postural tasks in the patients with CLBP.

Somatocognitive therapy of women with provoked vulvodynia: a pilot study

BACKGROUND AND AIMS

Provoked vestibulodynia (PVD) is a common persistent pain state among women in the Western world, causing dyspareunia, psychological distress and challenges against fertility. Therapies aimed at relieving pain (physiotherapy) and psychological distress (psychotherapy) are often recommended, sometimes in multimodal combinations. We have previously developed somatocognitive therapy (SCT) as a multimodal intervention, administered by a physiotherapist, to a different group of patients with gynecological pain, i.e. chronic (unprovoked) pelvic pain (CPP, also referred to as low abdominal pain). In a randomized, controlled study this intervention was shown to reduce pain experience and improve motor function or body awareness. Here we present the results of a clinical follow-up pilot study with 30 women with PVD, applying SCT administered by third year bachelor students in physiotherapy. Main outcome was pain experience, secondary outcomes were psychological distress and motor functions of the patients.

METHODS

Thirty women diagnosed with PVD were recruited from a tertiary university hospital clinic of gynecology, and included in the follow-up pilot study at an out-patient physiotherapy clinic. Each patient participated in 10-14 therapy sessions over 6 weeks. The students were supervised by an experienced physiotherapist with extensive background in this clinical area, who also performed two clinical sessions with each of the patients at the end of the treatment period. Before therapy, the patients were evaluated for pain experience (visual analogue scale of pain, VAS), psychological distress (Tampa scale of kinesiophobia, TSK) and General Health Questionnaire (GHQ-30) as well as body function (standardized Mensendieck test, SMT). Statistical analyzes were performed by using the average ± standard deviation, statistical significance of changes calculated by means of the t-test.

RESULTS

Average pain score before therapy were 7.77 ± 1.98, after 6 weeks of intervention 4.17 ± 2.07 and at 6 months' follow-up 1.66 ± 1.08 (average ± standard deviation), changes being significant below p < 0.01 level. Secondary outcome variables assessing psychological distress and sub optimal motor patterns were also significantly improved. For example, anxiety and depression scores were reduced by approximately 40%, and respiration pattern score improved by almost 80%.

CONCLUSIONS

Multimodal somatocognitive therapy reduced levels of pain and psychological distress, and improved motor functions in women with PVD after 6 weeks of interventions. All variables were further improved at 6 months' follow-up. Thus, somatocognitive therapy may be a useful treatment option for patients with PVD. However, there are limitations to this study, since there was no control group, and suboptimal blinding during assessment of the data.

IMPLICATIONS

Somatocognitive therapy may be a useful tool when treating PVD patients. More studies, in particular RCTs, should be performed to further evaluate this intervention and corroborate the results from this pilot study.

"Sit Up Straight": Time to Re-evaluate

Posture is a frequent topic of discussion for patients, clinicians, the media, and society. A common belief is that spinal pain is caused by sitting, standing, or bending "incorrectly." Despite the absence of strong evidence to support these common beliefs, a large posture industry has flourished, with many interventions and products claiming to "correct" posture and prevent pain. Unfortunately, many health care professionals provide advice in line with this non-evidence-based perspective. In this Viewpoint, the authors reflect on common beliefs regarding posture and spinal health and why they are so widely held, and consider how clinicians can positively influence these beliefs. J Orthop Sports Phys Ther 2019;49(8):562-564. doi:10.2519/jospt.2019.0610.

Neuromuscular exercise reduces low back pain intensity and improves physical functioning in nursing duties among female healthcare workers; secondary analysis of a randomised controlled trial

Background

Low back pain (LBP) is common among healthcare workers, whose work is physically strenuous and thus demands certain levels of physical fitness and spinal control. Exercise is the most frequently recommended treatment for LBP. However, exercise interventions targeted at sub-acute or recurrent patients are scarce compared to those targeted at chronic LBP patients. Our objective was to examine the effects of 6 months of neuromuscular exercise on pain, lumbar movement control, fitness, and work-related factors at 6- and 12-months’ follow-up among female healthcare personnel with sub-acute or recurrent low back pain (LBP) and physically demanding work.

Methods

A total of 219 healthcare workers aged 30–55 years with non-specific LBP were originally allocated to four groups (exercise, counselling, combined exercise and counselling, control). The present study is a secondary analysis comparing exercisers (n = 110) vs non-exercisers (n = 109). Exercise was performed twice a week (60 min) in three progressive stages focusing on controlling the neutral spine posture. The primary outcome was intensity of LBP. Secondary outcomes included pain interfering with work, lumbar movement control, fitness components, and work-related measurements. Between-group differences were analysed with a generalised linear mixed model according to the intention-to-treat principle. Per-protocol analysis compared the more exercised to the less exercised and non-exercisers.

Results

The mean exercise attendance was 26.3 (SD 12.2) of targeted 48 sessions over 24 weeks, 53% exercising 1–2 times a week, with 80% (n = 176) and 72% (n = 157) participating in 6- and in 12-month follow-up measurements, respectively. The exercise intervention reduced pain (p = 0.047), and pain interfering with work (p = 0.046); improved lumbar movement control (p = 0.042), abdominal strength (p = 0.033) and physical functioning in heavy nursing duties (p = 0.007); but had no effect on other fitness and work-related measurements when compared to not exercising. High exercise compliance resulted in less pain and better lumbar movement control and walking test results.

Conclusion

Neuromuscular exercise was effective in reducing pain and improving lumbar movement control, abdominal strength, and physical functioning in nursing duties compared to not exercising.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2678-x) contains supplementary material, which is available to authorized users.

Overall confidence in the results of systematic reviews on exercise therapy for chronic low back pain: a cross-sectional analysis using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) 2 tool

OBJECTIVE

To evaluate the overall confidence in the results of systematic reviews of exercise therapy for chronic non-specific low back pain using the AMSTAR 2 tool.

METHODS

PubMed, Embase, Cochrane Database of Systematic Reviews, PEDro and CINAHL was searched up to February 2017. Two independent reviewers selected systematic reviews of randomized controlled trials that investigated exercise therapy in patients with low back pain. AMSTAR 2 assessment was performed by pairs of reviewers, and the overall confidence in the results of the systematic reviews were rated as 'High', 'Moderate', 'Low' and 'Critically low'. Descriptive analysis was used to summarize the characteristics of included systematic reviews. The percentage of systematic reviews achieving each item from the AMSTAR 2 and the overall confidence in the results were tabulated.

RESULTS

The search identified 38 systematic reviews. Most of the reviews included a median of 10 clinical trials and total sample size of 813 participants per review. Five of 38 (13%) reviews were Cochrane reviews, and 8 (21%) systematic reviews had a protocol published or registered prospectively. The overall confidence in the results of 28 reviews (74%) was rated as 'Critically low', 6 (16%) as 'Low', 1 (2%) as Moderate, while 3 of 38 reviews (8%) were rated as 'High'.

CONCLUSION

The results demonstrate very low confidence in the results of most systematic reviews of exercise in chronic non-specific low back pain. Clinicians are more likely to deliver the most efficacious interventions to patients by critically appraising systematic reviews using AMSTAR 2 before making their decisions.

Postural awareness and its relation to pain: validation of an innovative instrument measuring awareness of body posture in patients with chronic pain

Background

Habitual postural patterns are associated with musculoskeletal pain, and improving a maladaptive posture requires postural awareness in order to lead to clinical improvements. This study aimed to develop and evaluate the psychometric properties of an innovative postural awareness scale.

Methods

A 12-item Postural Awareness Scale (PAS) was developed and administered to 512 chronic pain patients (50.3 ± 11.4 years, 91.6% female, 37.1% spinal/shoulder pain) to assess its factor structure and reliability. To determine convergent validity, measures of body awareness, body responsiveness, body image, and mindfulness were correlated with the PAS, as were clinical measures of pain intensity, disability, and mental health. Sensitivity to change was assessed in 202 outpatients participating in a 10-week multimodal mind-body program.

Results

Factor analysis revealed two factors (Ease/Familiarity with Postural Awareness and Need for Attention Regulation with Postural Awareness) that explained 50.8% of the variance. Cronbach’s alpha for the complete scale was 0.80; Spearman-Brown coefficient of split-half reliability was 0.67; and intra-class correlation was ICC_2,1 = 0.75 (95% confidence interval = 0.71, 0.78). Significant positive correlations were found for body awareness (r = 0.23), body responsiveness (r = 0.41), body image (r = 0.22–0.32), and mindfulness (r = 0.38); negative correlations for pain intensity (r = − 0.14), disability (r = − 0.12), depression (r = − 0.23), and stress (r = − 0.29). Postural awareness scores increased with a mind-body program (p < 0.001); changes in the PAS were negatively correlated with changes in pain intensity (r = − 0.35) in patients with spinal/shoulder pain.

Conclusion

Self-reported postural awareness is associated with clinical symptoms in chronic pain patients; improvements in postural awareness are longitudinally associated with reduced pain in patients with spinal/shoulder pain.

Eletromyography of abdominal muscles in different physical exercises: An update protocol for systematic review and meta-analysis

BACKGROUND

The abdominal muscles are extremely important because they are directly involved in the functions of support, containment of viscera, and help in the process of expiration, defecation, urination, vomiting, and also at the time of childbirth. Many exercises and equipment are used to strengthen the abdominal muscles, and the workouts are proposed for a variety of purposes, such as preventing and rehabilitating low back pain, improving sports performance, achieving aesthetic standards, among others. Exercises that potentiate the electromyographic activity promote a greater recruitment of muscle fibers and are more effective to improve or maintain of the force. The electromyographic activity analysis allows us to reflect on the quality of the exercises proposed, consequently, to choose and order the exercises properly in a training session.

METHODS

Our systematic review protocol will developed following the reporting items for the systematic review. To identify relevant studies, we sought articles on the following bases: MEDLINE, PubMed, Europubmed, SciELO, Physiotherapy Evidences Data Base (PEDro), Cochrane, and Google Scholar. The methodological quality of the studies included in the review will evaluated using a checklist and quality assessment. For intervention studies, risk of bias will estimated using the Cochrane Collaboration tool.

RESULTS

The results of this study will show the electromyographic activation of the abdomen in the different types of exercises.

CONCLUSION

Ethics approval was not required for this study because it was based on published studies. The results and findings of this study will be submitted and published in a scientific peer-reviewed journal.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018086172.

How clinicians analyze movement quality in patients with non-specific low back pain: a cross-sectional survey study with Dutch allied health care professionals

Background

Observation of movement quality (MQ) is an indelible element in the process of clinical reasoning for patients with non-specific low back pain (NS-LBP). However, the observation and evaluation of MQ in common daily activities are not standardized within allied health care. This study aims to describe how Dutch allied health care professionals (AHCPs) observe and assess MQ in patients with NS-LBP and whether AHCPs feel the need to have a specific outcome measure for assessing MQ in patients with NS-LBP.

Methods

In this cross-sectional digital survey study, Dutch primary care AHCPs (n = 114) answered one open and three closed questions about MQ in NS-LBP management. Qualitative and quantitative analyses were applied.

Results

Qualitative analyses of the answers to the open questions revealed four main themes: 1) movement pattern features, 2) motor control features, 3) environmental influences and 4) non-verbal expressions of pain and exertion. Quantitative analyses clearly indicated that AHCPs observe MQ in the diagnostic (92%), therapeutic (91%) and evaluation phases (86%), that they do not apply any objective measurement of MQ and that 63% of the AHCPs consider it important to have a specific outcome measure to assess MQ. The AHCPs expressed added benefits and critical notes regarding clinical reasoning and quality of care.

Conclusion

AHCPs recognize the importance of observing MQ in the assessment and management of LBP in a standardized way. However, there is no consensus amongst AHCPs how MQ should be standardized. Prior to standardization, it will be important to develop a theoretical framework to determine which observable and measurable dimensions of MQ are most valid and relevant for patients with NS-LBP to include in the assessment.

Contemporary biopsychosocial exercise prescription for chronic low back pain: questioning core stability programs and considering context

This commentary explores the importance of considering the biopsychosocial model and contextual factors when prescribing exercise. Diverse exercise programs for patients with chronic low back pain (CLBP) produce similar outcomes, without one specific exercise protocol demonstrating clear superiority. One clear barrier to positive outcomes is poor exercise adherence. We suggest that there are certain common contextual factors present in all exercise prescription scenarios that may impact adherence and health-related outcomes. While challenging common core stability exercise prescription, we present an argument for enhancing and intentionally shaping the following contextual factors: the therapeutic alliance, patient education, expectations and attributions of therapeutic success or failure, and mastery or cognitive control over a problem. Overall, this commentary argues that to improve exercise adherence and outcomes in the CLBP population, the context in which exercise is delivered and the meaning patients embody need to be considered and shaped by clinicians.

Medicine in spine exercise (MiSpEx) for nonspecific low back pain patients: study protocol for a multicentre, single-blind randomized controlled trial

BACKGROUND

Arising from the relevance of sensorimotor training in the therapy of nonspecific low back pain patients and from the value of individualized therapy, the present trial aims to test the feasibility and efficacy of individualized sensorimotor training interventions in patients suffering from nonspecific low back pain.

METHODS AND STUDY DESIGN

A multicentre, single-blind two-armed randomized controlled trial to evaluate the effects of a 12-week (3 weeks supervised centre-based and 9 weeks home-based) individualized sensorimotor exercise program is performed. The control group stays inactive during this period. Outcomes are pain, and pain-associated function as well as motor function in adults with nonspecific low back pain. Each participant is scheduled to five measurement dates: baseline (M1), following centre-based training (M2), following home-based training (M3) and at two follow-up time points 6 months (M4) and 12 months (M5) after M1. All investigations and the assessment of the primary and secondary outcomes are performed in a standardized order: questionnaires - clinical examination - biomechanics (motor function). Subsequent statistical procedures are executed after the examination of underlying assumptions for parametric or rather non-parametric testing.

DISCUSSION

The results and practical relevance of the study will be of clinical and practical relevance not only for researchers and policy makers but also for the general population suffering from nonspecific low back pain.

TRIAL REGISTRATION

Identification number DRKS00010129. German Clinical Trial registered on 3 March 2016.

How consistent are lordosis, range of movement and lumbo-pelvic rhythm in people with and without back pain?

BACKGROUND

Comparing movements/postures in people with and without lower back pain (LBP) may assist identifying LBP-specific dysfunction and its relationship to pain or activity limitation. This study compared the consistency in lumbo-pelvic posture and movement (range and pattern) in people with and without chronic LBP (>12 week's duration).

METHODS

Wireless, wearable, inertial measurement units measured lumbar lordosis angle, range of movement (ROM) and lumbo-pelvic rhythm in adults (n = 63). Measurements were taken on three separate occasions: two tests on the same day with different raters and a third (intra-rater) test one to two weeks later. Participants performed five repetitions of tested postures or movements. Test data were captured automatically. Minimal detectable change scores (MDC90) provided estimates of between-test consistency.

RESULTS

There was no significant difference between participants with and without LBP for lordosis angle. There were significant differences for pelvic flexion ROM (LBP 60.8°, NoLBP 54.8°, F(1,63) = 4.31, p = 0.04), lumbar right lateral flexion ROM (LBP 22.2°, NoLBP 24.6° F(1,63) = 4.48, p = .04), trunk right lateral flexion ROM (LBP 28.4°, NoLBP 31.7°, F(1,63) = 5.9, p = .02) and lumbar contribution to lumbo-pelvic rhythm in the LBP group (LBP 45.8 %, F(1,63) = 4.20, NoLBP 51.3 % p = .044). MDC90 estimates for intra and inter-rater comparisons were 10°-15° for lumbar lordosis, and 5°-15° for most ROM. For lumbo-pelvic rhythm, we found 8-15 % variation in lumbar contribution to flexion and lateral flexion and 36-56 % variation in extension. Good to excellent agreement (reliability) was seen between raters (mean r = .88, ICC (2,2)).

CONCLUSION

Comparisons of ROM between people with and without LBP showed few differences between groups, with reduced relative lumbar contribution to trunk flexion. There was no difference between groups for lordosis. Wide, within-group differences were seen for both groups for ROM and lordosis. Due to variability between test occasions, changes would need to exceed 10°-15° for lumbar lordosis, 5°-15° for ROM components, and 8-15 % of lumbar contribution to lumbo-pelvic rhythm, to have 90 % confidence that movements had actually changed. Lordosis, range of movement and lumbo-pelvic rhythm typically demonstrate variability between same-day and different-day tests. This variability needs to be considered when interpreting posture and movement changes.

THE RELATIONSHIP BETWEEN CORE ENDURANCE AND BACK DYSFUNCTION IN COLLEGIATE MALE ATHLETES WITH AND WITHOUT NONSPECIFIC LOW BACK PAIN

BACKGROUND

Physical activity and sports can be associated with low back pain. However, little is known about the relationship between core stability and nonspecific low back pain (LBP) among athletes.

PURPOSE

The purpose of this study was to investigate the relationship between core endurance and back dysfunction in collegiate male athletes with and without nonspecific LBP.

METHODS

Fifty-five male collegiate athletes from a variety of sports were recruited for this study. Their mean age was 21.50 ± (2.54) years, mean weight was 70.96 ± (5.33) kg., and mean height was 174.38 ± (4.37) cm. Thirty athletes with non-specific LBP and twenty five healthy athletes were assessed using McGill's anterior, posterior, and left and right plank core endurance tests (seconds) and for dysfunction using the Micheli functional scale (MFS). Pearson's product moment correlations examined the relationships between core endurance and MFS.

RESULTS

There were significant differences regarding the measured core endurance tests between the healthy athletes group and the nonspecific LBP group (p < 0.05). Additionally, good negative (r = -0.794) and moderate negative (r = -0.541) correlations were found between MFS and trunk extensor and flexor endurance tests, respectively in the group with nonspecific LBP.

CONCLUSION

The results of this study imply that poor core endurance is likely associated with nonspecific LBP in collegiate athletes. Injury risk reduction and back management programs for the athletic population should include strategies that emphasize endurance of the core muscles especially the trunk extensors and flexors.

LEVEL OF EVIDENCE

2b.

[Chronic low back pain : Comparison of mobilization and core stability exercises]

BACKGROUND

For the treatment of chronic low back pain (cLBP), both core stability and mobilization exercises were introduced. The aim of this prospective randomized clinical pilot study was to compare the efficacy of mobilization and core stability exercises with regard to objective and subjective outcome measures in patients with cLBP.

METHOD

After a per-protocol analysis, the data of 27 patients with cLBP, who were randomly allocated to one of the two groups, were analyzed. The intervention group (GM) performed mobilization exercises using the BALLance-Methode®, the control group (GS) carried out core stability exercises for 4 weeks, and continued the exercises for an additional 4 weeks at home. Flexibility, strength endurance of the core stabilizing muscles, pain-induced disability, and pain avoidance behavior were the objective and subjective outcomes that were measured before, 4 weeks after, and 8 weeks after the onset of the intervention. The significance of differences within and between groups was analyzed.

RESULTS

During the observation period, only in the GS patients could maintain the prone-plank position and the side-plank position improvements over time (p < 0.001), with significant differences compared with the GM (p < 0.05). Within both groups significant improvements in the subjective outcome measures were found (p < 0.05). Therefore, no significant differences existed between the groups.

CONCLUSION

With regard to their daily complaints, patients with cLBP can be treated using standardized mobilization exercises in addition to core stability exercises.

The effects of a free-weight-based resistance training intervention on pain, squat biomechanics and MRI-defined lumbar fat infiltration and functional cross-sectional area in those with chronic low back

Background

Low back pain is one of the most prevalent musculoskeletal conditions in the world. Many exercise treatment options exist but few interventions have utilised free-weight resistance training. To investigate the effects of a free-weight-based resistance training intervention on pain and lumbar fat infiltration in those with chronic low back pain.

Methods

Thirty participants entered the study, 11 females (age=39.6±12.4 years, height=164 cm±5.3 cm, body mass=70.9±8.2 kg,) and 19 males (age=39.7±9.7 years, height=179±5.9 cm, body mass=86.6±15.9 kg). A 16-week, progressive, free-weight-based resistance training intervention was used. Participants completed three training sessions per week. Participants completed a Visual Analogue Pain Scale, Oswestry Disability Index and Euro-Qol V2 quality of life measure at baseline and every 4 weeks throughout the study. Three-dimensional kinematic and kinetic measures were used for biomechanical analysis of a bodyweight squat movement. Maximum strength was measured using an isometric mid-thigh pull, and lumbar paraspinal endurance was measured using a Biering-Sorensen test. Lumbar paraspinal fat infiltration was measured preintervention and postintervention using MRIs.

Results

Postintervention pain, disability and quality of life were all significantly improved. In addition, there was a significant reduction in fat infiltration at the L3L4 and L4L5 levels and increase in lumbar extension time to exhaustion of 18%.

Conclusions

A free-weight-based resistance training intervention can be successfully utilised to improve pain, disability and quality of life in those with low back pain.

Validation of a Clinical Test of Thoracolumbar Dissociation in Chronic Low Back Pain

STUDY DESIGN

Clinical test validation.

OBJECTIVES

Preliminary study of concurrent and discriminant validity of a clinical test of thoracolumbar dissociation.

BACKGROUND

Control deficits of back muscles and trunk movement are common in chronic/recurrent low back pain (LBP). A reliable clinical test to rate an individual's ability to dissociate lumbopelvic movement from the thoracolumbar region has been described. This test rates the performance quality of 5 key aspects against criterion standards.

METHODS

Concurrent validity was examined by comparison of clinical test scores (overall score and each individual criterion) against spine kinematics. Discriminant validity was evaluated by comparison of scores between pain-free controls and participants with LBP. A receiver operating characteristic curve was calculated to determine the optimal cutoff or score to differentiate between good and poor performers.

RESULTS

Concurrent validity was supported by the significant correlation between the total score and motion of the T5 vertebra relative to the S1 vertebra (P<.05). Scores for some (4 correlations of 14 measures) but not all individual criteria were correlated with the kinematic features that each criterion was expected to reflect. Discriminant validity was supported by higher test scores for pain-free controls than for participants with LBP after 2 minutes of training (P = .045). Scores of less than 5.5 were more prevalent in the LBP group (pretraining LBP versus control, 72% versus 35%; P = .008; posttraining LBP versus control, 48% versus 16%; P = .018).

CONCLUSION

This preliminary study of concurrent and discriminant validity of the test provides a foundation to further investigate its utility to characterize thoracolumbar movement patterns in individuals with LBP.

The use of "stabilization exercises" to affect neuromuscular control in the lumbopelvic region: a narrative review

It is well-established that the coordination of muscular activity in the lumbopelvic region is vital to the generation of mechanical spinal stability. Several models illustrating mechanisms by which dysfunctional neuromuscular control strategies may serve as a cause and/or effect of low back pain have been described in the literature. The term "core stability" is variously used by clinicians and researchers, and this variety has led to several rehabilitative approaches suggested to affect the neuromuscular control strategies of the lumbopelvic region (e.g. "stabilization exercise", "motor control exercise"). This narrative review will highlight: 1) the ongoing debate in the clinical and research communities regarding the terms "core stability" and "stabilization exercise", 2) the importance of sub-grouping in identifying those patients most likely to benefit from such therapeutic interventions, and 3) two protocols that can assist clinicians in this process.

A clinical test of lumbopelvic control: development and reliability of a clinical test of dissociation of lumbopelvic and thoracolumbar motion

LBP is often associated with changes in motor control. Some subgroups of LBP have been argued to have a compromised ability to dissociate lumbopelvic movement from that of the thoracolumbar junction. Clinical methods to evaluate this task may aid identification of this LBP subgroup and determine the utility of this information to guide clinical interventions. The study aimed to develop a clinical test to assess the ability to dissociate lumbopelvic movement from that of the thoracolumbar junction, and to evaluate the inter-rater reliability of the test in individuals with and without low back pain (LBP) when performed by experienced and novice therapists. A clinical scale was developed to characterise quality of performance of lumbopelvic motion with limited motion at the thoracolumbar junction. Inter-tester repeatability was measured in three experiments. Test outcomes for pain-free controls were compared between three assessors with different amounts of clinical experience. Test scores for LBP participants were compared between two assessors, and between assessments undertaken from video recordings. Agreement between assessors was tested with weighted Kappa Coefficient. The test had acceptable reliability in pain-free and LBP participants, but was better when undertaken by experienced therapists. Kappa index ranged from 0.81 to 0.66 for live assessments, and 0.62 for video assessments. The results showed that the test is reliable when performed by experienced assessors. The test can assess thoracolumbar movements in different groups of individuals.

Proportional lumbar spine inter-vertebral motion patterns: a comparison of patients with chronic, non-specific low back pain and healthy controls

INTRODUCTION

Identifying biomechanical subgroups in chronic, non-specific low back pain (CNSLBP) populations from inter-vertebral displacements has proven elusive. Quantitative fluoroscopy (QF) has excellent repeatability and provides continuous standardised inter-vertebral kinematic data from fluoroscopic sequences allowing assessment of mid-range motion. The aim of this study was to determine whether proportional continuous IV rotational patterns were different in patients and controls. A secondary aim was to update the repeatability of QF measurement of range of motion (RoM) for inter-vertebral (IV) rotation.

METHODS AND MATERIALS

Fluoroscopic sequences were recorded of passive, recumbent coronal and sagittal motion, which was controlled for range and velocity. Segments L2-5 in 40 primary care CNSLBP patients and 40 matched controls were compared. Patients also completed the von Korff Chronic Pain Grade and Roland and Morris Disability Questionnaire. Sequences were processed using automated image tracking algorithms to extract continuous inter-vertebral rotation data. These were converted to continuous proportional ranges of rotation (PR). The continuous proportional range variances were calculated for each direction and combined to produce a single variable representing their fluctuation (CPRV). Inter- and intra-rater repeatability were also calculated for the maximum IV-RoM measurements obtained during controlled trunk motion to provide an updated indication of the reliability and agreement of QF for measuring spine kinematics.

RESULTS

CPRV was significantly higher in patients (0.011 vs. 0.008, Mann-Whitney two-sided p = 0.008), implying a mechanical subgroup. Receiver operating characteristic curve analysis found its sensitivity and specificity to be 0.78 % (60-90) and 0.55 % (37-73), respectively (area under the curve 0.672). CPRV was not correlated with pain severity or disability. The repeatability of maximum inter-vertebral range was excellent, but range was only significantly greater in patients at L4-5 in right side bending (p = 0.03).

CONCLUSION

The variation in proportional motion between lumbar vertebrae during passive recumbent trunk motion was greater in patients with CNSLBP than in matched healthy controls, indicating that biomechanical factors in passive structures play a part.