The effect of continuous ultrasound on chronic non-specific low back pain: a single blind placebo-controlled randomized trial

Safety Review of Therapeutic Ultrasound for Spinal Cord Neuromodulation and Blood-Spinal Cord Barrier Opening

New focused ultrasound spinal cord applications have emerged, particularly those improving therapeutic agent delivery to the spinal cord via blood-spinal cord barrier opening and the neuromodulation of spinal cord tracts. One hurdle in the development of these applications is safety. It may be possible to use safety trends from seminal and subsequent works in focused ultrasound to guide the development of safety guidelines for spinal cord applications. We collated data from decades of pre-clinical studies and illustrate a clear relationship between damage, time-averaged spatial peak intensity and exposure duration. This relationship suggests a thermal mechanism underlies ultrasound-induced spinal cord damage. We developed minimum and mean thresholds for damage from these pre-clinical studies. When these thresholds were plotted against the parameters used in recent pre-clinical ultrasonic spinal cord neuromodulation studies, the majority of the neuromodulation studies were near or above the minimum threshold. This suggests that a thermal neuromodulatory effect may exist for ultrasonic spinal cord neuromodulation, and that the thermal dose must be carefully controlled to avoid damage to the spinal cord. By contrast, the intensity-exposure duration threshold had no predictive value when applied to blood-spinal cord barrier opening studies that employed injected contrast agents. Most blood-spinal cord barrier opening studies observed slight to severe damage, except for small animal studies that employed an active feedback control method to limit pressures based on measured bubble oscillation behavior. The development of new focused ultrasound spinal cord applications perhaps reflects the recent success in the development of focused ultrasound brain applications, and recent work has begun on the translation of these technologies from brain to spinal cord. However, a great deal of work remains to be done, particularly with respect to developing and accepting safety standards for these applications.

Confirmation of the viability of a metaverse yoga class and investigation into the impact on pain, anxiety, and depression associated with low back pain after engaging in virtual yoga sessions

This study aimed to explore the influence of metaverse technology (MT) factors like presence, usability, and enjoyment on patients' satisfaction, with a focus on examining potential mediating effects. In addition, it sought to assess whether the yoga practice as an intervention therapy in MT induces changes in the pain, anxiety, and depression levels of patients experiencing back pain. From the pool of 202 participants, this study chose participants who had reported enduring low back pain over 12 weeks, with a visual analogue scale (VAS) rating of 4 or higher. After completing the questionnaire, patients were randomly assigned to either the control group (COG, n=100) or the yoga exercise group (YEG, n=99). Results showed that the construct validity for questionnaires and a reasonable model fit were confirmed, and that presence showed a statistically significant effect on psychological satisfaction via the mediating path of enjoyment (β=0.592, P=0.001). Following 8 weeks of the yoga practice, the VAS increased for the COG, while it decreased significantly by ~29% for the YEG (P=0.001). YEG also exhibited a decrease in the Oswestry Disability Index by ~17%, anxiety by ~7%, and depression by ~10% (P=0.001). In conclusion, psychological satisfaction in a yoga practice using a metaverse cannot be achieved solely through the sense of presence; enjoyment is necessary for patients' satisfaction. Moreover, it was verified that virtual yoga practice is effective in ameliorating psychological factors resulting from back pain.

Sustained acoustic medicine treatment of discogenic chronic low back pain: A randomized, multisite, double-blind, placebo-controlled trial

BACKGROUND

Sustained acoustic medicine (SAM) is a noninvasive long-term treatment that provides essential mechanical and thermal stimulus to accelerate soft tissue healing, alleviate pain, and improve physical activity. SAM increases localized deep tissue temperature, blood flow, cellular proliferation, migration, and nutrition exchange, resulting in reduced inflammation and an increased rate of tissue regeneration.

OBJECTIVE

To assess the efficacy of SAM treatment of discogenic back pain in the lower spinal column to reduce pain, improve quality of life, and lower pharmacotherapy use.

METHODS

Sixty-five subjects with chronic low back pain were randomly assigned to SAM (N= 33) or placebo (N= 32) groups. Subjects self-applied SAM device bilaterality on the lower lumbar region for 4 hours daily for 8 weeks and completed daily pain diaries before, during, and after treatment. Subjects recorded pain reduction using a numeric rating scale (NRS), medication use, and physical activity using the Global Rating of Change (GROC) and Oswestry Disability Index (ODI).

RESULTS

SAM treatment significantly reduced chronic lower back pain from baseline relative to placebo treatment (p< 0.0001). SAM treated subjects reported significantly lower back pain at 4 weeks, with the highest pain reduction (-2.58 points NRS, p< 0.0001) reported at 8 weeks. Similar trends were observed in improved physical activity (3.48 GROC, p< 0.0001, 69-88% ODI, p< 0.0001) and 22.5% (15.2 morphine milligram equivalent) reduction in the use of opioid medication from baseline to 8 weeks.

CONCLUSION

Daily, home-use SAM treatment significantly improves the clinical symptoms of chronic lower back pain, improves physical mobility, and reduces daily medication use. SAM treatment is well-tolerated by patients and may be considered a safe, non-invasive treatment option for chronic discogenic, lower back pain.

Effects of transcutaneous radiofrequency diathermy versus ultrasound on latent myofascial trigger points in the upper trapezius: A randomized crossover trial

BACKGROUND

Currently, the use of radiofrequency diathermy for the treatment of neck pain is booming.

OBJECTIVE

This study aimed to evaluate the clinical efficacy of Digital Capacitive Diathermy (DCD®) on stiffness, pain, cervical range of motion, and cervical disability and to compare it with ultrasound (US) in patients with latent myofascial trigger point (MTrP) in the upper trapezius.

METHODS

Nineteen participants with latent MTrPs in the upper trapezius were included in the assessor-masked, randomized, clinical crossover trial. Subjects were exposed to both interventions: US and DCD® and treatment effectiveness was measured by myotonometric variables, pressure pain threshold (PPT), visual analog scale (VAS), cervical side-bending flexion ranges, and the neck disability index scale (NDI).

RESULTS

There were no significant differences between US and DCD® interventions regarding changes in outcome measures. The US group achieved a statistically significant difference of 2.16 to 1.13 points (p= 0.005; r= 0.646) for the VAS. The DCD® intervention showed a statistically significant improvement of 1.11 points for the NDI at 1-week following intervention (95% CI 0.14-2.07; p= 0.27; d= 0.217).

CONCLUSION

Our findings suggest that DCD® and US can both be considered effective modalities for the treatment of latent MTrPs, having a longer duration of action with DCD® therapy.

Home Exercise Programs Are Infrequently Prescribed in Trials of Supervised Exercise for Individuals With Low Back Pain: A Scoping Review of 292 Randomized Controlled Trials

OBJECTIVES: To (1) determine how often home exercise programs (HEPs) are prescribed in supervised exercise trials for low back pain (LBP) and (2) describe characteristics of the HEP programs (design, purpose, dose, and adherence). DESIGN: Scoping review. LITERATURE SEARCH: PubMed, CINAHL, and Ovid MEDLINE were searched from January 1, 2010, to August 17, 2021. STUDY SELECTION CRITERIA: Randomized controlled trials that included adults with LBP who received exercise interventions. DATA SYNTHESIS: The presence or absence of a prescribed HEP and any details of the HEP including design, dose, and adherence were extracted and summarized. RESULTS: Of 2689 potentially relevant trials, 292 were eligible for inclusion. Ninety-four trials (32%) included a HEP. The most commonly prescribed home exercises were core stability, trunk strengthening, and motor control exercises. There was great variation in the frequency and duration with which HEPs were prescribed. Adherence to HEPs was measured in fewer than half of the trials, and the methods for measuring adherence were inconsistent. Adherence to HEPs ranged from 29% to 82% in the 21 trials that reported adherence. CONCLUSION: Home exercise programs are not regularly prescribed in supervised exercise trials for LBP. There was considerable variation in prescribing HEPs and monitoring exercise adherence in trials of exercise-based treatments for adults with LBP. There is no consistent method used to measure participants' adherence to HEPs, and adherence percentages vary widely. J Orthop Sports Phys Ther 2023;53(3):120-142. Epub: 16 January 2023. doi:10.2519/jospt.2023.11448.

An Updated Overview of Low Back Pain Management

We aimed to determine the recommendation level for the treatment of acute and chronic low back pain (LBP). A systematic review (SR) of the literature was performed and all English-language articles that discuss acute and chronic LBP, including MEDLINE and the Cochrane Database of Systematic Reviews, were searched. Of the 873 searched literature reports, 259 articles, including 131 clinical trials, 115 SRs, nine meta-analyses, and four clinical guidelines were analyzed. In these articles, high-quality randomized controlled trials, SRs, and used well-written clinical guidelines were reviewed. The results indicated multiple acute and chronic LBP treatment methods in the literature, and these reports when reviewed included general behavior, pharmacological therapy, psychological therapy, specific exercise, active rehabilitation and educational interventions, manual therapy, physical modalities, and invasive procedures. The Trial conclusions and SRs were classified into four categories of A, B, C, and D. If there were not enough high-quality articles, it was designated as "I" (insufficient). This review and summary of guidelines may be beneficial for physicians to better understand and make recommendations in primary care.

Comparison of the effectiveness of conventional physical therapy and extracorporeal shock wave therapy on pain, disability, functional status, and depression in patients with chronic low back pain

Objectives: The aim of this study was to compare the effectiveness of conventional physical therapy (transcutaneous electrical nerve stimulation, hot pack, and therapeutic ultrasound) and extracorporeal shock wave therapy (ESWT) on pain, disability, functional status, and depression in patients with chronic low back pain (LBP).

Patients and methods: Ninety-one patients with chronic LBP were included in the study and randomized to groups that received ESWT or conventional physiotherapy; of these, 70 completed the study (37 males, 33 females; mean age: 46.4±13.3 years; range, 18 to 65 years). Outcome measures included the Visual Analog Scale, the pressure pain algometer, Oswestry Disability Index (ODI), Health Assessment Questionnaire (HAQ), fingertip-to-floor distance, and the Beck Depression Inventory. The assessments were made before treatment and at the first and 12th weeks after treatment.

Results: Extracorporeal shock wave therapy was more effective than conventional physical therapy in terms of Visual Analog Scale scores, the pressure algometer, ODI, HAQ, and fingertip-to-floor distance at the first and 12th week.

Conclusion: Extracorporeal shock wave therapy is superior to conventional physical therapy in terms of improving pain, spinal mobility, and functional status in patients with chronic LBP.

A Comparison of the Effect of a 4.4-MHz Radiofrequency Deep Heating Therapy and Ultrasound on Low Back Pain: A Randomized, Double-Blind, Multicenter Trial

Despite the increasing interest in RF (Radiofrequency) therapy, little is known about its effectiveness for low back pain (LBP). The aim of this study was to investigate the effectiveness of 4.4-MHz RF diathermy compared to ultrasound (US) in patients with LBP. One-hundred-and-eighteen patients with LBP were randomized with RF (n = 62) or US (n = 56). Investigator and subjects were blinded to the treatment group. Either RF (4.4 MHz, 45 W/cm2) or US (1 MHz, 2 W/cm2) was applied for 10 to 15 min, 3 times per week for 4 weeks. The primary outcome was the Oswestry Disability Index (ODI, %). Secondary outcomes were numeric rating scale (NRS), Biering−Sorensen test, up-and-go test, successful pain relief, and successful functional improvement. Clinical outcomes were evaluated prior to intervention (baseline), and at 4 and 12 weeks after treatment. There were no significant differences between the groups regarding baseline demographic and clinical characteristics. Both groups observed a significant improvement of ODI (%), NRS, Biering−Sorensen test, and up-and-go test at 4 and 12 weeks after treatment (p < 0.05); however, no significant differences were found between groups. The RF group showed a higher proportion of successful pain relief at 12 weeks after treatment than the US group (p = 0.048). The RF diathermy showed favorable results in pain reduction, improvement of function, mobility, and back muscle endurance. Compared with US, RF diathermy obtained slightly better perception of patients in pain relief at 12 weeks after treatment. The results from this study indicated that 4.4-MHz RF diathermy can effectively be used as a conservative treatment option for patients with LBP.

Study on the effects of the use of therapeutic ultrasound in the treatment of osteoarticular diseases

Introduction. The use of therapeutic ultrasounds is a method that proved its efficiency in articu-lar and periarticular pathology, in the subacute and chronic stages. The biological effects of the ultrasound use are determined by their interaction with the cellular structures whereas the re-sults depend on the used parameters. The purpose of the survey is to evaluate / identify the ef-fects of using ultrasounds in the treatment of musculoskeletal conditions (lumbar discopathy), knee osteoarthritis). Material and method. The survey was conducted on an outpatient basis in a period of 7 months and it is of the longitudinal type. It included 151 patients diagnosed with low back pain and knee osteoarthritis. The evaluated parameters were: pain, functional skills, articu-lar rigidity and the quality of life. Results. The effects of the use of ultrasounds is found in the decrease of pain, the stiffness of the joints and the contracture of the muscles, as shown by the re-sults of several surveys. Our survey proves that the use of ultrasounds decreases pain and in-creases the functional skills, it influences the physical function more obviously in patients with knee osteoarthritis, which is an aspect found in others surveys. Discussion. The use of a complex ultrasound treatment (in the pulsed way to avoid thermal effects) and kinesiotherapy enabled in our research the decrease of the pain and of the rigidity in the joints, the increase of the function-al skills and the quality of life, whereas these obtained results are in accordance with those of others surveys. Conclusions. The use of the therapeutic ultrasounds can have the following ef-fects: the decrease of the pain and of the joint rigidity, the improvement of the physical capacity for daily activities and the improvement of the quality of life. The use of low intensity ultra-sounds can determine biological effects with actions for a short period or for an average one. Keywords: therapeutic ultrasound, treatment, osteoarticular diseases, quality of life

Low Back Pain Physiotherapy: Does Expectation Really Influence Outcome?

Objectives: Low Back Pain (LBP) is prevalent in most people of working age. The morbidity it causes cannot be taken lightly, as is its economic burden. Physiotherapy has long been prescribed to LBP patients, but treatment outcome measurements, along with the factors influencing it, have not been widely evaluated. In this study, we aim to assess the correlation between patient’s expectation and LBP physical therapy outcome. Methods: This was a cross sectional study conducted at physical rehabilitation outpatient clinic in September-December 2019. Participants were patients with LBP who were treated with physical therapy. One series of physical therapy consists of 5 sessions of modality only or modality with exercise therapy; one patient underwent 2 sessions per week. Oswestry disability index (ODI) score was used to evaluate treatment outcome and Stanford Expectation of Treatment Scale score was used to evaluate patient’s expectation. Data was collected twice, before and after 1 series of therapy. Results: There were 91 participants included in this study, most of whom were female. Most patients reported a significant decrease in ODI score, irrespective of the LBP chronicity or nutritional status. However, patients who received a combination of physical exercises and modalities reported lower after therapy ODI than those who only received modalities (p=0.009). No correlation was found between positive (p=0.567) or negative (p=0.910) expectations with ODI improvement. Conclusion: Our study did not find any correlation between positive or negative expectations towards ODI score improvement. Keywords: Low back pain; Physical therapy; Treatment outcome; Patient expectation; ODI score

A Review of Laser Therapy and Low-Intensity Ultrasound for Chronic Pain States

PURPOSE OF REVIEW

Chronic pain management therapies have expanded quickly over the past decade. In particular, the use of laser therapy and ultrasound in the management of chronic pain has risen in recent years. Understanding the uses of these types of therapies can better equip chronic pain specialists for managing complicated chronic pain syndromes. The purpose of this review was to summarize the current literature regarding laser radiation and ultrasound therapy used for managing chronic pain syndromes.

RECENT FINDINGS

In summary, there is stronger evidence supporting the usage of laser therapy for managing chronic pain states compared to low-intensity ultrasound therapies. As a monotherapy, laser therapy has proven to be beneficial in managing chronic pain in patients with a variety of pain syndromes. On the other hand, LIUS has less clear benefits as a monotherapy with an uncertain, optimal delivery method established. Both laser therapy and low-intensity ultrasound have proven beneficial in managing various pain syndromes and can be effective interventions, in particular, when utilized in combination therapy.

Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition

BACKGROUND

The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine.

METHODS

The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members.

RESULTS

Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature.

CONCLUSIONS

The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.

Emotionality and Quality of Life in Patients with Musculoskeletal Disorders

Introduction: It is well-known that musculoskeletal conditions are related with pain and anxiety. Anxiety is a complex concept that involves a transient state caused by different factors, as well as a persistent mood. Aim: The aim of the study is to reveal the associations between the discomfort caused by some musculoskeletal disorders and the emotionality (anxiety as a trait or a state) on the one hand and, on the other hand, the level of quality of life. Material and method: The study was cross-sectional and was performed in a period of 6 months on an outpatient basis of 174 patients with musculoskeletal disorders. Thus, we have taken into consideration 5 groups of patients, according to the presented medical condition: low back pain, law back osteoporosis, hand osteoarthritis, knee osteoarthritis, coxarthrosis. We have administered two scales to all the patients: The State Trait Anxiety Inventory (STAI) form X1 (anxiety a s a state) and form X2 (anxiety as a trait) and the Quality of Life (QOL) Results: For patients who were diagnosed with low back pain, quality of life was 60.71% of the maximum value. Anxiety by using the S.T.A.I. form X1 at an average value was 46.5, anxiety assessed by the STAI form X2 scale, indicates an average value of 39. In the case of osteoporosis, the value of their quality of life was 90.18%. Anxiety (form X1) was 36, and anxiety (form X2) was 52. For the patients diagnosed with hip osteoarthritis, respectively with knee osteoarthritis, the quality of life were 87.5% and 77.67%, anxiety (form X1) were 41 and 48, anxiety (form X2) were 47 and 61. For patients diagnosed with hand disorders, the quality of life was 81.25%, anxiety (form X1) was 62 and anxiety (form X2) was 47. Conclusions: It was found that in the case of the low back pain, the quality of life had the lowest value (60.71% of the maximum value). In knee osteoarthritis it was found the highest value of anxiety as a trait was 61, and the highest value of anxiety as a condition was found in osteoarthritis of the hand as 62. Keywords: anxiety, quality of life, musculoskeletal disorders,

Quality of Life and Negative Affectivity at the Patients with Stroke and Musculoskeletal Disorders

Introduction. Stroke can be a severe debilitating medical condition due to its medical consequences. When it occurs at an individual with pre-existent musculoskeletal disorders, the medical recovery becomes more problematic. Some consequences, like negative affectivity and a reduced quality of life intervene to varying degrees. Material and method. Our study included 150 outpatients who were diagnosed with stroke and one of five types of musculoskeletal disorders (low back pain, osteoporosis, hand disorders, hip osteoarthritis, knee osteoarthritis). We divided all the patients in five sub-groups. To assess the negative affectivity (anxiety) and quality of life we administered to the patients two scales: the State Trait Anxiety Inventory (STAI) form X1 (anxiety a s a state) and form X2 (anxiety as a trait) and The Quality of Life (QOL). Results. In patients diagnosed with stroke and osteoporosis, the quality of life was 83.92% of the maximum value. Anxiety as a state rated at an average of 50.5 and anxiety as a trait rated at an average of 45. In the case of stroke and degenerative diseases at the lower limbs, we registered the quality of life of 77.68% in knee osteoarthritis and 75.89% in hip osteoarthritis; anxiety as a condition had an average value of 65 and, as a trait, a value of 63 in knee osteoarthritis, while in hip osteoarthritis the anxiety as a condition, and, in the same time, as a trait, rated both at 49.5. Low back pain in stroke patients had a quality of life of 77.86% of the maximum value; anxiety as a condition was 48 and the anxiety trait has the value of 47. For the patients with stroke and hand disease, the quality of life was assessed at 88.83%. Anxiety as a condition recorded an average value of 48 and the average value of 51 for anxiety as a trait recorded an average value of 51. Conclusions. The lowest score of quality of life is recorded in the patient diagnosed with stroke and hip osteoarthritis (75.89% of the maximum value). This association converges with body dynamics, as the overlap of these two medical conditions may explain reduced functionality. The value of anxiety as a condition and also as a trait was higher in patients with stroke and osteoarthritis of the knee (65 and 63, respectively). The latter result is understandable, as intense pain and, therefore, discomfort related to osteoarthritis of the knee is well known. Keywords: stroke, anxiety, quality of life, musculoskeletal conditions,

Low-Intensity Continuous Ultrasound Therapies—A Systematic Review of Current State-of-the-Art and Future Perspectives

Therapeutic ultrasound has been studied for over seven decades for different medical applications. The versatility of ultrasound applications are highly dependent on the frequency, intensity, duration, duty cycle, power, wavelength, and form. In this review article, we will focus on low-intensity continuous ultrasound (LICUS). LICUS has been well-studied for numerous clinical disorders, including tissue regeneration, pain management, neuromodulation, thrombosis, and cancer treatment. PubMed and Google Scholar databases were used to conduct a comprehensive review of all research studying the application of LICUS in pre-clinical and clinical studies. The review includes articles that specify intensity and duty cycle (continuous). Any studies that did not identify these parameters or used high-intensity and pulsed ultrasound were not included in the review. The literature review shows the vast implication of LICUS in many medical fields at the pre-clinical and clinical levels. Its applications depend on variables such as frequency, intensity, duration, and type of medical disorder. Overall, these studies show that LICUS has significant promise, but conflicting data remain regarding the parameters used, and further studies are required to fully realize the potential benefits of LICUS.

Therapeutic Ultrasound for Chemotherapy-Related Pain and Sensory Disturbance in the Hands and Feet in Patients With Colorectal Cancer: A Pilot Randomized Controlled Trial

CONTEXT

This proof-of-concept trial was undertaken as a first step in exploring the clinical benefit of therapeutic ultrasound for pain and sensory disturbance in patients with colorectal cancer.

OBJECTIVES

The aim of this study was to determine the feasibility and preliminary efficacy of adding therapeutic ultrasound to a home-based therapeutic exercise program (current standard of care) for patients presenting with oxaliplatin-related pain and sensory disturbance in the hands and feet.

METHODS

Thirty-one colorectal cancer patients with presenting symptoms of peripheral sensory neuropathy, based on a physician-rated grade 1, 2, or 3 on the National Cancer Institute Common Terminology Criteria for Adverse Events for sensory and motor neuropathy, were enrolled in the trial. Patients were randomized to either 10 sessions of ultrasound therapy intervention over two-week period (continuous ultrasound at an intensity of 0.7 to 0.8 w/cm², and frequency of 3 MHz for 5 minutes) plus standard care (n = 16) or to standard care alone (n = 15). The feasibility of therapeutic ultrasound was determined by the recruitment rate, participants' adherence to the intervention, and the study completion rates. Assessments of pain, sensory disturbance, sensation, and balance were conducted at baseline, two and six weeks.

RESULTS

We achieved a recruitment rate of 84%, an adherence rate of 100% to the intervention, and a completion rate of 100%. Adding therapeutic ultrasound to standard care resulted in a statistically and clinically significant improvement in symptoms of pain and sensory disturbance (P = 0.003) at two weeks; however, no significance difference between the groups was found at the six-week follow-up.

CONCLUSIONS

The findings of this proof-of-concept study support the feasibility of the therapeutic ultrasound in addition to standard care as an intervention for colorectal cancer patients with oxaliplatin-related pain and sensory disturbance in the hands and feet. The findings warrant a large-scale placebo-controlled trial.

Effectiveness of Ultrasound Therapy on the Management of Chronic Non-Specific Low Back Pain: A Systematic Review

Non-specific chronic low back pain is the most common self-reported kind of musculoskeletal ache associated with substantial health and socioeconomic problem and responsible for most years lived with a disability as compared with any other medical condition. So treating chronic non-specific low back pain is one of the main problems faced among physical therapists in the rehabilitation area. The effects of ultrasound for patients with non-specific chronic low back pain remain unknown, however it is commonly used to treat clients with low back pain in rehabilitation setting. Therefore, the main aim of this review was to evaluate the up-to-date confirmation in the efficacy of ultrasound therapy on the treatment of non-specific chronic low back pain. A comprehensive search of four computerized electronic databases was performed to identify the effectiveness of ultrasound therapy on the management of chronic non-specific low back pain. Searching was done through the Google Scholar, PubMed, ScienceDirect, and Physiotherapy Evidence Databases (PEDro) and reported using preferred reporting items for systematic reviews and meta-analyses guidelines. The qualities of articles were appraised by the PEDro scale. The primary outcome measure visual analog scale was used. Six randomized clinical trials with a total sample size of 699 patients from the electronic database published in English were identified. In this review, the effect of UST in five articles was statically significant in reducing the visual analog scale (p<0.05) score. So this systematic review found ultrasound therapy could be an alternative treatment to reduce the intensity of pain in subjects with non-specific chronic LBP.

Therapeutic Ultrasound for Pain Management in Chronic Low Back Pain and Chronic Neck Pain: A Systematic Review

BACKGROUND

Low back pain (LBP) and neck pain are major causes of pain and disability that are experienced across all ages. The primary goals of treatment are to improve patient function and facilitate a return to the patient's desired level of daily activity. Therapeutic ultrasound is a noninvasive modality widely utilized in the management of musculoskeletal disorders, but there continues to be controversy regarding its use due to insufficient evidence of effectiveness. The objective of this systematic review was to evaluate the effectiveness of therapeutic ultrasound in the management of patients with chronic LBP and neck pain.

METHODS

Using PRISMA guidelines, a search of the PubMed and CENTRAL (The Cochrane Library) databases was performed to retrieve randomized controlled trials (RCTs) that evaluated therapeutic ultrasound in patients with chronic LBP or neck pain.

RESULTS

The search strategy identified 10 trials that met the criteria for inclusion. Three studies in LBP reported that both therapeutic and sham (placebo) ultrasound provided significant improvement in pain intensity. In each of these studies, ultrasound was found to be more effective than placebo when using only one of several validated instruments to measure pain. Three of the four studies on neck pain demonstrated significant pain relief with ultrasound in combination with other treatment modalities. However, only one of these studies demonstrated that the use of ultrasound was the cause of the statistically significant improvement in pain intensity.

CONCLUSIONS

Therapeutic ultrasound is frequently used in the treatment of LBP and neck pain and is often combined with other physiotherapeutic modalities. However, given the paucity of trials and conflicting results, we cannot recommend the use of monotherapeutic ultrasound for chronic LBP or neck pain. It does seem that ultrasound may be considered as part of a physical modality treatment plan that may be potentially helpful for short-term pain relief; however, it is undetermined which modality may be superior. In both pain syndromes, further trials are needed to define the true effect of low-intensity ultrasound therapy for axial back pain. No conclusive recommendations may be made for optimal settings or session duration.

Effects of core stability exercise combined with virtual reality in collegiate athletes with nonspecific low back pain: a randomized clinical trial

Background

Nonspecific low back pain (LBP) in collegiate athletes is shown to be accompanied by poor core endurance. Consequently, trunk muscle stabilization exercises for lumbar instability are widely used. Virtual reality (VR) training can activate the cerebral cortex and enhance the cortex to control balance and improve motion function. The purpose of the study was to assess the effect of combined core stability exercises (CSE) and VR training in improving body balance and function in collegiate male athletes with nonspecific low back pain (LBP).

Results

The post-values of the experimental group were significantly higher than that of the control group for the dynamic balance in anterior (p = 0.031), posterolateral (p = 0.034), and posteromedial (p = 0.037) directions. Moreover, there was a significant difference in the post-values of both groups regarding reducing the Micheli Functional Scale in favor of the experimental group (p = 0.012).

Conclusions

CSE training plus virtual reality is more effective than CSE training alone in improving total body balance and dysfunction level in collegiate male athletes with nonspecific LBP. It is recommended that clinicians consider CSE combined with VR to maximize the improvement in overall body balance when developing rehabilitation programs for collegiate athletes with nonspecific low back pain.

Trial registration

Pan African Clinical Trial Registry, PACTR201907749053096. Retrospectively registered on 15 April 2019. https://pactr.samrc.ac.za/Researcher/ManageTrials.aspx

Therapeutic ultrasound for chronic low back pain

BACKGROUND

This is an update of a Cochrane Review published in 2014. Chronic non-specific low back pain (LBP) has become one of the main causes of disability in the adult population around the world. Although therapeutic ultrasound is not recommended in recent clinical guidelines, it is frequently used by physiotherapists in the treatment of chronic LBP.

OBJECTIVES

The objective of this review was to determine the effectiveness of therapeutic ultrasound in the management of chronic non-specific LBP. A secondary objective was to determine the most effective dosage and intensity of therapeutic ultrasound for chronic LBP.

SEARCH METHODS

We performed electronic searches in CENTRAL, MEDLINE, Embase, CINAHL, PEDro, Index to Chiropractic Literature, and two trials registers to 7 January 2020. We checked the reference lists of eligible studies and relevant systematic reviews and performed forward citation searching.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on therapeutic ultrasound for chronic non-specific LBP. We compared ultrasound (either alone or in combination with another treatment) with placebo or other interventions for chronic LBP.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of each trial and extracted the data. We performed a meta-analysis when sufficient clinical and statistical homogeneity existed. We determined the certainty of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

We included 10 RCTs involving a total of 1025 participants with chronic LBP. The included studies were carried out in secondary care settings in Turkey, Iran, Saudi Arabia, Croatia, the UK, and the USA, and most applied therapeutic ultrasound in addition to another treatment, for six to 18 treatment sessions. The risk of bias was unclear in most studies. Eight studies (80%) had unclear or high risk of selection bias; no studies blinded care providers to the intervention; and only five studies (50%) blinded participants. There was a risk of selective reporting in eight studies (80%), and no studies adequately assessed compliance with the intervention. There was very low-certainty evidence (downgraded for imprecision, inconsistency, and limitations in design) of little to no difference between therapeutic ultrasound and placebo for short-term pain improvement (mean difference (MD) -7.12, 95% confidence interval (CI) -17.99 to 3.75; n = 121, 3 RCTs; 0-to-100-point visual analogue scale (VAS)). There was also moderate-certainty evidence (downgraded for imprecision) of little to no difference in the number of participants achieving a 30% reduction in pain in the short term (risk ratio 1.08, 95% CI 0.81 to 1.44; n = 225, 1 RCT). There was low-certainty evidence (downgraded for imprecision and limitations in design) that therapeutic ultrasound has a small effect on back-specific function compared with placebo in the short term (standardised mean difference -0.29, 95% CI -0.51 to -0.07 (MD -1.07, 95% CI -1.89 to -0.26; Roland Morris Disability Questionnaire); n = 325; 4 RCTs), but this effect does not appear to be clinically important. There was moderate-certainty evidence (downgraded for imprecision) of little to no difference between therapeutic ultrasound and placebo on well-being (MD -2.71, 95% CI -9.85 to 4.44; n = 267, 2 RCTs; general health subscale of the 36-item Short Form Health Survey (SF-36)). Two studies (n = 486) reported on overall improvement and satisfaction between groups, and both reported little to no difference between groups (low-certainty evidence, downgraded for serious imprecision). One study (n = 225) reported on adverse events and did not identify any adverse events related to the intervention (low-certainty evidence, downgraded for serious imprecision). No study reported on disability for this comparison. We do not know whether therapeutic ultrasound in addition to exercise results in better outcomes than exercise alone because the certainty of the evidence for all outcomes was very low (downgraded for imprecision and serious limitations in design). The estimate effect for pain was in favour of the ultrasound plus exercise group (MD -21.1, 95% CI -27.6 to -14.5; n = 70, 2 RCTs; 0-to-100-point VAS) at short term. Regarding back-specific function (MD - 0.41, 95% CI -3.14 to 2.32; n = 79, 2 RCTs; Oswestry Disability Questionnaire) and well-being (MD -2.50, 95% CI -9.53 to 4.53; n = 79, 2 RCTs; general health subscale of the SF-36), there was little to no difference between groups at short term. No studies reported on the number of participants achieving a 30% reduction in pain, patient satisfaction, disability, or adverse events for this comparison.

AUTHORS' CONCLUSIONS

The evidence from this systematic review is uncertain regarding the effect of therapeutic ultrasound on pain in individuals with chronic non-specific LBP. Whilst there is some evidence that therapeutic ultrasound may have a small effect on improving low back function in the short term compared to placebo, the certainty of evidence is very low. The true effect is likely to be substantially different. There are few high-quality randomised trials, and the available trials were very small. The current evidence does not support the use of therapeutic ultrasound in the management of chronic LBP.

Effects of Therapeutic Ultrasound Applied to the Lumbar Region on Renal Function: A Randomized Controlled Prospective Trial

OBJECTIVES

Therapeutic ultrasound (TUS) is one of the most commonly used modalities in low back pain treatment. The objective of this study was to determine whether TUS applied to the low back region in patients with chronic low back pain had any effect on renal function.

METHODS

Forty patients with chronic low back pain were randomized to 2 groups by a block randomization method. Thirty-seven patients completed the final evaluation. All patients were treated for 5 sessions per week for 3 weeks with the same physiotherapy modalities (superficial heating and transcutaneous electrical nerve stimulation) and exercise therapy; in addition to these treatments, the second group was treated with TUS for 10 minutes (frequency, 1 MHz; intensity, 1.5 W/cm² ; and effective irradiation area of the transducer head, 5 cm² ). The serum creatinine, serum cystatin C, 24-hour urine creatinine, creatinine clearance, 24-hour urine microalbumin and microprotein, urine volume, and glomerular filtration rate were measured. The patients were evaluated at baseline (day 0) and the end of the treatment (day 21).

RESULTS

The serum cystatin C levels were increased in both groups, but this increase was not significant (P > .05). There was no difference between the groups in the percent change in all outcome measures (P > .05).

CONCLUSIONS

This showed that TUS applied to the low back region does not affect renal function.

Low-Intensity Continuous Ultrasound for the Symptomatic Treatment of Upper Shoulder and Neck Pain: A Randomized, Double-Blind Placebo-Controlled Clinical Trial

Purpose

Low-intensity continuous ultrasound (LICUS) is an emerging high-dosimetry ultrasound-based therapy for accelerated tissue healing and the treatment of myofascial pain. In this study, LICUS treatment is clinically evaluated for chronic upper neck and shoulder pain in a randomized, multi-site, double-blind, placebo-controlled study.

Patients and Methods

CONSORT guidelines were followed in conducting and reporting the clinical trial. Thirty-three participants with upper trapezius myofascial pain were randomized for treatment with active (n=25) or placebo (n=8) devices. Investigators and subjects were blinded to treatment groups. Participants self-reported pain daily, rating from 0–10 on the numeric rating scale. If pain rating was more significant than or equal to 3, the LICUS (3MHz, 0.132W/cm², 1.3W, 4 hours) was self-applied for total energy dosimetry of 18,720 Joules per treatment. During the 4-week study, daily pain rating was recorded. If LICUS treatment was delivered, pain before, during, and after treatment were recorded as well as the global rate of change (GROC). Independent t-tests were used to assess change from baseline and differences between treatment groups. ClinicalTrials.gov: NCT02135094.

Results

There was a 100% completion rate for participants enrolled in the study and no significant differences between the groups regarding demographic variables or baseline outcome measures. Participants treated with active therapy observed a significant mean pain reduction from baseline of 2.61 points for active (p<0.001), compared to 1.58 points decrease from baseline for placebo (p=0.087), resulting in a 1.03 points significant decrease in the active group over placebo (p=0.003). The total GROC was significantly higher in the active group at 2.84 points compared to the placebo group at 0.46 points (p<0.001).

Conclusion

Low-intensity continuous ultrasound treatment significantly reduced pain in patients with upper trapezius myofascial pain of the neck and shoulder. LICUS treatment showed a clinically meaningful improvement in the GROC scores for patients. The results from this clinical trial indicate that the LICUS treatment of 18,720 Joules can effectively be used to treat clinical pain related to upper trapezius myofascial pain. Further research could investigate varying dosimetry to improve efficacy and/or reduce the dose.

Continuous shortwave diathermy with exercise reduces pain and improves function in Lateral Epicondylitis more than sham diathermy: A randomized controlled trial

INTRODUCTION

Lateral epicondylitis or tennis elbow, causes significant pain and disability in the upper extremity. Conservative approaches include using thermal and electrical agents. The aim of this study was to explore the effectiveness of shortwave diathermy on pain, function and grip strength of patients with chronic lateral epicondylitis. A randomized placebo-controlled design with concealed allocation, assessor blinding and intention-to-treat analysis was conducted.

METHODS

Fifty patients suffering from lateral epicondylitis for more than 3 months, without any systemic diseases or history of other pathologies, were divided into two groups. In both groups, the patients were instructed to perform specific stretching and strengthening exercises. In addition, the patients in the experimental group, received 15 min of 40-60 W, continuous short wave diathermy while sham diathermy was applied for the control group. The primary outcome measure was pain and the secondary outcome measures were functional ability and pain free grip strength. Outcomes were assessed at the base line, after the 5th and the 10th session of treatment as well as after 3 months.

RESULTS

Mixed ANOVA analysis showed significant improvement in both groups. Meanwhile, there was a significant interaction effect of time and group on all outcome measures implying the greater improvement in pain, function and grip strength in the group receiving real diathermy.

CONCLUSIONS

Adding continuous short wave diathermy to a specific regimen of exercises, reduces pain and improves function in patients suffering from chronic lateral epicondylitis more than sham diathermy and exercise.

TRIAL REGISTRATION

IRCT2016042321139N4.

Comparison of the effects of low-level laser and pulsed and continuous ultrasound on pain and physical disability in chronic non-specific low back pain: a randomized controlled clinical trial

OBJECTIVE

To compare the short-term effects of pulsed laser and pulsed and continuous ultrasound on pain and functional disability in women with chronic non-specific low back pain.

METHODS

The sample was composed of 100 volunteers randomly allocated into four groups: The Pulsed Laser Group (n = 26) was treated with 3 J/cm²; the Pulsed Ultrasound Group (n = 24; 3 MHz) was treated with 1 W/cm²; the Continuous Ultrasound Group (n = 26; 1 MHz) was treated with 1 W/cm²; and a Control Group (n = 24), where the patients were still waiting for treatment. Before and after 10 sessions of treatment, the intensity of pain was assessed using the visual analogue scale (VAS), the quality of pain was evaluated using the McGill pain questionnaire and functional disability was investigated using the Roland-Morris questionnaire.

RESULTS

The three treated groups exhibited a decrease in pain (p < 0.001); the Pulsed Laser Group showed the greater relative gain (91.2%), Meanwhile, the Control Group exhibited a worsening of - 5.8%. The three treated groups demonstrated improvement in the quality of pain (McGill) in the total, sensory and affective dimensions (p < 0.005; p < 0.002; p < 0.013, respectively). All treated groups showed a decrease in functional disability (p < 0.001), but the Pulsed Ultrasound Group showed the highest relative gain (83.3%).

CONCLUSIONS

The three modalities have significant effects to decreasing low back pain and improving functional disability in women with non-specific chronic low back pain, but the pulsed low-level laser had the best results on pain while the pulsed ultrasound had the best results on improve the functional disability.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02150096.

Abstracts of low back pain trials are poorly reported, contain spin of information and are inconsistent with the full text: An overview study

OBJECTIVE

To investigate trials abstracts evaluating treatments for low back pain with regards to completeness of reporting, spin (i.e., interpretation of study results that overemphasizes the beneficial effects of the intervention), and inconsistencies in data with the full text.

DATA SOURCES

The search was performed on Physiotherapy Evidence Database (PEDro) in February 2016.

STUDY SELECTION

This is an overview study of a random sample of 200 low back pain trials published between 2010 and 2015. The languages of publication were restricted to English, Spanish and Portuguese.

DATA EXTRACTION

Completeness of reporting was assessed using the CONSORT for Abstracts checklist (CONSORT-A). Spin was assessed using a SPIN-checklist. Consistency between abstract and full text were assessed by applying the assessment tools to both the abstract and full text of each trial and calculating inconsistencies in the summary score (paired t test) and agreement in the classification of each item (Kappa statistics). Methodological quality was analyzed using the total PEDro score.

DATA SYNTHESIS

The mean number of fully reported items for abstracts using the CONSORT-A was 5.1 (SD 2.4) out of 15 points and the mean number of items with spin was 4.9 (SD 2.6) out of 7 points. Abstract and full text scores were statistically inconsistent (P=0.01). There was slight to moderate agreement between items of the CONSORT-A in the abstracts and full text (mean Kappa 0.20 SD 0.13) and fair to moderate agreement for items of the SPIN-checklist (mean Kappa 0.47 SD 0.09).

CONCLUSIONS

The abstracts were incomplete, with spin and inconsistent with the full text. We advise health care professionals to avoid making clinical decisions based solely upon abstracts. Journal editors, reviewers and authors are jointly responsible for improving abstracts, which could be guided by amended editorial policies.

Effects of High - Intensity Laser in Treatment of Patients with Chronic Low Back Pain

BACKGROUND:

Chronic low back pain lasts longer than 12 weeks and is characterised by pain, muscle weakness, reduced functional ability and psychosocial burden.

AIM:

To compare the effects of two physical modalities, high-intensity laser against ultrasound therapy in the treatment of patients with chronic low back pain.

MATERIAL AND METHODS:

This was a prospective, monocentric, controlled clinical study comprising a group of 54 patients at the age between 25 and 65 years. Patients were divided into two groups: an examined group of 27 patients (high-intensity laser and exercises) and a control group of 27 patients (ultrasound therapy and exercises). The results were evaluated by the Numeric Pain Rating Scale, Oswestry Disability Index and Schober’s test. Clinical findings were evaluated at the same time points for all patients, before treatment, at two weeks and three months following treatment. Statistical analyses were made to compare the differences between the results obtained on admission and the two consecutive control check-ups. Statistical significance was defined as a P value < 0.05.

RESULTS:

The examined group showed statistically significantly better results than the control group after completion of the treatment (at two weeks) and at follow up after three months.

CONCLUSION:

This study has shown that patient with chronic low back pain treated with a high-intensity laser has significantly reduced low back pain, reduced disability and improved range of motion. Its positive effect maintained for three months. It seems to be an effective, safe and useful physical modality in the treatment of a patient with chronic low back pain.

Efficacy of diclofenac & thiocolchioside gel phonophoresis comparison with ultrasound therapy on acute low back pain; a prospective, double-blind, randomized clinical study

PURPOSE

To investigate the effect of Phonophoresis (PP) with the combination of nonsteroidal anti-inflammatory drugs (NSAID's) and myorelaxant versus routine Ultrasound (US) treatment with non-therapeutic gel on the patients with acute low back pain (ABP).

METHODS

Sixty patients with ABP were randomly assigned into 2 groups. In Group 1 (n = 30) US was applied using diclofenac + Thiocolchicoside gel for 10 min and for a total of 10 sessions. In Group 2 (n = 30) the same US protocol was applied with the same setting and timing with Group 1 using US gel that does not contain any pharmaceutical ingredient. Evaluation parameters were Visual numeric scale (VNS), Oswestry Disability Index (ODI), and Shober test.

RESULTS

Comparison of the results obtained from the two groups before treatment and at second (W2) and sixth weeks (W6) posttreatment showed significant improvement in all parameters in both groups (p < 0.05). Comparison of the groups showed significantly superior improvement in Group 1 for ODI while there was no difference in other parameters at W2. At W6, there was significantly superior improvement in all parameters (p < 0.05) except for Shober test in Group1.

CONCLUSION

Our results showed that PP treatment is superior than conventional US therapy at short term in ABP patients.

Effects of pulse ultrasound and kneading massage in managing individual with incessant pain at lower region of back using random allocation

The study examined the effect of pulsed therapeutic ultrasound in management of patients with incessant pain at lower region of the back (PWIPLB) in comparison with kneading massage (KM). Fifty PWIPLB recruited purposively were randomly assigned into ultrasound group (USG) and KM group (KMG) equally. Subjects received back extension exercises as baseline treatment. USG received pulse ultrasound (PUS) while KMG was treated using KM. The treatments were administered 2 times weekly for a 6-week period. Severity of pain (SP) and inability of patient (IoP) were evaluated at baseline, 3rd week and 6th week of treatment. Values of the variables obtained were classified and the implications were summarised. A significant change was observed in precompared with posttreatment SP (F=32.6, P=0.000) and IoP (F=2.5, P<0.021) in USG. A significant change was observed in precompared with posttreatment IoP (F=4.1, P<0.05) but not in SP (F=2.9, P<0.086). In the 6th week, there was a significant reduction of SP in the USG relative to SP in the KMG (F=11.98, P=0.000), and there was improvement significantly in the IoP in the KMG relative to that in the USG (F=2.58, P=0.05). PUS may be better than KM in management of SP but KM is better than PUS in IoP with PWCPLB.

No immediate analgesic effect of diadynamic current in patients with nonspecific low back pain in comparison to TENS

BACKGROUND AND DESIGN

Chronic nonspecific low back pain (CNSLBP) has major socioeconomic as well as personal impact in many industrialized and developing countries. Physiotherapy is a common intervention for this group of patients and using anti-pain physical modalities is a common part of the physical therapy. In a randomized controlled trial we investigated the immediate effect of the Diadynamic current in comparison to TENS on reducing the pain in patients suffering from non specific chronic low back pain.

METHODS

Thirty patients were randomized into the Diadynamic current and TENS groups. Electrical stimulation was applied for 10 min in the Diadynamic group and for 15 min in the TENS group for one session. Pain, on a 100 mm Visual Analog Scale, and Pressure Pain Threshold (PPT), using an Algometer, was measured before the treatment, after the current application, 20 min later and after 48 h.

RESULTS

Pain was decreased significantly after 20 min following the current application only in the TENS group, with no improvement at all measurement points in the group receiving Diadynamic current. PPT was increased immediately after current application in both groups but did not last until later measurements.

CONCLUSION

Diadynamic current had no positive effect on prompt relief of pain in patients suffering from recurrent CNSLBP.

Comparison of the effectiveness of two physiotherapy programs for female patients with lumbar spine discopathy

Background. Lower back pain is one of the most common problems in the human body relat-ed to the disturbances of the motor organ’s structure and function. It challenges contemporary physiotherapy which aim is to reduce or, when possible, eliminate pain, restore fitness for eve-ryday life and prevent recurrences. The aim of the study was to compare two physiotherapy programmes in terms of lowering pain intensity, improvement of lumbar and thoracolumbar spine mobility, as well as functional ability in females with lumbar spine discopathy. Material and methods. The study included 100 women aged 45-50 with lumbar spine disco-pathy being treated in outpatient conditions. The patients were divided into two 50-subject groups depending on the programme used. The physiotherapy programme for group I patients included classic massage, kinesiotherapy and interferential currents, and in group II: classic massage, kinesiotherapy and ultrasound. The research tool was the Numeric Pain Rating Scale (NRS), the Roland Morris Disability Questionnaire (RMDQ) and measurements of lumbar and thoracolumbar spine mobility. The Wilcoxon and Mann-Whitney U tests were used for the analysis. Results. After completion of the physiotherapy programme, the women in group I experi-enced significantly lower pain (p=0.037) and higher functional efficiency (p=0,001). The range of improvement, assessed by the difference in the results of study II and III, was signif-icantly higher for the II group of women (p=0,002). One month after completion of therapeu-tic treatment, there were no statistically significant differences between the groups (p=0,169, p=0,067). Conclusions. The use of interferential currents in the physiotherapy of individuals with lum-bar spine discopathy compared to ultrasound therapy allows for greater improvement in reduc-ing pain intensity, lumbar and thoracolumbar spine mobility, as well as higher functional effi-ciency. The effectiveness of ultrasound had increased over time since the end of therapy and only after one month in the case of both physiotherapy programmes, similar effects could be observed.

Effects of photobiomodulation therapy in patients with chronic non-specific low back pain: protocol for a randomised placebo-controlled trial

INTRODUCTION

Low back pain (LBP) is one of the largest and most frequent public health problems worldwide. Photobiomodulation therapy (PBMT) is a frequently used non-pharmacological therapy for the treatment of musculoskeletal disorders. However, there is little high-quality scientific evidence that demonstrates the effectiveness of PBMT in the treatment of patients with chronic LBP in the short, medium and long term. Therefore, the objective of this clinical trial is to evaluate the effects of PBMT in patients with chronic non-specific LBP in the short, medium and long term.

METHODS AND ANALYSES

This is a prospectively registered, two-arm randomised placebo-controlled trial with blinded patients, assessors and treatment providers. One hundred and forty-eight patients with chronic non-specific LBP will be recruited. Treatment sessions will be provided three times a week for 4 weeks (totaling 12 sessions) with patients receiving either placebo or active PBMT. For ethical reasons, all patients, regardless of treatment allocation, will also receive an information booklet based on 'The Back Book'. Clinical outcomes will be measured at baseline, at the end of treatment, as well as 3, 6 and 12 months after randomisation. The primary outcomes will be pain intensity and disability measured after 12 sessions of treatment. The secondary outcomes will be pain intensity and disability measured at 3, 6 and 12 months after randomisation, in addition to specific disability and global perceived effect in all time points.

ETHICS AND DISSEMINATION

The study was approved by the Research Ethics Committee of Universidade Cidade de São Paulo. The results will be disseminated through scientific publications and presentations at national and international scientific meetings.

TRIAL REGISTRATION NUMBER

NCT03089424.

McKenzie Method of Mechanical Diagnosis and Therapy was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific low back pain: a randomised placebo controlled trial with short and longer term follow-up

Background

The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is one of the exercise approaches recommended by low back pain (LBP) guidelines. We investigated the efficacy of MDT compared with placebo in patients with chronic LBP.

Methods

This was a prospectively registered, two-arm randomised placebo controlled trial, with a blinded assessor. A total of 148 patients seeking care for chronic LBP were randomly allocated to either MDT (n=74) or placebo (n=74). Patients from both groups received 10 treatment sessions over 5 weeks. Patients from both groups also received an educational booklet. Clinical outcomes were obtained at the end of treatment (5 weeks) and 3, 6 and 12 months after randomisation. Primary outcomes were pain intensity and disability at the end of treatment (5 weeks). We also conducted a subgroup analysis to identify potential treatment effect modifiers that could predict a better response to MDT treatment.

Results

The MDT group had greater improvements in pain intensity at the end of treatment (mean difference (MD) −1.00, 95% CI −2.09 to −0.01) but not for disability (MD −0.84, 95% CI −2.62 to 0.93). We did not detect between-group differences for any secondary outcomes, nor were any treatment effect modifiers identified. Patients did not report any adverse events.

Conclusion

We found a small and likely not clinically relevant difference in pain intensity favouring the MDT method immediately at the end of 5 weeks of treatment but not for disability. No other difference was found for any of the primary or secondary outcomes at any follow-up times.

Trial registration number

ClinicalTrials.gov (NCT02123394)

Effectiveness of ultrasound treatment applied with exercise therapy on patients with ankylosing spondylitis: a double-blind, randomized, placebo-controlled trial

The aim of our study was to evaluate effectiveness of ultrasound treatment applied with exercise therapy in patients with ankylosing spondylitis. Fifty-two patients, who were diagnosed according to modified New York criteria, were aged 25-60, and have spine pain, were randomly assigned to two groups. Ultrasound (US) and exercise therapy were applied to treatment group (27); placebo US treatment and exercise therapy were applied to control group (25). Patients were evaluated before treatment, at the end of treatment, and 4 weeks after the treatment. Daily and night pain, morning stiffness, patient global assessment (PGA), doctor global assessment (DGA), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire, Ankylosing Spondylitis Disease Activity Score (ASDAS) erythrocyte sedimentation rate (ESR), and ASDAS C-reactive protein (CRP) were used as clinical parameters. In US group, all parameters showed significant improvements at 2 and 6 weeks, in comparison with the baseline. In placebo US group, significant improvement was obtained for all parameters (except tragus-to-wall distance and modified Schober test at 2 weeks and lumbar side flexion and modified Schober test at 6 weeks). Comparison of the groups showed significantly superior results of US group for parameters of BASMI (p < 0.05), tragus-wall distance (p < 0.05), PGA (p < 0.01), and DGA (p < 0.05) at 2 weeks as well as for the parameters of daily pain (p < 0.01), PGA (p < 0.05), DGA (p < 0.01), BASDAI (p < 0.05), ASDAS-CRP (p < 0.05), ASDAS-ESR (p < 0.01), lumbar side flexion (p < 0.01), the modified Schober test (p < 0.01), and ASQoL (p < 0.05) at 6 weeks. Our study showed that ultrasound treatment increases the effect of exercise in patients with ankylosing spondylitis.

Therapeutic efficacy of Lofnac Gel via phonophoresis in the management of chronic nonspecific low back pain: A randomised controlled trial

BACKGROUND

The prevalence of nonspecific low back pain is very high among Nigerians and in Africa. Lofnac Gel is a nonsteroidal anti-inflammatory gel that has been used to treat musculoskeletal pain, but its efficacy on nonspecific low back pain is inconclusive.

OBJECTIVE

The objective of this study was to examine the therapeutic efficacy of Lofnac Gel in the management of nonspecific low back pain.

METHODS

Seventy patients diagnosed with mechanical low back pain of 3 months' duration were divided into two groups: experimental group (n = 35) and control group (n = 35). Participants in both groups were placed on supervised strengthening exercises for multifidus muscles of the low back. The experimental group was placed on ultrasound phonophoresis therapy with Lofnac Gel (with diclofenac and methyl salicylate as active ingredients), whereas the control group was placed on ultrasound with water as coupling medium. The treatment was applied twice per week for 6 weeks. Present pain intensity and disability were measured before treatment, and in the 3rd week and 6th week of treatment. Data were analysed using descriptive and inferential statistics, and post hoc analysis was carried out when necessary.

RESULTS

There was a significant difference between the pre- and posttreatment pain intensity and disability index for both the experimental (F = 17.947, p < 0.001; F = 20.712, p < 0.001) and control (F = 14.791, p < 0.001; F = 10.418, p < 0.001) groups. There was also a significant difference between the experimental and control group data in terms of pain intensity (F = 28.76, p < 0.001) and disability index (F = 39.817, p < 0.001) in the 6th week.

CONCLUSION

Exercise combined with Lofnac phonophoresis was more effective in the management of patients with chronic low back pain than exercise and ultrasound alone.

Comparison of high-intensity laser therapy and ultrasound treatment in the patients with lumbar discopathy

The aim of the present study was to evaluate the efficiency of high intensity laser and ultrasound therapy in patients who were diagnosed with lumbar disc herniation and who were capable of performing physical exercises. 65 patients diagnosed with lumbar disc were included in the study. The patients were randomly divided into three groups: Group 1 received 10 sessions of high intensity laser to the lumbar region, Group 2 received 10 sessions of ultrasound, and Group 3 received medical therapy for 10 days and isometric lumbar exercises. The efficacy of the treatment modalities was compared with the assessment of the patients before the therapy at the end of the therapy, and in third month after the therapy. Comparing the changes between groups, statically significant difference was observed in MH (mental health) parameter before treatment between Groups 1 and 2 and in MH parameter and VAS score in third month of the therapy between Groups 2 and 3. However, the evaluation of the patients after ten days of treatment did not show significant differences between the groups compared to baseline values. We found that HILT, ultrasound, and exercise were efficient therapies for lumbar discopathy but HILT and ultrasound had longer effect on some parameters.

Efficacy of the McKenzie method in patients with chronic nonspecific low back pain: a protocol of randomized placebo-controlled trial

BACKGROUND

The McKenzie method is widely used as an active intervention in the treatment of patients with nonspecific low back pain. Although the McKenzie method has been compared with several other interventions, it is not yet known whether this method is superior to placebo in patients with chronic low back pain.

OBJECTIVE

The purpose of this trial is to assess the efficacy of the McKenzie method in patients with chronic nonspecific low back pain.

DESIGN

An assessor-blinded, 2-arm, randomized placebo-controlled trial will be conducted.

SETTING

This study will be conducted in physical therapy clinics in São Paulo, Brazil.

PARTICIPANTS

The participants will be 148 patients seeking care for chronic nonspecific low back pain.

INTERVENTION

Participants will be randomly allocated to 1 of 2 treatment groups: (1) McKenzie method or (2) placebo therapy (detuned ultrasound and shortwave therapy). Each group will receive 10 sessions of 30 minutes each (2 sessions per week over 5 weeks).

MEASUREMENTS

The clinical outcomes will be obtained at the completion of treatment (5 weeks) and at 3, 6, and 12 months after randomization. The primary outcomes will be pain intensity (measured with the Pain Numerical Rating Scale) and disability (measured with the Roland-Morris Disability Questionnaire) at the completion of treatment. The secondary outcomes will be pain intensity; disability and function; kinesiophobia and global perceived effect at 3, 6, and 12 months after randomization; and kinesiophobia and global perceived effect at completion of treatment. The data will be collected by a blinded assessor.

LIMITATIONS

Therapists will not be blinded.

CONCLUSIONS

This will be the first trial to compare the McKenzie method with placebo therapy in patients with chronic nonspecific low back pain. The results of this study will contribute to better management of this population.

Therapeutic ultrasound for chronic low-back pain

BACKGROUND

Chronic non-specific low-back pain (LBP) has become one of the main causes of disability in the adult population around the world. Therapeutic ultrasound is frequently used by physiotherapists in the treatment of LBP and is one of the most widely used electro-physical agents in clinical practice.

OBJECTIVES

The objective of this review is to determine the effectiveness of therapeutic ultrasound in the management of chronic non-specific LBP.

SEARCH METHODS

Electronic searches were performed using CENTRAL, MEDLINE, EMBASE, PEDro, and PsycLIT databases in October 2013. Reference lists of eligible studies and relevant systematic reviews were checked and forward citation searching was also performed.

SELECTION CRITERIA

Randomised controlled trials on therapeutic ultrasound for non-specific chronic LBP were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of each trial and extracted the data. When sufficient clinical and statistical homogeneity existed, a meta-analysis was performed. The quality of the evidence for each comparison was determined using the GRADE approach.

MAIN RESULTS

Seven small randomised controlled trials involving a total of 362 participants with chronic LBP were included. Two of the studies had a low risk of bias, meeting six or more of the 12 criteria used for assessing risk of bias. All studies were carried out in secondary care settings and most applied therapeutic ultrasound in addition to exercise therapy, at various intensities for six to 18 treatment sessions. There was moderate quality evidence that therapeutic ultrasound improves back-specific function (standardised mean difference (SMD) [95%CI] -0.45 [-0.84 to -0.05]) compared with placebo in the short term. There was low quality evidence that therapeutic ultrasound is no better than placebo for short-term pain improvement (mean difference (MD) [95%CI] -7.12 [-17.99 to 3.75]; zero to100-point scale). There was low quality evidence that therapeutic ultrasound plus exercise is no better than exercise alone for short-term pain improvement (MD [95%CI] -2.16 [-4.66 to 0.34]; zero to 50-point scale), or functional disability (MD [95%CI] -0.41 [-3.14 to 2.32]; per cent). The studies comparing therapeutic ultrasound versus placebo or versus exercise alone did not report on overall satisfaction with treatment, or quality of life. There was low quality evidence that spinal manipulation reduces pain and functional disability more than ultrasound over the short to medium term. There is also very low quality evidence that there is no clear benefit on any outcome measure between electrical stimulation and therapeutic ultrasound; and that phonophoresis results in improved SF-36 scores compared to therapeutic ultrasound. None of the included studies reported on adverse events related to the application of therapeutic ultrasound.

AUTHORS' CONCLUSIONS

No high quality evidence was found to support the use of ultrasound for improving pain or quality of life in patients with non-specific chronic LBP. There is some evidence that therapeutic ultrasound has a small effect on improving low-back function in the short term, but this benefit is unlikely to be clinically important. Evidence from comparisons between other treatments and therapeutic ultrasound for chronic LBP were indeterminate and generally of low quality. Since there are few high quality randomised trials and the available trials are very small, future large trials with valid methodology are likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Electromyographic analysis of the vertebral extensor muscles during the Biering-Sorensen Test

The purpose of the study was to analyze the electromyographic signal of the multifidus, longissimus thoracis and the lumbar iliocostalis muscles during the Biering-Sorensen test in subjects without lower back pain. Twenty volunteers performed the test on three separate occasions. An analysis of variance detected a difference between the three test times (p = 0.0026). For the frequency domain, it was observed that there were differences between the multifidus and the lumbar erectors muscles; longissimus and iliocostalis muscles. However, in the time domain analysis, no difference was observed. As the values of the slope coefficients of median frequencies were higher for the multifidus muscle, compared to the longissimus and lumbar iliocostalis muscles, this may indicate a higher tendency toward muscle fatigue. Therefore, considering the applied methodology, the study of electromyographic signals in the frequency domain should be considered as an instrument to assess fatigue of the spinal extensor muscles in clinical situations.

Sonoporation-mediated transduction of siRNA ameliorated experimental arthritis using 3 MHz pulsed ultrasound

The goal of this feasibility study was to examine whether sonoporation assisted transduction of siRNA could be used to ameliorate arthritis locally. If successful, such approach could provide an alternative treatment for the patients that have or gradually develop adverse response to chemical drugs. Tumor necrosis factor alpha (TNF-α) produced by synovial fibroblasts has an important role in the pathology of rheumatoid arthritis, inducing inflammation and bone destruction. In this study, we injected a mixture of microbubbles and siRNA targeting TNF-α (siTNF) into the articular joints of rats, and transduced siTNF into synovial tissue by exposure to a collimated ultrasound beam, applied through a probe 6mm in diameter with an input frequency of 3.0 MHz, an output intensity of 2.0 W/cm(2) (spatial average temporary peak; SATP), a pulse duty ratio of 50%, and a duration of 1 min. Sonoporation increased skin temperature from 26.8 °C to 27.3 °C, but there were no adverse effect such as burns. The mean level of TNF-α expression in siTNF-treated knee joints was 55% of those in controls. Delivery of siTNF into the knee joints every 3 days (i.e., 7, 10, 13, and 16 days after immunization) by in vivo sonoporation significantly reduced paw swelling on days 20-23 after immunization. Radiographic scores in the siTNF group were 56% of those in the CIA group and 61% of those in the siNeg group. Histological examination showed that the number of TNF-α positive cells was significantly lower in areas of pannus invasion into the ankle joints of siTNF- than of siNeg-treated rats. These results indicate that transduction of siTNF into articular synovium using sonoporation may be an effective local therapy for arthritis.

Management options for patients with chronic back pain without an etiology

The treatment and management of low back pain is complex when there is no specific etiology such as cancer, fracture, or herniated disc. An organized approach to management that follows evidence based guidelines will facilitate care in a problem that reflects a lifetime prevalence of over 70 percent. The purpose of this review is to present a guideline to care for a common disabling process with a very heterogeneous etiology.