Effectiveness of classic physical therapy proposals for chronic non-specific low back pain: a literature review

A Comparison Between the Effectiveness of Tepurak Therapy Versus Deep Tissue Massage Stretching on Low Back Function in Nonspecific Low Back Pain

Introduction

The research carried out is a large research project that examined two different massage methods on many variables so that they can determine their effect on variables on a wider scale, namely pain, range of movement (ROM), and low back function. Pain and ROM variables have been published in different journals, and their acute effects are only known after treatment and the results are effective. This study examined the low back function variable 24, 48, and 72 hours after treatment.

Objective

This study aimed to determine the effectiveness of Tepurak and deep tissue massaging with stretching (DTMS) on low back function in nonspecific low back pain (NSLBP) and conduct a comparison of the effectiveness of Tepurak versus DTMS for low back function in NSLBP.

Methods

This research is a quasi-experiment using a pre-test/post-test design to determine the difference in scores before and after treatment. The variable measured involved the low back function using the Oswestry Disability Index. Measurements were carried out four times at pre-test, 24, 48, and 72 hours after the treatments. This study used two different sample groups. The research sample consisted of 42 NSLBP sufferers who were randomly divided into two groups, A and B. Group A received Tepurak treatment, while Group B received DTMS treatment. These treatments were carried out in one treatment session.

Results

The results of the different treatments for the low back function variables in the Tepurak treatment have a p-value of 0.000. The results of the low back function variables in the DTMS treatment have a p-value of 0.000. The results of the comparison test of Tepurak versus DTMS therapy for the low back function variable had a p-value of 0.771.

Conclusion

Both Tepurak and DTMS are effective in improving low back function in NSLBP cases. In comparison between Tepurak and DTMS, there was no significant difference in the effectiveness in improving low back function in NSLBP cases.

Management of low back pain and lumbosacral radicular syndrome: the Guideline of the Royal Dutch Society for Physical Therapy (KNGF)

BACKGROUND

Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines.

AIM

To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists.

DESIGN

Clinical practice guideline.

SETTING

Inpatient and outpatient.

POPULATION

Adults with LBP and/or LRS.

METHODS

Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase.

RESULTS

The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment.

CONCLUSIONS

An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises.

CLINICAL REHABILITATION IMPACT

This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.

Effects of physical interventions on pain and disability in chronic low back pain with pronated feet: a systematic review and meta-analysis

BACKGROUND

A link between pronated feet (PF) and chronic low back pain (CLBP) has been reported in the literature. However, physical interventions (PI) like physiotherapy and orthotics mainly target the lower back, neglecting the broader biomechanical impacts of PF that affect the feet, ankles, and overall posture. Currently, there is a lack of comprehensive meta-analyses or systematic reviews on this subject.

OBJECTIVES

This systematic review with a meta-analysis aimed to evaluate the effects of PI on pain and disability in patients having CLBP with PF.

METHODS

From inception until October 15, 2023, Medline/PubMed, Web of Science, and Scopus databases were searched using the desired keywords for randomized control trials (RCTs). The quality of the RCTs was evaluated using the PEDro scale and risk of bias tool.

RESULTS

Four studies involving 268 patients were identified, two compared custom-made foot orthoses to non-biomechanical foot insoles, while the other two used exercises. The meta-analysis included four studies for pain and three for disability. The results showed a significant change in pain [-2.43 (95% CI -2.73 to -2.13, p < .001)] and disability of -6.69 (95% CI -8.04 to -5.33, p < .001)].

CONCLUSIONS

This systematic review and meta-analysis of four RCTs elucidates that PI, specifically targeting PF, significantly alleviate pain and reduce disability in patients having CLBP with PF. These findings advocate for integrating foot-based PI within the treatment protocols for patients suffering from CLBP accompanied by PF.

Global perceived improvement and health-related quality of life after physical therapy in Lebanese patients with chronic non-specific low back pain

BACKGROUND

The effectiveness of physical therapy (PT) in patients with chronic non-specific low back pain (CNSLBP) is mainly evaluated through pain, disability, and health-related quality of life (HRQOL). However, recent studies have recommended the consideration of improvement from patients' perspectives.

OBJECTIVE

This study aimed to investigate the relationship between the global perception of improvement in Lebanese patients with CNSLBP who have undergone PT, the HRQOL levels, as well as pain intensity.

METHODS

132 patients with CNSLBP who have undergone PT completed a questionnaire consisting of sociodemographic and CNSLBP characteristics questions, pain intensity numeric scale (NRS), 12-Item Short-Form Health Survey (SF-12), and the Global Perceived Effect scale (GPE). Binary logistic regressions and Pearson correlation coefficient were used for analyses.

RESULTS

Global perceived improvement of PT varies according to HRQOL levels. A significant correlation was found between pain intensity after PT, perceived improvement from PT, and HRQOL. Educational level and pain irradiation have been shown to be predictive factors of perceived improvement after PT.

CONCLUSION

Pain and HRQOL are interrelated and contributed to elucidating the global perception of improvement after PT in patients with CNSLBP. The findings suggest that patients' global perception of improvement should be considered in evaluating the benefits of physical therapy in addition to pain and HRQOL.

Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques

BACKGROUND CONTEXT

Posterior percutaneous long-segment internal fixation and open fixation with long-segment screws have been used to treat thoracolumbar fractures in ankylosing spondylitis patients.

PURPOSE

To observe the clinical effect of posterior percutaneous long-segment internal fixation in 26 ankylosing spondylitis (AS) patients with thoracolumbar fractures.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Forty-seven AS patients who were diagnosed with thoracolumbar fractures and treated from December 2014 to December 2018.

OUTCOME MEASURES

Visual analog scale score, Cobb angle, American Spinal Injury Association Grade, SF-Qualiveen score, pedicle screw misplacement rate, operative duration, blood loss, complications, bed rest duration and modified MacNab score.

METHODS

All patients were divided into the percutaneous group (PG) and the open group. Twenty-six patients were treated with percutaneous long-segment internal fixation, and the remaining 21 underwent open fixation with long-segment screws. The minimum follow-up period was 12 months.

RESULTS

The operations were successful in both groups. A patient in the PG showed class C wound healing, while the others showed class A healing, and some patients experienced perioperative complications. All patients were followed up for 12-48 months (mean, 33.81 months), and all patients showed clinical osseous fracture healing. Significant differences were found in operative duration, intraoperative blood loss and postoperative bed rest duration between the two groups (P < 0.05). No significant difference was found in improvement of the visual analog scale score, Cobb angle of spinal kyphosis or neurological function after the operation (P > 0.05).

CONCLUSIONS

As a minimally invasive procedure, posterior percutaneous long-segment internal fixation requires less time, results in less blood loss and causes less trauma. This procedure can also improve patients' pain, neurological function and kyphotic deformity and achieve effects similar to those of traditional methods. With this curative clinical effect, this procedure can be used as an ideal surgical treatment for thoracolumbar fractures in AS patients, especially for elderly patients with underlying diseases and high surgical risk.

Detecting Low Back Physiotherapy Exercises and Postures with Inertial Sensors and Machine Learning (Preprint)

Background

Objective

Methods

Results

Conclusions

Altered muscle strength and flexibility among a subgroup of women with chronic nonspecific low back pain: Cross-sectional case-control study

OBJECTIVE

To compare muscle strength and flexibility among a subgroup of women with extension-related chronic nonspecific low back pain (CNLBP) with healthy controls.

METHODS

In this case-control study, 32 subjects with and without extension-related CNLBP were tested (n = 16 in each group). Gluteal, abdominal, paravertebral, and hamstring strength, along with hip flexor flexibility and hamstring flexibility were compared between groups. Data were analyzed using the Mann-Whitney test (p < .007).

RESULTS

The CNLBP subgroup displayed significantly lower strength of all muscles analyzed (p < .007), with the exception of gluteus medius. The flexibility of the hip flexors and hamstrings were not significantly reduced among the women with CNLBP (p > .007).

DISCUSSION

The present study showed that alterations in muscle strength, but not flexibility, partly consistent with those previously hypothesized but not objectively reported, were present among a subgroup of women with extension-related CNLBP. These results may have implications for the selection of therapeutic exercises among this subgroup of people with CNLBP.

Effectiveness of Global Postural Re-Education in Chronic Non-Specific Low Back Pain: Systematic Review and Meta-Analysis

Background: The aim of this systematic review and meta-analysis was to evaluate the global postural re-education (GPR) program’s effectiveness compared to other exercise programs in subjects with persistent chronic low back pain. Methods: A systematic review and meta-analysis were carried out using PRISMA2020. An electronic search of scientific databases was performed from their inception to January 2021. Randomized controlled trials that analyzed pain and patient-reported outcomes were included in this review. Four meta-analyses were performed. The outcomes analyzed were disability due to back pain and pain. The risk of bias and quality of evidence were evaluated. The final search was conducted in March. Results: Seven trials were included, totaling 334 patients. The results showed improvement in pain measured by Visual Analogue Scale (VAS) (Standardised Mean Difference (SMD) = −0.69; 95% Confidence Interval (CI), −1.01 to −0.37; p < 0.0001), Numerical Pain Scale (NRS) (SMD = −0.40; 95% CI, −0.87 to 0.06); p = 0.022), VAS + NRS (SMD = −1.32; 95% CI, −1.87 to −0.77; p < 0.0001) and function (Roland Morris Disability Questionnaire (RMDQ)) (SMD = −0.55; 95% CI, −0.83 to −0.27; p < 0.0001) after GPR treatment. Conclusion: This meta-analysis provides reliable evidence that GPR may be an effective method for treating LBP by decreasing pain and improving function, with strong evidence.

Effect of Physiotherapy Treatment in the Autonomic Activation and Pain Perception in Male Patients with Non-Specific Subacute Low Back Pain

Introduction: Physiotherapy treatment is a common intervention for low back pain (LBP) patients. These interventions have been related to physiological effects in the central nervous system. Thus, the aim of this study was to analyze the effect of physiotherapy treatment in patients with LBP in the autonomic nervous system activation and subjective pain perception of patients. Methods: A total of 30 male subjects diagnosed with non-specific subacute LBP received a 50 min session consisting of (a) a manual therapy based on joint mobilization and soft tissues techniques in the lumbo-pelvic area, (b) a stretching program, and (c) motor control exercises of the core muscles. The autonomic modification of participants was assessed prior to and after the physiotherapy treatment. Results: Heart rate variability (HRV) analysis reported a significant increase in average RR (p = 0.001), RMSSD (p = 0.008), LRMSSD (p = 0.001), SDNN (p = 0.005), and PNN50 (p = 0.024) after the session. Frequency-domain measures showed a significant increase in LF (p = 0.030) and HF (p = 0.014), and a decrease in LF/HF ratio (p = 0.046). A significant decrease was found in minimum HR values (p = 0.001) and average HR (p = 0.001). Moreover, maximal HR decreased its value from 116.7 ± 26.1 to 113.7 ± 40.8 after intervention. In addition, subjective pain perception (VAS scores) was significantly lower (p = 0.001) in the post-session assessment. Conclusions: Physiotherapy treatment produced an increase in parasympathetic nervous system activation and a decrease in subjective pain perception in non-specific subacute LBP patients.

Therapeutic Effectiveness of AxioBionics Wearable Therapy Pain Management System in Patients with Chronic Lower Back Pain

Chronic lower back pain is one of the most common medical conditions leading to a significant decrease in quality of life. This study retrospectively analyzed whether the AxioBionics Wearable Therapy Pain Management (WTPM) System, a customized and wearable electrical stimulation device, alleviated chronic lower back pain, and improved muscular function. This study assessed self-reported pain levels using the visual analog scale before and during the use of the AxioBionics WTPM System when performing normal activities such as sitting, standing, and walking (n = 69). Results showed that both at-rest and activity-related pain were significantly reduced during treatment with the AxioBionics WTPM System (% reduction in pain: 64% and 60%, respectively; P < .05). Thus, this study suggests that the AxioBionics WTPM System is efficacious in treating chronic lower back pain even when other therapies have failed to sufficiently decrease reported pain levels.

Efficacy of silver needle therapy for the treatment of chronic nonspecific low back pain: a prospective, single-center, randomized, parallel-controlled clinical trial

BACKGROUND

Chronic nonspecific low back pain (CNSLBP) troubles approximately 30% of people worldwide. Silver needle therapy (SNT) is a treatment method to relieve soft tissue pain through heating. Therefore, this study aimed to observe the effects of SNT on CNSLBP.

METHODS

In this study, 100 patients were randomly divided into 2 groups: silver needle (SN) group and control group (n = 50). In the SN group, patients received SNT and physiotherapy, while patients received physiotherapy alone in the control group. At the 6-month follow-up, the numerical rating scale (NRS), Oswestry Disability Index (ODI), Short-Form 12 of quality of life (SF-12), the natural logarithms of low-frequency measurement (InLF), and the natural logarithms of high-frequency measurement (InHF) of heart rate variability (HRV) were recorded.

RESULTS

In both groups, NRS, ODI, SF-12 scores, and HRV at 2 weeks after treatment were improved and maintained for 6 months. Compared with the control group, more significant improvements were observed in the NRS and SF-12 scores at 1, 2, 3, and 6 months and in the ODI scores at 1 and 2 months in the SN group (P <  0.05). However, there was no significant difference between the groups in the ODI scores at 3 and 6 months. InLF and InHF in the SN group were higher than those in the control group at 3 and 6 months (P <  0.05).

CONCLUSIONS

SNT relieved pain and improved quality of life and autonomic nerve activity, especially parasympathetic nerve, in patients with CNSLBP, without serious complications.

TRIAL REGISTRATION

Chinese Clinical Trial Registry No. ChiCTR-OOC-17013237 . Registered on November 11, 2017.

A critical review of the biopsychosocial model of low back pain care: time for a new approach?

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model.

MATERIAL AND METHODS

We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases.

RESULTS

Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care].

CONCLUSION

Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.IMPLICATIONS FOR REHABILITATIONWhen using the biopsychosocial model with patients with low back pain, researchers narrowly focus on biological and cognitive behavioural aspects of the model.Social and broader aspects such as cultural, interpersonal and institutional power dynamics, appear to be neglected by researchers when taking a biopsychosocial approach to the care of patients with low back pain.The biopsychosocial model may be inadequate to address complexities of people with low back pain, and a reworking of the model may be necessary.There is a lack of research conceptualising how physiotherapy applies the biopsychosocial model in research and practice.

The association between pelvic asymmetry and non-specific chronic low back pain as assessed by the global postural system

BACKGROUND

Empirical evidence that demonstrates the relationship between pelvic asymmetry and non-specific chronic low back pain (NCLBP) is currently lacking.

OBJECTIVE

To establish the reliability of the Global Postural System (GPS) in assessing pelvic asymmetry and identify the association between pelvic asymmetry parameters and the occurrence of NCLBP in young adults.

DESIGN

A cross-sectional, regression study.

METHODS

People who were aged between 18 and 30 and were diagnosed with NCLBP were recruited. Healthy individuals who were matched for age, sex, and education level were recruited as controls. Global Postural System (GPS) was employed to assess pelvic asymmetry. Prior to exploring the association, the reliability of GPS was assessed by the ICC (2, k) for interrater reliability, ICC (3, k) for intra-rater reliability, standard error and minimal detectable difference. Bivariate correlation analysis and logistic regression analysis were used to determine the relationship between pelvic asymmetry and the occurrence of NCLBP.

RESULTS

Twenty-eight healthy participants and 28 people with NCLBP were recruited. Moderate to excellent ICCs were observed for the inter-rater and intra-rater reliability of most postural parameters. The bivariate correlation analysis indicated that age, body mass index and pelvic asymmetry parameters were related to the occurrence of NCLBP. Pelvic angle asymmetry (odds ratio = 1.17), and asymmetry of the distance between the posterior superior iliac spine and the floor (odds ratio = 1.21) were associated with NCLBP.

LIMITATIONS

This study did not explore the causal relationship between pelvic asymmetry in the sagittal plane/pelvic asymmetry in the transverse plane and the occurrence of NCLBP. The interpretation of the results may not be generalized beyond the sample population.

CONCLUSIONS

The GPS is a reliable method to assess pelvic asymmetry in a clinical setting. Two pelvic parameters were associated with the presence of NLBP. Measurement of pelvic asymmetry may assist in the early identification of potential occurrence of NCLBP but further work is required.

Effectiveness of Global Postural Reeducation in Ankylosing Spondylitis: A Systematic Review and Meta-Analysis

The aim of this study was to determine the role of global postural reeducation for people with ankylosing spondylitis. We compared the effects of treatments on pain, dysfunction (using the Bath Ankylosing Spondylitis Disease Activity Index and Bath Ankylosing Spondylitis Functional Index), range of motion, and chest expansion in a specific population aged over 18 years old with ankylosing spondylitis. We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statements. The search was conducted using the PubMed, Physiotherapy Database (PEDro), Scientific Electronic Library Online (SciELO), and Web of Science (WoS) databases. Clinical trials and systematic reviews/meta-analysis were reviewed. Results: 154 studies were found. Finally, four were included. Conclusions: global postural reeducation is beneficial for ankylosing spondylitis, but no more so than other conventional treatments, except for spinal mobility, where Global Postural Reeducation demonstrated an advantage.

Are Opioids Needed to Treat Chronic Low Back Pain? A Review of Treatment Options and Analgesics in Development

The continued prevalence of chronic low back pain (CLBP) is a testament to our lack of understanding of the potential causes, leading to significant treatment challenges. CLBP is the leading cause of years lived with disability and the fifth leading cause of disability-adjusted life-years. No single non-pharmacologic, pharmacologic, or interventional therapy has proven effective as treatment for the majority of patients with CLBP. Although non-pharmacologic therapies are generally helpful, they are often ineffective as monotherapy and many patients lack adequate access to these treatments. Noninvasive treatment measures supported by evidence include physical and chiropractic therapy, yoga, acupuncture, and non-opioid and opioid pharmacologic therapy; data suggest a moderate benefit, at most, for any of these therapies. Until our understanding of the pathophysiology and treatment of CLBP advances, clinicians must continue to utilize rational multimodal treatment protocols. Recent Centers for Disease Control and Prevention guidelines for opioid prescribing recommend that opioids not be utilized as first-line therapy and to limit the doses when possible for fear of bothersome or dangerous adverse effects. In combination with the current opioid crisis, this has caused providers to minimize or eliminate opioid therapy when treating patients with chronic pain, leaving many patients suffering despite optimal nonopioid therapies. Therefore, there remains an unmet need for effective and tolerable opioid receptor agonists for the treatment of CLBP with improved safety properties over legacy opioids. There are several such agents in development, including opioids and other agents with novel mechanisms of action. This review critiques non-pharmacologic and pharmacologic treatment modalities for CLBP and examines the potential of novel opioids and other analgesics that may be a useful addition to the treatment options for patients with chronic pain.

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

BACKGROUND

The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial.

METHODS

After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached.

RESULTS

17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary).

CONCLUSIONS

Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

[Treatment of non-specific low back pain: Evidence map of systematic reviews from 2015 to 2019]

BACKGROUND

Low back pain represents a major healthcare challenge in Germany and worldwide. The research field is highly dynamic. The aim of this evidence map was to create a compact overview of current systematic reviews on interventions for non-specific low back pain.

METHODS

Medline (PubMed), the Cochrane Database of Systematic Reviews and Epistemonikos were systematically searched from March 2015 to March 2019 for systematic reviews addressing any interventions for acute, subacute or chronic non-specific low back pain and reporting at least one patient-relevant outcome. Key information on the characteristics and conclusions of the included reviews were extracted and aspects of the methodological quality of the included reviews were assessed independently by two reviewers. The data were tabulated.

RESULTS

The search identified 1,436 records. 53 systematic reviews were included in the evidence map. The quality of the reviews and of the studies included therein varied. The reviews addressed a variety of different interventions, with considerable heterogeneity of their characteristics and methodological aspects. Many reviews found evidence for positive effects of the studied interventions, some found evidence for no effect, but the quantity and quality of the evidence were often judged as insufficient for formulating robust conclusions. Relatively few data were available on adverse events.

CONCLUSION

This evidence map provides a compact resource for the use of current systematic reviews on interventions for non-specific low back pain. The methodological deficits of many reviews require a careful approach towards their findings and conclusions and suggest a need for methodologically rigorous reviews.

Transcranial direct current stimulation for nonspecific low back pain: double-blind randomized sham-controlled trial

Introduction: Low back pain is recognized as a major cause of morbidity worldwide. Between 70 and 80% of adults experience at least one occasion of low back pain with duration of 3 months or longer in their lifetime. Aside from the classic treatment methods, there are other new techniques yet to be clinically investigated. Transcranial direct current stimulation (tDCS) has been reported to alleviate pain by affecting the central nervous system. To date only a small number of studies have been published on the effects of tDCS on chronic low back pain. Some of these were pilot studies and others were low-powered in terms of their inference. Therefore the clinical application of tDCS requires further careful evaluation. Objective: To assess the efficacy of transcranial direct current stimulation for treatment of chronic nonspecific low back pain. Materials and methods: We carried out a double-blind randomized sham-controlled trial in a University Hospital. In total 70 people (15 women) with low back pain were randomized to either active or sham stimulation. The primary outcome was intensity of low back pain on the Visual Analog Scale. We also used the Oswestry Disability Questionnaire to evaluate the effects of back pain on daily activities. For the active stimulation group we administered 2 mA tDCS, 20 minutes for each session, once daily, 5 days per week for 2 weeks, totaling 10 sessions. For the sham stimulation group a similar program was followed with no stimulation. Both groups used analgesic medication. Results: Within-group analysis showed that an initial decrease in pain intensity was significant in both groups (both p < 0.001). However, pain reduction became stable only in the active treatment group. There was a significant difference in the pattern of change in mean pain scores in favor of tDCS (p < 0.001). Active treatment also significantly reduced disability scores (all p values < 0.001), whereas participants in the sham treatment group did not experience functional recovery. Mixed ANOVA indicated that the pattern of change in mean scores of disability differed between the two groups throughout the study course, in favor of active stimulation (p < 0.001). Conclusion: Transcranial direct current stimulation is an effective and safe initial treatment for chronic nonspecific low back pain, and the benefits remain for at least several months.

Therapeutic exercise based on biobehavioral approach for the rehabilitation of a radial nerve injury after surgical removal of a schwannoma: a case report

Schwannoma is a benign tumor located in the Schwann cells of the nerves. A 36-year-old white man underwent surgery after being diagnosed with radial nerve schwannoma of the upper right extremity between the triceps brachii muscle and brachioradialis muscle, after which a complete axonotmesis of the aforementioned nerve trunk occurred. The symptomatology presented by the patient included a loss of both motor and sensory function of the fingers, hand, and right forearm. The treatment was a biobehavioral physiotherapy approach that included therapeutic exercise, neuro-orthopedic manual physical therapy, therapeutic education, and sensitivity retraining. The biobehavioral approach in physiotherapy includes a multimodal approach that encompasses biological aspects, along with cognitive-evaluating and motivational-affective components. Two weekly sessions were held for 6 months, resulting in a total of 48 sessions. Using multimodal physiotherapy based on a biobehavioral approach, after 6 months of treatment, the symptoms improved. The motor function of the upper limb improved considerably due to the recovery of increased activity of the superficial musculature dependent on the radial nerve. However, the functions dependent on deep forearm and hand musculature recovered to a lesser extent. At the sensory level, the retraining of sensitivity allowed the patient to regain an important sensitivity. This case report explains the treatment used and the findings obtained, given a large percentage of the functionality that had been lost was recovered.

Are Mindful Exercises Safe and Beneficial for Treating Chronic Lower Back Pain? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Chronic low back pain (CLBP) is a common health issue worldwide. Tai Chi, Qigong, and Yoga, as the most widely practiced mindful exercises, have promising effects for CLBP-specific symptoms. Objective: We therefore conducted a comprehensive review investigating the effects of mindful exercises versus active and/or non-active controls while evaluating the safety and pain-related effects of mindful exercises in adults with CLBP. Methods: We searched five databases (MEDLINE, EMBASE, SCOPUS, Web of Science, and Cochrane Library) from inception to February 2019. Two investigators independently selected 17 eligible randomized controlled trials (RCT) against inclusion and exclusion criteria, followed by data extraction and study quality assessment. Standardized mean difference (SMD) was used to determine the magnitude of mindful exercises versus controls on pain- and disease-specific outcome measures. Results: As compared to control groups, we observed significantly favorable effects of mindful exercises on reducing pain intensity (SMD = −0.37, 95% CI −0.5 to −0.23, p < 0.001, I² = 45.9 %) and disability (SMD = −0.39, 95% CI −0.49 to −0.28, p < 0.001, I² = 0 %). When compared with active control alone, mindful exercises showed significantly reduced pain intensity (SMD = −0.40, p < 0.001). Furthermore, of the three mindful exercises, Tai Chi has a significantly superior effect on pain management (SMD= −0.75, 95% CI −1.05 to −0.46, p < 0.001), whereas Yoga-related adverse events were reported in five studies. Conclusion: Findings of our systematic review suggest that mindful exercises (Tai Chi and Qigong) may be beneficial for CLBP symptomatic management. In particular, Tai Chi appears to have a superior effect in reducing pain intensity irrespective of non-control comparison or active control comparison (conventional exercises, core training, and physical therapy programs). Importantly, training in these mindful exercises should be implemented with certified instructors to ensure quality of movement and injury prevention.

Physiotherapy Based on a Biobehavioral Approach with or Without Orthopedic Manual Physical Therapy in the Treatment of Nonspecific Chronic Low Back Pain: A Randomized Controlled Trial

Objective

To compare the effectiveness of a biobehavioral approach with and without orthopedic manual physical therapy on the intensity and frequency of pain in patients diagnosed with nonspecific chronic low back pain.

Methods

A single-blind randomized controlled trial. Fifty patients were randomly allocated into two groups: one group received biobehavioral therapy with orthopedic manual physical therapy, and the other group received only biobehavioral therapy. Both groups completed a total of eight sessions, with a frequency of two sessions per week. The somatosensory, physical, and psychological variables were recorded at baseline and during the first and third month after initiation of treatment.

Results

In both groups, the treatment was effective, presenting significant differences for all the variables in the time factor. There were no significant differences between groups in intensity or frequency of pain, with a large effect size (&gt;0.80), but there were intragroup differences for both intervention groups at one- and three-month follow-up. There were also no significant differences between groups in the secondary variables during the same follow-up period.

Conclusions

The results of this study suggest that orthopedic manual physical therapy does not increase the effects of a treatment based on biobehavioral therapy in the short or medium term, but these results should be interpreted with caution.

[Nonpharmacological pain therapy for chronic pain]

The treatment of chronic pain should be a multimodal combination of pharmacological and nonpharmacological components. This article describes some of the nonpharmacological treatment options and their evidence (e.g. physical therapy, massage, manual therapy, electrotherapy, acupuncture and music therapy). The evidence for an empirically detected effectiveness of all these forms of therapy is not very high and often inconsistent. Nevertheless, this does not mean that these forms of treatment should not be used but that they should be selected on an individual basis to improve the well-being of patients by being adjusted to their needs.