A clinical prediction rule to identify patients with low back pain who are likely to experience short-term success following lumbar stabilization exercises: a randomized controlled validation study

Interrater reliability of the modified prone instability test for lumbar segmental instability in individuals with mechanical low back pain

OBJECTIVE

The purpose of this study was to establish the interrater reliability of measures obtained with a novel Modified Prone Instability Test (mPIT), which, like the original Prone Instability Test (PIT), is proposed to identify lumbar segmental instability. The mPIT has clinical feasibility advantages to the PIT, but its psychometric properties are yet to be determined.

DESIGN

Repeated measures (test-retest) design, methods study.

METHODS

The mPIT was administered by two blinded testers, an orthopedic physical therapy resident with < 1 year experience and board-certified orthopedic specialist physical therapist with >25 years' experience. Procedures were administered at an outpatient physical therapy clinic of a tertiary Medical Center. Participants included 50 adults (≥18 years old) with mechanical low back pain and no radicular (below the knee) symptoms (mean age 50.7 years, 66% female, 76% reported previous episodes of low back pain). Interrater reliability was measured via Fleiss' kappa coefficient.

RESULTS

Assessments of the mPIT had moderate interrater agreement (κ = .579 [95% CI = .302 to .856], p < .001.).

CONCLUSION

Measures obtained using the mPIT demonstrated moderate interrater reliability between a new graduate and an experienced clinician, which aligns with several studies examining interrater reliability of the original PIT. Further study examining comparative validation of the mPIT with other lumbar instability measures is warranted.

Disability reduction following a lumbar stabilization exercise program for low back pain: large vs. small improvement subgroup analyses of physical and psychological variables

BACKGROUND

Little is known about why patients with low back pain (LBP) respond differently to treatment, and more specifically, to a lumbar stabilization exercise program. As a first step toward answering this question, the present study evaluates how subgroups of patients who demonstrate large and small clinical improvements differ in terms of physical and psychological changes during treatment.

METHODS

Participants (n = 110) performed the exercise program (clinical sessions and home exercises) over eight weeks, with 100 retained at six-month follow-up. Physical measures (lumbar segmental instability, motor control impairments, range of motion, trunk muscle endurance and physical performance tests) were collected twice (baseline, end of treatment), while psychological measures (fear-avoidance beliefs, pain catastrophizing, psychological distress, illness perceptions, outcome expectations) were collected at four time points (baseline, mid-treatment, end of treatment, follow-up). The participants were divided into three subgroups (large, moderate and small clinical improvements) based on the change of perceived disability scores. ANOVA for repeated measure compared well-contrasted subgroups (large vs. small improvement) at different times to test for SUBGROUP × TIME interactions.

RESULTS

Statistically significant interactions were observed for several physical and psychological measures. In all these interactions, the large- and small-improvement subgroups were equivalent at baseline, but the large-improvement subgroup showed more improvements over time compared to the small-improvement subgroup. For psychological measures only (fear-avoidance beliefs, pain catastrophizing, illness perceptions), between-group differences reached moderate to strong effect sizes, at the end of treatment and follow-up.

CONCLUSIONS

The large-improvement subgroup showed more improvement than the small-improvement subgroup with regard to physical factors typically targeted by this specific exercise program as well as for psychological factors that are known to influence clinical outcomes.

[Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach : German version]

INTRODUCTION

Chronic low back pain (cLBP) is highly prevalent in the United States and globally, resulting in functional impairment and lowered quality of life. While many treatments are available for cLBP, clinicians have little information about which specific treatment(s) will work best for individual patients or subgroups of patients. The Back Pain Research Consortium, part of the National Institutes of Health Helping to End Addiction Long-termSM (HEAL) Initiative, will conduct a collaborative clinical trial, which seeks to develop a personalized medicine algorithm to optimize patient and provider treatment selection for patients with cLBP.

OBJECTIVE

The primary objective of this article is to provide an update on evidence-based cLBP interventions and describe the process of reviewing and selecting interventions for inclusion in the clinical trial.

METHODS

A working group of cLBP experts reviewed and selected interventions for inclusion in the clinical trial. The primary evaluation measures were strength of evidence and magnitude of treatment effect. When available in the literature, duration of effect, onset time, carryover effect, multimodal efficacy, responder subgroups, and evidence for the mechanism of treatment effect or biomarkers were considered.

CONCLUSION

The working group selected 4 leading, evidence-based treatments for cLBP to be tested in the clinical trial and for use in routine clinical treatment. These treatments include (1) duloxetine, (2) acceptance and commitment therapy, (3) a classification-based exercise and manual therapy intervention, and (4) a self-management approach. These interventions each had a moderate to high level of evidence to support a therapeutic effect and were from different therapeutic classes.

Comparison of cognitive functional therapy and movement system impairment treatment in chronic low back pain patients: a randomized controlled trial

BACKGROUND

This study aimed to compare the effects of cognitive functional therapy (CFT) and movement system impairment (MSI)-based treatment on pain intensity, disability, Kinesiophobia, and gait kinetics in patients with chronic non-specific low back pain (CNSLBP).

METHODS

In a single-blind randomized clinical trial, we randomly assigned 91 patients with CNSLBP into CFT (n = 45) and MSI-based treatment (n = 46) groups. An 8-week training intervention was given to both groups. The researchers measured the primary outcome, which was pain intensity (Numeric rating scale), and the secondary outcomes, including disability (Oswestry disability index), Kinesiophobia (Tampa Kinesiophobia Scale), and vertical ground reaction force (VGRF) parameters at self-selected and faster speed (Force distributor treadmill). We evaluated patients at baseline, at the end of the 8-week intervention (post-treatment), and six months after the first treatment. We used mixed-model ANOVA to evaluate the effects of the interaction between time (baseline vs. post-treatment vs. six-month follow-up) and group (CFT vs. MSI-based treatment) on each measure.

RESULTS

CFT showed superiority over MSI-based treatment in reducing pain intensity (P < 0.001, Effect size (ES) = 2.41), ODI (P < 0.001, ES = 2.15), and Kinesiophobia (P < 0.001, ES = 2.47) at eight weeks. The CFT also produced greater improvement in VGRF parameters, at both self-selected (FPF[P < 0.001, ES = 3], SPF[P < 0.001, ES = 0.5], MSF[P < 0.001, ES = 0.67], WAR[P < 0.001, ES = 1.53], POR[P < 0.001, ES = 0.8]), and faster speed, FPF(P < 0.001, ES = 1.33, MSF(P < 0.001, ES = 0.57), WAR(P < 0.001, ES = 0.67), POR(P < 0.001, ES = 2.91)] than the MSI, except SPF(P < 0.001, ES = 0.0) at eight weeks.

CONCLUSION

This study suggests that the CFT is associated with better results in clinical and cognitive characteristics than the MSI-based treatment for CNSLBP, and the researchers maintained the treatment effects at six-month follow-up. Also, This study achieved better improvements in gait kinetics in CFT. CTF seems to be an appropriate and applicable treatment in clinical setting.

TRIAL REGISTRATION

The researchers retrospectively registered the trial 10/11/2022, at https://www.umin.ac.jp/ with identifier number (UMIN000047455).

Effectiveness of motor control exercise, aerobic walking, and muscle strengthening programs in improving outcomes in a subgroup of population with chronic low back pain positive for central sensitization: a study protocol for a randomized controlled trial

BACKGROUND

The role of pain sensitivity in the development and maintenance of chronic pain states, impaired executive functioning, and patient recovery is being investigated. Conditioned pain modulation (CPM) is widely used to measure musculoskeletal pain associated with central sensitization (CS). Despite the recommendations of many reviews and clinical practice guidelines that exercise programs reduce pain and disability, the overall confidence in these results is considered "critically low." The "active ingredient" of exercise programs and the dominant factor influencing CPM remain largely unknown. The objectives of this trial are to determine: • If different exercises cause different results on the CPM in a subgroup of people with chronic low back pain (CLBP) who are labeled as having CS pain, • If a program of exercise interventions for 12 weeks would alter executive functioning, quality of life (QoL), disability, and pain in persons with CLBP. • The relationship between patient characteristics, executive functions, CPM, and QoL METHODS: The trial is a randomized, controlled, multi-center study with four experimental groups and one healthy control group. Both the researchers and the people in the study will be blinded to the results. This paper describes the protocol for a trial examining the effects of 12-week individualized, twice-weekly exercise sessions lasting 30 to 60 min in persons with CLBP, who are positive for CS. Participants will be randomized to receive either patient education with motor control exercises (MCE), superficial strengthening (SS), aerobic exercises (AE), or patient education alone. Another group comprised of healthy volunteers will serve as controls. The primary outcomes are changes in CPM outcomes as measured by the cold pressor test (CPT). The secondary objectives are to evaluate executive functioning, pain, disability, quality of life, and spine muscle strength. The outcomes will be measured at 3 months and at a 6-month follow-up.

DISCUSSION

The outcomes of the study will help in gaining more information and evidence about exercise-induced analgesia from the perspective of CPM. Measuring exercise outcomes will aid in scientifically prescribing exercise prescriptions in people with CLBP. The study outcomes will also assist in identifying the characteristics of individuals who will respond or respond indifferently to exercises. Investigating the relationship between the study's various outcomes could provide information for future trials.

TRIAL REGISTRATION

Clinical Trials Registry of India (CTRI) identifier: CTRI/2022/03/041143. Registered on 16 March 2022.

Effectiveness of patient education plus motor control exercise versus patient education alone versus motor control exercise alone for rural community-dwelling adults with chronic low back pain: a randomised clinical trial

BACKGROUND

Chronic low back pain (CLBP) is a common health problem in rural Nigeria but access to rehabilitation is limited. Current clinical guidelines unanimously recommend patient education (PE) including instruction on self-management, and exercises as frontline interventions for CLBP. However, the specific content of these interventions and how they are best delivered remain to be well-described, particularly for low-resource communities. This study determined the effectiveness of PE plus motor control exercise (MCE) compared with either therapy alone among rural community-dwelling adults with CLBP.

METHODS

A single-blind, three-arm parallel-group, randomised clinical trial including 120 adult rural dwellers (mean [SD] age, 46.0 [14.7] years) with CLBP assigned to PE plus MCE group (n = 40), PE group (n = 40), and MCE group (n = 40) was conducted. The PE was administered once weekly and the MCE twice weekly. Each group also received stretching and aerobic exercises twice weekly. All interventions were administered for 8 weeks. Blinded assessments for pain intensity and disability level as primary outcomes, and quality of life, global perceived recovery, fear-avoidance beliefs, pain catastrophising, back pain consequences belief and pain medication use as secondary outcomes were conducted at baseline, 8-week (immediately after intervention) and 20-week follow-ups.

RESULTS

All the groups showed significant improvements in all the primary and secondary outcomes evaluated over time. Compared with PE alone, the PE plus MCE showed a significantly greater reduction in pain intensity by an additional -1.15 (95% confidence interval [CI], -2.04 to -0.25) points at the 8-week follow-up and -1.25 (95% CI, -2.14 to -0.35) points at the 20-week follow-up. For disability level, both PE plus MCE and MCE alone showed a significantly greater improvement compared with PE alone by an additional -5.04% (95% CI, -9.57 to -0.52) and 5.68% (95% CI, 1.15 to 10.2) points, respectively, at the 8-week follow-up, and -5.96% (95% CI, -9.84 to -2.07) and 6.57% (95% CI, 2.69 to 10.4) points, respectively, at the 20-week follow-up. For the secondary outcomes, at the 8-week follow-up, PE plus MCE showed a significantly greater reduction in fear-avoidance beliefs about physical activity compared with either therapy alone, and a significantly greater reduction in pain medication use compared with PE alone. However, compared with PE plus MCE, PE alone showed a significantly greater reduction in pain catastrophising at all follow-up time points, and a significantly greater improvement in back pain consequences belief at the 20-week follow-up. Additionally, PE alone compared with MCE alone showed a significantly greater improvement in back pain consequences belief at all follow-up time points. No significant between-group difference was found for other secondary outcomes.

CONCLUSIONS

Among rural community-dwelling adults with CLBP, PE plus MCE led to greater short-term improvements in pain and disability compared with PE alone, although all intervention strategies were associated with improvements in these outcomes. This trial provides additional support for combining PE with MCE, as recommended in current clinical guidelines, to promote self-management and reduce the burden of CLBP in low-resource rural communities.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03393104), Registered on 08/01/2018.

Validity of the KOJI AWARENESS self-screening test for body movement and comparison with functional movement screening

OBJECTIVE

This study aimed to validate the KOJI AWARENESS™, a self-screening movement test, and compare it with the Functional Movement Screen (FMS).

METHODS

Fifty-seven healthy participants completed the KOJI AWARENESS™ and functional movement screening. Pearson's correlation coefficients were used to assess the validity of the test. Subsequently, partial correlation analysis was used to determine the associations between age, sex, body mass index, and sports level as control variables and motor function.

RESULTS

Correlation and partial correlation analyses showed a strong positive correlation between the functional movement screening and the KOJI AWARENESS™ scores.

CONCLUSION

This study found that the KOJI AWARENESS™ test is valid and comparable to functional movement screening. It can be used for self-screening of movement.

Current Clinical Concepts: Management of Common Lumbar Spine Posterior Column Disorders in Young, Active Individuals

Although posterior column disorders, such as spondylolysis and spondylolisthesis, are not commonly encountered in the general population, athletic trainers frequently see these conditions in athletic and active individuals due to the repetitive spinal extension and rotational loads placed on the pars interarticularis while participating in sport. Athletic trainers can successfully evaluate patients with posterior column disorders by performing a complete and comprehensive clinical examination to identify the location of pain, test spinal stability, and recognize compensatory movement patterns. Conservative management typically leads to a successful outcome in this population, with rest, bracing, and the use of therapeutic exercise having the best supporting evidence. In this Current Clinical Concepts review, we outlined the etiology and risk factors frequently associated with disorders of the posterior column. Additionally, we synthesized the literature for common evaluation techniques and interventions associated with the posterior column and provided a proposed rehabilitation progression to use in a younger, athletic population.

Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach

Literature on current treatments for chronic low back pain (cLBP) were reviewed and 4 interventions were recommended for inclusion in a multisite cLBP clinical trial.

Introduction:

Objective:

Methods:

Conclusion:

Over Half of Clinical Trials of Mobilization and Manipulation for Patients With Low Back Pain May Have Limited Real-World Applicability: A Systematic Review of 132 Clinical Trials

OBJECTIVE

To evaluate the existing body of trials assessing manual therapy for low back pain (LBP) to determine where it falls on the efficacyeffectiveness continuum.

DESIGN

Methodology systematic review.

LITERATURE SEARCH

PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and PEDro (Physiotherapy Evidence Database) were searched for trials published between January 1, 2000, and April 30, 2021.

STUDY SELECTION CRITERIA

We included randomized clinical trials investigating joint mobilization and manipulation for adults with nonspecific LBP that were available in English.

DATA SYNTHESIS

We used the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool to score included trials across 4 domains: participant characteristics, trial setting, flexibility of intervention(s), and clinical relevance of experimental and comparison intervention(s). Proportions of trials with greater emphasis on efficacy or effectiveness were calculated for each domain.

RESULTS

Of the 132 included trials, a greater proportion emphasized efficacy than effectiveness for domains participant characteristics (50% vs 38%), trial setting (71% vs 20%), and flexibility of intervention(s) (61% vs 25%). The domain clinical relevance of experimental and comparison intervention(s) had lower emphasis on efficacy (41% vs 50%).

CONCLUSION

Most trials investigating manual therapy for LBP lack pragmatism across the RITES domains (ie, they emphasize efficacy). To improve real-world implementation, more research emphasizing effectiveness is needed. This could be accomplished by recruiting from more diverse participant pools, involving multiple centers that reflect common clinical practice settings, involving clinicians with a variety of backgrounds/experience, and allowing flexibility in how interventions are delivered. J Orthop Sports Phys Ther 2022;52(8):532-545. Epub: 19 June 2022. doi:10.2519/jospt.2022.10962.

Treatment-based classification for low back pain: systematic review with meta-analysis

OBJECTIVE

To systematically review the effects of treatment-based classification (TBC) in patients with specific and nonspecific acute, subacute and chronic low back pain.

METHODS

The following databases were searched: MEDLINE, EMBASE, PsycINFO, Global Health, CENTRAL, Web of Science, CINAHL, SPORTDiscus, PEDro and WHO from inception up to December 2021. We used the PEDro scale, the TIDieR checklist and the GRADE approach to evaluate the risk of bias, quality on reporting and the certainty of the evidence, respectively.

RESULTS

Twenty-three trials (pooled n = 2,649) met the inclusion criteria. We have identified a total of 22 comparisons and 134 estimates of treatment effects. There was a very large heterogeneity with regards to the comparison groups. Most of individual trials had low risk of bias with a mean score of 6.8 (SD = 1.3) on a 0-10 scale. The certainty of evidence for most comparisons was low, which indicates that more high quality and robust trials are needed. We were able to pool the data using a meta-analysis approach for only two comparisons (TBC versus mobility exercises in patients with acute low back pain and traction for patients with sciatica). In general, the TBC approach seems to be useful for patients with acute low back pain, sciatica and with spinal stenosis. We strongly suggest readers to carefully read our summary of findings table for further details on each comparison.

CONCLUSION

The TBC approach seems to be useful for patients with acute low back pain, sciatica and with spinal stenosis.

Well-described exercises for chronic low back pain in Life Science Literature: A systematic review

BACKGROUND

Therapeutic exercise (TE) is recommended in multimodal treatment for patients with non-specific chronic back pain (cLBP).

OBJECTIVE

The aim of this study is to identify an exercise or a spectrum of exercises, well described and reproducible by the clinician, for cLBP patients.

METHODS

Systematic review by researching in the databases MEDLINE, EMBASE, PEDro, CINAHL, and Scopus. Evidence from Randomized Controlled Trials (RCTs) supported the TE in patients with non-specific cLBP, provided that it was well described and could be repeated by another therapist. Methodological evaluation was performed using the PEDro scale and only studies with a score of ⩾ 6 were included. The assessment of the intervention description was carried out with the TIDieR checklist. The risk of bias was examined.

RESULTS

Twenty-one articles were included in this systematic review. The defective description and the poorly reporting of the intervention makes it more difficult for the clinician to include the TE into clinical practice.

CONCLUSIONS

The findings of this study showed that the reporting of the intervention in high quality RCT on chronic low back pain is low, threatening the external validity of the results.

Derivation of clinical prediction rules for identifying patients with non-acute low back pain who respond best to a lumbar stabilization exercise program at post-treatment and six-month follow-up

Low back pain (LBP) remains one of the most common and incapacitating health conditions worldwide. Clinical guidelines recommend exercise programs after the acute phase, but clinical effects are modest when assessed at a population level. Research needs to determine who is likely to benefit from specific exercise interventions, based on clinical presentation. This study aimed to derive clinical prediction rules (CPRs) for treatment success, using a lumbar stabilization exercise program (LSEP), at the end of treatment and at six-month follow-up. The eight-week LSEP, including clinical sessions and home exercises, was completed by 110 participants with non-acute LBP, with 100 retained at the six-month follow-up. Physical (lumbar segmental instability, motor control impairments, posture and range of motion, trunk muscle endurance and physical performance tests) and psychological (related to fear-avoidance and home-exercise adherence) measures were collected at a baseline clinical exam. Multivariate logistic regression models were used to predict clinical success, as defined by ≥50% decrease in the Oswestry Disability Index. CPRs were derived for success at program completion (T8) and six-month follow-up (T34), negotiating between predictive ability and clinical usability. The chosen CPRs contained four (T8) and three (T34) clinical tests, all theoretically related to spinal instability, making these CPRs specific to the treatment provided (LSEP). The chosen CPRs provided a positive likelihood ratio of 17.9 (T8) and 8.2 (T34), when two or more tests were positive. When applying these CPRs, the probability of treatment success rose from 49% to 96% at T8 and from 53% to 92% at T34. These results support the further development of these CPRs by proceeding to the validation stage.

The Effectiveness of Group-Based Core Stability Exercise and Educational Booklet for Hospital Workers in Taiwan with Nonspecific Low Back Pain: A Preliminary Study

To investigate the effectiveness of health promotion strategies for nonspecific low back pain in hospital workers, we compared the therapeutic effects of group-based core stability exercises and an educational booklet. Subjects participated in a 60-min core stability exercise on a weekly basis for 8 weeks (N = 24) or consulted an educational booklet for advice (N = 22). The numerical rating scale (NRS), Oswestry Disability Index (ODI), and the brief version of the World Health Organization’s Quality of Life (WHOQOL-BREF) were used as outcome measures. The ODI, as well as the total score and domains of overall, physical, and psychological health in the WHOQOL-BREF were significantly improved in the exercise group (p < 0.05). The NRS score significantly improved in the booklet group (p < 0.05). The total score, psychological domain, and environmental domain of the WHOQOL-BREF improved significantly in the exercise group compared with the booklet group (p < 0.05). Group-based core stability exercises and educational booklets are helpful to hospital workers in different ways for nonspecific low back pain. In contrast to the pain reduction by the educational booklet, more active participation in group-based core stability exercise can provide a better outcome in the overall quality of life, especially in the psychological and environmental domains of hospital workers.

Classification Approaches for Treating Low Back Pain Have Small Effects That Are Not Clinically Meaningful: A Systematic Review With Meta-analysis

OBJECTIVE

To determine whether classification systems improve patient-reported outcomes for people with low back pain (LBP).

DESIGN

Systematic review with meta-analysis.

LITERATURE SEARCH

The MEDLINE, Embase, CINAHL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 21, 2021. Reference lists of prior systematic reviews and included trials were screened.

STUDY SELECTION CRITERIA

We included randomized trials comparing a classification system (eg, the McKenzie method or the STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (eg, fractures or tumors) were excluded.

DATA SYNTHESIS

Outcomes were patient-reported LBP intensity, leg pain intensity, and disability. We used the revised Cochrane Collaboration Risk of Bias Tool to assess risk of bias, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. We used random-effects meta-analysis, with the Hartung-Knapp-Sidik- Jonkman adjustment, to estimate the standardized mean difference (SMD; Hedges' g) and 95% confidence interval (CI). Subgroup analyses explored classification system, comparator type, pain type, and pain duration.

RESULTS

Twenty-four trials assessing classification systems and 34 assessing subclasses were included. There was low certainty of a small effect at the end of intervention for LBP intensity (SMD, -0.31; 95% CI: -0.54, -0.07; P = .014, n = 4416, n = 21 trials) and disability (SMD, -0.27; 95% CI: -0.46, -0.07; P = .011, n = 4809, n = 24 trials), favoring classified treatments compared to generalized interventions, but not for leg pain intensity. At the end of intervention, no specific type of classification system was superior to generalized interventions for improving pain intensity and disability. None of the estimates exceeded the effect size that one would consider clinically meaningful.

CONCLUSION

For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems over generalized interventions when managing LBP. J Orthop Sports Phys Ther 2022;52(2):67-84. Epub 15 Nov 2021. doi:10.2519/jospt.2022.10761.

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

Motor control exercise (MCE) is commonly prescribed for patients with low back pain. Although MCE can improve clinical outcomes, lumbar multifidus muscle (LM) activation remains unchanged. Neuromuscular electrical stimulation (NMES) can be used to re-activate motor units prior to MCE which should result in increased LM activation. Therefore, this study aimed to explore the immediate effects of NMES combined with MCE on LM activation and motor performance. Twenty-five participants without low back pain (NoLBP) and 35 participants with movement control impairment (MCI) were recruited. Participants with MCI were further randomized to combined NMES with MCE (COMB) or sham-NMES with MCE (MCE) group. Ultrasound imaging was used to measure LM thickness at rest, maximum voluntary isometric contraction (MVIC), and NMES with MVIC. These data were used to calculate LM activation. Quadruped rocking backward was used to represent motor performance. LM activation and motor performance were measured at baseline and after one-session of intervention. Results showed that both COMB and MCE groups had significantly lower (P < 0.05) LM activation compared with NoLBP group at baseline. Additionally, both COMB and MCE groups demonstrated significant improvement (P < 0.05) in motor performance while COMB group demonstrated significantly greater improvement (P < 0.05) in LM activation compared with MCE group. Individuals with MCI still have persisting LM activation deficit. Our key findings suggest that combined NMES and MCE may have better ability to improve LM activation in individuals with MCI. These findings would support the utility of NMES to induce a priming effect before MCE.

"How does physical examination findings influence physiotherapists' decision-making when matching treatment to patients with low back pain?"

BACKGROUND

Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed.

OBJECTIVE

The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making.

DESIGN

This was an exploratory interview study using inductive content analysis.

METHOD

Fifteen semi-structured individual interviews were used to collect data of physiotherapists' treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden.

FINDINGS

Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity).

CONCLUSION

This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.

Existing validated clinical prediction rules for predicting response to physiotherapy interventions for musculoskeletal conditions have limited clinical value: A systematic review

OBJECTIVE

To systematically review clinical prediction rules (CPRs) that have undergone validation testing for predicting response to physiotherapy-related interventions for musculoskeletal conditions.

STUDY DESIGN AND SETTING

PubMed, EMBASE, CINAHL and Cochrane Library were systematically searched to September 2020. Search terms included musculoskeletal (MSK) conditions, physiotherapy interventions and clinical prediction rules. Controlled studies that validated a prescriptive CPR for physiotherapy treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility. Original derivation studies of each CPR were identified. Risk of bias was assessed with the PROBAST tool (derivation studies) and the Cochrane Effective Practice and Organisation of Care group criteria (validation studies).

RESULTS

Nine studies aimed to validate seven prescriptive CPRs for treatment response for MSK conditions including back pain, neck pain, shoulder pain and carpal tunnel syndrome. Treatments included manipulation, traction and exercise. Seven studies failed to demonstrate an association between CPR prediction and outcome. Methodological quality of derivation studies was poor and for validation studies was good overall.

CONCLUSION

Results do not support the use of any CPRs identified to aid physiotherapy treatment selection for common musculoskeletal conditions, due to methodological shortcomings in the derivation studies and lack of association between CPR and outcome in validation studies.

Effects of specific muscle activation for low back pain on activity limitation, pain, work participation, or recurrence: A systematic review

BACKGROUND

Specific muscle activation (SMA) is a commonly used treatment for people with low back pain (LBP) however there is variability in systematic reviews to date on effectiveness. This may be because of the use of eligibility criteria incongruent with original descriptions of the SMA approach.

PURPOSE

The purpose of this study was to determine the effectiveness of SMA on improving activity limitation, pain, work participation or recurrence for people with LBP.

STUDY DESIGN

Systematic review METHODS: Computer databases were searched for randomised controlled trials (RCTs) published in English up to September 6, 2019. Eligibility criteria were chosen to ensure all clinically relevant RCTs were included and trials of poorly defined or executed SMA excluded. Outcomes for activity limitation, pain, work participation or recurrence were extracted.

RESULTS

Twenty-eight RCTs were included in this review with 18 being considered high quality. GRADE quality assessment revealed low to high quality evidence that SMA was more effective than exercise, conservative medical management, multi-modal physiotherapy, placebo, advice and minimal intervention.

CONCLUSIONS

This systematic review is the first to evaluate the effectiveness of SMA in accordance with the original clinical descriptions. We found significant evidence supporting the effectiveness of SMA for the treatment of LBP. Where significant results were demonstrated, the between-group differences were in many comparisons clinically important based on contemporary definitions and an effect size of 0.5 or more. Practitioners should consider SMA as a treatment component in their patients with LBP.

Comparison between high-velocity low-amplitude manipulation and muscle energy technique on pain and trunk neuromuscular postural control in male workers with chronic low back pain: A randomised crossover trial

BACKGROUND

A therapeutic recommendation for restoring function in individuals with chronic low back pain (CLBP) is manual therapy through manipulative spinal or muscle energy techniques.

OBJECTIVES

To compare the effectiveness of two osteopathic manipulative techniques on clinical low back symptoms and trunk neuromuscular postural control in male workers with CLBP.

METHOD

Ten male workers with CLBP were randomly allocated to two groups: high-velocity low-amplitude (HVLA) manipulation or muscle energy techniques (MET). Each group received one therapy per week for both techniques during 7 weeks of treatment. Pain and function were measured by using the Numeric Pain-Rating Scale, the McGill Pain Questionnaire and the Roland Morris Disability Questionnaire. The lumbar flexibility was assessed by Modified Schober Test. Electromyography (EMG) and force platform measurements were used for evaluation of trunk muscular activation and postural balance, respectively at three different times: baseline, post intervention, and 15 days later.

RESULTS

Both techniques were effective (p < 0.01) in reducing pain with large clinical differences (-1.8 to -2.8) across immediate and after 15 days. However, no significant effect between groups and times was found for other variables, namely neuromuscular activation and postural balance measures.

CONCLUSION

Both techniques (HVLA thrust manipulation and MET) were effective in reducing back pain immediately and 15 days later. Neither technique changed the trunk neuromuscular activation patterns nor postural balance in male workers with LBP.

CLINICAL IMPLICATIONS

These results may facilitate clinical decision-making for CLBP management in physiotherapy programs.

Dose-response-relationship of stabilisation exercises in patients with chronic non-specific low back pain: a systematic review with meta-regression

Stabilization exercise (SE) is evident for the management of chronic non-specific low back pain (LBP). The optimal dose-response-relationship for the utmost treatment success is, thus, still unknown. The purpose is to systematically review the dose-response-relationship of stabilisation exercises on pain and disability in patients with chronic non-specific LBP. A systematic review with meta-regression was conducted (Pubmed, Web of Knowledge, Cochrane). Eligibility criteria were RCTs on patients with chronic non-specific LBP, written in English/German and adopting a longitudinal core-specific/stabilising/motor control exercise intervention with at least one outcome for pain intensity and/or disability. Meta-regressions (dependent variable = effect sizes (Cohens d) of the interventions (for pain and for disability), independent variable = training characteristics (duration, frequency, time per session)), and controlled for (low) study quality (PEDro) and (low) sample sizes (n) were conducted to reveal the optimal dose required for therapy success. From the 3,415 studies initially selected, 50 studies (n = 2,786 LBP patients) were included. N = 1,239 patients received SE. Training duration was 7.0 ± 3.3 weeks, training frequency was 3.1 ± 1.8 sessions per week with a mean training time of 44.6 ± 18.0 min per session. The meta-regressions' mean effect size was d = 1.80 (pain) and d = 1.70 (disability). Total R² was 0.445 and 0.17. Moderate quality evidence (R² = 0.231) revealed that a training duration of 20 to 30 min elicited the largest effect (both in pain and disability, logarithmic association). Low quality evidence (R² = 0.125) revealed that training 3 to 5 times per week led to the largest effect of SE in patients with chronic non-specific LBP (inverted U-shaped association). In patients with non-specific chronic LBP, stabilization exercise with a training frequency of 3 to 5 times per week (Grade C) and a training time of 20 to 30 min per session (Grade A) elicited the largest effect on pain and disability.

Alternating lumbar lateral shift: a case report

BACKGROUND

A lumbar lateral shift (LLS) is a common clinical observation in patients with low back pain (LBP), and a shift contralateral to the side of pain is the most common presentation. An LLS that can rapidly alternate sides presents several treatment difficulties and has rarely been described. The purpose of the current case report was to describe the presentation and management of a patient with an alternating LLS.

CASE DESCRIPTION

A 39-year-old male with a 7-week history of LBP and previous lower extremity radicular pain was referred to physical therapy. An alternating LLS was present.

OUTCOMES

The patient was treated for six visits over 37 days. Treatment included modified self-correction of the LLS, motor control and trunk muscle endurance training, and development of an activity management program. The patient's LLS resolved, his worst pain improved from 3/10 to 0/10, and the Oswestry Disability Index improved from 26% to 4% disability. The patient reported maintenance of improvement at 6-month follow-up.

DISCUSSION

The current approach produced a positive outcome in a patient with an alternating LLS. The current understanding of mechanisms and optimal treatment of an alternating LLS is limited.

LEVEL OF EVIDENCE

4.

Examination of a Subgroup of Patients With Chronic Low Back Pain Likely to Benefit More From Pilates-Based Exercises Compared to an Educational Booklet

OBJECTIVE

To investigate whether 2 previously published classification approaches, the updated treatment-based classification system and a Pilates subgroup defined by a preliminary clinical prediction rule, could identify patients with chronic low back pain who would benefit more from Pilates exercises compared to an educational booklet.

DESIGN

Secondary analysis of a randomized controlled trial.

METHODS

Two hundred twenty-two patients received advice and were randomly allocated to a group that received an educational booklet with no additional treatment (n = 74) or a group that received Pilates-based exercise treatment (n = 148) 2 or 3 times a week. At baseline, using a treatment-based classification system, patients were classified as having a good prognosis (positive movement control) or a poor prognosis. Similarly, using the Pilates clinical prediction rule, patients were classified as having a good prognosis (positive) or a poor prognosis (negative). The analysis was conducted using linear regression models to analyze the interaction between subgroup characteristics and treatment effect size, with changes in pain and disability from baseline to 6 weeks after randomization as dependent variables.

RESULTS

None of the interaction terms for pain and disability were statistically significant. The treatment effect of Pilates versus an educational booklet was similar in all subgroups.

CONCLUSION

The treatment-based classification system and the Pilates clinical prediction rule did not differentiate subgroups of patients with chronic low back pain who were more or less likely to benefit more from Pilates compared to an educational booklet. J Orthop Sports Phys Ther 2020;50(4):189-197. Epub 23 Aug 2019. doi:10.2519/jospt.2019.8839.

Individuals With and Without Low Back Pain Use Different Motor Control Strategies to Achieve Spinal Stiffness During the Prone Instability Test

BACKGROUND

The prone instability test is used to identify individuals with low back pain (LBP) who would benefit from trunk stabilization exercises. Although activity from muscles during the leg-raising portion of the prone instability test theoretically enhances spinal stiffness and reduces pain, evidence for this is lacking.

OBJECTIVES

To compare and contrast (1) pain and stiffness changes between prone instability testing positions, and (2) muscle activation patterns during the prone instability test leg raise in individuals with and without LBP.

METHODS

Participants with (n = 10) and without (n = 10) LBP participated in this laboratory case-control study. Spinal stiffness was measured using a beam-bending model and 3-D kinematic data. Stiffness changes were compared across the test positions and between groups. Surface electromyographic data were collected on trunk and limb musculature. Principal-component analysis was used to extract muscle synergies.

RESULTS

Spinal stiffness increased across testing positions in all participants (P<.05). Participants with LBP experienced reduced pain during the test (P<.001). No between-group difference was found in spinal stiffness during leg raising during the test (P>.05). Participants without LBP used 3 muscle synergies during the leg raise and participants with LBP used 2 muscle synergies.

CONCLUSION

Spinal stiffness increased in all participants; however, participants without LBP demonstrated a muscle synergy pattern where each synergy was associated with a distinct function of the prone instability test. Participants with LBP used a more global stabilization pattern, which may reflect a maladaptive method of enhancing spinal stability. J Orthop Sports Phys Ther 2019;49(12):899-907. Epub 3 Aug 2019. doi:10.2519/jospt.2019.8577.

The contemporary management of nonspecific lower back pain

Low back pain (LBP) is extremely common and causes an enormous burden on the society. This perspective article aims to provide an evidence-based summary in the field of LBP. More specifically, we aimed to present epidemiological data on cost, diagnosis, prognosis, prevention and interventions for patients with LBP. It is critical that both clinicians and policymakers follow best practices by using high-value care for patients with LBP. In addition, nonevidence-based procedures must be immediately abandoned. These actions are likely to reduce societal costs and will improve the quality of life of these patients.

One session of motor control exercise improves joint position sense assessed by an iPhone application: a randomized controlled trial

[Purpose] To establish the test-retest reliability of an iPhone application and determine the immediate effect of motor control exercise (MCE) on lumbar position sense. [Participants and Methods] This study used a two-arm, randomized controlled trial design with a blinded assessor. Sixty healthy participants were randomized into the exercise or control group. The exercise group underwent 30-min MCE, whereas the control group rested for 15 min. Lumbar motion measured by two iPhones with goniometer application was used to determine the test-retest reliability. Absolute repositioning errors (pre- and post-test) from the control and exercise groups were used to determine the immediate effect of MCE on lumbar position sense. [Results] The test-retest reliability was 0.67–0.95. A significant interaction effect was found for Angle*Time, main effect of Angle, and main effect of Time. Post-hoc comparison showed a significant improvement in position sense at 45° and 60° in the exercise group. [Conclusion] The findings suggest that a mobile phone application has the ability to detect changes in lumbar position sense between sessions that exceed measurement error following MCE. One session of specific MCE can improve lumbar position sense at high lumbar flexion.

Evaluation of the Bourban Trunk Muscle Strength Test Based on Electromyographic Parameters

(1) Background: The importance of a strong and stable trunk musculature is well known, but there is a lack of reliable, valid and objective test batteries with the necessary test economy, practicability and cost-benefit ratio. The aim of the present study was to evaluate the Bourban test for the validity of its exercise selection representing the ventral, right/left lateral and dorsal muscle chain. (2) Methods: 33 male sports students (24.1 ± 2.4 years, 181.6 ± 5.5 cm, 80.8 ± 7.3 kg) participated in the study. Median Frequency (MDF) and Mean Frequency (MNF) were calculated from the electromyographic signals and used to check whether fatigue of the suggested target musculature actually occurs during the different exercises and thus the exercise is representative for this part of the trunk. (3) Results: In all exercises significant fatigue was measured for MDF and MNF in the muscles working as agonists. (4) Conclusion: It can be stated that the Bourban trunk muscle strength test is a valid and economic test instrument for the evaluation of trunk strength (endurance). Compared to technically supported measuring systems, the Bourban test seems to be a flexible and cost-effective alternative for the broad mass.

Clinical spinal instability: 10 years since the derivation of a clinical prediction rule. A narrative literature review

BACKGROUND

Between 2005 and 2015 significant changes in the clinical decision making paradigm for the treatment of spinal instability occurred. This was largely motivated by a clinical prediction rule (CPR) derivation study that was developed to specifically identify patients with low back pain who are more likely to respond positively to lumbar stabilization exercises.

OBJECTIVE

This is a narrative literature review on the recent advances physiotherapy has made in the treatment of clinical spinal instability.

METHODS

Literature discussing the conservative treatment of lumbar spinal instability published from 2005-2015 was identified with electronic searches of PubMed (MEDLINE) Advanced search, Web of Science, BIOSIS Previews, MEDLINE (EBSCO), SportDISCUS (EBSCO), CINAHL (EBSCO), PEDro, Scopus and Cochrane and reviewed.

RESULTS

Five systematic reviews, 2 with meta-analyses, and 1 systematic review on the quality of systematic reviews were found. There seems to be some benefit from specific stabilization exercise programs in regards to pain reduction, but they might not be more effective than other forms of exercise. The currently existing CPR for stabilization exercises is not far enough developed to use in clinical practice and is not validated as of yet.

CONCLUSION

Stabilization exercises seem to decrease chronic low back pain, although it is not clear that this pain has to be caused by clinical spinal instability. Caution should be exercised when using CPRs in the clinic; they are not meant to be strict treatment guidelines, but rather a tool that helps facilitate clinical decision-making.

Association Between Clinical Tests Related to Motor Control Dysfunction and Changes in Pain and Disability After Lumbar Stabilization Exercises in Individuals With Chronic Low Back Pain

OBJECTIVE

To investigate whether clinical tests used to detect motor control dysfunction can predict improvements in pain and disability in patients with chronic nonspecific low back pain (LBP) who have undergone an 8-week lumbar stabilization exercise program.

STUDY DESIGN

A prospective cohort study.

SETTING

Outpatient physical therapy university clinic.

PARTICIPANTS

Seventy people with chronic nonspecific LBP were recruited, and 64 completed the exercise program (N=64).

INTERVENTIONS

The lumbar stabilization program was provided twice a week for 8 weeks.

MAIN OUTCOME MEASURES

Pain intensity (11-point numerical rating scale) and disability (Roland Morris Disability Questionnaire) and clinical tests, such as the Deep Muscle Contraction (DMC) scale, Clinical Test of Thoracolumbar Dissociation (CTTD), and Passive Lumbar Extension (PLE) test. Univariate and multivariate linear regression models were used in the prediction analysis.

RESULTS

Mean changes in pain intensity and disability following the 8-week stabilization program were -3.8 (95% confidence interval [CI], -3.2 to -4.4) and -7.4 (95% CI, -6.3 to -8.5), respectively. Clinical test scores taken at baseline did not predict changes in pain and disability at 8-week follow-up.

CONCLUSION

Our findings revealed that the DMC scale, CTTD, PLE test, clinical tests used to assess motor control dysfunction, do not predict improvements in pain and disability in patients with chronic nonspecific LBP following an 8-week lumbar stabilization exercise program.

Decreased amplitude of surface electromyo- graphic recordings of muscle activation along the posterior myofascial kinematic chain in subjects with chronic nonspecific low back pain compared to healthy subjects

BACKGROUND

The concept of myofascial continuity suggests that muscles activate along kinematic chains with common fascial coverings. Yet, the literature lacks evidence in regards to the function of anatomical chains in populations suffering from low back pain (LBP).

OBJECTIVE

To examine muscle activations along the superficial back line in LBP patients compared to healthy controls.

METHODS

The sample study included 20 males with chronic LBP (mean age 28.7 (± 3.05) years, mean BMI 24.91 (± 2.76)) and 17 healthy controls (mean age 31.06 (± 7.76) years, mean BMI 23.46 (± 3.43)). Muscle activation (gastrocnemius, hamstrings, erector spine, and upper trapezius) along the superficial back line was measured using surface EMG. All subjects underwent five test conditions: Conditions 1-3 involved passive movement, active movement and active movement against maximum isometric resistance of the right gastrocnemius muscle. Conditions 4 and 5 involved neck extension without and with isometric resistance from the prone position. The main outcome was relative muscle activation amplitude between research and control subjects.

RESULTS

Muscle activation along the posterior anatomical chain was observed during distal movement (plantar flexion or neck extension). LBP patients showed significant lower muscle activation in the erector spine of lower back region compared with the control group during active plantar flexion and active neck extension (p< 0.05). Lower muscle activation in other regions (gastrocnemius, hamstrings, erector spine level T6) was observed in the research group (although not significant).

CONCLUSION

LBP may cause or result in a lower muscle activation of the posterior kinematic myofascial chain muscles.

Motor control exercise and patient education program for low resource rural community dwelling adults with chronic low back pain: a pilot randomized clinical trial

This pilot randomized clinical trial assessed the feasibility of implementing motor control exercise (MCE) and patient education (PE) program for the management of chronic low back pain (CLBP) in a low resource rural Nigerian community. Thirty patients with CLBP were recruited and randomly assigned to MCE, PE, or MCE plus PE groups. The MCE program was provided twice a week while the PE program was provided once a week all for 6 weeks. Feasibility was assessed through recruitment rate, treatment compliance, retention/dropout rate, report of adverse events, perceived helpfulness, overall satisfaction, and clinical outcome of pain (numeric pain rating scale) and functional disability (Oswestry Disability Index). Many patients were willing to participate in the study and the recruitment rate was 77%. Treatment compliance in all the three groups were >65% for supervised treatment sessions and <50% for prescribed home program. Retention rate was high and greater overall satisfaction with the interventions was reported. Compared with the baseline, all the three groups improved significantly in pain and disability (P<0.05) after 6 weeks. Pairwise comparison revealed that the MCE plus PE group was superior to the PE group for pain and to the MCE for disability (P<0.05), with large effect size. It was concluded that the designed interventions are promising and conducting a full-scale randomized clinical trial in the future is feasible to confirm the effectiveness of the interventions for the management CLBP in rural Nigeria. (Trial registration: ClinicalTrials.gov, NCT03398174).

Prognostic factors of a favorable outcome following a supervised exercise program for soldiers with sub-acute and chronic low back pain

Background

Low back pain (LBP) encompasses heterogeneous patients unlikely to respond to a unique treatment. Identifying sub-groups of LBP may help to improve treatment outcomes. This is a hypothesis-setting study designed to create a clinical prediction rule (CPR) that will predict favorable outcomes in soldiers with sub-acute and chronic LBP participating in a multi-station exercise program.

Methods

Military members with LBP participated in a supervised program comprising 7 stations each consisting of exercises of increasing difficulty. Demographic, impairment and disability data were collected at baseline. The modified Oswestry Disability Index (ODI) was administered at baseline and following the 6-week program. An improvement of 50% in the initial ODI score was considered the reference standard to determine a favorable outcome. Univariate associations with favorable outcome were tested using chi-square or paired t-tests. Variables that showed between-group (favorable/unfavorable) differences were entered into a logistic regression after determining the sampling adequacy. Finally, continuous variables were dichotomized and the sensitivity, specificity and positive and negative likelihood ratios were determined for the model and for each variable.

Results

A sample of 85 participants was included in analyses. Five variables contributed to prediction of a favorable outcome: no pain in lying down (p = 0.017), no use of antidepressants (p = 0.061), FABQ work score < 22.5 (p = 0.061), fewer than 5 physiotherapy sessions before entering the program (p = 0.144) and less than 6 months’ work restriction (p = 0.161). This model yielded a sensitivity of 0.78, specificity of 0.80, LR+ of 3.88, and LR- of 0.28. A 77.5% probability of favorable outcome can be predicted by the presence of more than three of the five variables, while an 80% probability of unfavorable outcome can be expected if only three or fewer variables are present.

Conclusion

The use of prognostic factors may guide clinicians in identifying soldiers with LBP most likely to have a favorable outcome. Further validation studies are needed to determine if the variables identified in our study are treatment effect modifiers that can predict success following participation in the multi-station exercise program.

Trial registration

ClinicalTrials.gov Identifier: NCT03464877 registered retrospectively on 14 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2022-x) contains supplementary material, which is available to authorized users.

The Modified Low Back Pain Disability Questionnaire: Reliability, Validity, and Responsiveness of a Dutch Language Version

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

The goal of this study is to translate the English version of the Modified Low Back Pain Disability Questionnaire (MDQ) into a Dutch version and investigate its clinimetric properties for patients with nonspecific chronic low back pain (CLBP).

SUMMARY OF BACKGROUND DATA

Fritz et al (2001) developed a modified version of the Oswestry Disability Questionnaire (ODI) to assess functional status and named it the MDQ. In this version, a question regarding employment and homemaking ability was substituted for the question related to sex life. Good clinimetric properties for the MDQ were identified but up until now it is not clear whether the clinimetric properties of the MDQ would change if it was translated into a Dutch version.

METHODS

Translation of the MDQ into Dutch was done in 4 steps. Test-retest reliability was investigated using the intraclass correlation coefficient (ICC) model. Validity was calculated using Pearson correlations and a 2-way analysis of variance for repeated measures. Finally, responsiveness was calculated with the area under the curve (AUC), minimal detectable change (MDC), and the standardized response mean (SRM).

RESULTS

A total of 80 completed questionnaires were collected in 3 different hospitals and a total of 43 patients finished a 9 weeks intervention period, completing the retest. Test-retest reliability was excellent with an ICC of 0.89 (95% confidence interval [CI], 0.74-0.95). To confirm the convergent validity, the MDQ answered all predefined hypothesises (r = -0.65-0.69/P = 0.01-0.00) and good results for construct validity were found (P = 0.02). The MDQ had an AUC of 0.64 (95% confidence interval [CI], 0.47-0.81), an MDC of 8.80 points, and a SRM of 0.65.

CONCLUSION

The Dutch version of the MDQ shows good clinimetric properties and is shown to be usable in the assessment of the functional status of Dutch-speaking patients with nonspecific CLBP.

LEVEL OF EVIDENCE

3.

Muscle Control and Non-specific Chronic Low Back Pain

Objectives

Chronic low back pain (CLBP) is the most prevalent of the painful musculoskeletal conditions. CLBP is a heterogeneous condition with many causes and diagnoses, but there are few established therapies with strong evidence of effectiveness (or cost effectiveness). CLBP for which it is not possible to identify any specific cause is often referred to as non‐specific chronic LBP (NSCLBP). One type of NSCLBP is continuing and recurrent primarily nociceptive CLBP due to vertebral joint overload subsequent to functional instability of the lumbar spine. This condition may occur due to disruption of the motor control system to the key stabilizing muscles in the lumbar spine, particularly the lumbar multifidus muscle (MF).

Methods

This review presents the evidence for MF involvement in CLBP, mechanisms of action of disruption of control of the MF, and options for restoring control of the MF as a treatment for NSCLBP.

Results

Imaging assessment of motor control dysfunction of the MF in individual patients is fraught with difficulty. MRI or ultrasound imaging techniques, while reliable, have limited diagnostic or predictive utility. For some patients, restoration of motor control to the MF with specific exercises can be effective, but population results are not persuasive since most patients are unable to voluntarily contract the MF and may be inhibited from doing so due to arthrogenic muscle inhibition.

Conclusions

Targeting MF control with restorative neurostimulation promises a new treatment option.

Treatment-based Classification System for Patients With Low Back Pain: The Movement Control Approach

We present the movement control approach as part of the treatment-based classification system. This approach proposes a movement control schema that clarifies that movement control is a product of the interplay among multiple biopsychosocial components. The schema illustrates that for movement to occur in a dynamically controlled fashion, the lumbar spine requires both local mobility and global stability. Local mobility means that the lumbar spine and its adjacent regions possess adequate nerve and joint(s) mobility and soft tissue compliance (ie, the malleability of tissue to undergo elastic deformation). Global stability means that the muscles of the lumbar spine and its adjacent regions can generate activation that is coordinated with various joint movements and incorporated into activities of daily living. Local mobility and global stability are housed within the bio-behavioral and socio-occupational factors that should be addressed during movement rehabilitation. This schema is converted into a practical physical examination to help the rehabilitation provider to construct a clinical rationale as to why the movement impairment(s) exist. The examination findings are used to guide treatment. We suggest a treatment prioritization that aims to consecutively address neural sensitivity, joint(s) and soft tissue mobility, motor control, and endurance. This prioritization enables rehabilitation providers to better plan the intervention according to each patient's needs. We emphasize that treatment for patients with low back pain is not a static process. Rather, the treatment is a fluid process that changes as the clinical status of the patient changes. This movement control approach is based on clinical experience and indirect evidence; further research is needed to support its clinical utility.

Kinematic characterization of clinically observed aberrant movement patterns in patients with non-specific low back pain: a cross-sectional study

Background

Clinical observation of aberrant movement patterns during active forward bending is one criterion used to identify patients with non-specific low back pain suspected to have movement coordination impairment. The purpose of this study was to describe and quantify kinematic patterns of the pelvis and trunk using a dynamics systems approach, and determine agreement between clinical observation and kinematic classification.

Method

Ninety-eight subjects performed repeated forward bending with clinical observation and kinematic data simultaneously collected. Kinematic data were plotted using angle-angle, coupling-angle, and phase-plane diagrams. Accuracy statistics in conjunction with receiver operating characteristic curves were used to determine agreement between clinical observation and kinematic patterns.

Results

Kinematic patterns were consistent with clinical observation and definitions of typical and aberrant movement patterns with moderate agreement (kappa = 0.46–0.50; PABAK = 0.49–0.73). Early pelvic motion dominance in lumbopelvic coupling-angle diagram ≥59° within the first 38% of the movement represent observed altered lumbopelvic rhythm. Frequent disruptions in lumbar spine velocity represented by phase-plane diagrams with local minimum occurrences ≥6 and sudden decoupling in lumbopelvic coupling-angle diagrams with sum of local minimum and maximum occurrences ≥15 represent observed judder.

Conclusion

These findings further define observations of movement coordination between the pelvis and lumbar spine for the presence of altered lumbopelvic rhythm and judder. Movement quality of the lumbar spine segment is key to identifying judder. This information will help clinicians better understand and identify aberrant movement patterns in patients with non-specific low back pain.

Effect of modified bridge exercise on trunk muscle activity in healthy adults: a cross sectional study

•

Bridge exercise with unstable surface increases trunk muscle activities.

•

Bridge exercise with hip abduction increases trunk muscles activities.

•

Modified bridge exercises are useful for co-activation of trunk muscles.

Design

This is a cross-sectional study.

Setting

University research laboratory.

Participants

Fifteen healthy adults (mean age: 27.47 years) volunteered for this study.

Intervention

The individuals performed standard bridge exercise and modified bridge exercises with right leg-lift (single-leg-lift bridge exercise, single-leg-lift bridge exercise on an unstable surface, and single-leg-lift hip abduction bridge exercise).

Main outcome measures

During the bridge exercises, electromyography of the rectus abdominis, internal oblique, erector spinae, and multifidus muscles was recorded using a wireless surface electromyography system. Two-way repeated-measures analysis of variance (exercise by side) with post hoc pairwise comparisons using Bonferroni correction was used to compare the electromyography data collected from each muscle.

Results

Bilateral internal oblique muscle activities showed significantly greater during single-leg-lift bridge exercise (95% confidence interval: right internal oblique = −8.99 to −1.08, left internal oblique = −6.84 to −0.10), single-leg-lift bridge exercise on an unstable surface (95% confidence interval: right internal oblique = −7.32 to −1.78, left internal oblique = −5.34 to −0.99), and single-leg-lift hip abduction bridge exercise (95% confidence interval: right internal oblique = −17.13 to −0.89, left internal oblique = −8.56 to −0.60) compared with standard bridge exercise. Bilateral rectus abdominis showed greater electromyography activity during single-leg-lift bridge exercise on an unstable surface (95% confidence interval: right rectus abdominis = −9.33 to −1.13, left rectus abdominis = −4.80 to −0.64) and single-leg-lift hip abduction bridge exercise (95% confidence interval: right rectus abdominis = −14.12 to −1.84, left rectus abdominis = −6.68 to −0.16) compared with standard bridge exercise. In addition, the right rectus abdominis muscle activity was greater during single-leg-lift hip abduction bridge exercise compared with single-leg-lift bridge exercise on an unstable surface (95% confidence interval = −7.51 to −0.89). For erector spinae, muscle activity was greater in right side compared with left side during all exercises (95% confidence interval: standard bridge exercise = 0.19–4.53, single-leg-lift bridge exercise = 0.24–10.49, single-leg-lift bridge exercise on an unstable surface = 0.74–8.55, single-leg-lift hip abduction bridge exercise = 0.47–11.43). There was no significant interaction and main effect for multifidus.

Conclusions

Adding hip abduction and unstable conditions to bridge exercises may be useful strategy to facilitate the co-activation of trunk muscles.

Predictive factors for reporting adverse events following spinal manipulation in randomized clinical trials - secondary analysis of a systematic review

While spinal manipulative therapy (SMT) is recommended for the treatment of spinal disorders, concerns exist about adverse events associated with the intervention. Adequate reporting of adverse events in clinical trials would allow for more accurate estimations of incidence statistics through meta-analysis. However, it is not currently known if there are factors influencing adverse events reporting following SMT in randomized clinical trials (RCTs). Thus our objective was to investigate predictive factors for the reporting of adverse events in published RCTs involving SMT. The Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs involving SMT. Domains of interest included: sample size; publication date relative to the 2010 CONSORT statement; risk of bias; the region treated; and number of intervention sessions. 7398 records were identified, of which 368 articles were eligible for inclusion. A total of 140 (38.0%) articles reported on adverse events. Articles were more likely to report on adverse events if they possessed larger sample sizes, were published after the 2010 CONSORT statement, had a low risk of bias and involved multiple intervention sessions. The region treated was not a significant predictor for reporting on adverse events. Predictors for reporting on adverse events included larger sample size, publication after the 2010 CONSORT statement, low risk of bias and trials involving multiple intervention sessions. We recommend that researchers focus on developing robust methodologies and participant follow-up regimens for RCTs involving SMT.

Physical Therapy for Musculoskeletal Disorders of Workers: Role of Physical Therapists in Occupational Health

Musculoskeletal disorders in workers decrease the productivity of companies and result in socioeconomic losses. Low back pain accounted for approximately 60% of occupational diseases in the past and this is still true at present, making it a major occupational health problem in Japan. Herein, the findings about low back pain are explained as follows: the correlation between imaging examination findings and low back pain is low; psychosocial factors are involved in the onset of low back pain and how it becomes chronic; and improvement of activity is more useful than rest. Furthermore, the advantages of employing physical therapists for improving occupational health are as follows: they can 1) evaluate and intervene ergonomically; 2) provide instructions using a behavioral modification technique based on psychosocial factors; and 3) provide instructions regarding exercise programs considering obstacles to the development of a good exercise habit (painful diseases including osteoarthritis and other diseases such as hypertension and diabetes). In addition, falling, whose incidence has recently been increasing and is an important issue in occupational health, is examined from the aspect of musculoskeletal disorders. The following activities of physical therapists are introduced: the items to be checked during a tour of inspection of a workplace and detailed descriptions of work management and working environment management measures. Physical therapists are rarely involved in studies of low back pain and falling, but their knowledge and skills have been demonstrated to contribute to improving occupational health.

Motor Control Exercise for Nonspecific Low Back Pain: A Cochrane Review

STUDY DESIGN

A systematic review.

OBJECTIVE

The aim of this review was to evaluate the effectiveness of motor control exercise (MCE) in patients with nonspecific low back pain (LBP).

SUMMARY OF BACKGROUND DATA

MCE is a common form of exercise used for managing LBP. MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles, progressing to more complex and functional tasks integrating the activation of deep and global trunk muscles.

METHODS

We conducted electronic searches of CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers from their inception up to April 2015. Two independent review authors screened the search results, assessed risk of bias, and extracted the data. A third reviewer resolved any disagreement. We included randomized controlled trials comparing MCE with no treatment, another treatment, or as a supplement to other interventions in patients with nonspecific LBP. Primary outcomes were pain intensity and disability. We assessed risk of bias using the Cochrane Back and Neck (CBN) Review Group 12-item criteria. We combined results in a meta-analysis expressed as mean difference and 95% confidence interval. We assessed the overall quality of the evidence using the GRADE approach.

RESULTS

We included 32 trials (n = 2628). Most included trials had a low risk of bias. For acute LBP, low to moderate quality evidence indicates no clinically important differences between MCE and spinal manipulative therapy or other forms of exercise. There is very low-quality evidence that the addition of MCE to medical management does not provide clinically important improvements. For recurrence at one year, there is very low-quality evidence that MCE and medical management decrease the risk of recurrence. For chronic LBP, there is low to moderate quality evidence that MCE is effective for reducing pain compared with minimal intervention. There is low to high-quality evidence that MCE is not clinically more effective than other exercises or manual therapy. There is very low to low quality evidence that MCE is clinically more effective than exercise and electrophysical agents (EPAs) or telerehabilitation for pain and disability.

CONCLUSION

MCE is probably more effective than a minimal intervention for reducing pain, but probably does not have an important effect on disability, in patients with chronic LBP. There was no clinically important difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP.

LEVEL OF EVIDENCE

1.

Clinical Prediction Rules That Don't Hold Up-Where to Go From Here?

Clinical prediction rules (CPRs) are created to help guide clinical decision making. To do this, they use the presence or absence of certain factors that have been shown to meaningfully predict a patient's prognosis, diagnosis, or response to treatment. While representing a seminal methodological step forward in individualized care, one of the main drawbacks of CPRs continues to be validation studies that do not support the initially derived CPR. This is particularly important because validation of CPRs in an independent patient population prior to clinical implementation is essential. Why is it quite common for existing CPRs to fall down at the validation stage? And what does this mean for research that aims to individualize treatment? J Orthop Sports Phys Ther 2016;46(7):502-505. doi:10.2519/jospt.2016.0606.

Treatment-Based Classification System for Low Back Pain: Revision and Update

The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patient's clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent-new or recurrent-LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Association's clinical practice guidelines for low back pain.

Psychometric properties of the Hebrew version of the Oswestry Disability Index

BACKGROUND

Low back pain (LBP) is one of the most common health complaints, with lifetime prevalence rates as high as 84%. The Oswestry Disability Index (ODI) is often the measure of choice for LBP in both research and clinical settings and, as such, has been translated into 29 languages and dialects. Currently, however, there is no validated version of Hebrew-translated ODI (ODI-H).

OBJECTIVE

To examine the psychometric properties of the ODI-H.

METHODS

Cross-culturally appropriate translation into Hebrew was conducted. A convenience sample of 115 participants (Case Group) with LBP and 68 without LBP (Control Group) completed the ODI-H, SF-36 Health Survey, and two Visual Analog Scales (VAS).

RESULTS

Internal consistency was α = 0.94 and test-retest reliability for 18 participants repeating the ODI-H was 0.97. No floor or ceiling effects were noted for Cases, although there was a floor effect for the Control Group. Scores were significantly different for the two groups, indicating discriminant validity. Concurrent validity was reflected by significant correlations with SF-36 scores, particularly the Physical Functioning and Bodily Pain subscales (-0.83 and -0.79, respectively) and with the VAS (0.84 and 0.79).

CONCLUSIONS

The ODI-H is a valid and reliable measure of low back pain-related disability for the Hebrew-speaking public.