Motor control exercise for chronic non-specific low-back pain

Efficacy of specific exercises in general population with non-specific low back pain: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Localized exercises are employed to activate, train, or restore the function of particular muscles and they are usually considered as part of treating individuals suffering low back pain. So, this systematic review and meta-analysis aimed to assess the efficacy of specific exercises in general population with non-specific low back pain (LBP).

METHODS

We conducted electronic searches in MEDLINE/PubMed, Scopus, Web of Science (WoS), and Google scholar from January 1990 to June 2021. Initially, 47,740 records were identified. Following the removal of duplicates, 32,138 records were left. After reviewing titles and abstracts, 262 papers were chosen for thorough assessment. Among these, 208 studies were excluded, resulting in 54 trials meeting the inclusion criteria for this study. Additionally, 46 of these trials were randomized controlled trials and were further evaluated for the meta-analysis. We included trials investigating the effectiveness of exercise therapy, including isometric activation of deep trunk muscles, strengthening exercises, stabilization exercises, stretching exercises, and proprioceptive neuromuscular facilitation exercises (PNF) in LBP patients. The primary outcome was pain intensity, measured using tools such as the visual analogue scale (VAS) and numeric pain rating scale (NPRS). The secondary outcome was disability, assessed through instruments such as the Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI). The quality of the eligible studies was assessed using the Verhagen tool, and the level of evidence was evaluated using the GRADE approach.

RESULTS

Based on the Verhagen tool, 46 trials (85.2%) were categorized as having low methodological quality, while 8 studies (14.8%) were considered to have medium methodological quality. The meta-analysis indicated a small efficacy in favor of isometric activation of deep trunk muscles (-0.37, 95% CI: -0.88 to 0.13), a moderate efficacy in favor of stabilization exercises (-0.53, 95% CI: -1.13 to 0.08), and a large efficacy in favor of PNF exercises (-0.91, 95% CI: -1.62 to -0.2) for reducing pain intensity as assessed by VAS or NPRS tools. Moreover, the meta-analysis revealed a moderate efficacy for isometric activation of deep trunk muscles (-0.61, CI: -1.02 to -0.19), and a large efficacy for PNF exercises (-1.26, 95% CI: -1.81 to -0.72) in improving disability, assessed using RMDQ or ODI questionnaires. The level of certainty in the evidence, as determined by the GRADE approach, was very low to low.

CONCLUSION

These findings emphasize the importance of incorporating localized therapeutic exercises as a fundamental aspect of managing non-specific LBP. Clinicians should consider utilizing localized therapeutic exercise tailored to individual patient needs. Furthermore, further research investigating optimal exercise therapy, optimal dose of the exercises, durations, and long-term adherence is warranted to enhance the precision and efficacy of exercise-based interventions for non-specific LBP.

Clinical indicators to monitor health care in low back pain: a scoping review

Clinical care indicators for low back pain can be used to monitor healthcare practices and consequently be used to evaluate success of strategies to improve care quality. The aim of this study was to identify the clinical care indicators that have been used to measure appropriateness of health care for patients with low back pain. We conducted a systematic search of five electronic databases and Google to identify clinical care indicators that have been used to measure any aspect of care for people with low back pain. Care indicators were narratively described according to their type (i.e. structure, process, or outcomes) and categorized by their purpose (e.g. to measure aspects related to assessment, imaging requests, treatment/prevention, and outcomes). A total of 3562 and 2180 records were retrieved from electronic databases and Google searches, respectively. We identified 280 indicators related to low back pain care from 40 documents and publications. Most quality indicators were process indicators (n = 213, 76%), followed by structure (n = 41, 15%) and outcome indicators (n = 26, 9%). The most common indicators were related to imaging requests (n = 41, 15%), referral to healthcare providers (n = 30, 11%), and shared decision-making (n = 21, 7%). Our review identified a range of clinical care indicators that have been used to measure the quality of health care for people with low back pain. Our findings will support a Delphi study to reach international consensus on what would be the most important and feasible indicators for a minimum dataset to be collected globally.

Appropriateness of exercise therapy delivery in chronic low back pain management: cross-sectional online survey of physiotherapy practice in Germany

BACKGROUND

In Germany, exercise therapy represents the most commonly prescribed physiotherapy service for non-specific, chronic low back pain (NSCLBP). So far, little is known about current practice patterns of German physiotherapists in delivering this intervention. Thus, the aim of this study was to investigate the appropriateness of exercise therapy delivered to NSCLBP patients in German physiotherapy care and to identify practitioner-related drivers of appropriate exercise delivery.

METHODS

We used a vignette-based, exploratory, cross-sectional, online-survey study design (76-items; data collection between May and July 2023). Eligible participants were required to hold a professional degree in physiotherapy and were required to be practicing in Germany. Access links to anonymous online surveys were spread via established German physiotherapy networks, educational platforms, social media, e-mail lists, and snowball sampling. Appropriateness of exercise therapy was calculated by an equally weighted total score (400 points) including scales on shared-decision-making, exercise dose selection, pain knowledge and self-management promotion. "Appropriate exercise delivery" was determined by a relative total score achievement of > 80%. "Partly appropriate exercise delivery" was determined by a relative total score achievement of 50-79%, and "inappropriate exercise delivery" by a score achievement of < 50%. Practitioner-related drivers of exercise appropriateness were calculated by bivariate and multiple linear regression analyses.

RESULTS

11.9% (N = 35) of 298 physiotherapists' exercise delivery was considered "appropriate", 83.3% (N = 245) was "partly appropriate", and 4.8% (N = 14) was "inappropriate". In the final multiple regression model, most robust parameters positively influencing appropriate delivery of exercise therapy were increased scientific literacy (B = 10.540; 95% CI [0.837; 20.243]), increased average clinical assessment time (B = 0.461; 95% CI [0.134; 0.789]), increased self-perceived treatment competence (B = 7.180; 95% CI [3.058; 11.302], and short work experience (B = - 0.520; 95% CI [-0.959; - 0.081]).

CONCLUSION

Appropriate exercise delivery in NSCLBP management was achieved by only 11.9% of respondents. However, the vast majority of 95.2% of respondents was classified to deliver exercise therapy partly appropriate. Long work experience seemed to negatively affect appropriate exercise delivery. Positive influences were attributed to scientific literacy, the average clinical assessment time per patient as well as the perceived treatment competence in NSCLBP management.

REGISTRATION

Open science framework: https://doi.org/10.17605/OSF.IO/S76MF .

Efficacy of a Psychologically-Informed Physiotherapy Intervention in Patients with Chronic Low Back Pain at High Risk of Poor Prognosis: A Pilot and Feasibility Randomized Controlled Trial

Purpose

To determine the feasibility of a randomized controlled trial (RCT) testing the efficacy of psychologically-informed physiotherapy (PIPT), which includes usual physiotherapy (UP) interventions, compared with UP, and to explore the preliminary effectiveness of the interventions.

Method

People with chronic low back pain at high risk of poor prognosis (using the STarT Back screening tool) were recruited and allocated to PIPT or UP. Effectiveness of recruitment strategies, adherence to intervention, risk of contamination, and specific challenges were assessed. Functional capacity, pain, quality of life, kinesiophobia, catastrophization, central sensitization, and self-efficacy were measured at baseline, 6-, 12- and 24-week follow-ups.

Results

Forty participants were recruited mainly by diffusing through Laval University's email list, and 10 physiotherapists treated the participants recruited. The retention rate of participants at 24 weeks was 72.5%. Adherence to treatment by participants and physiotherapists was very good. The risk of contamination was low, and the specific challenges identified were modifiable. Significant improvement over time in all clinical variables of interest, except self-efficacy, was observed with no difference between groups.

Conclusions

As most success criteria were met, conducting an RCT evaluating PIPT and PU is feasible with modifications. PIPT and UP appear to be similarly effective.

Neuromuscular Control and Resistance Training for People With Chronic Low Back Pain: A Randomized Controlled Trial

OBJECTIVE: To determine if adding lumbar neuromuscular control retraining exercises to a 12-week program of strengthening exercises had greater effect for improving disability than 12 weeks of strengthening exercises alone in people with chronic low back pain (LBP). DESIGN: Single-center, participant- and assessor-blinded, comparative effectiveness randomized controlled trial. METHODS: Sixty-nine participants (31 females; 29 males; mean age: 46.5 years) with nonspecific chronic LBP were recruited for a 12-week program involving lumbar extension neuromuscular retraining in addition to resistance exercises (intervention) or 12 weeks of resistance exercises alone (control). The primary outcome measure was the Oswestry Disability Index. Secondary outcome measures included the Numeric Rating Scale, Tampa Scale for Kinesiophobia, Pain Self-Efficacy Questionnaire, and the International Physical Activity Questionnaire. Outcomes were measured at baseline, 6 weeks, and 12 weeks. RESULTS: Forty-three participants (22 control, 21 intervention) completed all outcome measures at 6 and 12 weeks. Fourteen participants were lost to follow-up, and 12 participants discontinued due to COVID-19 restrictions. Both groups demonstrated clinically important changes in disability, pain intensity, and kinesiophobia. The difference between groups with respect to disability was imprecise and not clinically meaningful (mean difference, -4.4; 95% CI: -10.2, 1.4) at 12 weeks. Differences in secondary outcomes at 6 or 12 weeks were also small with wide confidence intervals. CONCLUSIONS: Adding lumbar neuromuscular control retraining to a series of resistance exercises offered no additional benefit over resistance exercises alone over a 12-week period. J Orthop Sports Phys Ther 2024;54(5):1-10. Epub 18 March 2024. doi:10.2519/jospt.2024.12349.

The effects of Core Stability Exercises and Mulligan's mobilization with movement techniques on sacroiliac joint dysfunction

Purpose

Sacroiliac joint dysfunction (SIJD), while being the primary contributor to low back pain, is still disregarded and treated as low back pain. Mulligan's Mobilization with Movement (MWM) Techniques and Core Stability Exercises (CSE) are often used to treat low back pain. There is not much evidence that it is effective in SIJD. To evaluate the effectiveness of CSE coupled with MWM (CSE + MWM) in the treatment of SIJD.

Methods

39 patients with SIJD were recruited and randomly divided into distinct groups as follows: control group (n = 13), CSE group (n = 13) and CSE + MWM group (n = 13). The Numerical Pain Rating Scale (NPRS), the Roland Morris Disability Questionnaire (RMDQ), the Range of Motion (ROM), the Pressure Pain Threshold (PPT) and the pelvic tilt angle asymmetry ratio in the sagittal plane (PTAR) were used to gauge the intervention's success both before (M0) and after (M1) it. All experimental data were statistically analyzed.

Results

The SIJ-related pain metric significantly decreased in both the CSE + MWM group and the CSE group between M0 and M1, as determined by the NPRS and RMDQ. Between M0 and M1, The CSE group's left axial rotation ROM and lumbar flexion ROM were significantly decreased. The CSE + MWM group's extension ROM and left lateral flexion ROM both significantly increased between M0 and M1. In the difference variable (M1-M0), the CSE + MWM group substantially outperformed control group in the left lateral flexion ROM and outperformed the CSE group in the left axial rotation ROM.

Conclusion

In individuals with SIJD, CSE + MWM is beneficial in lowering pain, disability, and function. Treatment with CSE and MWM approaches for SIJ appears to boost this efficacy.

Graded exercise with motion style acupuncture therapy for a patient with failed back surgery syndrome and major depressive disorder: a case report and literature review

Effective treatment of failed back surgery syndrome (FBSS) remains challenging despite urgent medical attention requirements. Depression is a contributing factor to the development and poor prognosis of FBSS, and vice versa. We report the case of a patient with FBSS and major depressive disorder (MDD) treated with graded exercise combined with motion-style acupuncture therapy (MSAT). A 53-year-old male veteran who had undergone lumbar discectomy and laminectomy with instrumented fusion was admitted to the hospital with re-current back pain and radiative pain in the left leg. The effects of failed surgery triggered MDD as a comorbidity. After a six-week routine treatment without remarkable improvement, a three-week program of graded exercise with MSAT was applied. The numeric rating scale (NRS) and short form-36 (SF-36) were used to assess low back pain with radiating leg pain, and daily functioning levels, respectively. The voluntary walking distance of the patients was measured. To analyze the therapeutic effects and other applications of the intervention, we surveyed clinical trials using MSAT or graded exercise therapy (GET). Three weeks of graded exercise with MSAT reduced physical and mental functional disabilities (SF-36, physical component: 15.0 to 37.2, mental component: 21.9 to 30.1) as well as the intensity of low back pain and/or radiative leg pain (NRS: 50 to 30). Furthermore, as the therapeutic intensity gradually increased, there was a significant corresponding increase in daily walking distance (mean daily walking distance, the first week vs. baseline, second, and third week, 3.05 ± 0.56: 2.07 ± 0.79, 4.27 ± 0.96, and 4.72 ± 1.04 km, p = 0.04, p = 0.02, and p = 0.003, respectively). Three randomized controlled trials of GET were included, all showing statistically significant antidepressant effects in the diseased population. Graded exercise with MSAT may be an effective rehabilitative therapy for patients with FBSS and MDD who have impaired daily routines.

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.

The Effectiveness and Optimal Dose of Resistance Training in Patients With Subacute and Persistent Low Back-Related Leg Pain: A Systematic Review

A subgroup of patients with low back pain (LBP) suffers from low back-related leg pain (LBLP), which can be classified as radicular pain, or somatic referred pain without nerve root involvement. LBLP is considered an obstacle to recovery and a strong negative prognostic factor for medium- and long-term disability. In this review, we aimed to investigate the effectiveness and optimal dose of resistance training (RT) in patients with subacute or persistent LBLP to provide clinical recommendations for practice. This systematic review was conducted by adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the recommendations of the Cochrane Collaboration. We conducted a literature search on PubMed, PEDro, Cochrane Library, Scopus, and Web of Science databases. Only randomized controlled trials (RCTs) involving patients ≥18 years of age were included. The risk of bias in the included studies was assessed using "the Cochrane Collaboration's tool for assessing risk of bias" (RoB) and the inter-rater agreement for full-text selection was evaluated using Cohen's Kappa (K). The search elicited a total of 4.537 records, and two RCTs involving a total of 196 participants were identified through a selection process based on title, abstract, and full-text assessment. Both studies had a low to moderate risk of bias. The inter-examiner concordance index for the selection of full text was excellent (K=1). RT seems to be an effective and safe intervention for patients with LBLP, but its long-term effectiveness, superiority over other types of exercise-based therapies, and optimal dosage still constitute a gray area in the literature.

Physical Therapists' Acceptance of a Wearable, Fabric-Based Sensor System (Motion Tape) for Use in Clinical Practice: Qualitative Focus Group Study

BACKGROUND

Low back pain (LBP) is a costly global health condition that affects individuals of all ages and genders. Physical therapy (PT) is a commonly used and effective intervention for the management of LBP and incorporates movement assessment and therapeutic exercise. A newly developed wearable, fabric-based sensor system, Motion Tape, uses novel sensing and data modeling to measure lumbar spine movements unobtrusively and thus offers potential benefits when used in conjunction with PT. However, physical therapists' acceptance of Motion Tape remains unexplored.

OBJECTIVE

The primary aim of this research study was to evaluate physical therapists' acceptance of Motion Tape to be used for the management of LBP. The secondary aim was to explore physical therapists' recommendations for future device development.

METHODS

Licensed physical therapists from the American Physical Therapy Association Academy of Leadership Technology Special Interest Group participated in this study. Overall, 2 focus groups (FGs; N=8) were conducted, in which participants were presented with Motion Tape samples and examples of app data output on a poster. Informed by the Technology Acceptance Model, we conducted semistructured FGs and explored the wearability, usefulness, and ease of use of and suggestions for improvements in Motion Tape for PT management of LBP. FG data were transcribed and analyzed using rapid qualitative analysis.

RESULTS

Regarding wearability, participants perceived that Motion Tape would be able to adhere for several days, with some variability owing to external factors. Feedback was positive for the low-profile and universal fit, but discomfort owing to wires and potential friction with clothing was of concern. Other concerns included difficulty with self-application and potential skin sensitivity. Regarding usefulness, participants expressed that Motion Tape would enhance the efficiency and specificity of assessments and treatment. Regarding ease of use, participants stated that the app would be easy, but data management and challenges with interpretation were of concern. Physical therapists provided several recommendations for future design improvements including having a wireless system or removable wires, customizable sizes for the tape, and output including range of motion data and summary graphs and adding app features that consider patient input and context.

CONCLUSIONS

Several themes related to Motion Tape's wearability, usefulness, and ease of use were identified. Overall, physical therapists expressed acceptance of Motion Tape's potential for assessing and monitoring low back posture and movement, both within and outside clinical settings. Participants expressed that Motion Tape would be a valuable tool for the personalized treatment of LBP but highlighted several future improvements needed for Motion Tape to be used in practice.

[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.

Direction-Specific Changes in Trunk Muscle Synergies in Individuals With Extension-Related Low Back Pain

Background Identifying altered trunk control is critical for treating extension-related low back pain (ERLBP), a common subgroup classified by clinical manifestations. The changed coordination of trunk muscles within this group during particular trunk tasks is still not clearly understood. Objectives The objective of this study is to investigate trunk muscle coordination during 11 trunk movement and stability tasks in individuals with ERLBP compared to non-low back pain (LBP) participants. Methods Thirteen individuals with ERLBP and non-LBP performed 11 trunk movement and stability tasks. We recorded the electromyographic activities of six back and abdominal muscles bilaterally. Trunk muscle coordination was assessed using the non-negative matrix factorization (NMF) method to identify trunk muscle synergies. Results The number of synergies in the ERLBP group during the cross-extension and backward bend tasks was significantly higher than in the non-LBP group (p<0.05). The cluster analysis identified the two trunk synergies for each task with strikingly similar muscle activation patterns between groups. In contrast, the ERLBP group exhibited additional trunk muscle synergies that were not identified in the non-LBP group. The number of synergies in the other tasks did not differ between groups (p>0.05). Conclusion Individuals with ERLBP presented directionally specific alterations in trunk muscle synergies that were considered as increased coactivations of multiple trunk muscles. These altered patterns may contribute to the excessive stabilization of and the high frequency of hyperextension in the spine associated with the development and persistence of ERLBP.

Trunk muscle dysfunction in patients with myotonic dystrophy type 2 and its contribution to chronic low back pain

Introduction

Myotonic dystrophy type 2 (MD2) presents with a varied manifestation. Even though the myopathy in these patients is more widespread, axial musculature involvement is one of the most prominent conditions. MD2 patients also often report chronic low back pain (CLBP). The purpose of this study was to evaluate trunk muscle function, including respiratory muscles, in patients with MD2 and to compare it with healthy controls, to determine the occurrence of CLBP in patients with MD2, and to assess whether trunk muscle dysfunction increases the risk of CLBP in these patients.

Methods

We enrolled 40 MD2 patients (age range 23 to 76 years, 26 women). A comprehensive battery of tests was used to evaluate trunk muscle function. The tests consisted of quantitative muscle strength testing of low back extensor muscles and respiratory muscles and the assessment of trunk muscle endurance. A neurological evaluation contained procedures assessing the distribution of muscle weakness, myotonia, and pain, and used questionnaires focused on these items and on disability, depression, and physical activity.

Results

The results of this study suggest that patients with MD2 show significant dysfunction of the trunk muscles, including the respiratory muscles, expressed by decreased muscle strength and endurance. The prevalence of CLBP in patients with MD2 was 52.5%. Based on our analysis, the only independent significant risk factor for CLBP in these patients was maximal isometric lower back extensor strength in a prone position ≤ 15.8 kg (OR = 37.3). Other possible risk factors were severity of myotonia and reduced physical activity.

Conclusion

Outcomes of this study highlighted the presence of axial muscle dysfunction, respiratory muscle weakness, and frequent occurrence of CLBP together with its risk factors in patients with MD2. We believe that the findings of this study may help in management and prevention programs for patients with MD2.

Regional vs global physical therapy interventions to treat chronic pain in survivors of trauma: a randomized controlled trial

BACKGROUND

A history of traumatic life events is associated with chronic pain in later life. Physical therapists utilize a variety of methods to treat pain, however, they have struggled to find effective interventions to improve patient outcomes.

OBJECTIVE

To compare impairment-based, regional (REGION-PT) physical therapy (PT) to a global (GLOBAL-PT) model consisting of pain neuroscience education, graded motor imagery, and exercise for adults with chronic pain and history of trauma.

DESIGN

Randomized Controlled Trial.

METHODS

Adults ≥ 18 years of age with chronic pain and a history of ≥1 trauma identified through the Life Events Checklist received the allocated intervention once a week for six weeks. Treatment effects were assessed using linear mixed models.

RESULTS

Ninety-eight participants completed the trial. There were no difference in outcomes between groups. There were significant interactions between race and intervention. Both interventions were associated with improvements in pain interference for white participants, but non-white participants experienced improvement only with GLOBAL-PT. Regardless of allocation, participants improved in physical function, six of the PROMIS-29 domains, and in pain interference measures.

CONCLUSION

Both interventions are reasonable strategies for individuals with chronic pain and a history of trauma.

Diaphragm and core stabilization exercises in low back pain: A narrative review

INTRODUCTION

Core stabilization is a vital concept in clinical rehabilitation (including low back pain rehabilitation) and competitive athletic training. The core comprises of a complex network of hip, trunk and neck muscles including the diaphragm.

AIMS

The paper aims to discuss the role of the diaphragm in core stability, summarize current evidence and put forth ideal core training strategies involving the diaphragm.

METHOD

Narrative review RESULTS: The diaphragm has a dual role of respiration and postural control. Evidence suggests that current core stability exercises for low back pain are superior than minimal or no treatment, however, no more beneficial than general exercises and/or manual therapy. There appears to be a higher focus on the transversus abdominis and multifidi muscles and minimal attention to the diaphragm. We propose that any form of core stabilization exercises for low back pain rehabilitation should consider the diaphragm. Core stabilization program could commence with facilitation of normal breathing patterns and progressive systematic restoration of the postural control role of the diaphragm muscle.

CONCLUSION

The role of the diaphragm is often overlooked in both research and practice. Attention to the diaphragm may improve the effectiveness of core stability exercise in low back pain rehabilitation.

The association between morphological characteristics of paraspinal muscle and spinal disorders

BACKGROUND

Spinal disorders affect millions of people worldwide, and can cause significant disability and pain. The paraspinal muscles, located on either side of the spinal column, play a crucial role in the movement, support, and stabilization of the spine. Many spinal disorders can affect paraspinal muscles, as evidenced by changes in their morphology, including hypertrophy, atrophy, and degeneration.

OBJECTIVES

The objectives of this review were to examine the current literature on the relationship between the paraspinal muscles and spinal disorders, summarize the methods used in previous studies, and identify areas for future research.

METHODS

We reviewed studies on the morphological characteristics of the paravertebral muscle and discussed their relationship with spinal disorders, as well as the current limitations and future research directions.

RESULTS

The paraspinal muscles play a critical role in spinal disorders and are important targets for the treatment and prevention of spinal disorders. Clinicians should consider the role of the paraspinal muscles in the development and progression of spinal disorders and incorporate assessments of the paraspinal muscle function in clinical practice.

CONCLUSION

The findings of this review highlight the need for further research to better understand the relationship between the paraspinal muscles and spinal disorders, and to develop effective interventions to improve spinal health and reduce the burden of spinal disorders.

Bibliometric Analysis of Research Trends on Manual Therapy for Low Back Pain Over Past 2 Decades

Purpose

Low back pain (LBP) is a prevalent musculoskeletal disorder, and manual therapy (MT) is frequently employed as a non-pharmacological treatment for LBP. This study aims to explore the research hotspots and trends in MT for LBP. MT has gained widespread acceptance in clinical practice due to its proven safety and effectiveness. The study aims to analyze the developments in the field of MT for LBP over the past 23 years, including leading countries, institutions, authoritative authors, journals, keywords, and references. It endeavors to provide a comprehensive summary of the existing research foundation and to analyze the current cutting-edge research trends.

Methods

Relevant articles between 2000 and 2023 were retrieved from the Web of Science Core Collection (WOSCC) database. We used the software VOSviewer and CiteSpace to perform the analysis and summarize current research hotspots and emerging trends.

Results

Through screening, we included 1643 papers from 2000 to 2023. In general, the number of articles published each year showed an upward trend. The United States had the highest number of publications and citations. Canadian Memorial Chiropractic College was the most published research institution. The University of Pittsburgh in the United States had the most collaboration with other research institutions. Long, Cynthia R. was the active author. Journal of Manipulative and Physiological Therapeutics was the most prolific journal with 234 publications.

Conclusion

This study provides an overview of the current status and trends of clinical studies on MT for LBP in the past 23 years using the visualization software, which may help researchers identify potential collaborators and collaborating institutions, hot topics, and new perspectives in research frontiers, while providing new clinical practice ideas for the treatment of LBP.

Cause of non-specific low back pain in women: pelvic floor muscle weakness

INTRODUCTION AND HYPOTHESIS

This study aimed to evaluate the relationship between pelvic floor muscle (PFM) strength and low back pain (LBP) in women with and without non-specific low back pain (NSLBP) with similar demographic and physical characteristics.

METHODS

The study included 40 women (35.73±6.74 years) with NSLBP (with LBP group) and 32 women (34.59±5.93) without LBP (without LBP group). PFM strength with a perineometer, pain intensity with a Visual Analog Scale (VAS), quality of life with the Short Form-36 (SF-36), and perceptions of LBP and related disability with the Rolland Morris Disability Questionnaire (RMDQ) were evaluated.

RESULTS

There was no difference between the groups in terms of age, BMI, number of births (0, 1, and 2 births) and mode of delivery (vaginal/cesarean section) (p>0.05). There was a statistical difference between the groups in all parameters except SF-36 Emotional Role Limitation subscale (p<0.05). We found PFM strength an independent predictor of the RMDQ score, and RMDQ and VAS scores as independent predictors of SF-36 physical and mental components (p<0.05).

CONCLUSIONS

Decreased PFM strength in women causes non-specific mechanical low back pain and disability independent of age, BMI, and the number and type of delivery. Decreased PFM strength is a predictor of disability. Disability and pain are also independent predictors of decreased quality of life. PFM measurement should be prioritized when evaluating women with NSLBP. PFM strength may be a determinant of LBP.

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

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

Physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents

BACKGROUND

Chronic pain is a major health and socioeconomic burden, which is prevalent in children and adolescents. Among the most widely used interventions in children and adolescents are physical activity (including exercises) and education about physical activity.

OBJECTIVES

To evaluate the effectiveness of physical activity, education about physical activity, or both, compared with usual care (including waiting-list, and minimal interventions, such as advice, relaxation classes, or social group meetings) or active medical care in children and adolescents with chronic musculoskeletal pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PEDro, and LILACS from the date of their inception to October 2022. We also searched the reference lists of eligible papers, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared physical activity or education about physical activity, or both, with usual care (including waiting-list and minimal interventions) or active medical care, in children and adolescents with chronic musculoskeletal pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently determined the eligibility of the included studies. Our primary outcomes were pain intensity, disability, and adverse events. Our secondary outcomes were depression, anxiety, fear avoidance, quality of life, physical activity level, and caregiver distress. We extracted data at postintervention assessment, and long-term follow-up. Two review authors independently assessed risk of bias for each study, using the RoB 1. We assessed the overall certainty of the evidence using the GRADE approach. We reported continuous outcomes as mean differences, and determined clinically important differences from the literature, or 10% of the scale.

MAIN RESULTS

We included four studies (243 participants with juvenile idiopathic arthritis). We judged all included studies to be at unclear risk of selection bias, performance bias, and detection bias, and at high risk of attrition bias. We downgraded the certainty of the evidence for each outcome to very low due to serious or very serious study limitations, inconsistency, and imprecision. Physical activity compared with usual care Physical activity may slightly reduce pain intensity (0 to 100 scale; 0 = no pain) compared with usual care at postintervention (standardised mean difference (SMD) -0.45, 95% confidence interval (CI) -0.82 to -0.08; 2 studies, 118 participants; recalculated as a mean difference (MD) -12.19, 95% CI -21.99 to -2.38; I² = 0%; very low-certainty evidence). Physical activity may slightly improve disability (0 to 3 scale; 0 = no disability) compared with usual care at postintervention assessment (MD -0.37, 95% CI -0.56 to -0.19; I² = 0%; 3 studies, 170 participants; very low-certainty evidence). We found no clear evidence of a difference in quality of life (QoL; 0 to 100 scale; lower scores = better QoL) between physical activity and usual care at postintervention assessment (SMD -0.46, 95% CI -1.27 to 0.35; 4 studies, 201 participants; very low-certainty evidence; recalculated as MD -6.30, 95% CI -18.23 to 5.64; I² = 91%). None of the included studies measured adverse events, depression, or anxiety for this comparison. Physical activity compared with active medical care We found no studies that could be analysed in this comparison. Education about physical activity compared with usual care or active medical care We found no studies that could be analysed in this comparison. Physical activity and education about physical activity compared with usual care or active medical care We found no studies that could be analysed in this comparison.

AUTHORS' CONCLUSIONS

We are unable to confidently state whether interventions based on physical activity and education about physical activity are more effective than usual care for children and adolescents with chronic musculoskeletal pain. We found very low-certainty evidence that physical activity may reduce pain intensity and improve disability postintervention compared with usual care, for children and adolescents with juvenile idiopathic arthritis. We did not find any studies reporting educational interventions; it remains unknown how these interventions influence the outcomes in children and adolescents with chronic musculoskeletal pain. Treatment decisions should consider the current best evidence, the professional's experience, and the young person's preferences. Further randomised controlled trials in other common chronic musculoskeletal pain conditions, with high methodological quality, large sample size, and long-term follow-up are urgently needed.

The effect of skilled motor training on corticomotor control of back muscles in different presentations of low back pain

Transcranial magnetic stimulation (TMS) has revealed differences in the motor cortex (M1) between people with and without low back pain (LBP). There is potential to reverse these changes using motor skill training, but it remains unclear whether changes can be induced in people with LBP or whether this differs between LBP presentations. This study (1) compared TMS measures of M1 (single and paired-pulse) and performance of a motor task (lumbopelvic tilting) between individuals with LBP of predominant nociceptive (n = 9) or nociplastic presentation (n = 9) and pain-free individuals (n = 16); (2) compared these measures pre- and post-training; and (3) explored correlations between TMS measures, motor performance, and clinical features. TMS measures did not differ between groups at baseline. The nociplastic group undershot the target in the motor task. Despite improved motor performance for all groups, only MEP amplitudes increased across the recruitment curve and only for the pain-free and nociplastic groups. TMS measures did not correlate with motor performance or clinical features. Some elements of motor task performance and changes in corticomotor excitability differed between LBP groups. Absence of changes in intra-cortical TMS measures suggests regions other than M1 are likely to be involved in skill learning of back muscles.

The McKenzie method for (sub)acute non-specific low back pain

BACKGROUND

There is widespread agreement amongst clinicians that people with non-specific low back pain (NSLBP) comprise a heterogeneous group and that their management should be individually tailored. One treatment known by its tailored design is the McKenzie method (e.g. an individualized program of exercises based on clinical clues observed during assessment).

OBJECTIVES

To evaluate the effectiveness of the McKenzie method in people with (sub)acute non-specific low back pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two trials registers up to 15 August 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) investigating the effectiveness of the McKenzie method in adults with (sub)acute (less than 12 weeks) NSLBP.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review included five RCTs with a total of 563 participants recruited from primary or tertiary care. Three trials were conducted in the USA, one in Australia, and one in Scotland. Three trials received financial support from non-commercial funders and two did not provide information on funding sources. All trials were at high risk of performance and detection bias. None of the included trials measured adverse events. McKenzie method versus minimal intervention (educational booklet; McKenzie method as a supplement to other intervention - main comparison) There is low-certainty evidence that the McKenzie method may result in a slight reduction in pain in the short term (MD -7.3, 95% CI -12.0 to -2.56; 2 trials, 377 participants) but not in the intermediate term (MD -5.0, 95% CI -14.3 to 4.3; 1 trial, 180 participants). There is low-certainty evidence that the McKenzie method may not reduce disability in the short term (MD -2.5, 95% CI -7.5 to 2.0; 2 trials, 328 participants) nor in the intermediate term (MD -0.9, 95% CI -7.3 to 5.6; 1 trial, 180 participants). McKenzie method versus manual therapy There is low-certainty evidence that the McKenzie method may not reduce pain in the short term (MD -8.7, 95% CI -27.4 to 10.0; 3 trials, 298 participants) and may result in a slight increase in pain in the intermediate term (MD 7.0, 95% CI 0.7 to 13.3; 1 trial, 235 participants). There is low-certainty evidence that the McKenzie method may not reduce disability in the short term (MD -5.0, 95% CI -15.0 to 5.0; 3 trials, 298 participants) nor in the intermediate term (MD 4.3, 95% CI -0.7 to 9.3; 1 trial, 235 participants). McKenzie method versus other interventions (massage and advice) There is very low-certainty evidence that the McKenzie method may not reduce disability in the short term (MD 4.0, 95% CI -15.4 to 23.4; 1 trial, 30 participants) nor in the intermediate term (MD 10.0, 95% CI -8.9 to 28.9; 1 trial, 30 participants).

AUTHORS' CONCLUSIONS

Based on low- to very low-certainty evidence, the treatment effects for pain and disability found in our review were not clinically important. Thus, we can conclude that the McKenzie method is not an effective treatment for (sub)acute NSLBP.

Physiotherapeutic effects of an innovative golf swing-assist device on discomfort and mobility in amateur golfers with low back pain: A randomized controlled trial

BACKGROUND

Although the biomechanical features of the golf swing are extremely determined, multiple joint movements with limited pelvic and thoracic rotation movement can cause injury to the golfer and are linked with low back pain (LBP). We have developed the Pulley Master machine (PM), which is designed to offer active movement evaluation and monitoring as well as repetitive and task-specific training.

OBJECTIVE

The primary goal of the present research was to analyze the effects of PM and Transfer of Electricity-Capacitive and Resistive (TECAR) therapy on the lumbar pain scale and thoracic and pelvic mobility in amateur golfers with LBP.

METHODS

Twenty-one amateur golfers with LBP (six females, mean age = 23.43 ± 2.36 years) were randomly assigned to either PM or TECAR groups for five days per week over one week. Clinical outcome measurements included pelvic and thoracic mobility as well as a pain rating scale. Statistical analyses were presented using the analysis of variance (ANOVA), and the statistical significance level was set at P< 0.05.

RESULTS

ANOVA showed that PM outperformed TECAR in terms of pelvic and thoracic mobility as well as a pain rating scale.

CONCLUSION

The results provide novel and encouraging clinical evidence that PM improves pain control and mobility in amateur golfers with LBP.

Effect of Cognitive Load on Anticipatory Postural Adjustment Latency and its Relationship with Pain-Related Dysfunction in Non-specific Chronic Low Back Pain: A Cross-Sectional Study

INTRODUCTION

This study aimed to investigate the effect of cognitive load on anticipatory postural adjustment (APA) latency in patients with non-specific chronic low back pain (NCLBP) and its relationship with pain-related functional changes.

METHODS

A cross-sectional study was conducted from December 15, 2022 to January 25, 2023. Participants were divided into a healthy control group (n = 29) and an NCLBP group (n = 29). Each group was assigned a single task of rapid arm raising and a dual task of rapid arm raising combined with a cognitive load. The cognitive load task was conducted using visual conflict. The APA latency for bilateral trunk muscles was observed using electromyography. The duration of electromyography recording in each task cycle was 28 s. Pain related-functional changes were evaluated using Roland-Morris Disability Questionnaire (RMDQ) before all tasks.

RESULTS

The APA latency for the right multifidus was significantly delayed in the NCLBP group [25.38, 95% confidence interval (CI) 13.41-37.35] than in the healthy control group (- 5.80, 95% CI - 19.28 to 7.68) during dual task (p = 0.0416). The APA latency for the right multifidus (25.38, 95% CI 13.41-37.35) and transverse abdominis/internal oblique (29.15, 95% CI 18.81-39.50) were significantly delayed compared with on the left side in the NCLBP group during dual task (- 3.03, 95% CI - 15.18-9.13, p = 0.0220; 3.69, 95% CI - 6.81 to 14.18, p = 0.0363). The latency delay of the right and left multifidus APA in the NCLBP group under the dual-task was positively correlated with RMDQ scores (r = 0.5560, p = 0.0017; r = 0.4010, p = 0.0311).

CONCLUSIONS

Cognitive load could induce APA delay in the right trunk muscles and co-activation pattern changes in bilateral trunk muscle APA in patients with NCLBP. The APA onset delay in multifidus is positively related to pain-related daily dysfunction. Trial Registration ChiCTR2300068580 (retrospectively registered in February 23, 2023).

Mawangdui-Guidance Qigong Exercise for patients with chronic non-specific low back pain: Study protocol of a randomized controlled trial

Introduction

Worldwide, there is a high frequency of chronic non-specific low back pain (CNLBP), which is a significant public health concern. The etiology is complicated and diverse, and it includes a number of risk factors such as diminished stability and weak core muscles. Mawangdui-Guidance Qigong has been employed extensively to bolster the body in China for countless years. However, the effectiveness of treating CNLBP has not been assessed by a randomized controlled trial (RCT). In order to verify the results of the Mawangdui-Guidance Qigong Exercise and examine its biomechanical mechanism, we intend to perform a randomized controlled trial.

Methods and analysis

Over the course of 4 weeks, 84 individuals with CNLBP will be randomly assigned to receive either Mawangdui-Guidance Qigong Exercise, motor control exercise, or medication (celecoxib). Electromyographic data, including muscle activation time, iEMGs, root mean square value (RMS) and median frequency (MF), will be the main outcomes. The Japanese Orthopedic Association (JOA) Score, the Mcgill Pain Questionnaire (MPQ), beta-endorphin, and substance P are examples of secondary outcomes. At the start of treatment and 4 weeks later, all outcomes will be evaluated. SPSS version 20.0 (SPSS Inc., Chicago, IL, USA) will be used for all of the analysis.

Discussion

The prospective findings are anticipated to offer an alternative treatment for CNLBP and provide a possible explanation of the mechanism of Mawangdui-Guidance Qigong Exercise on CNLBP.

Ethics and dissemination

The Sichuan Regional Ethics Review Committee on Traditional Chinese Medicine has given the study approval (Approval No. 2020KL-067). It has also registered at the website of China Clinical Trial Center Registration. The application adheres to the Declaration of Helsinki’s tenets (Version Edinburgh 2000). Peer-reviewed papers will be used to publicize the trial’s findings.

Trial registration number

ClinicalTrials.gov, identifier ChiCTR2000041080.

Education of physiotherapists improves inter-rater reliability in lumbar spine motor control tests: A randomized controlled trial

OBJECTIVES

To determine the effect of 1-h education session, compared with no education, on physiotherapists' (PTs) inter-rater reliability in two lumbar spine motor control tests (MCTs): waiter's bow (WB) and sitting knee extension (SKE). To determine whether reliability at baseline and the effect of education are affected by PT's clinical experience, knowledge and experience of MCTs, and post-graduate education in manual therapy.

DESIGN

Randomized controlled trial.

PARTICIPANTS

54 PTs.

INTERVENTION

The experimental group (EG) took part in a 1-h group education session. Control group (CG) had no intervention.

MEASUREMENTS

At baseline and after EG had completed the education session, therapists rated 40 SKE and 40 WB video recordings.

ANALYSIS

Changes in Fleiss' kappa were compared between groups. Differences >0.1 in kappa values were considered meaningful. Regression analysis was used to evaluate the effect of therapist's characteristics on inter-rater reliability at baseline and changes in inter-rater reliability.

RESULTS

Education had significant and meaningful effect on reliability compared with no education. WB kappa values improved from 0.36 to 0.63 in the experimental group and from .39 to .46 in the control group. SKE kappa values improved from .50 to .71 in the EG and from 0.49 to 0.57 in the CG. None of PTs' characteristics affected reliability at baseline or education effects.

CONCLUSION

The effect of 1-h group education session for physiotherapists on inter-rater reliability in MCTs is significant and meaningful. Provision of education for PTs in performing observational tests would improve inter-rater reliability, resulting in improved treatment planning and outcome evaluation.

Adherence and Effect of Home-Based Rehabilitation with Telemonitoring Support in Patients with Chronic Non-Specific Low Back Pain: A Pilot Study

Home-based exercises have been on the rise recently. This pilot study aimed to assess the adherence and effect of a home-based rehabilitation programme using telemonitoring in patients with chronic non-specific low back pain (CNLBP). Twenty-seven patients with CNLBP were enrolled in the study, each of whom underwent a neurological assessment, including patient-oriented measures and a functional assessment-a battery of tests that comprehensively evaluated trunk muscle function. The rehabilitation programme lasted 18 weeks and included daily home-based exercises. A mobile application or an exercise diary was used to monitor compliance. Adherence to the programme was excellent for both the diary and mobile application groups, with 82.3% in the diary group exercising at least once a day and 72.9% twice a day, and 94.8% in the mobile application group exercising at least once a day and 86.6% twice a day. Both patient-oriented and functional outcomes improved significantly; however, the relative changes of the parameters in these two groups did not correlate, which supports the idea that trunk muscle function does not directly relate to patient complaints and that CNLBP is a multifactorial issue. This model of rehabilitation programme should be used in clinical practice, as its adherence and effectiveness seem noticeable.

Multimedia Instructions for Motor Control Exercises in Patients With Chronic Nonspecific Low Back Pain

BACKGROUND

Low back pain (LBP) is one of the top 3 diseases that may lead to disability. Current treatment guidelines define exercise as a first-line treatment for nonspecific LBP (NSLBP). There are various evidence-based exercise approaches for treating NSLBP, and many of them include motor control principles. Motor control exercises (MCEs) are better than general exercises that do not include motor control principles. Many patients find learning these exercises complex and challenging, in that MCE exercises have no standard teaching method. The researchers of this study developed multimedia instructions for an MCE program to make teaching MCE easier; thus, more effective.

METHODS

The participants were randomized into multimedia or standard (face-to-face) instruction groups. We applied the same treatments to both groups at the same dosage. The only differences between groups were the exercise instruction methods. The multimedia group learned MCE from multimedia videos; the control group learned MCE from a physiotherapist with face-to-face instructions. Treatment lasted 8 weeks. We evaluated patients' exercise adherence with Exercise Adherence Rating Scale (EARS), pain with the Visual Analog Scale, and disability with Oswestry Disability Index. Evaluations were made before and after treatment. Follow-up evaluations were carried out 4 weeks after the end of treatment.

RESULTS

There was no statistically significant interaction between the group and time on pain, F2,56 = 0.068, P = .935, partial η2 = .002 and Oswestry Disability Index scores, F2,56 = 0.951, P = .393, partial η2 = .033. Also, there was no statistically significant interaction between the group and time on Exercise Adherence Rating Scale total scores F1,20 = 2.343, P = .142, partial η2 = .105.

CONCLUSIONS

This study showed that multimedia instructions for MCE have similar effects to standard (face-to-face) instructions on pain, disability, and exercise adherence in patients with NSLBP. To our knowledge, with these results, the developed multimedia instructions became the first free, evidence-based instructions that have objective progression criteria and a Creative Commons license.

Tai Chi for spatiotemporal gait features and dynamic balancing capacity in elderly female patients with non-specific low back pain: A six-week randomized controlled trial

BACKGROUND

Non-specific low back pain (NS-LBP) is a serious public health problem. Tai Chi is promising in reducing the risk of falls and alleviating symptoms in this population.

OBJECTIVE

To investigate the effect of Tai Chi on gait and dynamic balance in elderly women with NS-LBP.

METHODS

20 women (age > 65 yr.) with NS-LBP were randomly assigned to a Tai Chi group (n= 10) or a control group (n= 10). The Tai Chi group practiced Tai Chi exercise 3 times a week for 6 weeks. Each session lasted 60 minutes. Pain, spatiotemporal gait features and dynamic balancing capacity were assessed at 0 and 6 weeks.

RESULTS

Compared to the control group at 6 weeks, the Tai Chi group had a significant decrease in VAS (p= 0.027) and stride width (p= 0.019), significant improvement in gait velocity, stride length (p< 0.001). Regarding dynamic balance capacity, the Tai Chi group had significant improvements in anterior (Left: p= 0.001; Right: p= 0.038), postero-lateral (Left: p< 0.001; Right: p= 0.038), and postero-medial (Left: p= 0.015; Right: p= 0.018).

CONCLUSION

6-week Tai Chi can relieve pain and improve gait and dynamic balance in elderly women with NS-LBP, which suggests Tai Chi could be a promising rehabilitation intervention to reduce the risk of falls in this population.

K, A. P. K, J. P, B. A. Effect of Mulligan’s mobilization combined with motor control exercises on pain functional ability and muscle activity in sacroiliac joint dysfunction

Introduction and Aim: Sacroiliac joint dysfunction accounts 15% to 30% 0f low back ache conditions, If the SIJ is hypomobile, it cannot be effectively absorbed forces causing other body parts may be overstressed causing musculoskeletal dysfunction. This study’s aim is to identify the effect of mulligan’s joint mobilization techniques, motor control exercises and, aerobic exercises on pain functional ability and muscle activity in patients with SI joint dysfunction.   Methodology: Randomized controlled study was done by selecting patients with SI joint dysfunction. 185 participants with low back pain were evaluated and out of them 116 had positive SI joint dysfunction and 95 were selected based on selection criteria.  Computer- assisted randomization was done to divide the participants into three groups. Based on that group I has got 30, group II has 33, and group III has 32. Group I participants underwent Mulligan’s mobilisation for SI joint and followed by motor control exercises, Group II participants underwent motor control exercises and Group III participants underwent Aerobic exercises. All the treatment was given for 45 minutes 5 days per week for 6 weeks of duration. This study uses functional disability, Transverses abdominis muscle endurance, and pain measured using the Oswestry disability index, pressure biofeedback and numerical pain scale respectively.   Results:  On comparing group I and group II, the group I shows a significant improvement in all the outcomes. The ANOVA results show that the p-value is < .00001. The result is significant at p <0.05.   Conclusion: This study concludes that mulligans mobilization with motor control exercises would significantly improve pain, functional disability, and transverses abdominis muscle endurance.

Acute effects of game-based biofeedback training on trunk motion in chronic low back pain: a randomized cross-over pilot trial

Background

Improving movement control might be a promising treatment goal during chronic non-specific low back pain (CLBP) rehabilitation. The objective of the study is to evaluate the effect of a single bout of game-based real-time feedback intervention on trunk movement in patients with CLBP.

Methods

Thirteen CLBP patients (8female;41 ± 16 years;173 ± 10 cm;78 ± 22 kg) were included in this randomized cross-over pilot trial. During one laboratory session (2 h), participants performed three identical measurements on trunk movement all including: first, maximum angle of lateral flexion was assessed. Secondly, a target trunk lateral flexion (angle: 20°) was performed. Main outcome was maximum angle ([°]; MA). Secondary outcomes were deviation [°] from the target angle (angle reproduction; AR) and MA of the secondary movement planes (rotation; extension/flexion) during lateral flexion. The outcomes were assessed by an optical 3D-motion-capture-system (2-segment-trunk-model). The measurements were separated by 12-min of intervention and/or resting (randomly). The intervention involved a sensor-based trunk exergame (guiding an avatar through virtual worlds). After carryover effect-analysis, pre-to-post intervention data were pooled between the two sequences followed by analyses of variances (paired t-test).

Results

No significant change from pre to post intervention for MA or AR for any segment occurred for the main movement plane, lateral flexion (p > .05). The upper trunk segment showed a significant decrease of the MA for trunk extension/flexion from pre to post intervention ((4.4° ± 4.4° (95% CI 7.06–1.75)/3.5° ± 1.29° (95% CI 6.22–0.80); p = 0.02, d = 0.20).

Conclusions

A single bout of game-based real-time feedback intervention lead to changes in the secondary movement planes indicating reduced evasive motion during trunk movement.

Trial registration No. DRKS00029765 (date of registration 27.07.2022). Retrospectively registered in the German Clinical Trial Register.

Comparison of supervised exercise therapy with or without biopsychosocial approach for chronic nonspecific low back pain: a randomized controlled trial

Background

A biopsychosocial rehabilitation is recommended for chronic nonspecific low back pain (CNLBP); however, its effectiveness compared to the traditional supervised exercise therapy of CNLBP treatment is still unclear.

Methods

This was a parallel-group randomized controlled clinical trial. The sample consisted of 180 participants of both sexes, aged ≥18 years, with CNLBP for ≥3 months. Using web randomization and concealed allocation, they were assigned to three groups; graded activity receiving cognitive-behavioral therapy, group-based combined exercise therapy and education (GA; n = 59), supervised group-based combined exercise therapy and education (SET; n = 63), and a control group receiving usual care (n = 58). Interventions were administered for 4 weeks (8 sessions). The primary outcome was pain intensity. Outcome measures were collected baseline, after interventions (4 weeks), and during two follow-up periods (3 and 6 months).

Results

After the intervention, GA had a significant large effect on pain reduction compared to the control group (MD of 22.64 points; 95% CI = 16.10 to 29.19; p < 0.0001; Cohen’s d = 1.70), as well as SET compared with the control group (MD of 21.08 points; 95% CI = 14.64 to 27.52; p < 0.0001; Cohen’s d = 1.39), without significant difference between two intervention groups. At 3 and 6 months of follow-up, GA had a statistically significantly better effect in reducing pain, disability and fear-avoidance beliefs, and improving spinal extensor endurance, range of extension and quality of life compared to SET and the control group. A statistically significantly better effect of SET compared with the control group was found in reducing pain, disability, fear-avoidance beliefs, and improving the physical component of quality of life. Harms were not reported.

Conclusion

This study suggests that graded activity and group-based supervised exercise therapy have beneficial effects over the control group in the treatment of CNLBP. The graded activity was more beneficial than supervised group-based exercise therapy only during the follow-up.

Trial registration

Clinicaltrials.gov (NCT04023162; registration date: 17/07/2019).

Sensor-based intervention to enhance movement control of the spine in low back pain: Protocol for a quasi-randomized controlled trial

Introduction

Chronic low back pain is a common condition that imposes an enormous burden on individuals and society. Physical exercise with education is the most effective treatment, but generally results in small, albeit significant improvements. However, which type of exercise is most effective remains unknown. Core stability training is often used to improve muscle strength and spinal stability in these patients. The majority of the core stability exercises mentioned in intervention studies involve no spinal movements (static motor control exercises). It is questionable if these exercises would improve controlled movements of the spine. Sensor-based exergames controlled with spinal movements could help improve movement control of the spine. The primary aim of this study is to compare the effects of such sensor-based exergames to static motor control exercises on spinal movement control.

Methods and analysis

In this quasi-randomized controlled trial, 60 patients with chronic low back pain who are already enrolled in a multidisciplinary rehabilitation programme will be recruited. Patients will be randomly allocated into one of two groups: the Sensor-Based Movement Control group (n = 30) or the Static Motor Control group (n = 30). Both groups will receive 8 weeks of two supervised therapy sessions and four home exercises per week in addition to the rehabilitation programme. At baseline (week 1) and after the intervention (week 10), movement control of the spine will be assessed using a tracking task and clinical movement control test battery. Questionnaires on pain, disability, fear avoidance and quality of life will be taken at baseline, after intervention and at 6- and 12 months follow-up. Repeated measures ANOVAs will be used to evaluate if a significant Group x Time interaction effect exists for the movement control evaluations.

Discussion

Sensor-based spinal controlled exergames are a novel way to train spinal movement control using meaningful and engaging feedback. The results of this study will inform clinicians and researchers on the efficacy of movement control training for patients with low back pain.

Ethics and dissemination

Ethical approval for this study protocol was obtained from the METC Brabant (protocol number NL76811.028.21).

Trial registration

Open Science Framework Registries (https://osf.io/v3mw9/), registration number: 10.17605/OSF.IO/V3MW9, registered on 1 September 2021.

Effectiveness of a Group-Based Rehabilitation Program Combining Education with Multimodal Exercises in the Treatment of Patients with Nonspecific Chronic Low Back Pain: A Retrospective Uncontrolled Study

Currently, there is no consensus on the best rehabilitation program to perform for nonspecific chronic low back pain (NSCLBP). However, multimodal exercises, education, and group-based sessions seem to be beneficial. We, therefore, launched such a treatment program and aimed to evaluate its effectiveness in improving patient health status. We retrospectively analyzed the records of 23 NSCLB patients who followed the MyBack program at La Tour hospital from 2020 to 2022 (25 sessions, 8 weeks). Patients were evaluated before and after intervention using pain on a visual analog scale (pVAS), Roland−Morris Disability Questionnaire (RMDQ), Pain Catastrophizing Scale (PCS), Tampa Scale of Kinesiophobia (TSK), and the EuroQol-5D-3L (EQ-5D-3L). Responder rates were calculated using minimal clinically important differences. Patients reported a significant reduction (p < 0.05) in the pVAS (5.3 ± 1.2 vs. 3.1 ± 1.6), RMDQ (8.8 ± 3.3 vs. 4.0 ± 3.7), PCS (24.5 ± 9.4 vs. 11.7 ± 7.9) and TSK (41.5 ± 9.2 vs. 32.7 ± 7.0). The EQ-5D-3L also statistically improved (score: 0.59 ± 0.14 vs. 0.73 ± 0.07; and VAS: 54.8 ± 16.8 vs. 67.0 ± 15.2). The responder rates were 78% for the pVAS and PCS, 74% for the RMDQ and TSK, and only 26% for the EQ-5D-3L. The MyBack program combining education with multimodal group exercises led to satisfactory clinical, functional, and psychosocial outcomes.

The Effect of Lumbar Belts with Different Extensibilities on Kinematic, Kinetic, and Muscle Activity of Sit-to-Stand Motions in Patients with Nonspecific Low Back Pain

Although lumbar belts can be used for the treatment and prevention of low back pain, the role of the lumbar belt remains unclear without clear guidelines. This study aimed to investigate the effect of lumbar belts with different extensibilities on the kinematics, kinetics, and muscle activity of sit-to-stand motions in terms of motor control in patients with nonspecific low back pain. A total of 30 subjects participated in the study: 15 patients with nonspecific low back pain and 15 healthy adults. Participants performed the sit-to-stand motion in random order of three conditions: no lumbar belt, wearing an extensible lumbar belt, and wearing a non-extensible lumbar belt. The sit-to-stand motion's kinematic, kinetic, and muscle activity variables in each condition were measured using a three-dimensional motion analysis device, force plate, and surface electromyography. An interaction effect was found for the time taken, anterior pelvic tilt angle, and muscle activity of the vastus lateralis and biceps femoris. The two lumbar belts with different extensibilities had a positive effect on motor control in patients with nonspecific low back pain. Therefore, both types of extensible lumbar belts can be useful in the sit-to-stand motion, which is an important functional activity for patients with nonspecific low back pain.

Summarizing the effects of different exercise types in chronic low back pain - a systematic review of systematic reviews

Background

In chronic LBP (CLBP), guideline-endorsed treatment is to stay active, return to normal activity, and to exercise. Several reviews on various exercise types used in CLBP have been published. We aimed to identify systematic reviews of common exercise types used in CLBP, to appraise their quality, and to summarize and compare their effect on pain and disability.

Methods

We searched the databases OVID MEDLINE, EMBASE, COCHRANE LIBRARY, and WEB OF SCIENCE (Core collection) for systematic reviews and meta-analyses on adults between 18 and 70 years of age suffering from chronic or recurrent LBP for a period of at least 12 weeks, which investigated the effects of exercises on pain and disability. All searches were conducted without language restriction. The search was performed up until 2022–01-26. The included reviews were grouped into nine exercise types: aerobic training, aquatic exercises, motor control exercises (MCE), resistance training, Pilates, sling exercises, traditional Chinese exercises (TCE), walking, and yoga. The study quality was assessed with AMSTAR-2. For each exercise type, a narrative analysis was performed, and the level of evidence for the effects of exercise was assessed through GRADE.

Results

Our database search resulted in 3,475 systematic reviews. Out of the 253 full texts that were screened, we included 45 systematic reviews and meta-analyses. The quality of the included reviews ranged from high to critically low. Due to large heterogeneity, no meta-analyses were performed. We found low-to-moderate evidence of mainly short-term and small beneficial effects on pain and disability for MCE, Pilates, resistance training, TCE, and yoga compared to no or minimal intervention.

Conclusions

Our findings show that the effect of various exercise types used in CLBP on pain and disability varies with no major difference between exercise types. Many of the included systematic reviews were of low-to-moderate quality and based on randomized controlled trials with high risk of bias. The conflicting results seen, undermine the certainty of the results leading to very-low-to-moderate quality of evidence for our results. Future systematic reviews should be of higher quality to minimize waste of resources.

Trial registration

PROSPERO: Reg no 190409 Registration date 01AUG 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05722-x.

Sling Exercise Can Drive Cortical Representation of the Transversus Abdominis and Multifidus Muscles in Patients With Chronic Low Back Pain

Objective

The transversus abdominis (TrA) and multifidus (MF) muscles are essential in preventing chronic low back pain (CLBP) recurrence by maintaining segmental stabilization and stiffness. Sling exercise is a high-level core stability training to effectively improve the activities of the TrA and MF muscles. However, the neural mechanism for sling exercise-induced neural plasticity change in the primary motor cortex (M1) remains unclear. This study aimed to investigate the role of sling exercise in the reorganization of the motor cortical representation of the TrA and MF muscles.

Methods

Twenty patients with CLBP and 10 healthy individuals were recruited. For map volume, area, the center of gravity (CoG) location (medial-lateral location and anterior-posterior location), and latency, two-way ANOVA was performed to compare the effects of groups (the CLBP-pre, CLBP-post, and healthy groups) and the two muscles (the TrA and MF muscles). The Visual Analog Scale (VAS), the Oswestry Disability Index (ODI), and postural balance stability were assessed at baseline and at the end of 2 weeks of sling exercise. Linear correlations between VAS or ODI and CoG locations were assessed by Pearson's correlation test.

Results

2 weeks of sling exercise induced both the anterior-medial (P &lt; 0.001) and anterior-posterior (P = 0.025) shifts of the MF muscle representation at the left motor cortex in patients with CLBP. Anterior-medial (P = 0.009) shift of the TrA muscle representation at the right motor cortex was observed in patients with CLBP. The motor cortical representation of the two muscles in patients with CLBP after sling exercise (TrA: 2.88 ± 0.27 cm lateral and 1.53 ± 0.47 cm anterior of vertex; MF: 3.02 ± 0.48 cm lateral and 1.62 ± 0.40 cm anterior of vertex) closely resembled that observed in healthy individuals (TrA: 2.83 ± 0.48 cm lateral and 2.00 ± 0.43 cm anterior of vertex; MF: 2.94 ± 0.43 cm lateral and 1.77 ± 0.48 cm anterior of vertex). The VAS and the ODI were reduced following the sling exercise (VAS: P &lt; 0.001; ODI: P &lt; 0.001).

Conclusion

This study provides evidence that sling training can drive plasticity changes in the motor system, which corresponds with the reduction in pain and disability levels in patients with CLBP. This study was registered in the Chinese Clinical Trial Registry (Clinical Trial Registration Number: ChiCTR2100045904, http://www.chictr.org.cn/showproj.aspx?proj=125819).

Clinical Trial Registration

ChiCTR2100045904.

Feedback on Trunk Movements From an Electronic Game to Improve Postural Balance in People With Nonspecific Low Back Pain: Pilot Randomized Controlled Trial

Background

Postural balance is compromised in people with low back pain, possibly by changes in motor control of the trunk. Augmenting exercising interventions with sensor-based feedback on trunk posture and movements might improve postural balance in people with low back pain.

Objective

We hypothesized that exercising with feedback on trunk movements reduces sway in anterior-posterior direction during quiet standing in people with low back pain. Secondary outcomes were lumbar spine and hip movement assessed during box lift and waiter bow tasks, as well as participant-reported outcomes. Adherence to the exercising intervention was also examined.

Methods

A randomized controlled trial was conducted with the intervention group receiving unsupervised home exercises with visual feedback using the Valedo Home, an exergame based on 2 inertial measurement units. The control group received no intervention. Outcomes were recorded by blinded staff during 4 visits (T1-T4) at University Hospital Zurich. The intervention group performed 9 sessions of 20 minutes in the 3 weeks between T2 and T3 and were instructed to exercise at their own convenience between T3 and T4. Postural balance was assessed on a force platform. Lumbar spine and hip angles were obtained from 3 inertial measurement units. The assessments included pain intensity, disability, quality of life, and fear of movement questionnaires.

Results

A total of 32 participants with nonspecific low back pain completed the first assessment T1, and 27 (84%) participants were randomized at T2 (n=14, 52% control and n=13, 48% intervention). Intention-to-treat analysis revealed no significant difference in change in anterior-posterior sway direction during the intervention period with a specified schedule (T2-T3) between the groups (W=99; P=.36; r=0.07). None of the outcomes showed significant change in accordance with our hypotheses. The intervention group completed a median of 61% (55/90; range 2%-99%) of the exercises in the predefined training program. Adherence was higher in the first intervention period with a specified schedule.

Conclusions

The intervention had no significant effect on postural balance or other outcomes, but the wide range of adherence and a limited sample size challenged the robustness of these conclusions. Future work should increase focus on improving adherence to digital interventions.

Trial Registration

ClinicalTrials.gov NCT04364243; https://clinicaltrials.gov/ct2/show/NCT04364243

International Registered Report Identifier (IRRID)

RR2-10.2196/26982

Effect of m-health-based core stability exercise combined with self-compassion training for patients with non-specific chronic low back pain: study protocol for a randomized controlled trial

Background

Non-specific chronic low back pain (NCLBP) has a high incidence, which has a significant impact on a patient’s body and mind and is a common condition affecting people’s quality of life. Core stability exercise (CSE) is a modestly effective treatment for NCLBP; however, CSE has only been shown to be a useful treatment option in the short term. Many clinical practice guidelines recommend the use of a biopsychosocial framework to guide the management of NCLBP. Self-compassion training (SCT) is a promising psychotherapy treatment option for NCLBP; however, there is still a lack of research on CSE combined with SCT. In this study, we will seek to determine whether CSE combined with SCT is an effective treatment option for patients with NCLBP compared to CSE alone.

Methods

In this study, we will randomize 166 adults with NCLBP to a combined SCT and CSE arm or a CSE alone arm (83 participants per group). Both interventions will consist of four weekly 1.5-h group sessions of CSE supplemented by home practice. The combined group protocol also includes 2 h of SCT before CSE. Interviewers masked to the treatment assignments will assess the outcomes at 4 and 16 weeks post-randomization. The primary outcomes are back pain disability (based on the Roland-Morris Disability Questionnaire) and pain intensity (NRS; average pain, worst pain, average pain) at 16 weeks.

Discussion

If SCT is found to enhance the effectiveness of CSE for patients with chronic back pain, the results of the study may promote the development of mind-body therapies for chronic low back pain.

Trial registration

Chinese Clinical Trial Registry ChiCTR2100042810. Registered on 21 January 2021

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

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

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

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

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

Effect of Six-Week Resistance and Sensorimotor Training on Trunk Strength and Stability in Elite Adolescent Athletes: A Randomized Controlled Pilot Trial

Intervention in the form of core-specific stability exercises is evident to improve trunk stability. The purpose was to assess the effect of an additional 6 weeks sensorimotor or resistance training on maximum isokinetic trunk strength and response to sudden dynamic trunk loading (STL) in highly trained adolescent athletes. The study was conducted as a single-blind, 3-armed randomized controlled trial. Twenty-four adolescent athletes (14f/10 m, 16 ± 1 yrs.;178 ± 10 cm; 67 ± 11 kg; training sessions/week 15 ± 5; training h/week 22 ± 8) were randomized into resistance training (RT; n = 7), sensorimotor training (SMT; n = 10), and control group (CG; n = 7). Athletes were instructed to perform standardized, center-based training for 6 weeks, two times per week, with a duration of 1 h each session. SMT consisted of four different core-specific sensorimotor exercises using instable surfaces. RT consisted of four trunk strength exercises using strength training machines, as well as an isokinetic dynamometer. All participants in the CG received an unspecific heart frequency controlled, ergometer-based endurance training (50 min at max. heart frequency of 130HF). For each athlete, each training session was documented in an individual training diary (e.g., level of SMT exercise; 1RM for strength exercise, pain). At baseline (M1) and after 6 weeks of intervention (M2), participants’ maximum strength in trunk rotation (ROM:63°) and flexion/extension (ROM:55°) was tested on an isokinetic dynamometer (concentric/eccentric 30°/s). STL was assessed in eccentric (30°/s) mode with additional dynamometer-induced perturbation as a marker of core stability. Peak torque [Nm] was calculated as the main outcome. The primary outcome measurements (trunk rotation/extension peak torque: con, ecc, STL) were statistically analyzed by means of the two-factor repeated measures analysis of variance (α = 0.05). Out of 12 possible sessions, athletes participated between 8 and 9 sessions (SMT: 9 ± 3; RT: 8 ± 3; CG: 8 ± 4). Regarding main outcomes of trunk performance, experimental groups showed no significant pre–post difference for maximum trunk strength testing as well as for perturbation compensation (p &gt; 0.05). It is concluded, that future interventions should exceed 6 weeks duration with at least 2 sessions per week to induce enhanced trunk strength or compensatory response to sudden, high-intensity trunk loading in already highly trained adolescent athletes, regardless of training regime.

Does m-health-based exercise (guidance plus education) improve efficacy in patients with chronic low-back pain? A preliminary report on the intervention's significance

Background

The utilization of mobile health (m-health) has rapidly expanded during the COVID-19 pandemic, and there is still a lack of relevant clinical data pertaining to chronic low-back pain (CLBP) management. This study was designed to compare the effectiveness of m-health-based exercise (via guidance plus education) versus exercise (via guidance) during CLBP management.

Methods

Participants (n = 40) were randomly assigned to intervention and control groups. The intervention group received m-health-based exercise (via guidance plus education), whereas the control group received m-health-based exercise (via guidance). The exercise prescription video and educational content were sent to participants by the application (app), Ding Talk. Repeated-measures analysis of variance was used to test the baseline’s intervention effects, 6-week follow-up, and 18-week follow-up. We selected function (Roland and Morris Disability Questionnaire) and pain intensity (current, mean, and most severe Numeric Rating Scale in the last 2 weeks) as the primary outcomes, changes of negative emotion (depression, anxious), and quality of life as the secondary outcomes.

Results

Time’s significant effect was found in pain, function, and health-related quality of life in both groups, but time did not show significant interaction effects. Participants were able to use m-based education with their anxiety and depression after treatment, but the relief only lasted until week 6. No differences were found on the aspect of mental health-related quality of life.

Conclusion

Preliminary findings suggest that m-health-based exercise (via guidance) may be a convenient and effective method to treat CLBP. However, additional health education didn't help more. More rigorous controlled trials are needed to improve the therapeutic effect in future studies.

Trial registration

Chinese Clinical Trials Registry Number ChiCTR2000041459. Registered on December 26, 2020.

Pain Neuroscience Education and Motor Control Exercises versus Core Stability Exercises on Pain, Disability, and Balance in Women with Chronic Low Back Pain

Background: Several interventions have been used to relieve chronic low back pain (CLBP). This study aimed to compare the effects of pain neuroscience education (PNE) followed by motor control exercises (MCEs) with core stability training (CST) on pain, disability, and balance in women with CLBP. Methods: Thirty-seven women with CLBP were randomly divided into two groups of PNE/MCE (n = 18, 55.2 ± 2.6 years) or CST (n = 19, 54.6 ± 2.4 years). Eight weeks of PNE/MCE or CST were prescribed for each group, independently. Pain intensity (VAS scale), disability (Roland Morris Disability Questionnaire), unipodal static balance, and dynamic balance (time up and go test) were measured at the beginning and 8 weeks after the intervention. Two-way mixed ANOVA was used to analyze the results with alpha of 5%. Results: After 8 weeks, there was a significant difference in VAS scale between groups (p = 0.024), with both PNE/MCE and CST showing 58% and 42% reductions, respectively. There were no differences for all other variables between groups. Regarding pre- to post-comparisons, both groups showed improvements in all dependent variables (p < 0.001). Conclusion: The treatment with PNE/MCE was more effective in improving pain disability and unipodal static and dynamic balance than treatment with CST. Even so, both treatments were shown to be valid and safe in improving all dependent variables analyzed in women with CLBP.

3D Stereophotogrammetric Quantitative Evaluation of Posture and Spine Proprioception in Subacute and Chronic Nonspecific Low Back Pain

The literature shows that low back pain causes a reduced lumbar range of movement, affecting patients’ proprioception and motor control. Nevertheless, studies have found that proprioception and motor control of the spine and posture are vague and individually expressed even in healthy young adults. This study aimed to investigate the standing posture and its modifications induced by an instinctive self-correction manoeuvre in subacute and chronic nonspecific low back pain (NSLBP) patients to clarify how NSLBP relates to body upright posture, proprioception, and motor control and how these are modified in patients compared to healthy young adults (121 healthy young adults: 57 females and 64 males). A cohort of 83 NSLBP patients (43 females, 40 males) were recruited in a cross-sectional observational study. Patients’ entire body posture, including 3D spine shape reconstruction, was measured using a non-ionising 3D optoelectronic stereophotogrammetric approach. Thirteen quantitative biomechanical parameters describing the nature of body posture were computed. The statistical analysis was performed using multivariate methods. NSLBP patients did not present an altered proprioception and motor control ability compared to healthy young adults. Furthermore, as for healthy subjects, NSLBP patients could not focus and control their posture globally. Proprioception and motor control in natural erect standing are vague for most people regardless of gender and concurrent nonspecific low back pain. Self-correction manoeuvres improving body posture and spine shape must be learned with specific postural training focusing on the lumbar spine.

Associations of low-back pain and pain-related cognitions with lumbar movement patterns during repetitive seated reaching

BACKGROUND

Development of more effective interventions for nonspecific chronic low back pain (LBP), requires a robust theoretical framework regarding mechanisms underlying the persistence of LBP. Altered movement patterns, possibly driven by pain-related cognitions, are assumed to drive pain persistence, but cogent evidence is missing.

AIM

To assess variability and stability of lumbar movement patterns, during repetitive seated reaching, in people with and without LBP, and to investigate whether these movement characteristics are associated with pain-related cognitions.

METHODS

60 participants were recruited, matched by age and sex (30 back-healthy and 30 with LBP). Mean age was 32.1 years (SD13.4). Mean Oswestry Disability Index-score in LBP-group was 15.7 (SD12.7). Pain-related cognitions were assessed by the 'Pain Catastrophizing Scale' (PCS), 'Pain Anxiety Symptoms Scale' (PASS) and the task-specific 'Expected Back Strain' scale(EBS). Participants performed a seated repetitive reaching movement (45 times), at self-selected speed. Lumbar movement patterns were assessed by an optical motion capture system recording positions of cluster markers, located on the spinous processes of S1 and T8. Movement patterns were characterized by the spatial variability (meanSD) of the lumbar Euler angles: flexion-extension, lateral-bending, axial-rotation, temporal variability (CyclSD) and local dynamic stability (LDE). Differences in movement patterns, between people with and without LBP and with high and low levels of pain-related cognitions, were assessed with factorial MANOVA.

RESULTS

We found no main effect of LBP on variability and stability, but there was a significant interaction effect of group and EBS. In the LBP-group, participants with high levels of EBS, showed increased MeanSD_{lateral-bending} (p = 0.004, η² = 0.14), indicating a large effect. MeanSD_{axial-rotation} approached significance (p = 0.06).

SIGNIFICANCE

In people with LBP, spatial variability was predicted by the task-specific EBS, but not by the general measures of pain-related cognitions. These results suggest that a high level of EBS is a driver of increased spatial variability, in participants with LBP.

Making exercise count: Considerations for the role of exercise in back pain treatment

INTRODUCTION

Chronic low back pain (CLBP) is pain that has persisted for greater than three months. It is common and burdensome and represents a significant proportion of primary health presentations. For the majority of people with CLBP, a specific nociceptive contributor cannot be reliably identified, and the pain is categorised as 'non-specific'. Exercise therapy is recommended by international clinical guidelines as a first-line treatment for non-specific CLBP.

AIM

This comprehensive review aims to synthesise and appraise the current research to provide practical, evidence-based guidance concerning exercise prescription for non-specific CLBP. We discuss detailed initial assessment and being informed by patient preferences, values, expectations, competencies and goals.

METHODS

We searched the Cochrane Database of Systematic Reviews, PubMed and the Physiotherapy Evidence Database (PEDro) using broad search terms from January 2000 to March 2021, to identify the most recent clinical practice guidelines, systematic reviews and randomised controlled trials on exercise for CLBP.

RESULTS/DISCUSSION

Systematic reviews show exercise is effective for small, short-term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, and serious adverse events are rare. A range of individualised or group-based exercise modalities have been demonstrated as effective in reducing pain and disability. Despite this consensus, controversies and significant challenges remain.

CONCLUSION

To promote recovery, sustainable outcomes and self-management, exercise can be coupled with education strategies, as well as interventions that enhance adherence, motivation and patient self-efficacy. Clinicians might benefit from intentionally considering their own knowledge and competencies, potential harms of exercise and costs to the patient. This comprehensive review provides evidence-based practical guidance to health professionals who prescribe exercise for people with non-specific CLBP.

Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis

QUESTION

What are the effects of specific types of exercise treatments on pain intensity and functional limitation outcomes for adults with chronic low back pain?

DESIGN

Systematic review with network meta-analysis of randomised controlled trials.

PARTICIPANTS

Adults with non-specific low back pain for ≥ 12 weeks.

INTERVENTION

Exercise treatments prescribed or planned by a health professional that involved conducting specific activities, postures and/or movements with a goal to improve low back pain outcomes.

OUTCOME MEASURES

Pain intensity (eg, visual analogue scale or numerical rating scale) and back-related functional limitations (eg, Roland Morris Disability Questionnaire or Oswestry Disability Index), each standardised to range from 0 to 100.

RESULTS

This review included 217 randomised controlled trials with 20,969 participants and 507 treatment groups. Most exercise types were more effective than minimal treatment for pain and functional limitation outcomes. Network meta-analysis results were compatible with moderate to clinically important treatment effects for Pilates, McKenzie therapy, and functional restoration (pain only) and flexibility exercises (function only) compared with minimal treatment, other effective treatments and other exercise types. The estimated mean differences for these exercise types compared with minimal treatment ranged from -15 to -19 for pain and from -10 to -12 for functional limitation.

CONCLUSION

This review found evidence that Pilates, McKenzie therapy and functional restoration were more effective than other types of exercise treatment for reducing pain intensity and functional limitations. Nevertheless, people with chronic low back pain should be encouraged to perform the exercise that they enjoy to promote adherence.

REGISTRATION

DOI:10.1002/14651858.CD009790.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Ability of Physiotherapists and Physiotherapy Students to Evaluate and Classify Lumbar Movement Control Using Lumbopelvic Movement Control Tests

Purpose: The aims of our study were to (1) describe the tests that physiotherapists use to assess lumbopelvic movement control and (2) compare physiotherapists' and physiotherapy students' ability to evaluate lumbar movement dysfunction in patients with non-specific low back pain (NSLBP). Method: A quantitative, observational, cross-sectional study design was used. A total of 93 qualified physiotherapists and 96 students participated in our study. The physiotherapists reported whether they were familiar with lumbopelvic movement control tests and indicated which tests they used to assess lumbopelvic movement control (Part 1). Both the physiotherapists and the students evaluated and classified lumbopelvic movement control while observing videos of patients with NSLBP (Part 2). The responses from physiotherapists and students were described and compared between the two groups using the Fisher exact test (p ≤ 0.05). Odds ratios were calculated in terms of years of experience and level of education. Results: A total of 80 physiotherapists (86%) were familiar with lumbopelvic movement control tests, but only a few were using those tests as part of the assessment of patients; 12 (13%) used waiter's bow; 16 (17%) used rocking forward; 17 (18%) used rocking backward; 32 (34%) used sitting knee extension; 34 (37%) used prone knee flexion; and 70 (75%) used posterior pelvic tilt. The physiotherapy students and qualified physiotherapists generally agreed on the ratings of most of the videos (e.g., as correct or incorrect). A difference was found in only 3 of 24 videos for both the qualified physiotherapists and the physiotherapy students (p = 0.001, p = 0.007, and p = 0.033, respectively), which indicates that qualified physiotherapists and students agreed and classified 21 videos the same. No differences were found in the ability of physiotherapists (regardless of experience) or students to classify patients as presenting with either a flexion or an extension pattern. Conclusions: The majority of physiotherapists were familiar with lumbopelvic movement control tests, but only a few used them. Both the physiotherapists and the students were able to classify patients with NSLBP presenting with either a flexion or an extension pattern.