Motor control exercise for acute 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.

Lumbar Paravertebral Muscle Pain Management Using Kinesitherapy and Electrotherapeutic Modalities

BACKGROUND

Low back pain is considered a public health problem internationally. Low back pain is a cause of disability that occurs in adolescents and causes negative effects in adults as well. The work environment and physical and psychosocial factors can influence the occurrence and evolution of low back pain.

METHODS

The purpose of this paper is to highlight the physiological and functional changes in young adults with painful conditions of the lumbar spine, after using exercise therapy. The study was of the longitudinal type and was carried out over a period 6 months in an outpatient setting. The rehabilitation treatment included electrotherapeutic modalities and kinesitherapy.

RESULTS

The results obtained when evaluating each parameter, for all moments, show statistically significant values in both groups. The results obtained regarding the relationship between the therapeutic modalities specific to rehabilitation medicine and low back pain are consistent with those reported in studies.

CONCLUSIONS

Depending on the clinical-functional status of each patient, kinesitherapy can accelerate the heart rate and increase the blood pressure and oxygen saturation of the arterial blood, values that can later return to their initial levels, especially through training.

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.

Exercise therapy for treatment of acute non-specific low back pain

BACKGROUND

Low back pain (LBP) is the leading cause of disability globally. It generates considerable direct costs (healthcare) and indirect costs (lost productivity). The many available treatments for LBP include exercise therapy, which is practised extensively worldwide.

OBJECTIVES

To evaluate the benefits and harms of exercise therapy for acute non-specific low back pain in adults compared to sham/placebo treatment or no treatment at short-term, intermediate-term, and long-term follow-up.

SEARCH METHODS

This is an update of a Cochrane Review first published in 2005. We conducted an updated search for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, four other databases, and two trial registers. We screened the reference lists of all included studies and relevant systematic reviews published since 2004.

SELECTION CRITERIA

We included RCTs that examined the effects of exercise therapy on non-specific LBP lasting six weeks or less in adults. Major outcomes for this review were pain, functional status, and perceived recovery. Minor outcomes were return to work, health-related quality of life, and adverse events. Our main comparisons were exercise therapy versus sham/placebo treatment and exercise therapy versus no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We evaluated outcomes at short-term follow-up (time point within three months and closest to six weeks after randomisation; main follow-up), intermediate-term follow-up (between nine months and closest to six months), and long-term follow-up (after nine months and closest to 12 months); and we used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 23 studies (13 from the previous review, 10 new studies) that involved 2674 participants and provided data for 2637 participants. Three small studies are awaiting classification, and four eligible studies are ongoing. Included studies were conducted in Europe (N = 9), the Asia-Pacific region (N = 9), and North America (N = 5); and most took place in a primary care setting (N = 12), secondary care setting (N = 6), or both (N = 1). In most studies, the population was middle-aged and included men and women. We judged 10 studies (43%) at low risk of bias with regard to sequence generation and allocation concealment. Blinding is not feasible in exercise therapy, introducing performance and detection bias. There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on pain scores in the short term (mean difference (MD) -0.80, 95% confidence interval (CI) -5.79 to 4.19; 1 study, 299 participants). The absolute difference was 1% less pain (95% CI 4% more to 6% less), and the relative difference was 4% less pain (95% CI 20% more to 28% less). The mean pain score was 20.1 (standard deviation (SD) 21) for the intervention group and 20.9 (SD 23) for the control group. There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on functional status scores in the short term (MD 2.00, 95% CI -2.20 to 6.20; 1 study, 299 participants). The absolute difference was 2% worse functional status (95% CI 2% better to 6% worse), and the relative difference was 15% worse (95% CI 17% better to 47% worse). The mean functional status score was 15.3 (SD 19) for the intervention group and 13.3 (SD 18) for the control group. We downgraded the certainty of the evidence for pain and functional status by one level for risk of bias and by two levels for imprecision (only one study with fewer than 400 participants). There is very low-certainty evidence that exercise therapy compared with no treatment has no clinically relevant effect on pain or functional status in the short term (2 studies, 157 participants). We downgraded the certainty of the evidence by two levels for imprecision and by one level for inconsistency. One study associated exercise with small benefits and the other found no differences. The first study was conducted in an occupational healthcare centre, where participants received one exercise therapy session. The other study was conducted in secondary and tertiary care settings, where participants received treatment three times per week for six weeks. We did not pool data from these studies owing to considerable clinical heterogeneity. In two studies, there were no reported adverse events. One study reported adverse events unrelated to exercise therapy. The remaining studies did not report whether any adverse events had occurred. Owing to insufficient reporting of adverse events, we were unable to reach any conclusions on the safety or harms related to exercise therapy.

AUTHORS' CONCLUSIONS

Exercise therapy compared to sham/placebo treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. Exercise therapy compared to no treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. We downgraded the certainty of the evidence to very low for inconsistency, risk of bias concerns, and imprecision (few participants).

Factors that influence the provision of home-based rehabilitation services for people needing rehabilitation: a qualitative evidence synthesis

BACKGROUND

To increase people's access to rehabilitation services, particularly in the context of the COVID-19 pandemic, we need to explore how the delivery of these services can be adapted. This includes the use of home-based rehabilitation and telerehabilitation. Home-based rehabilitation services may become frequently used options in the recovery process of patients, not only as a solution to accessibility barriers, but as a complement to the usual in-person inpatient rehabilitation provision. Telerehabilitation is also becoming more viable as the usability and availability of communication technologies improve.

OBJECTIVES

To identify factors that influence the organisation and delivery of in-person home-based rehabilitation and home-based telerehabilitation for people needing rehabilitation.

SEARCH METHODS

We searched PubMed, Global Health, the VHL Regional Portal, Epistemonikos, Health Systems Evidence, and EBM Reviews as well as preprints, regional repositories, and rehabilitation organisations websites for eligible studies, from database inception to search date in June 2022.  SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; and that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services responding to patients' needs in different phases of their health conditions.   DATA COLLECTION AND ANALYSIS: We used a purposive sampling approach and applied maximum variation sampling in a four-step sampling frame. We conducted a framework thematic analysis using the CFIR (Consolidated Framework for Implementation Research) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach.  MAIN RESULTS: We included 223 studies in the review and sampled 53 of these for our analysis. Forty-five studies were conducted in high-income countries, and eight in low-and middle-income countries. Twenty studies addressed in-person home-based rehabilitation, 28 studies addressed home-based telerehabilitation services, and five studies addressed both modes of delivery. The studies mainly explored the perspectives of healthcare providers, patients with a range of different health conditions, and their informal caregivers and family members.  Based on our GRADE-CERQual assessments, we had high confidence in eight of the findings, and moderate confidence in five, indicating that it is highly likely or likely respectively that these findings are a reasonable representation of the phenomenon of interest. There were two findings with low confidence. High and moderate confidence findings Home-based rehabilitation services delivered in-person or through telerehabilitation  Patients experience home-based services as convenient and less disruptive of their everyday activities. Patients and providers also suggest that these services can encourage patients' self-management and can make them feel empowered about the rehabilitation process. But patients, family members, and providers describe privacy and confidentiality issues when services are provided at home. These include the increased privacy of being able to exercise at home but also the loss of privacy when one's home life is visible to others.  Patients and providers also describe other factors that can affect the success of home-based rehabilitation services. These include support from providers and family members, good communication with providers, the requirements made of patients and their surroundings, and the transition from hospital to home-based services. Telerehabilitation specifically Patients, family members and providers see telerehabilitation as an opportunity to make services more available. But providers point to practical problems when assessing whether patients are performing their exercises correctly. Providers and patients also describe interruptions from family members.  In addition, providers complain of a lack of equipment, infrastructure and maintenance and patients refer to usability issues and frustration with digital technology. Providers have different opinions about whether telerehabilitation is cost-efficient for them. But many patients see telerehabilitation as affordable and cost-saving if the equipment and infrastructure have been provided. Patients and providers suggest that telerehabilitation can change the nature of their relationship. For instance, some patients describe how telerehabilitation leads to easier and more relaxed communication. Other patients describe feeling abandoned when receiving telerehabilitation services.  Patients, family members and providers call for easy-to-use technologies and more training and support. They also suggest that at least some in-person sessions with the provider are necessary. They feel that telerehabilitation services alone can make it difficult to make meaningful connections. They also explain that some services need the provider's hands. Providers highlight the importance of personalising the services to each person's needs and circumstances.

AUTHORS' CONCLUSIONS

This synthesis identified several factors that can influence the successful implementation of in-person home-based rehabilitation and telerehabilitation services. These included factors that facilitate implementation, but also factors that can challenge this process. Healthcare providers, program planners and policymakers might benefit from considering these factors when designing and implementing programmes.

Core Synergies Measured with Ultrasound in Subjects with Chronic Non-Specific Low Back Pain and Healthy Subjects: A Systematic Review

Low back pain represents the leading cause of disability since 1990. In 90% of cases, it is classified as non-specific low back pain, being chronic in 10% of subjects. Ultrasound has proven to be an effective measurement tool to observe changes in the activity and morphology of the abdominal muscles. This article reviews which core synergies are studied with ultrasound in healthy subjects and with chronic non-specific low back pain. A systematic review was conducted on studies analyzing synergies between two or more core muscles. Publications from 2005 until July 2021 were identified by performing structured searched in Pubmed/MEDLINE, PEDro and WOS. Fifteen studies were eligible for the final systematic review. A total of 56% of the studies established synergies between the core muscles and 44% between the homo and contralateral sides of the core muscles. The most studied core synergies were transversus abdominis, internal oblique and external oblique followed by the rectus abdominis and the lumbar multifidus. No studies establishing synergies with diaphragm and pelvic floor were found. Eight studies were conducted in healthy subjects, five studies in subjects with chronic non-specific low back pain compared to healthy subjects and two studies in subjects with chronic non-specific low back pain.

Using Intervention Mapping to Develop a Decision Support System–Based Smartphone App (selfBACK) to Support Self-management of Nonspecific Low Back Pain: Development and Usability Study

Background

International guidelines consistently endorse the promotion of self-management for people with low back pain (LBP); however, implementation of these guidelines remains a challenge. Digital health interventions, such as those that can be provided by smartphone apps, have been proposed as a promising mode of supporting self-management in people with chronic conditions, including LBP. However, the evidence base for digital health interventions to support self-management of LBP is weak, and detailed descriptions and documentation of the interventions are lacking. Structured intervention mapping (IM) constitutes a 6-step process that can be used to guide the development of complex interventions.

Objective

The aim of this paper is to describe the IM process for designing and creating an app-based intervention designed to support self-management of nonspecific LBP to reduce pain-related disability.

Methods

The first 5 steps of the IM process were systematically applied. The core processes included literature reviews, brainstorming and group discussions, and the inclusion of stakeholders and representatives from the target population. Over a period of >2 years, the intervention content and the technical features of delivery were created, tested, and revised through user tests, feasibility studies, and a pilot study.

Results

A behavioral outcome was identified as a proxy for reaching the overall program goal, that is, increased use of evidence-based self-management strategies. Physical exercises, education, and physical activity were the main components of the self-management intervention and were designed and produced to be delivered via a smartphone app. All intervention content was theoretically underpinned by the behavior change theory and the normalization process theory.

Conclusions

We describe a detailed example of the application of the IM approach for the development of a theory-driven, complex, and digital intervention designed to support self-management of LBP. This description provides transparency in the developmental process of the intervention and can be a possible blueprint for designing and creating future digital health interventions for self-management.

Ultrasound Imaging as a Visual Biofeedback Tool in Rehabilitation: An Updated Systematic Review

Rehabilitative ultrasound imaging (RUSI) is used by physical therapists as a feedback tool for measuring changes in muscle morphology during therapeutic interventions such as motor control exercises (MCE). However, a structured overview of its efficacy is lacking. We aimed to systematically review the efficacy of RUSI for improving MCE programs compared with no feedback and other feedback methods. MEDLINE, PubMed, SCOPUS and Web of Science databases were searched for studies evaluating efficacy data of RUSI to improve muscular morphology, quality, and/or function of skeletal muscles and MCE success. Eleven studies analyzing RUSI feedback during MCE were included. Most studies showed acceptable methodological quality. Seven studies assessed abdominal wall muscles, one assessed pelvic floor muscles, one serratus anterior muscle, and two lumbar multifidi. Eight studies involved healthy subjects and three studies clinical populations. Eight studies assessed muscle thickness and pressure differences during MCE, two assessed the number of trials needed to successfully perform MCE, three assessed the retain success, seven assessed the muscle activity with electromyography and one assessed clinical severity outcomes. Visual RUSI feedback seems to be more effective than tactile and/or verbal biofeedback for improving MCE performance and retention success, but no differences with pressure unit biofeedback were found.

Optimization of Spinal Manipulative Therapy Protocols: A Factorial Randomized Trial Within a Multiphase Optimization Framework

Spinal manipulative therapy (SMT) is a common nonpharmacological treatment for low back pain (LBP). Although generally supported by systematic reviews and practice guidelines, clinical trials evaluating SMT have been characterized by small effect sizes. This study adopts a Multiphase Optimization Strategy framework to examine individual components of an SMT delivery protocol using a single-blind trial with the goal of identifying and optimizing a multicomponent SMT protocol. We enrolled 241 participants with LBP. All participants received 2 SMT treatment sessions in the first week then were randomly assigned additional treatment based on a fully factorial design. The 3 randomized treatment components provided in twice weekly sessions over 3 weeks were multifidus activating exercise, spinal mobilizing exercise, and additional SMT dose. Primary outcomes included clinical (Oswestry Disability Index, numeric pain intensity rating) and mechanistic (spinal stiffness, multifidus muscle activation) measures assessed at baseline, 1, 4, and 12 weeks. Significant differences were found for the Oswestry index after 12 weeks for participants receiving multifidus activating exercise (mean difference = -3.62, 97.5% CI: -6.89, -0.35; P= .01). There were no additional significant main or interaction effects for other treatment components or different outcome measures. The optimized SMT protocol identified in this study included SMT sessions followed by multifidus activating exercises. PERSPECTIVE: Optimizing the effects of nonpharmacological treatments such as SMT for LBP is challenging due to uncertainty regarding mechanisms and the complexity of multicomponent protocols. This factorial randomized trial examined SMT protocols provided with differing co-interventions with mechanistic and patient-centered outcomes. Patient-centered outcomes were optimized by inclusion of lumbar multifidus strengthening exercises.

Do people with acute low back pain have an attentional bias to threat-related words?

OBJECTIVES

It has been hypothesised that attentional bias to environmental threats can contribute to persistent pain. It is unclear whether people with acute low back pain (LBP) have an attentional bias to environmental threats. We investigated if attentional bias of threat related words is different in people with acute LBP and pain-free controls.

METHODS

People with acute LBP and pain-free people completed a free viewing eye tracking task. Participants were simultaneously presented with two words, a threat related word and a neutral control word. Threat related words were general threat, affective pain and sensory pain. We conducted linear mixed models to detect differences between acute LBP and pain-free participants on five eye tracking outcome measures (dwell time, first fixation, latency to first fixation, first run dwell time and number of fixations). We calculated absolute reliability, (standard error of measure), and relative reliability (intraclass correlation coefficients [ICC 2,1]) for each eye tracking outcome measures.

RESULTS

We recruited 65 people with acute LBP and 65 pain-free controls. Participants with acute LBP had a higher proportion of fixations towards the affective pain words (M=0.5009, 95% CI=0.4941, 0.5076) than the pain-free controls had (M=0.4908, 95% CI=0.4836, 0.4979), mean between group difference = -0.0101, 95% CI [-0.0198, -0.0004], p=0.0422. There was no difference between acute LBP and pain-free controls for the remaining eye tracking outcome measures (all p>0.05). The only outcome measure that had an ICC of more than 0.7 was the latency to first fixation (affective pain words ICC=0.73, general threat words ICC=0.72).

CONCLUSIONS

When compared with pain-free controls, people with acute LBP looked more often at affective pain words relative to neutral control words. This may indicate a form of engagement bias for people with acute LBP. Attentional bias was not consistent across outcome measures or word groups. Further research is needed to investigate the potential role of attentional bias in the development of persistent pain.

Effectiveness of motor control exercise on non-specific chronic low back pain, disability and core muscle morphological characteristics: A meta-analysis of randomized controlled trials

INTRODUCTION

Chronic low back pain (CLBP) has been recognized as the leading cause of disability. Up to 90% of patients with CLBP are classified as having non-specific CLBP (NSCLBP). Motor control exercise (MCE) is one of the most popular and widespread treatment options, and has many advantages in alleviating pain and disability. This meta-analysis is aimed to investigate the effectiveness of MCE on NSCLBP, disability, and core muscles reported in randomized controlled trials (RCTs).

METHODS

PubMed, Web of Science, and EMBASE were searched from inception to August 2020. Articles were eligible if they were RCTs that evaluated MCE against sham or other treatments in isolation and measured outcomes including pain intensity and disability or core muscles morphologic characteristics.

RESULTS

Two authors independently extracted the data. Eighteen studies of 897 studies with a total of 1333 individuals with NSCLBP were retained for the meta-analysis. Compared with other conservative treatments, MCE was better in reducing pain and disability posttreatment and was better in reducing pain at the 6-month follow-up period. However, it had comparable effects on pain reduction at 12-month and 24-month follow-up period, and on disability at the 6-month, 12-month and 24-month follow-up period. MCE resulted in comparable effects to other treatments in improving the core muscle thickness posttreatment. However, other important outcomes, such as the function, strength and endurance of core muscles, which could hamper a comprehensive understanding of the effects of MCE on NSCLBP.

LIMITATIONS

Publication bias was not assessed in several comparisons due to the scarcity of data in published literature. This might downgrade the strength of the evidence. The protocol of this meta-analysis was reviewed by an expert committee, but was not registered in a public trial registry.

CONCLUSIONS

Low to very low quality of evidence supported that MCE resulted in a greater reduction of pain and disability posttreatment, and a greater reduction of pain at the 6-month follow-up than other treatments for NSCBLP. The findings in this review further support that MCE may be more effective than other treatments at short-term followups, and at least has equivalent long-term effects to other forms of treatments in NSCLBP.

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

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

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Defining pain and interference recovery trajectories after acute non-catastrophic musculoskeletal trauma through growth mixture modeling

BACKGROUND

Recovery trajectories support early identification of delayed recovery and can inform personalized management or phenotyping of risk profiles in patients. The objective of this study was to investigate the trajectories in pain severity and functional interference following non-catastrophic musculoskeletal (MSK) trauma in an international, mixed injury sample.

METHODS

A prospective longitudinal cohort (n = 241) was formed from patients identified within four weeks of trauma, from attendance at emergency or urgent care centres located in London, ON, Canada, or Chicago, IL, USA. Pain interference was measured via the Brief Pain Inventory (London cohort) or the Neck Disability Index (Chicago cohort). Pain severity was captured in both cohorts using the numeric pain rating scale. Growth mixture modeling and RM repeated measures ANOVA approaches identified distinct trajectories of recovery within pain interference and pain severity data.

RESULTS

For pain interference, the three trajectories were labeled accordingly: Class 1 = Rapid recovery (lowest intercept, full or near full recovery by 3 months, 32.0% of the sample); Class 2 = Delayed recovery (higher intercept, recovery by 12 months, 26.7% of the sample); Class 3 = Minimal or no recovery (higher intercept, persistently high interference scores at 12 months, 41.3% of the sample). For pain severity, the two trajectories were labeled: Class 1 = Rapid recovery (lower intercept, recovery by 3 months, 81.3% of the sample); and Class 2 = Minimal or no recovery (higher intercept, flat curve, 18.7% of the sample). The "Minimal or No Recovery" trajectory could be predicted by female sex and axial (vs. peripheral) region of trauma with 74.3% accuracy across the 3 classes for the % Interference outcome. For the Pain Severity outcome, only region (axial trauma, 81.3% accuracy) predicted the "Minimal or No Recovery" trajectory.

CONCLUSIONS

These results suggest that three meaningful recovery trajectories can be identified in an international, mixed-injury sample when pain interference is the outcome, and two recovery trajectories emerge when pain severity is the outcome. Females in the sample or people who suffered axial injuries (head, neck, or low back) were more likely to be classed in poor outcome trajectories.

TRIAL REGISTRATION

National Institutes of Health - clinicaltrials.gov ( NCT02711085 ; Retrospectively registered Mar 17, 2016).

Effects of exercise therapy in patients with acute low back pain: a systematic review of systematic reviews

BACKGROUND

Acute low back pain is associated with pain and disability, but symptoms are often self-healing. The effectiveness of exercise therapy for acute low back pain remains uncertain with conflicting evidence from systematic reviews. The aim of this systematic review of systematic reviews was to assess the overall certainty of evidence for the effects of exercise therapy, compared with other interventions, on pain, disability, recurrence, and adverse effects in adult patients with acute low back pain.

METHODS

PubMed, the Cochrane library, CINAHL, PEDro, Open Grey, Web of Science, and PROSPERO were searched for systematic reviews of randomized controlled trials. Methodological quality was assessed independently by two authors using AMSTAR. Meta-analyses were performed if possible, using data from the original studies. Data for pain, disability, recurrence, and adverse effects were analyzed. Certainty of evidence was assessed using GRADE.

RESULTS

The searches retrieved 2602 records, of which 134 publications were selected for full-text screening. Twenty-four reviews were included, in which 21 randomized controlled trials (n = 2685) presented data for an acute population, related to 69 comparisons. Overlap was high, 76%, with a corrected covered area of 0.14. Methodological quality varied from low to high. Exercise therapy was categorized into general exercise therapy, stabilization exercise, and McKenzie therapy. No important difference in pain or disability was evident when exercise therapy was compared with sham ultrasound, nor for the comparators usual care, spinal manipulative therapy, advice to stay active, and educational booklet. Neither McKenzie therapy nor stabilization exercise yielded any important difference in effects compared with other types of exercise therapy. Certainty of evidence varied from very low to moderate.

CONCLUSIONS

The findings suggest very low to moderate certainty of evidence that exercise therapy may result in little or no important difference in pain or disability, compared with other interventions, in adult patients with acute low back pain. A limitation of this systematic review is that some included reviews were of low quality. When implementing findings of this systematic review in clinical practice, patients' preferences and the clinician's expertise also should be considered, to determine if and when exercise therapy should be the intervention of choice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD46146, available at: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=46146 .

Is There a Relationship Between Workload and Occurrence of Back Pain and Back Injuries in Athletes?

The back is subjected to a great deal of strain in many sports. Up to 20% of all sports injuries involve an injury to the lower back or neck. Repetitive or high impact loads (e.g., running, gymnastics, skiing) and weight loading (e.g., weightlifting) affect the lower back. Rotation of the torso (e.g., golf, tennis) causes damage to both, the lumbar and thoracic spine. The cervical spine is most commonly injured in contact sports (e.g., boxing, football). One of the factors that increases the odds of injuries in athletes is excessive and rapid increases in training loads. In spite of currently emerging evidence on this issue, little is known about the balance between physiological loading on the spine and athletic performance, versus overloading and back pain and/or injury in athletes. This scoping review aims (i) to map the literature that addresses the association between the training load and the occurrence of back pain and/or injury, especially between the Acute:Chronic Workload Ratio (ACWR) and back problems in athletes of individual and team sports, and (ii) to identify gaps in existing literature and propose future research on this topic. A literature search of six electronic databases (i.e., MEDLINE, PubMed, Web of Science, SCOPUS, SportDiscus, and CINAHL) was conducted. A total of 48 research articles met the inclusion criteria. Findings identified that fatigue of the trunk muscles induced by excessive loading of the spine is one of the sources of back problems in athletes. In particular, high training volume and repetitive motions are responsible for the high prevalence rates. The most influential are biomechanical and physiological variations underlying the spine, though stress-related psychological factors should also be considered. However, limited evidence exists on the relationship between the ACWR and back pain or non-contact back injuries in athletes from individual and team sports. This may be due to insufficiently specified the acute and chronic time window that varies according to sport-specific schedule of competition and training. More research is therefore warranted to elucidate whether ACWR, among other factors, is able to identify workloads that could increase the risk of back problems in athletes.

Early Return to Work Has Benefits for Relief of Back Pain and Functional Recovery After Controlling for Multiple Confounds

OBJECTIVE

The aim of the study was to evaluate the effect on health outcomes of an early or immediate return-to-work (RTW) after acute low back pain (LBP).

METHODS

A longitudinal cohort of workers (N = 557) consulting for uncomplicated LBP were assessed on demographic, pain, occupational, and psychosocial variables. Pain and function were assessed at 3-month postpain onset. We tested the longitudinal effects of an early RTW on 3-month outcomes.

RESULTS

Pain and function improved more rapidly for workers with an immediate (30.7%) or early (1 to 7 days) RTW (36.8%). Eleven demographic, health, or workplace variables were identified as potential confounds, but controlling for these factors only partially attenuated the benefits of an early RTW.

CONCLUSIONS

An early RTW improves acute LBP and functional recovery, and alternate confounding explanations only partially eclipse this therapeutic effect.

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

Effectiveness of treatments for acute and sub-acute mechanical non-specific low back pain: protocol for a systematic review and network meta-analysis

BACKGROUND

Non-specific low back pain (LBP) is the leading cause of disability worldwide. Acute LBP usually has a good prognosis, with rapid improvement within the first 6 weeks. However, the majority of patients develop chronic LBP and suffer from recurrences. For clinical management, a plethora of treatments is currently available but evidence of the most effective options is lacking. The objective of this study will be to identify the most effective interventions to relieve pain and reduce disability in acute and sub-acute non-specific LBP.

METHODS/DESIGN

We will search electronic databases (MEDLINE, Embase, CENTRAL) from inception onwards. The eligible population will be individuals with non-specific LBP older than 18 years, both males and females, who experience pain less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Eligible interventions and comparators will include all conservative rehabilitation or pharmacological treatments provided by any health professional; the only eligible study design will be a randomized controlled trial. The primary outcomes will be pain intensity and back-specific functional status. Secondary outcomes will be any adverse events. Studies published in languages other than English will also potentially be included. Two reviewers will independently screen the titles and abstracts retrieved from a literature search, as well as potentially relevant full-text articles. General characteristics, potential effect modifiers, and outcome data will be extracted from the included studies, and the risk of bias will be appraised. Conflicts at all levels of screening and abstraction will be resolved through team discussions. After describing the results of the review, if appropriate, a random effects meta-analysis and network meta-analysis will be conducted in a frequentist setting, assuming equal heterogeneity across all treatment comparisons and accounting for correlations induced by multi-arm studies using a multivariate normal model.

DISCUSSION

Our systematic review will address the uncertainties in the use of pharmacological or non-pharmacological treatments, and their relative efficacy, for acute and subacute LBP. These findings will be useful for patients, healthcare providers, and policymakers.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018102527.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence

BACKGROUND

Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain.

METHODS

GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created.

RESULTS

Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions.

CONCLUSION

From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

Feasibility of high intensity training in nonspecific chronic low back pain: A clinical trial

BACKGROUND

Although low to moderate intensity exercise therapy is a predominant part of rehabilitation in nonspecific chronic low back pain (NSCLBP), effect sizes are small and optimal exercise modalities/intensities are unclear. Conversely, effects of high intensity training have not yet been investigated in this population.

OBJECTIVE

The aim of this study is to investigate the feasibility of high intensity training (HIT) and to explore the magnitude of the effects of a HIT program on exercise capacity and disease related outcome measures compared to conventional therapy for persons with NSCLBP.

METHODS

In this non-randomized controlled feasibility study, treatment satisfaction, adherence, disability, pain, physical activity, body composition, exercise capacity and self-reported motivation, were assessed in persons with NSCLBP, before (PRE) and after (POST) 6 weeks (12 sessions, 1.5 hours/session, 2 x/week) of high intensity cardiovascular (100% VO2Max) and high load resistance (80% 1RM) training (HIT, n= 10) and compared to average intensity/load (60% VO2max) conventional physical therapy (CON, n= 10).

RESULTS

At PRE, CON and HIT did not differ, except for gender ratio and lean mass. Compared to CON, HIT retained motivation to rehabilitate better (HIT: +3%; CON: -25%) and had higher therapy adherence (+16%) during the study course. No adverse events were noted in both groups. Whereas disability reduced in both groups (HIT: -10.4%; CON: -8.3%), peak workload (+7.0%), time to exhaustion (+9.5%), and activity level (+5.6%) only improved in HIT.

CONCLUSIONS

High intensity exercise therapy appears to be a feasible rehabilitation approach in NSCLBP. Outcomes improved following the HIT protocol, warranting the investigation of its effectiveness in future large scale RCT studies.

Pain education for patients with non-specific low back pain in Nepal: protocol of a feasibility randomised clinical trial (PEN-LBP Trial)

INTRODUCTION

Low back pain (LBP) is the leading cause of years lived with disability in Nepal and elsewhere. Management of LBP that is evidence-based, easily accessible, cost-effective and culturally appropriate is desirable. The primary aim of this feasibility study is to determine if it is feasible to conduct a full randomised clinical trial evaluating the effectiveness of pain education as an intervention for individuals with LBP in Nepal, relative to guideline-based physiotherapy treatment. The findings of the study will inform the planning of a full clinical trial and if any modifications are required to the protocol before undertaking a full trial.

METHODS/ANALYSIS

This protocol describes an assessor-blinded feasibility clinical trial investigating feasibility of the pain education intervention in patients with non-specific LBP in a physiotherapy hospital in Kathmandu, Nepal. Forty patients with LBP will be randomly allocated to either pain education or guideline-based physiotherapy treatment (control). Outcomes will be assessed at baseline and at a 1 week post-treatment. The primary outcomes are related to feasibility, including: (1) participant willingness to participate in a randomised clinical trial, (2) feasibility of assessor blinding, (3) eligibility and recruitment rates, (4) acceptability of screening procedures and random allocation, (5) possible contamination between the groups, (6) intervention credibility, (7) intervention adherence, (8) treatment satisfaction and (9) difficulty in understanding the interventions being provided.

ETHICS/DISSEMINATION

The protocol was approved by Nepal Health Research Council (NHRC; registration number: 422/2017) and University of Otago Human Ethics Committee for Health (registration number: H17/157). The results of the study will be presented at national and international conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03387228; Pre-results.

Risk Factors Associated with Pain Severity in Patients with Non-specific Low Back Pain in Southern China

STUDY DESIGN

A prospective cross-sectional study.

PURPOSE

To evaluate the risk factors associated with the severity of pain intensity in patients with non-specific low back pain (NSLBP) in Southern China.

OVERVIEW OF LITERATURE

Low back pain (LBP) is the leading cause of activity limitation and work absence throughout the world, so a firm understanding of the risk factor associated with NSLBP can provide early and prompt interventions that are aimed at attaining long-term results.

METHODS

Participants were recruited from January 2014 to January 2016 and were surveyed using a self-designed questionnaire. Anonymous assessments included Short Form 36-Item Health Survey (SF-36) and Visual Analogue Scale (VAS). The association between the severity of NSLBP and these potential risk factors were evaluated.

RESULTS

A total of 1,046 NSLBP patients were enrolled. The patients with primary school education, high body mass index (BMI), those exposed to sustained durations of driving and sitting, smoking, recurrent LBP had increased VAS and Oswestry Disability Index (ODI) scores with lower SF-36 scores (p <0.01). Workers and drivers compared with waiters and patients who lifted >10 kg objects in a quarter of their work time for >10 years had higher VAS and ODI scores with lower SF-36 scores (p <0.01). Multiple logistic regression showed lower levels of education, LBP for 1-7 days, long-lasting LBP in last year, smoking, long duration driving, and higher BMI were associated with more severe VAS score.

CONCLUSIONS

The severity of NSLBP is associated with lower levels of education, poor standards of living, heavy physical labor, long duration driving, and sedentary lifestyle. Patients with recurrent NSLBP have more severe pain. Reducing rates of obesity, the duration of heavy physical work, driving or riding, and attenuating the prevalence of sedentary lifestyles and smoking may reduce the prevalence of NSLBP.

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

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Bridge exercise with unstable surface increases trunk muscle activities.

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Bridge exercise with hip abduction increases trunk muscles activities.

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

Design

This is a cross-sectional study.

Setting

University research laboratory.

Participants

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

Intervention

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

Main outcome measures

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

Results

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

Conclusions

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

Specific or general exercise strategy for subacromial impingement syndrome-does it matter? A systematic literature review and meta analysis

Background

Exercise is frequently suggested as a treatment option for patients presenting with symptoms of subacromial impingement syndrome. Some would argue implementing a specific exercise strategy with special focus on correction of kinematic deficits would be superior to general exercise strategy. There is however a lack of evidence comparing such exercise strategies to determine which is the most effective in the treatment of subacromial impingement syndrome. The aim of this review is to evaluate whether implementing specific exercise strategies involving resistive exercises are more effective than a general exercise strategy for the treatment of patients with subacromial impingement syndrome.

Methods

Randomized controlled trials were identified through an electronic search on PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and PEDro. In addition, article reference lists and Clinicaltrials.gov were searched. Studies were considered eligible if they included interventions with resistive specific exercises as compared to general resistance exercise. Four reviewers assessed risk of bias and methodological quality guided by Cochrane recommendations. Results were synthesised qualitatively or quantitatively, where appropriate.

Results

Six randomized controlled trials were included with 231 participants who experienced symptoms of subacromial impingement syndrome. Four studies evaluated the effectiveness of specific scapular exercise strategy and two studies evaluated the effectiveness of specific proprioceptive strategy. Five studies were of moderate quality and one study was of low quality. No consistent statistical significant differences in outcomes between treatment groups were reported in the studies. Standardized mean difference (SMD) for pain was SMD −0.19 (95% CI −0.61, 0.22) and SMD 0.30 (95% CI −0.16, 0.76) for function.

Conclusions

There is insufficient evidence to support or refute the effectiveness of specific resistive exercise strategies in the rehabilitation of subacromial impingement syndrome. More high quality research is needed to accurately assess this. This review provides suggestions on how to improve the methodological design of future studies in this area.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1518-0) contains supplementary material, which is available to authorized users.

Motor control exercise for symptomatic lumbar disc herniation: protocol for a systematic review and meta-analysis

INTRODUCTION

Lumbar disc herniation (LDH) is a common condition in adults and can impose a heavy burden on both the individual and society. It is defined as displacement of disc components beyond the intervertebral disc space. Various conservative treatments have been recommended for the treatment of LDH and physical therapy plays a major role in the management of patients. Therapeutic exercise is effective for relieving pain and improving function in individuals with symptomatic LDH. The aim of this systematic review is to evaluate the effectiveness of motor control exercise (MCE) for symptomatic LDH.

METHODS AND ANALYSIS

We will include all clinical trial studies with a concurrent control group which evaluated the effect of MCEs in patients with symptomatic LDH. We will search PubMed, SCOPUS, PEDro, SPORTDiscus, CINAHL, CENTRAL and EMBASE with no restriction of language. Primary outcomes of this systematic review are pain intensity and functional disability and secondary outcomes are functional tests, muscle thickness, quality of life, return to work, muscle endurance and adverse events. Study selection and data extraction will be performed by two independent reviewers. The assessment of risk of bias will be implemented using the PEDro scale. Publication bias will be assessed by funnel plots, Begg's and Egger's tests. Heterogeneity will be evaluated using the I2 statistic and the χ2 test. In addition, subgroup analyses will be conducted for population and the secondary outcomes. All meta-analyses will be performed using Stata V.12 software.

ETHICS AND DISSEMINATION

No ethical concerns are predicted. The systematic review findings will be published in a peer-reviewed journal and will also be presented at national/international academic and clinical conferences.

TRIAL REGISTRATION NUMBER

CRD42016038166.