A pilot study of the effects of high-intensity aerobic exercise versus passive interventions on pain, disability, psychological strain, and serum cortisol concentrations in people with chronic low back pain

Work Disability Prevention and Management

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's (ACOEM) Work Disability Prevention and Management Guideline reviews the available evidence and provides recommendations to clinicians regarding interventions to help patients remain at or return to work.

METHODS

Systematic literature reviews were conducted. Studies were graded and evidence tables were created, with involvement of a multidisciplinary expert panel that evaluated the evidence and finalized recommendations for all clinical questions. Extensive peer review was performed. Consensus recommendations were formulated when evidence was lacking.

RESULTS

Evidence-based recommendations have been developed to guide work disability prevention and management.

CONCLUSIONS

Clinicians should utilize quality evidence in determining treatment methods to prevent and alleviate work disability for workers. This guideline offers an evidence-based framework for preventing and mitigating work disability for individual adults in the active workforce. It is designed for use by healthcare clinicians who desire to minimize the negative impact of health conditions on working people's lives and livelihoods.

Running is acceptable and efficacious in adults with non-specific chronic low back pain: the ASTEROID randomised controlled trial

OBJECTIVES

Running is one of the most accessible forms of exercise, yet its suitability for adults with chronic low back pain (LBP) is unknown. This study assessed the efficacy and acceptability of running in adults with chronic LBP.

METHODS

This two-arm parallel (1:1) individually randomised controlled trial allocated 40 participants (mean (SD) age: 33 (6) years, female: 50%) with non-specific chronic LBP to a 12-week intervention or waitlist control. The intervention was a progressive run-walk interval programme comprising three 30-min sessions per week that were digitally delivered and remotely supported by an exercise physiologist. Efficacy outcomes were self-reported pain intensity (100-point visual analogue scale) and disability (Oswestry Disability Index). Acceptability outcomes were attrition, adherence and adverse events.

RESULTS

At 12-week follow-up, the intervention improved average pain intensity (mean net difference (95% CI): -15.30 (-25.33, -5.27) points, p=0.003), current pain intensity (-19.35 (-32.01, -6.69) points, p=0.003) and disability (-5.20 (-10.12, -0.24) points, P=0.038), compared with control. There was no attrition, and mean (SD) training adherence was 70% (20%; ie, 2.1 of 3 sessions per week). Nine non-serious adverse events deemed likely study-related were reported (lower limb injury/pain: n=7, syncope associated with an underlying condition: n=1, LBP: n=1).

CONCLUSIONS

A run-walk programme was considered an acceptable intervention by the participants to improve the pain intensity and disability in individuals aged 18-45 years with non-specific chronic LBP when compared with the control. An individualised and conservative run-walk programme should be considered a suitable form of physical activity for adults with chronic LBP.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry: ACTRN12622001276741. Registered on 29 September 2022.

Yoga, Physical Therapy and Home Exercise Effects on Chronic Low Back Pain: Pain Perception, Function, Stress, and Quality of Life in a Randomized Trial

Low back pain is a common health problem. In this study, we investigated the effects of yoga, physical therapy (PT), and home exercise (HE) on pain perception, function, stress, and quality of life in chronic low back pain (cLBP). We randomly assigned 54 participants to three distinct treatment groups: (a) a physical therapy group (PT) who received spinal stabilization exercises (SSE) combined with local heat and transcutaneous electrical stimulation; (b) a home exercise group (HE) who received SSE as part of the home program; and (c) a yoga group who received yoga exercises. The primary outcome measures were a Visual Analog Scale (VAS) for measuring pain, and the Oswestry Disability Index (ODI) to measure function. Secondary outcome measures were the Tampa Kinesiophobia Scale (TKS), Central Sensitization Inventory (CSI), pain sensitivity (L3 and deltoid R/L PPTs), Spielberger State-Trait Anxiety Inventory (STAI), plasma cortisol and DHEA-S levels, Transversus Abdominis (TrA) muscle activation, and the Nottingham Health Profile (NHP). Assessments were conducted before and after a six-week intervention period. All three groups demonstrated improvements in pain on the VAS, function on the ODI, pain sensitivity on the L3 and deltoid R/L PPTs, CSI, anxiety on the STAI, TrA muscle activation, and quality of life on the NHP (p < .05). The PT group exhibited a more pronounced improvement on the ODI score (p < .05) than the other groups. Cortisol levels only decreased in the PT group (p < .05). The exercises did not impact DHEA-S and NHP-S parameters. Thus, all interventions resulted in decreased stress, pain intensity, pain sensitivity, central sensitization, and improved function and quality of life; there was no singularly superior approach between interventions. These findings will aid in tailoring treatment programs for managing cLBP according to individual needs.

Endogenous Opioids and Exercise-Related Hypoalgesia: Modern Models, Measurement, and Mechanisms of Action

This chapter will focus on the role exercise appears to have on activation and modulating factors within the central nervous system related to endogenous like opioids and its possible contribution to exercise-induced hypoalgesia. The implications for the exercise-mediated alterations of CNS activation factors related to opioids, specifically endorphins and enkephalins, will be presented. In this update, we discuss utilization of new technology and methods to monitor mechanisms of opioid involvement to suggest their contribution with exercise mediated hypoalgesia as well as their relationships to alterations of perceptions of pain and mood. Several special populations were included to suggest that not all individuals will respond to the exercise by mediating hypoalgesia. Factors that may confound the current understanding and suggestions from the recent literature will be presented as well as suggestions for future investigations.

Effect of aerobic exercises on patients with chronic mechanical low back pain: A randomized controlled clinical trial

BACKGROUND

Chronic mechanical low back pain (CMLBP) is one of the most prevalent and costly disorders. Determining its most effective treatment approach is a priority for researchers.

PURPOSE

To examine the effects of including aerobic exercise within a conventional therapy regimen for young adults with CMLBP.

METHODS

Fifty CMLBP patients (22 males and 28 females) were randomly and equally assigned to one of two groups to receive the prescribed treatment for 8 weeks. The control group received the traditional program only (infrared, ultrasound, burst TENS, and exercises); for the experimental group, an aerobic training program using a stationary bicycle was added. Back pain intensity was the primary outcome. Secondary outcomes included the Oswestry disability index, back extensor endurance measured by the Sorensen test, and physical performance indicated by the back performance scale and the 6-min walk test. A Two-way MANOVA was used for data analysis.

RESULTS

Multivariate tests revealed statistically significant effects of group (p = 0.002, partial η2 = 0.182), time (p < 0.001, partial η2 = 0.928), and group-by-time interaction (p = 0.01, partial η2 = 0.149). Univariate group-by-time interactions were significant for back disability (p = 0.043), extensor endurance (p = 0.023) and results of the 6-min walk test (p = 0.023) showing greater improvement in the experimental group. However, back pain intensity and the back performance scale revealed no significant group-by-time interactions. Within-group comparisons were significant for all measured variables in both groups (p < 0.001).

CONCLUSION

Although a traditional program of infrared, ultrasound, TENS, and exercises is beneficial for CMLBP treatment, adding aerobic exercises to the program leads to more beneficial outcomes.

Exercise intervention for patients with chronic low back pain: a systematic review and network meta-analysis

Purpose

Chronic low back pain (CLBP) is an aging and public health issue that is a leading cause of disability worldwide and has a significant economic impact on a global scale. Treatments for CLBP are varied, and there is currently no study with high-quality evidence to show which treatment works best. Exercise therapy has the characteristics of minor harm, low cost, and convenient implementation. It has become a mainstream treatment method in clinics for chronic low back pain. However, there is insufficient evidence on which specific exercise regimen is more effective for chronic non-specific low back pain. This network meta-analysis aimed to evaluate the effects of different exercise therapies on chronic low back pain and provide a reference for exercise regimens in CLBP patients.

Methods

We searched PubMed, EMBASE, Cochrane Library, and Web of Science from inception to 10 May 2022. Inclusion and exclusion criteria were used for selection. We collected information from studies to compare the effects of 20 exercise interventions on patients with chronic low back pain.

Results

This study included 75 randomized controlled trials (RCTs) with 5,254 participants. Network meta-analysis results showed that tai chi [standardized mean difference (SMD), -2.11; 95% CI, -3.62 to -0.61], yoga (SMD, -1.76; 95% CI -2.72 to -0.81), Pilates exercise (SMD, -1.52; 95% CI, -2.68, to -0.36), and sling exercise (SMD, -1.19; 95% CI, -2.07 to -0.30) showed a better pain improvement than conventional rehabilitation. Tai chi (SMD, -2.42; 95% CI, -3.81 to -1.03) and yoga (SMD, -2.07; 95% CI, -2.80 to -1.34) showed a better pain improvement than no intervention provided. Yoga (SMD, -1.72; 95% CI, -2.91 to -0.53) and core or stabilization exercises (SMD, -1.04; 95% CI, -1.80 to -0.28) showed a better physical function improvement than conventional rehabilitation. Yoga (SMD, -1.81; 95% CI, -2.78 to -0.83) and core or stabilization exercises (SMD, -1.13; 95% CI, -1.66 to -0.59) showed a better physical function improvement than no intervention provided.

Conclusion

Compared with conventional rehabilitation and no intervention provided, tai chi, toga, Pilates exercise, sling exercise, motor control exercise, and core or stabilization exercises significantly improved CLBP in patients. Compared with conventional rehabilitation and no intervention provided, yoga and core or stabilization exercises were statistically significant in improving physical function in patients with CLBP. Due to the limitations of the quality and quantity of the included studies, it is difficult to make a definitive recommendation before more large-scale and high-quality RCTs are conducted.

Erector Spinae Muscle Activation During Forward Movement in Individuals With or Without Chronic Lower Back Pain: A Systematic Review and Meta-analysis

Objective

To investigate the differences between erector spinae muscle activation in healthy individuals and patients with Chronic Lower Back Pain (CLBP) by conducting (a) systematic review and (b) meta-analysis.

Data Sources

PubMed, ScienceDirect, SPORTDiscus, and Google Scholar were used to conduct the searches, which included studies up to the 31st of March 2023 with no start date specified.

Study Selection

Any study otherwise meeting eligibility criteria was included if it reported either (1) a standard mean difference effect size; or (2) the means, SDs, and sample sizes for both the patient group and the comparator group.

Data Extraction

A total of 7 case control trials were used for the systematic review and meta-analysis.

Data Synthesis

The systematic review and meta-analysis revealed that total standardized mean difference in erector spinae muscle activation between healthy individuals vs patients with CLBP expressed in % maximum voluntary isometric contraction was 0.48 (95% confidence interval=0.21-0.74; P<.001) with the heterogeneity being I2=0% (P=.890). The electromyography (EMG) outputs showed significant differences in activation levels between the healthy and CLBP cohorts (P<.001).

Conclusions

A small effect size was found in the meta-analysis. The muscle activation levels of the erector spinae during forward propulsion were higher in CLBP individuals compared with healthy cohorts. The findings provide more clarity about the muscles that were the focus of previous research, what procedures were used to evaluate muscular contributions and what speeds the participants were moving at during the test sessions. Given the limited methodological quality of the included studies, the findings should be interpreted with caution. Future research should evaluate the effect of other factors such as walking distance and any changes in walking surfaces and gradients (ie, non-flat surfaces).

The effectiveness of different aerobic exercises to improve pain intensity and disability in chronic low back pain patients: a systematic review

Background: Physical activity, including aerobic exercise, is highly recommended for chronic low back pain (CLBP) patients to improve pain intensity and functional disability. Objectives: To assess the effectiveness of different aerobic exercises to reduce pain intensity and functional disability in patients with CLBP. Methods: A computer-aided search was performed to find Randomised Controlled Trials (RCTs) that evaluated the effectiveness of different aerobic exercises in CLBP. Articles published between January 2007 to December 2020 were included in the review. Quality assessment using the PEDro scale, extraction of relevant information, and evaluation of outcomes were done by two reviewers independently. Results: A total of 17 studies were included that involved 1146 participants. Outcomes suggested that aerobic exercise combined with other interventions was more effective than aerobic exercise alone. Aerobic exercise with higher frequency (≥ 5 days/week) and longer duration (≥ 12 weeks) were effective to gain clinically significant (≥ 30%) improvements. Environment and using pedometer did not seem to influence the outcomes. Conclusions: Pain intensity and functional disability in CLBP patients can be minimized by prescribing aerobic exercise. However, to get better improvements, aerobic exercise should be done in combination with other interventions and at optimum frequency and duration. Further studies should emphasize examining the optimal doses and duration of different aerobic exercises.

Exercise training and depression and anxiety in musculoskeletal pain patients: a meta-analysis of randomized control trials

BACKGROUND

Depression and anxiety in patients with musculoskeletal pain harm health and exercise can be effective in improving the condition of these patients. This study was aimed at systematically reviewing and providing a meta-analysis of the effect of exercise training on improving depression and anxiety in patients with musculoskeletal pain.

METHODS

The search was done in three databases including PubMed, the Cochrane Library, and Google Scholar up to August 2021. For each of the studies included in the meta-analysis, the mean, standard deviation, and sample size were extracted in the post-test, and the effect size was calculated. Publication bias and heterogeneity were assessed in studies at the end of the analysis.

RESULTS

Nineteen randomized control trials were included in the meta-analysis. Exercise training has a positive effect on depression in patients with musculoskeletal pain, so exercise reduces depression and Hedges' g was equal to -0.21, with confidence intervals of -0.40, -0.02. Exercise training has a positive effect on anxiety in patients with musculoskeletal pain, so exercise reduces anxiety and Hedges' g was equal to -0.63, with confidence intervals of -1.08, -0.19.

CONCLUSIONS

It was found that exercise training is effective in improving depression and anxiety in patients with musculoskeletal pain and therefore this treatment should be given more attention from clinical specialists.

Best Exercise Options for Reducing Pain and Disability in Adults With Chronic Low Back Pain: Pilates, Strength, Core-Based, and Mind-Body. A Network Meta-analysis

OBJECTIVE

To determine which type of exercise is best for reducing pain and disability in adults with chronic low back pain (LBP).

DESIGN

Systematic review with a network meta-analysis (NMA) of randomized controlled trials (RCTs).

LITERATURE SEARCH

Six electronic databases were systematically searched from inception to July 2021.

STUDY SELECTION CRITERIA

RCTs testing the effects of exercise on reducing self-perceived pain or disability in adults (aged 18-65 years) with chronic LBP.

DATA SYNTHESIS

We followed the PRISMA-NMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses, incorporating NMAs of health care interventions) statement when reporting our NMA. A frequentist NMA was conducted. The probability of each intervention being the most effective was conducted according to surface under the cumulative ranking curve (SUCRA) values.

RESULTS

We included 118 trials (9710 participants). There were 28 head-to-head comparisons, 7 indirect comparisons for pain, and 8 indirect comparisons for disability. Compared with control, all types of physical exercises were effective for improving pain and disability, except for stretching exercises (for reducing pain) and the McKenzie method (for reducing disability). The most effective interventions for reducing pain were Pilates, mind-body, and core-based exercises. The most effective interventions for reducing disability were Pilates, strength, and core-based exercises. On SUCRA analysis, Pilates had the highest likelihood for reducing pain (93%) and disability (98%).

CONCLUSION

Although most exercise interventions had benefits for managing pain and disability in chronic LBP, the most beneficial programs were those that included (1) at least 1 to 2 sessions per week of Pilates or strength exercises; (2) sessions of less than 60 minutes of core-based, strength, or mind-body exercises; and (3) training programs from 3 to 9 weeks of Pilates and core-based exercises. J Orthop Sports Phys Ther 2022;52(8):505-521. Epub: 19 June 2022. doi:10.2519/jospt.2022.10671.

The Influence of Exercise Intensity on Psychosocial Outcomes in Musculoskeletal Disorders: A Systematic Review

CONTEXT

Psychosocial parameters play an important role in the onset and persistence of chronic musculoskeletal disorders (CMSDs). Exercise therapy is a valuable therapeutic modality as part of CMSD rehabilitation. Hereby, exercise intensity is an important factor regarding changes in pain and disability in multiple CMSDs. However, the impact of exercise intensity on psychosocial outcomes remains poorly explored.

OBJECTIVE

To identify the effects of different modes of exercise intensity on psychosocial outcomes in persons with CMSDs.

DATA SOURCES

A systematic search was conducted up to November 2020 using the following databases: PubMed/MEDline, PEDro, Cochrane Library, and Web of Science.

STUDY SELECTION

Studies reporting exercise therapy in CMSDs with a predefined display of exercise intensity and an evaluation of at least 1 psychosocial outcome were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 2a.

DATA EXTRACTION

Data regarding demographics, exercise intensity, and psychosocial outcomes were included in a descriptive analysis. Methodological quality was assessed using the PEDro scale and Critical Appraisal Skills Programme (CASP) checklist.

RESULTS

A total of 22 studies, involving 985 participants (with fibromyalgia, chronic low back pain, knee osteoarthritis, psoriatic arthritis, and axial spondyloarthritis) were included (mean PEDro score = 5.77/10). The most common psychosocial outcomes were quality of life (QoL) (n = 15), depression (n = 10), and anxiety (n = 9). QoL improved at any exercise intensity in persons with fibromyalgia. However, persons with fibromyalgia benefit more from exercising at low to moderate intensity regarding anxiety and depression. In contrast, persons with chronic low back pain benefit more from exercising at a higher intensity regarding QoL, anxiety, and depression. Other CMSDs only showed limited or conflicting results regarding the value of certain exercise intensities.

CONCLUSION

Psychosocial outcomes are influenced by the intensity of exercise therapy in fibromyalgia and chronic low back pain, but effects differ across other CMSDs. Future research is necessary to determine the exercise intensity that yields optimal exercise therapy outcomes in specific CMSDs.

Low Back Pain: A Comprehensive Review on the Diagnosis, Treatment Options, and the Role of Other Contributing Factors

BACKGROUND: In recent years, low back pain (LBP) is a growing major health issue around the world and mostly addressed in primary healthcare settings. This may be due to changing work environment including the nature of long sitting work hours, especially in the booming information and technology (IT) and Business Process Outsourcing (BPO) industry. LBP is normally considered as a combination of various types of pain and its related conditions, which eventually lead to disabilities. AIM: In this article, the aim is to discuss the current and future perspectives of LBP mainly on diagnosis and therapeutic front of LBP. METHODS: A search was performed using electronic databases, which include PubMed Central and Google Scholar, using the related key words “back pain and low back pain.” All related peer reviewed published articles were included regardless of the language, region, or the publication date. RESULTS: Although the management of LBP both in terms of diagnosis as well as in the therapeutic options has witnessed considerable progress but challenges are still exist not only within countries but also in the regions and continents among various medical professionals. However, in the past few years, a huge array of coordinated but randomized multi-center clinical studies were performed and various detailed insight investigations have been done, and substantial clinical guidelines have become available. Hence, a new view on evidence-based management approach for LBP has significantly improved recently and discussed here. CONCLUSION: Based on the available evidence and literature, this comprehensive review discusses the present and future perspectives of LBP mainly on diagnosis and therapeutic front for LBP. In addition, current intervention and prevention plans have failed to lessen the considerable burden of LBP and hence several areas which require more details, which deserves additional discussion to augment us through an understanding of this very important topic on improvements of multi tasked outcomes to benefit the affected patients.

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.

Research Relating to Low Back Pain and Physical Activity Reported Over the Period of 2000-2020

BACKGROUND

Low back pain (LBP) is a highly prevalent musculoskeletal disorder that contributes to the greatest degree of disability worldwide. It has become a very serious public health problem that has attracted considerable research interest. The number of publications associated with LBP and physical activity (PA) is gradually increasing. Nevertheless, few studies have utilised visualisation in analysing the general aspects of this field. Therefore, we aimed to provide a systematic overview of global scientific research related to low back pain and physical activity from 2000 to 2020. It has significant benefits in terms of providing researchers with the status and trends of research on low back pain and physical activity.

METHODS

Publications on Science Citation Index-Expanded of Web of Science from 2000 to 2020 were searched, and publications relevant to LBP and PA were analysed using Citespace and SPSS. Analyses mainly included cooperation amongst authors, countries and institutions; co-occurrence analysis of keywords; and co-citation analysis of references, revealing productive researchers and contributing institutions tracking the status and trend of research fields.

RESULTS

Results of linear regression analysis showed that the number of publications on LBP and PA studies increased significantly (p<0.001). The subject categories predominantly focused on orthopaedics (2579, 26.54%), rehabilitation (2544, 26.18%) and sport sciences (2015, 25.44%). The United States had the highest number of published papers (2700, 27.789%) and citations (86, 958). In terms of the number of publications, amongst the top 20 journals, Spine contributed the most, whilst the British Journal of Sports Medicine had the highest impact factor (IF2019, 12.022). The University of Sydney had the highest number of publications (330 publications). Maher published the most papers (123 papers) and had the highest H-index (41). Several citation articles and keywords (such as aerobic, obesity and fear-avoidance beliefs) can be used to provide frontier clues for research on LBP and PA.

CONCLUSION

The results of our study may provide information, such as research trends and frontiers of research and collaborating partners, institutions and countries, on LBP and PA.

Aerobic Physical Exercise for Pain Intensity, Aerobic Capacity, and Quality of Life in Patients With Chronic Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Currently, chronic pain is a disabling condition that is difficult to manage, which generates a high burden on health systems. The objective is to determine the effects of aerobic physical exercise in adults with chronic pain.

METHODS

A systematic review of searches in databases including MEDLINE, LILACS, ScienceDirect, PEDro, OTseeker, The Cochrane Library, EBSCO, and Google Scholar was conducted. The search process was carried out until July 31, 2020, and the study selection process was independently carried out through a criteria analysis for each phase. Outcome measures were chosen: aerobic capacity, physical function, quality of life, and pain.

RESULTS

Twenty-seven studies were included in which aerobic exercise was considered as an option to treat chronic pain. These studies showed significant results compared with other treatment options in terms of pain measurements (-0.22 [-0.42 to -0.03]) and aerobic capacity. For quality of life, there were significant improvements in the physical function component over the mental health component evaluated with the short form health survey-36/12.

CONCLUSION

Aerobic exercise is a nonpharmacological therapeutic option for treatment. Also, aerobic capacity and endurance improved when this type of exercise was prescribed, thus resulting in a substantial improvement in the quality of life of people suffering from chronic pain.

Moderation of the Stressor-Strain Process in Interns by Heart Rate Variability Measured with a Wearable and Smartphone App: a Within-Subject Design Using Continuous Monitoring

Background

The emergence of smartphones and wearable sensor technologies enables easy and unobtrusive monitoring of physiological and psychological data related to an individual’s resilience. Heart rate variability (HRV) is a promising biomarker for resilience based on between-subject population studies, but observational studies that apply a within-subject design and use wearable sensors in order to observe HRV in a naturalistic real-life context are needed.

Objective

This study aims to explore whether resting HRV and total sleep time (TST) are indicative and predictive of the within-day accumulation of the negative consequences of stress and mental exhaustion. The tested hypotheses are that demands are positively associated with stress and resting HRV buffers against this association, stress is positively associated with mental exhaustion and resting HRV buffers against this association, stress negatively impacts subsequent-night TST, and previous-evening mental exhaustion negatively impacts resting HRV, while previous-night TST buffers against this association.

Methods

In total, 26 interns used consumer-available wearables (Fitbit Charge 2 and Polar H7), a consumer-available smartphone app (Elite HRV), and an ecological momentary assessment smartphone app to collect resilience-related data on resting HRV, TST, and perceived demands, stress, and mental exhaustion on a daily basis for 15 weeks.

Results

Multiple linear regression analysis of within-subject standardized data collected on 2379 unique person-days showed that having a high resting HRV buffered against the positive association between demands and stress (hypothesis 1) and between stress and mental exhaustion (hypothesis 2). Stress did not affect TST (hypothesis 3). Finally, mental exhaustion negatively predicted resting HRV in the subsequent morning but TST did not buffer against this (hypothesis 4).

Conclusions

To our knowledge, this study provides first evidence that having a low within-subject resting HRV may be both indicative and predictive of the short-term accumulation of the negative effects of stress and mental exhaustion, potentially forming a negative feedback loop. If these findings can be replicated and expanded upon in future studies, they may contribute to the development of automated resilience interventions that monitor daily resting HRV and aim to provide users with an early warning signal when a negative feedback loop forms, to prevent the negative impact of stress on long-term health outcomes.

Are endogenous opioid mechanisms involved in the effects of aerobic exercise training on chronic low back pain? A randomized controlled trial

Aerobic exercise is believed to be an effective chronic low back pain (CLBP) intervention, although its mechanisms remain largely untested. This study evaluated whether endogenous opioid (EO) mechanisms contributed to the analgesic effects of an aerobic exercise intervention for CLBP. Individuals with CLBP were randomized to a 6-week, 18-session aerobic exercise intervention (n = 38) or usual activity control (n = 44). Before and after the intervention, participants underwent separate laboratory sessions to assess responses to evoked heat pain after receiving saline placebo or intravenous naloxone (opioid antagonist) in a double-blinded, crossover fashion. Chronic pain intensity and interference were assessed before and after the intervention. Endogenous opioid analgesia was indexed by naloxone-placebo condition differences in evoked pain responses (blockade effects). Relative to controls, exercise participants reported significantly greater pre-post intervention decreases in chronic pain intensity and interference (Ps < 0.04) and larger reductions in placebo condition evoked pain responsiveness (McGill Pain Questionnaire-Short Form [MPQ]-Total). At the group level, EO analgesia (MPQ-Total blockade effects) increased significantly pre-post intervention only among female exercisers (P = 0.03). Dose-response effects were suggested by a significant positive association in the exercise group between exercise intensity (based on meeting heart rate targets) and EO increases (MPQ-Present Pain Intensity; P = 0.04). Enhanced EO analgesia (MPQ-Total) was associated with a significantly greater improvement in average chronic pain intensity (P = 0.009). Aerobic exercise training in the absence of other interventions appears effective for CLBP management. Aerobic exercise-related enhancements in endogenous pain inhibition, in part EO-related, likely contribute to these benefits.

Effects of physical exercise on low back pain and cortisol levels: a systematic review with meta-analysis of randomized controlled trials

Aim: To verify the effects of physical exercise on low back pain (LBP) and serum cortisol levels in individuals with chronic LBP. Materials & methods: Randomized controlled trials evaluating the effects of exercise on LBP perception and cortisol levels in adults with nonspecific chronic LBP were included. Results: Four randomized controlled trials were included, with a total of 85 participants in the exercise group and 84 in the control group. The interventions reduced -1.61 (95% CI: -2.36 to -0.85) with inconsistency I2 = 72% (p = 0.031) the LBP level and increased 1.05 (95% CI: 0.22–2.32) with inconsistency I2 = 86% (p < 0.0001) the cortisol levels. Conclusion: The practice of physical exercise for 6 weeks or more reduced LBP levels, whereas the rate of progression of an exercise-training program in people with chronic LBP is greater than 4 weeks, but increased the cortisol serum levels in individuals with LBP.

Resolution of chronic lower back pain symptoms through high-intensity therapeutic exercise and motor imagery program: a case-report

BACKGROUND AND PURPOSE

Nonspecific chronic lower back pain (CLBP) is a difficult to manage clinical condition that is more prevalent in adulthood but also affects adolescents, compromising their well-being and activities of daily living. This case report aimed to describe the clinical evolution of a female adolescent with nonspecific and severe CLBP treated successfully through a combination of high-intensity exercise and motor imagery training. Case Description: A 13-year-old girl with CLBP with radicular pain to the lower limbs, spasms, and movement limitations, for whom pharmacological treatment (i.e. analgesic and muscle relaxant agents) and hydrotherapy, hot wet therapy, and muscle relaxation were unsuccessful. After a careful physiotherapy evaluation, the patient underwent a 36-session intervention, performed 3 times/week for 12 weeks, which was composed of high-intensity therapeutic exercise, adjusted for the patient condition, along with motor imagery training. The patient was reevaluated after the intervention and again 3 years later by the same physiotherapist. Outcomes: The intervention led to a favorable clinical outcome, with pain relief, improved posture, and decreased disability. The patient's clinical condition remained stable at the time of the last follow-up evaluation. Conclusion: These results show that the adjusted combined program led to favorable clinical improvement in the condition, with sustained long-term effects after the intervention.

Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis

OBJECTIVE

Examine the effectiveness of specific modes of exercise training in non-specific chronic low back pain (NSCLBP).

DESIGN

Network meta-analysis (NMA).

DATA SOURCES

MEDLINE, CINAHL, SPORTDiscus, EMBASE, CENTRAL.

ELIGIBILITY CRITERIA

Exercise training randomised controlled/clinical trials in adults with NSCLBP.

RESULTS

Among 9543 records, 89 studies (patients=5578) were eligible for qualitative synthesis and 70 (pain), 63 (physical function), 16 (mental health) and 4 (trunk muscle strength) for NMA. The NMA consistency model revealed that the following exercise training modalities had the highest probability (surface under the cumulative ranking (SUCRA)) of being best when compared with true control: Pilates for pain (SUCRA=100%; pooled standardised mean difference (95% CI): -1.86 (-2.54 to -1.19)), resistance (SUCRA=80%; -1.14 (-1.71 to -0.56)) and stabilisation/motor control (SUCRA=80%; -1.13 (-1.53 to -0.74)) for physical function and resistance (SUCRA=80%; -1.26 (-2.10 to -0.41)) and aerobic (SUCRA=80%; -1.18 (-2.20 to -0.15)) for mental health. True control was most likely (SUCRA≤10%) to be the worst treatment for all outcomes, followed by therapist hands-off control for pain (SUCRA=10%; 0.09 (-0.71 to 0.89)) and physical function (SUCRA=20%; -0.31 (-0.94 to 0.32)) and therapist hands-on control for mental health (SUCRA=20%; -0.31 (-1.31 to 0.70)). Stretching and McKenzie exercise effect sizes did not differ to true control for pain or function (p>0.095; SUCRA<40%). NMA was not possible for trunk muscle endurance or analgesic medication. The quality of the synthesised evidence was low according to Grading of Recommendations Assessment, Development and Evaluation criteria.

SUMMARY/CONCLUSION

There is low quality evidence that Pilates, stabilisation/motor control, resistance training and aerobic exercise training are the most effective treatments, pending outcome of interest, for adults with NSCLBP. Exercise training may also be more effective than therapist hands-on treatment. Heterogeneity among studies and the fact that there are few studies with low risk of bias are both limitations.

Evolving concepts in ventral hernia repair and physical therapy: prehabilitation, rehabilitation, and analogies to tendon reconstruction

PURPOSE

The abdominal wall and musculoskeletal tendons share many anatomic, physiologic, and functional characteristics. This review aims to highlight these similar characteristics and to present a rationale why the treatment principles of successful musculoskeletal tendon reconstruction, including principles of surgical technique and physical therapy, can be used in the treatment of complex abdominal wall reconstruction or ventral hernia repair.

METHODS

The MEDLINE/PubMed database was used to identify published literature relevant to the purpose of this review.

CONCLUSIONS

There are several anatomical and functional similarities between the linea alba and musculoskeletal tendons. Because of this reason, many of the surgical principles for musculoskeletal tendon repair and ventral hernia repair overlap. Distribution of tension is the main driving principle for both procedures. Suture material and configuration are chosen to maximize tension distribution among the tissue edges, as seen in the standard of care multistrand repairs for musculoskeletal tendons, as well as in the small bites for laparotomy technique described in the STITCH trial. Physical therapy is also one of the mainstays of tendon repair, but surprisingly, is not routine in ventral hernia repair. The evidence surrounding physical therapy prehabilitation and rehabilitation protocols in other disciplines is significant. This review challenges the fact that these protocols are not routinely implemented for ventral hernia repair, and presents the rationale and feasibility for the routine practice of physical therapy in ventral hernia repair.

Moderated mediation for exercise maintenance in pain and posttraumatic stress disorder: A randomized trial

This study utilizes the Science of Behavior Change (SOBC) experimental medicine approach to evaluate the effects of a 3-month, individually prescribed progressive exercise training program on neurobiological, cognitive and motivational mechanisms by which our exercise-training paradigm may foster exercise maintenance. We will investigate hypothesized relationships between exercise-training associated augmentation of neuropeptide Y (NPY) system function and improvements in self-regulation and reward sensitivity-cognitive control and motivational processes posited to promote self-efficacy and intrinsic motivation, which have been shown to predict exercise maintenance. This study will recruit Veterans with chronic low back pain and posttraumatic stress disorder (PTSD). Procedures include a baseline, acute cardiopulmonary exercise challenge assessment that will inform the exercise prescription for a 12-week progressive exercise training program comprised of three 45-minute aerobic exercise sessions per week-all of which will be supervised by an exercise physiologist. Additionally, a week-7 and week-14 exercise challenge assessment will track changes in NPY system function and the variables of interest. We hypothesize that increases in the capacity to release NPY in response to acute exercise testing will be associated with improvements in self-regulation and reward sensitivity, which will in turn be associated with self-efficacy and intrinsic motivation to maintain regular exercise. Ninety participants will be randomized either to the "active exercise training condition" or to the "wait list symptom monitoring condition". The study aims to demonstrate the feasibility of procedures and elucidate mechanisms relevant to developing individually prescribed, motivationally based exercise regimens to reduce negative consequences of PTSD and low back pain over the long-term. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The longitudinal effects of a physical activity programme on the physical fitness and disability of back pain patients: Service evaluation

OBJECTIVE

To evaluate the longitudinal effect of a group physical activity service to help patients self-manage un-resolving back pain.

BACKGROUND

Back pain is one of the most common and costly conditions. Large scale trials have demonstrated a role for less traditional treatment including exercise, yet the long term effects of patient centred, group physical activity programmes remains unclear.

METHODS

One hundred and eighty-one un-resolving back pain patients (aged 53 ± 17 years) completed a 6 × 2 h physical activity programme. All activities were relevant to activities of daily living and incorporated activities to develop aerobic fitness, flexibility, core activation, and muscular strength and endurance. Dietary advice, home diaries and pedometers were provided.

RESULTS

Measures of back pain, aerobic fitness, muscular endurance and body composition showed significant (p< 0.05) pre-post intervention improvements. Disability rating decreased by 19% alongside improvements in aerobic fitness (15%), back extension (36%) back flexion (16%) and grip strength (5%). Six month follow up identified (p< 0.05) reductions in body fat (6.5%) whilst aerobic fitness, disability rating and muscular strength and endurance remained stable.

CONCLUSION

Group physical activity programmes could contribute to the self-management of back pain, enabling sustained improvements in fitness, physical activity and body fatness.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

Exercise Intensity Matters in Chronic Nonspecific Low Back Pain Rehabilitation

INTRODUCTION

Exercise therapy (ET) is advocated as a treatment for chronic nonspecific low back pain (CNSLBP). However, therapy effect sizes remain low. In other chronic disorders, training at higher intensity has resulted in greater improvements on both general health related and disease specific outcomes compared to lower-intensity ET. Possibly, high-intensity training also improves effect sizes in CNSLBP.

OBJECTIVE

To compare the effects of a high-intensity ET program with a similar moderate-intensity ET program on disability, pain, function, exercise capacity, and abdominal/back muscle strength in persons with CNSLBP.

METHODS

In a randomized controlled trial, persons with CNSLBP performed a 12-wk ET program (24 sessions, 1.5 h per session, twice per week) at high-intensity training (HIT) or moderate-intensity training (MIT). Questionnaires to assess disability (Modified Oswestry Index [MODI]), pain intensity (Numeric Pain Rating Scale), and function (Patient Specific Functioning Scale), a cardiopulmonary exercise test to assess exercise capacity (V˙O2max, cycling time), and a maximum isometric muscle strength test to assess abdominal/back muscle strength (maximum muscle torque) were administered at baseline and after the training program.

RESULTS

Thirty-eight participants (HIT: n = 19, MIT: n = 19) were included (mean age, 44.1 yr, SD = 9.8, 12 males). Groups did not differ at baseline. Between group differences (P < 0.01) in favor of HIT were found for MODI, V˙O2max, and cycling time. Within group improvements (P < 0.01) were found in both groups on MODI (HIT:-64%, MIT:-33%), Numeric Pain Rating Scale (HIT, -56%; MIT, -39%), Patient-Specific Functioning Scale (HIT:+37%, MIT:+39%), V˙O2max (HIT:+14, MIT:+4%), cycling time (HIT:+18%, MIT:+13%), and back muscle strength (HIT:+10%, MIT:+14%).

CONCLUSIONS

High-intensity training proved to be a feasible, well tolerated, and effective therapy modality in CNSLBP. Moreover, it shows greater improvements on disability and exercise capacity than a similar ET performed at moderate intensity.

The effectiveness of an aerobic exercise training on patients with neck pain during a short- and long-term follow-up: a prospective double-blind randomized controlled trial

Objective:

To examine the effect of adding aerobic exercise (AE) to neck-specific exercise treatment for patients with neck pain (NP) to reduce pain and disability.

Design:

A prospective multicentre randomized controlled trial.

Setting:

Physiotherapy outpatient clinics.

Subjects:

Patients with nonspecific NP.

Intervention:

Patients with NP were randomly assigned to six weeks of neck-specific exercise with and without the addition of AE.

Measures:

Patients were classified as having a successful or non-successful outcome according to the Global Rating of Change (GROC). Outcome measures included Visual Analogue Scale (VAS), Neck Disability Index (NDI), Fear Avoidance Beliefs Questionnaire (FABQ) and cervicogenic headache. Assessments were performed at six-week, and three- and six-month follow-ups.

Results:

A total of 139 participants (mean age: 54.6 ± 10.5 years) were recruited ( n = 69 AE, n = 70 control). According to GROC, 77.4% of the AE group reported a successful outcome at six months vs. 40% in the control group ( P < 0.001). There was a significant reduction in VAS from baseline to six months in the AE vs. control group 6.73 (±1.69) to 1.89 (±1.37) vs. 6.65 (±1.67) to 3.32 (±1.82), respectively ( P  < 0.001). Significant improvements were also obtained for NDI and FABQ from baseline to six weeks in the AE group: NDI from 16.10 (±4.53) to 7.78 (±4.78) vs. 17.01 (±4.84) to 11.09 (±5.64) in the control group ( P = 0.003); FABQ from 33.53 (±9.31) to 20.94 (±841) in the AE vs. 33.45 (±10.20) to 26.83 (±10.79) in the control group ( P < 0.001). The AE group also demonstrated significant reduction in cervicogenic headache from baseline to six months ( P = 0.003).

Conclusion:

Adding AE to long-term neck-specific exercises is an effective treatment for reducing NP and headache in patients with NP.

Effects of aerobic exercise in the treatment of older adults with chronic musculoskeletal pain: a protocol of a systematic review

BACKGROUND

Chronic musculoskeletal pain affects the quality of life of older adults by interfering in their ability to perform activities of daily living. Aerobic exercise programs have been used in the treatment of various health conditions, including musculoskeletal disorders. However, there is still little evidence on the effects of aerobic exercise for the treatment of older adults with chronic musculoskeletal pain. Thus, the objective of this study is to assess the effects of aerobic exercise in improving pain and function of older adults with chronic pain as a consequence of different chronic musculoskeletal conditions.

METHODS

The databases to be used in the search are PubMed, EMBASE, CINAHL, PEDro, and Cochrane Central Register of Controlled Trials (CENTRAL). Randomized controlled trials that used aerobic exercise in the treatment of older adults with chronic musculoskeletal pain will be included. Primary outcomes will be pain and function. We will use the PEDro scale to evaluate the methodological quality and statistical description of each included study, and the strength of the recommendations will be summarized using GRADE.

DISCUSSION

The results of this systematic review will provide a synthesis of the current evidence on the effects of aerobic exercise in the treatment of older adults with chronic musculoskeletal pain. In addition, this information can help health professionals in decision-making about the use of aerobic exercise in the treatment of older adults with chronic musculoskeletal pain.

ETHICS AND DISSEMINATION

This systematic review was recorded prospectively, and the results will be part of a doctoral thesis to be published in a peer-reviewed international journal and possibly presented at international conferences.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019118903.

Physical rehabilitation therapists' perspective of the opioid crisis with evidence-based recommendations

In 2017, the Secretary of Health and Human Services and Office of the Surgeon General declared the opioid crisis of our nation to be a public health emergency. In response to the Office of the Assistant Secretary of Health and Office of the Surgeon General's 'Call to Action', the Therapist category of the US Public Health Service commissioned a nine-member task force consisting of pain science subject matter experts to study the Therapists' role in effectively reducing chronic pain and opioid abuse. This article addresses the opioid epidemic, how patients with chronic pain have been managed inappropriately, and five key, evidence-based recommendations from this task force.

The effect of lumbar stabilization and walking exercises on chronic low back pain: A randomized controlled trial

BACKGROUND

Various exercises have been proposed to mitigate chronic low back pain (LBP). However, to date, no one particular exercise has been shown to be superior. Hence, the aim of this study was to compare the efficiency between 2 exercises: the individualized graded lumbar stabilization exercise (IGLSE) and walking exercise (WE).

METHODS

A randomized controlled trial was conducted in 48 participants with chronic LBP. After screening, participants were randomized to 1 of 4 groups: flexibility exercise, WE, stabilization exercise (SE), and stabilization with WE (SWE) groups. Participants underwent each exercise for 6 weeks. The primary outcome was visual analog scale (VAS) of LBP during rest and physical activity. Secondary outcomes were as follows: VAS of radiating pain measured during rest and physical activity; frequency of medication use (number of times/day); Oswestry disability index; Beck depression inventory; endurances of specific posture; and strength of lumbar extensor muscles.

RESULTS

LBP during physical activity was significantly decreased in all 4 groups. Exercise frequency was significantly increased in the SE and WE groups; exercise time was significantly increased in the SE group. The endurance of supine, side lying, and prone posture were significantly improved in the WE and SWE groups.

CONCLUSIONS

Lumbar SE and WE can be recommended for patients with chronic LBP because they not only relieve back pain but also prevent chronic back pain through improving muscle endurance.

Lumbar Muscle Activation Pattern During Forward and Backward Walking in Participants With and Without Chronic Low Back Pain: An Electromyographic Study

Objective

The purpose of this study was to investigate the electromyographic activity of lumbar multifidus (MF) and erector spinae (ES) muscle during forward walking (FW) and backward walking (BW) in participants with and without chronic low back pain (CLBP).

Methods

Twenty-one patients with CLBP were recruited from outpatient department of Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia. Twenty-one age-matched healthy controls without CLBP were recruited from community. Maximum voluntary isometric contraction (MVIC) was quantified for MF and ES using standard guidelines. Electromyographic activity of MF and ES was recorded using surface electrodes during FW and BW on a motorized treadmill, which was later normalized by respective MVIC's of each muscle.

Results

Muscle activity (in percentage MVIC) was determined to be higher for both the muscles during BW. Activity of MF muscle was significantly higher in CLBP patients compared with healthy controls (P < .04). Electromyographic activity of MF and ES was significantly increased during BW (MF: P < .001; ES: P < .001) compared with FW in both healthy and CLBP groups.

Conclusion

BW leads to greater activation of the paraspinal muscles. Along with global extensor (ES), activity of core extensor (MF) is also higher during BW than FW in both healthy participants and CLBP patients. BW is a more favorable aerobic activity to enhance lumbar paraspinal recruitment. These findings may have important clinical implications in the rehabilitation of CLBP.

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.

Environmental enrichment alleviates chronic pain in rats following a spared nerve injury to induce neuropathic pain. A preliminary study

Background

In mice, chronic pain can be alleviated with enriched environments (EEs). The purpose of this preliminary study is to investigate whether pain behaviors in rats with peripheral neuropathy would be altered when keeping these animals in either 1) standard laboratory cages or in 2) a significantly EE.

Methods

Two groups of rats (n=8/group) underwent a spare nerve injury surgery of the right hind leg; one group (n=8) was returned to standard ventilated cages (2 rats/cage), the other (n=8) placed in an EE (8 rats/ferret cage with toys). A third group (n=8) underwent a sham surgery and was used as control. These animals were returned to standard ventilated cages (2 rats per cage). Spare nerve injury surgery consisted of ligation/transection of the tibial and common peroneal branches of the sciatic nerve of the right leg only. Von Frey Filaments were applied to test mechanical sensitivity of both hind paws.

Results

The right paw of nerve-injured animals was hypersensitive to mechanical stimuli at 2, 4, and 8 weeks following the surgery; however, animals in the EE conditions showed significantly (P<0.05) less mechanical sensitivity than rats left in the standard caging environment (2, 4, and 8 weeks postsurgery: standard environment 2.8±0.5, 2.8±0.7, and 2.6±0.4 and EE 4.7±0.6, 5.8±0.5, and 5.5±0.7). Sham animals were unaffected by the surgery.

Conclusion

Environmental enrichment alleviated mechanically induced chronic pain in a spared nerve injury rat model of neuropathic pain. Findings also suggest that environmental enrichment, as a method to alleviate pain, may be species-specific, motor behaviors being a very important parameter when considering pain modulation.

Swimming Training Reduces Neuroma Pain by Regulating Neurotrophins

Introduction

Neuroma formation after peripheral nerve transection leads to severe neuropathic pain in amputees. Previous studies suggested that physical exercise could bring beneficial effect on alleviating neuropathic pain. However, the effect of exercise on neuroma pain still remained unclear. In addition, long-term exercise can affect the expression of neurotrophins (NT), such as nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF), which play key roles in nociceptor sensitization and nerve sprouting after nerve injury. Here, we investigated whether long-term swimming exercise could relieve neuroma pain by modulating NT expression.

Methods

We used a tibial neuroma transposition (TNT) rat model to mimic neuroma pain. After TNT surgery, rats performed swimming exercise for 5 wk. Neuroma pain and tactile sensitivities were detected using von Frey filaments. Immunofluorescence was applied to analyze neuroma formation. NGF and BDNF expressions in peripheral neuroma, dorsal root ganglion, and the spinal cord were measured using enzyme-linked immunosorbent assay and Western blotting.

Results

TNT led to neuroma formation, induced neuroma pain, and mechanical allodynia in hind paw. Five-week swimming exercise inhibited neuroma formation and relieved mechanical allodynia in the hind paw and neuroma pain in the lateral ankle. The analgesic effect lasted for at least 1 wk, even when the exercise ceased. TNT elevated the expressions of BDNF and NGF in peripheral neuroma, dorsal root ganglion, and the spinal cord to different extents. Swimming also decreased the elevation of NT expression.

Conclusions

Swimming exercise not only inhibits neuroma formation induced by nerve transection but also relieves pain behavior. These effects might be associated with the modulation of NT.

The effects of a standardized belly dance program on perceived pain, disability, and function in women with chronic low back pain

BACKGROUND

An alternative approach to facilitate movement and control through the trunk and pelvis is belly dancing. Investigations of belly dancing mechanics indicate similar muscular activation patterns of those known to influence chronic low back pain (cLBP). However, no documented studies have examined its effectiveness as a treatment for cLBP.

OBJECTIVE

The purpose of this study was to investigate the influence of a standardized belly dance program in women with cLBP.

METHODS

A single subject design was used to evaluate weekly outcomes during a three-week baseline period, six-week belly dance program, and again at a two-month follow-up. Outcome measures for pain, disability, function, and fear-avoidance beliefs were utilized.

RESULTS

Two subjects completed the program. No significant differences were noted during the baseline assessment period. At two months, subject one demonstrated change scores of -1.12, -1%, and 2.2 for pain, disability, and function respectively while subject two demonstrated change scores of 5.4, 5%, and 1.1 for pain, disability, and function, respectively. Subject one showed a clinically significant change score for both fear avoidance of work and physical activity, with score changes of 4 and 3.3, respectively.

CONCLUSION

The results of this study suggest a standardized belly dance program may positively influence pain and function in women with cLBP.

Kindlin-1 is a key protein in hyperbaric oxygen therapy for the treatment of neuropathic pain

Background

Hyperbaric oxygen therapy is increasingly used in adjuvant therapies to treat neuropathic pain. However, the specific targets of hyperbaric oxygen treatment in neuropathic pain remain unclear. Recently, we found that hyperbaric oxygen therapy produces an antinociceptive response via the kindlin-1/wnt-10a signaling pathway in a chronic pain injury model in rats.

Methods

The rats received an intraperitoneal injection of AAV-FERMT1 or an adeno-associated virus control vector 20 days before the chronic constriction injury operation. During five consecutive days of hyperbaric oxygen treatment, mechanical withdrawal threshold and thermal withdrawal latency tests were performed. Then, kindlin-1 expression was examined by real-time polymerase chain reaction and Western blot analysis. Meanwhile, the activation of glial cells and the production of TNF-α, IL-1β, and fractalkine were also determined.

Results

Our findings demonstrated that hyperbaric oxygen therapy inhibited the chronic constriction injury–induced increase in kindlin-1 expression. Furthermore, overexpression of kindlin-1 reversed the antinociceptive effects of hyperbaric oxygen therapy. The observed hyperbaric oxygen–induced reductions in glial cell activation and neuroinflammation, as indicated by the production of TNF-α, IL-1β, and fractalkine, were also prominently diminished in the group with kindlin-1 overexpression.

Conclusions

Our findings demonstrate that kindlin-1 is a key protein in the action of hyperbaric oxygen therapy in the treatment of neuropathic pain. Indeed, interference with kindlin-1 may be a drug target for reducing the neuroinflammatory responses of the glial population in neuropathic pain.

Optimising conservative management of chronic low back pain: study protocol for a randomised controlled trial

Background

Lower back pain is a global health issue affecting approximately 80% of people at some stage in their life. The current literature suggests that any exercise is beneficial for reducing back pain. However, as pain is a subjective evaluation and physical deficits are evident in low back pain, using it as the sole outcome measure to evaluate superiority of an exercise protocol for low back pain treatment is insufficient. The overarching goal of the current clinical trial is to implement two common, conservative intervention approaches and examine their impact on deficits in chronic low back pain.

Methods/design

Forty participants, 25–45 years old with chronic (>3 months), non-specific low back pain will be recruited. Participants will be randomised to receive either motor control and manual therapy (n = 20) or general strength and conditioning (n = 20) exercise treatments for 6 months. The motor control/manual therapy group will receive twelve 30-min sessions, ten in the first 3 months (one or two per week) and two in the last 3 months. The general exercise group will attend two 1-hour sessions weekly for 3 months, and one or two a week for the following 3 months. Primary outcome measures are average lumbar spine intervertebral disc T2 relaxation time and changes in thickness of the transversus abdominis muscle on a leg lift using magnetic resonance imaging (MRI). Secondary outcomes include muscle size and fat content, vertebral body fat content, intervertebral disc morphology and water diffusion measured by MRI, body composition using dual energy X-ray absorptiometry, physical function through functional tests, changes in corticospinal excitability and cortical motor representation of the spinal muscles using transcranial magnetic stimulation and self-reported measure of pain symptoms, health and disability. Outcome measures will be conducted at baseline, at the 3-month follow-up and at 6 months at the end of intervention. Pain, depressive symptomology and emotions will be captured fortnightly by questionnaires.

Discussion

Chronic low back pain is ranked the highest disabling disorder in Australia. The findings of this study will inform clinical practice guidelines to assist with decision-making approaches where outcomes beyond pain are sought for adults with chronic low back pain.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12615001270505. Registered on 20 November 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1913-8) contains supplementary material, which is available to authorized users.

Physician Self-Referral of Physical Therapy Services for Patients with Low Back Pain: Implications for Use, Types of Treatments Received and Expenditures

Prior research on treatment of low back pain has documented large increases in use of spinal surgery, MRIs and lumbosacral injections linked to physician self-referral arrangements. No recent research has examined whether physician ownership of physical therapy services results in greater use of physical therapy to treat low back pain. The objective of this study is to investigate whether physician ownership of physical therapy services affects frequency of use, visits and types of physical therapy services received by patients with low back pain. Using claims records from insured patients covered by Blue Cross Blue Shield of Texas (2008-2011) we compared several metrics of use of physical therapy services for low back pain episodes controlling for self-referral status. We identified 158,151 low back pain episodes, 27% met the criteria to be classified as "self-referral." Only 10% of "non-self-referral" episodes received physical therapy compared to 26% of self-referral episodes (p<0.001). The unadjusted and regression adjusted self-referral effect was identical - about 16 percentage point difference (p<0.001). Among patients who received some physical therapy, self-referral episodes were comprised of 2.26 fewer visits and 11 fewer physical therapy service units (p<0.001). Non-self-referring episodes included a significantly higher proportion of "active" (hands on or patient engaged) as opposed to "passive" treatments (p<0.001). The regression-adjusted difference was 30 percentage points when measured as actual counts and 29 percentage points when measured in RVUs (p<0.001). Total spending on back-related care was 35% higher for self-referred episodes compared to their non-self-referred counterparts (p<0.001). Ownership of physical therapy services influence physicians' referral to initiate a course of physical therapy to treat low back pain, but also affect the types of physical therapy services a patient receives.

Person-Centered, Physical Activity for Patients with Low Back Pain: Piloting Service Delivery

Low back pain (LBP) is one of the most common and costly conditions in industrialized countries. Exercise therapy has been used to treat LBP, although typically using only one mode of exercise. This paper describes the method and initial findings of a person-centered, group physical activity programme which featured as part of a multidisciplinary approach to treating LBP. Six participants (aged 50.7 ± 17 years) completed a six-week physical activity programme lasting two hours per week. A multicomponent approach to physical activity was adopted which included aerobic fitness, core activation, muscular strength and endurance, Nordic Walking, flexibility and exercise gaming. In addition, participants were required to use diary sheets to record physical activity completed at home. Results revealed significant (p < 0.05) improvements in back strength (23%), aerobic fitness (23%), negative wellbeing (32%) and disability (16%). Person’s Correlation Coefficient analysis revealed significant (p < 0.05) relationships between improvement in perceived pain and aerobic fitness (r = 0.93). It was concluded that a person-centered, multicomponent approach to physical activity may be optimal for supporting patients who self-manage LBP.

A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain

Back pain is a major health issue in Western countries and 60%–80% of adults are likely to experience low back pain. This paper explores the impact of back pain on society and the role of physical activity for treatment of non-specific low back pain. A review of the literature was carried out using the databases SPORTDiscuss, Medline and Google Scholar. A general exercise programme that combines muscular strength, flexibility and aerobic fitness is beneficial for rehabilitation of non-specific chronic low back pain. Increasing core muscular strength can assist in supporting the lumbar spine. Improving the flexibility of the muscle-tendons and ligaments in the back increases the range of motion and assists with the patient’s functional movement. Aerobic exercise increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that can result in back pain.

Anxiety, coping skills and hypothalamus-pituitary-adrenal (HPA) axis in patients with endometriosis

Background

Endometriosis is an inflammatory disease that is defined by growth of endometrial tissue outside the uterus, resulting in pain, infertility, and emotional distress. Previous studies have shown that the HPA axis is compromised in patients with chronic, painful diseases, including endometriosis. However, the underlying mechanisms and the physiological and emotional consequences of dysfunctions in the HPA axis in these patients are largely unknown. We aimed to understand whether diurnal circulating cortisol levels in women with endometriosis are affected and how this impacts their emotional and behavioral responses.

Methods

Thirty-two patients with endometriosis and 36 healthy control women provided saliva samples and completed a series of psychological questionnaires. Salivary cortisol levels were measured in duplicate using a colorimetric immunoassay.

Results

There were significant differences in average cortisol levels between endometriosis patients and controls. A negative correlation was found between cortisol levels and infertility and dyspareunia. Furthermore, incapacitating pain was found to be a strong predictor of hypocortisolism. Women with endometriosis reported higher levels of trait anxiety, but showed no differences in perceived stress or in coping styles compared to the control group.

Conclusions

This study supports previous reports of hypocortisolism as a biomarker of aberrant HPA responses in women with endometriosis. Moreover, it provides further insight into the link between HPA axis dysregulation, emotional responses, and the high comorbidity between endometriosis and other inflammatory conditions.

Efficacy of aerobic exercise for treatment of chronic low back pain: a meta-analysis

OBJECTIVE

A meta-analysis of relevant cohort studies was performed to investigate the efficacy of aerobic exercise for the treatment of patients with chronic low back pain (CLBP).

METHOD

A range of electronic databases were searched: MEDLINE (1966-2013), the Cochrane Library Database (issue 12, 2013), EMBASE (1980-2013), CINAHL (1982-2013), Web of Science (1945~2013), and the Chinese Biomedical Database (1982-2013), without language restrictions. The Roland-Morris Disability Questionnaire, the Oswestry Disability Questionnaire, the McGill Pain Questionnaire, visual analog scale, and heart rate, sit-and-reach test, and maximum oxygen consumption were used to evaluate the efficacy of aerobic exercise. Meta-analysis was performed with the use of the STATA statistical software. The standardized mean difference (SMD) with its corresponding 95% confidence interval (CI) was calculated. Eight clinical cohort studies with a total of 310 CLBP patients were included in the meta-analysis.

RESULTS

The results of this meta-analysis indicated that CLBP patients exhibited positive decreases in scores on the Roland-Morris Disability Questionnaire (SMD, 0.44; 95% CI, 0.20-0.68; P < 0.001), Oswestry Disability Questionnaire (SMD, 1.03; 95% CI, 0.67-1.39; P < 0.001), Hospital Anxiety and Depression Scale (SMD, 1.35; 95% CI, 0.34-2.37; P = 0.009), and McGill Pain Questionnaire (SMD, 0.32; 95% CI, 0.07-0.56; P = 0.011) after aerobic exercise. It was also observed that aerobic exercise could markedly reduce the visual analog scale score for pain of CLBP patients (SMD, 0.75; 95% CI, 0.48-1.02; P < 0.001). Nevertheless, this study's findings showed that aerobic exercise had no effects on heart rate, sit-and-reach test, and maximum oxygen consumption of CLBP patients (all P > 0.05).

CONCLUSION

The current meta-analysis provides reliable evidence that aerobic exercise could effectively diminish pain intensity and improve the physical and psychologic functioning of CLBP patients. Thus, aerobic exercise may be a good choice in the treatment for CLBP.

Synergistic effect of a rehabilitation program and treadmill exercise on pain and dysfunction in patients with chronic low back pain

[Purpose] The present study examined the influence of treadmill exercise added to a low back pain rehabilitation program on low back extensor strength, pain, and dysfunction in chronic low back pain patients. [Subjects and Methods] Twenty men aged 22–36 years with chronic low back pain were randomly divided into experimental and control groups of 10 patients each. Both groups underwent a low back pain rehabilitation program lasting 30 min each, thrice/week for 8 weeks. The experimental group was prescribed an additional 30 min of treadmill exercise without a slope at a speed of 3.0–3.5 km/h, at which patients could walk comfortably. Low back extensor strength was tested using the Medx lumbar extension machine, pain level was tested, using the visual analog scale, and dysfunction was tested, using the Oswestry Low Back Pain Disability Questionnaire. [Results] Changes in low back extensor strength by angle showed significant interaction effects between measurement time and group at 12°, 24°, and 36°. The results of the visual analog scale and Oswestry Questionnaire showed a decreasing trend after the experiment in both groups. However, there was no interaction effect of the additional treadmill exercise in the experimental group. [Conclusion] The combination of a low back pain rehabilitation program and treadmill exercise has a synergistic effect, to some extent, on the improvement of low back extensor strength and should be considered for treatment and rehabilitation of low back pain patients.