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van Amstel R, Noten K, Malone S, Vaes P. Fascia Tissue Manipulations in Chronic Low Back Pain: A Pragmatic Comparative Randomized Clinical Trial of the 4xT Method ® and Exercise Therapy. Life (Basel) 2023; 14:7. [PMID: 38276256 PMCID: PMC10820544 DOI: 10.3390/life14010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND The 4xT method is a protocolized practice in treating musculoskeletal disorders. The 4xT method consists of four components: Test (functional diagnostic test), Trigger (fascia tissue manipulations), Tape (elastic taping), and Train (exercise). There is a lack of clinical studies evaluating the treatment effects of the use of the 4xT method. METHODS A randomized controlled trial was conducted to compare the effectiveness of the 4xT method and exercise therapy-only in patients with chronic nonspecific low back pain. Based on a priori sample size calculation, fifty-one individuals with chronic nonspecific low back pain were randomly assigned to either the 4xT or exercise group. Both groups underwent a six-week rehabilitation program with two treatments per week. The primary outcomes were trunk flexion and extension mobility, trunk flexion, and extension mobility-dependent pain, and quality of life evaluated during a 6-week therapy period and after a 6-week therapy-off period. RESULTS Interaction effects were noted in all outcomes. The 4xT group showed significant improvements over time for trunk flexion and extension mobility, trunk flexion and extension mobility-dependent pain, and quality of life (p < 0.05), with no significant relapse post-therapy (except for extension mobility). The exercise group exhibited significant within-time changes in the quality of life, as measured with the VAS (p < 0.05), but not for EQ-5D-3L. CONCLUSIONS The results of this study demonstrate that the 4xT method stands out as a promising and impactful treatment option for chronic nonspecific low back pain individuals, as it demonstrated significant reductions in mobility-dependent pain, increased trunk mobility, and improved quality of life compared to exercise-only treatments.
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Affiliation(s)
- Robbert van Amstel
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, 1081 Amsterdam, The Netherlands
- Fysio Science Department, Fysio Physics Groups, 3401 IJsselstein, The Netherlands
| | - Karl Noten
- Fysio Science Department, Fysio Physics Groups, 3401 IJsselstein, The Netherlands
| | - Shaun Malone
- Department of Rehabilitation Sciences and Physiotherapy (MOVANT), University of Antwerp, Wilrijk, 2000 Antwerpen, Belgium
| | - Peter Vaes
- Faculty of Rehabilitation Science and Physical Therapy, Vrije Universiteit Brussel, 1050 Brussels, Belgium;
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Kearns GA, Day M, Moore AK, Munger L. Care for the patient with low back pain. Nurse Pract 2023; 48:21-28. [PMID: 37487044 DOI: 10.1097/01.npr.0000000000000078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
ABSTRACT Low back pain (LBP) continues to be one of the most common conditions leading patients to seek medical care globally. The NP is on the frontline, playing an integral role in caring for patients with LBP. Understanding the etiology of LBP is essential in the treatment.
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Nikles J, Evans K, Hams A, Sterling M. A systematic review of N-of-1 trials and single case experimental designs in physiotherapy for musculoskeletal conditions. Musculoskelet Sci Pract 2022; 62:102639. [PMID: 35961063 DOI: 10.1016/j.msksp.2022.102639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 07/24/2022] [Accepted: 07/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Single Case Experimental Designs (SCEDs) are especially useful for small heterogeneous samples. Their role in evaluation of physiotherapy interventions for musculoskeletal conditions has not been systematically reviewed. OBJECTIVES Systematically review use, purpose, and outcomes of SCEDs for physiotherapy interventions for musculoskeletal conditions. DATA SOURCES Electronic databases and grey literature, searched using pre-defined terms. STUDY SELECTION OR ELIGIBILITY CRITERIA Studies of human participants enrolled in eligible SCEDs (individual or a series). STUDY APPRAISAL AND SYNTHESIS METHODS We extracted study characteristics, analytic methods and results, synthesising these descriptively. We used RoBiN-T scale to assess risk of bias. RESULTS We included 19 SCEDs comprising 92 participants, with wide variability in design, methodology, analysis and in conditions and interventions evaluated. 95% of participants responded favourably to the tested intervention. Overall risk of bias was high, due to poor internal validity, especially regarding randomisation, blinding, inter-rater agreement and measurement of treatment adherence. Visual analysis alone was performed in 55% of studies. Assessment of provider and participant satisfaction was limited. CONCLUSIONS AND IMPLICATIONS of key findings: SCEDs may be well-suited to evaluation of physiotherapy interventions for musculoskeletal conditions, but the risk of bias in studies to date is high. Following SCED guidelines to minimize the risk of bias and maximise clinical usefulness is recommended.
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Affiliation(s)
- J Nikles
- Recover Injury Research Centre, NHMRC CRE Better Health Outcomes for Compensable Injury, The University of Queensland, Surgical, Treatment and Rehabilitation Service (STARS), 296 Herston Rd, HERSTON, QLD, 4029, Australia.
| | - K Evans
- Faculty of Medicine and Health, 75 East Street, Lidcombe, The University of Sydney, NSW, 2141, Australia; Healthia Limited, Australia25 Montpelier Road, Bowen Hills, QLD, 4006, Australia.
| | - A Hams
- School of Allied Health Sciences, Griffith University, Gold Coast Campus, Gold Coast, QLD, 4222, Australia.
| | - M Sterling
- Recover Injury Research Centre, NHMRC CRE Better Health Outcomes for Compensable Injury, The University of Queensland, Surgical, Treatment and Rehabilitation Service (STARS), 296 Herston Rd, HERSTON, QLD, 4029, Australia.
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Liew BXW, Ford JJ, Scutari M, Hahne AJ. How does individualised physiotherapy work for people with low back pain? A Bayesian Network analysis using randomised controlled trial data. PLoS One 2021; 16:e0258515. [PMID: 34634071 PMCID: PMC8504753 DOI: 10.1371/journal.pone.0258515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/12/2021] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Individualised physiotherapy is an effective treatment for low back pain. We sought to determine how this treatment works by using randomised controlled trial data to develop a Bayesian Network model. METHODS 300 randomised controlled trial participants (153 male, 147 female, mean age 44.1) with low back pain (of duration 6-26 weeks) received either individualised physiotherapy or advice. Variables with potential to explain how individualised physiotherapy works were included in a multivariate Bayesian Network model. Modelling incorporated the intervention period (0-10 weeks after study commencement-"early" changes) and the follow-up period (10-52 weeks after study commencement-"late" changes). Sequences of variables in the Bayesian Network showed the most common direct and indirect recovery pathways followed by participants with low back pain receiving individualised physiotherapy versus advice. RESULTS Individualised physiotherapy directly reduced early disability in people with low back pain. Individualised physiotherapy exerted indirect effects on pain intensity, recovery expectations, sleep, fear, anxiety, and depression via its ability to facilitate early improvement in disability. Early improvement in disability, led to an early reduction in depression both directly and via more complex pathways involving fear, recovery expectations, anxiety, and pain intensity. Individualised physiotherapy had its greatest influence on early change variables (during the intervention period). CONCLUSION Individualised physiotherapy for low back pain appears to work predominately by facilitating an early reduction in disability, which in turn leads to improvements in other biopsychosocial outcomes. The current study cannot rule out that unmeasured mechanisms (such as tissue healing or reduced inflammation) may mediate the relationship between individualised physiotherapy treatment and improvement in disability. Further data-driven analyses involving a broad range of plausible biopsychosocial variables are recommended to fully understand how treatments work for people with low back pain. TRIALS REGISTRATION ACTRN12609000834257.
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Affiliation(s)
- Bernard X. W. Liew
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex, United Kingdom
| | - Jon J. Ford
- Discipline of Physiotherapy, School of Allied Health, Human Services & Sport, La Trobe University, Melbourne, Australia
| | - Marco Scutari
- Istituto Dalle Molle di Studi sull’Intelligenza Artificiale (IDSIA), Lugano, Switzerland
| | - Andrew J. Hahne
- Discipline of Physiotherapy, School of Allied Health, Human Services & Sport, La Trobe University, Melbourne, Australia
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Price J, Rushton A, Tyros V, Heneghan NR. Expert consensus on the important chronic non-specific neck pain motor control and segmental exercise and dosage variables: An international e-Delphi study. PLoS One 2021; 16:e0253523. [PMID: 34197481 PMCID: PMC8248695 DOI: 10.1371/journal.pone.0253523] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 06/07/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Chronic non-specific neck pain is highly prevalent, resulting in significant disability. Despite exercise being a mainstay treatment, guidance on optimal exercise and dosage variables is lacking. Combining submaximal effort deep cervical muscles exercise (motor control) and superficial cervical muscles exercise (segmental) reduces chronic non-specific neck pain, but evaluation of optimal exercise and dosage variables is prevented by clinical heterogeneity. OBJECTIVE To gain consensus on important motor control and segmental exercise and dosage variables for chronic non-specific neck pain. METHODS An international 3-round e-Delphi study, was conducted with experts in neck pain management (academic and clinical). In round 1, exercise and dosage variables were obtained from expert opinion and clinical trial data, then analysed thematically (two independent researchers) to develop themes and statements. In rounds 2 and 3, participants rated their agreement with statements (1-5 Likert scale). Statement consensus was evaluated using progressively increased a priori criteria using descriptive statistics. RESULTS Thirty-seven experts participated (10 countries). Twenty-nine responded to round 1 (79%), 26 round 2 (70%) and 24 round 3 (65%). Round 1 generated 79 statements outlining the interacting components of exercise prescription. Following rounds 2 and 3, consensus was achieved for 46 important components of exercise and dosage prescription across 5 themes (clinical reasoning, dosage variables, exercise variables, evaluation criteria and progression) and 2 subthemes (progression criteria and progression variables). Excellent agreement and qualitative data supports exercise prescription complexity and the need for individualised, acceptable, and feasible exercise. Only 37% of important exercise components were generated from clinical trial data. Agreement was highest (88%-96%) for 3 dosage variables: intensity of effort, frequency, and repetitions. CONCLUSION Multiple exercise and dosage variables are important, resulting in complex and individualised exercise prescription not found in clinical trials. Future research should use these important variables to prescribe an evidence-informed approach to exercise.
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Affiliation(s)
- Jonathan Price
- Musculoskeletal Physiotherapy Services, Birmingham Community Healthcare NHS Foundation Trust, Birmingham, United Kingdom
- College of Life and Environmental Sciences, Centre of Precision Rehabilitation for Spinal Pain (CPR Spine) School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Alison Rushton
- College of Life and Environmental Sciences, Centre of Precision Rehabilitation for Spinal Pain (CPR Spine) School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
- School of Physical Therapy, Western University, Ontario, Canada
| | | | - Nicola R. Heneghan
- College of Life and Environmental Sciences, Centre of Precision Rehabilitation for Spinal Pain (CPR Spine) School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
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Gabel CP, Mokhtarinia HR, Melloh M, Mateo S. Slacklining as therapy to address non-specific low back pain in the presence of multifidus arthrogenic muscle inhibition. World J Orthop 2021; 12:178-196. [PMID: 33959482 PMCID: PMC8082507 DOI: 10.5312/wjo.v12.i4.178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/18/2021] [Accepted: 03/13/2021] [Indexed: 02/06/2023] Open
Abstract
Low back pain (LBP) represents the most prevalent, problematic and painful of musculoskeletal conditions that affects both the individual and society with health and economic concerns. LBP is a heterogeneous condition with multiple diagnoses and causes. In the absence of consensus definitions, partly because of terminology inconsistency, it is further referred to as non-specific LBP (NSLBP). In NSLBP patients, the lumbar multifidus (MF), a key stabilizing muscle, has a depleted role due to recognized myocellular lipid infiltration and wasting, with the potential primary cause hypothesized as arthrogenic muscle inhibition (AMI). This link between AMI and NSLBP continues to gain increasing recognition. To date there is no 'gold standard' or consensus treatment to alleviate symptoms and disability due to NSLBP, though the advocated interventions are numerous, with marked variations in costs and levels of supportive evidence. However, there is consensus that NSLBP management be cost-effective, self-administered, educational, exercise-based, and use multi-modal and multi-disciplinary approaches. An adjuvant therapy fulfilling these consensus criteria is 'slacklining', within an overall rehabilitation program. Slacklining, the neuromechanical action of balance retention on a tightened band, induces strategic indirect-involuntary therapeutic muscle activation exercise incorporating spinal motor control. Though several models have been proposed, understanding slacklining's neuro-motor mechanism of action remains incomplete. Slacklining has demonstrated clinical effects to overcome AMI in peripheral joints, particularly the knee, and is reported in clinical case-studies as showing promising results in reducing NSLBP related to MF deficiency induced through AMI (MF-AMI). Therefore, this paper aims to: rationalize why and how adjuvant, slacklining therapeutic exercise may positively affect patients with NSLBP, due to MF-AMI induced depletion of spinal stabilization; considers current understandings and interventions for NSLBP, including the contributing role of MF-AMI; and details the reasons why slacklining could be considered as a potential adjuvant intervention for NSLBP through its indirect-involuntary action. This action is hypothesized to occur through an over-ride or inhibition of central down-regulatory induced muscle insufficiency, present due to AMI. This subsequently allows neuroplasticity, normal neuro-motor sequencing and muscle re-activation, which facilitates innate advantageous spinal stabilization. This in-turn addresses and reduces NSLBP, its concurrent symptoms and functional disability. This process is hypothesized to occur through four neuro-physiological processing pathways: finite neural delay; movement-control phenotypes; inhibition of action and the innate primordial imperative; and accentuated corticospinal drive. Further research is recommended to investigate these hypotheses and the effect of slacklining as an adjuvant therapy in cohort and control studies of NSLBP populations.
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Affiliation(s)
- Charles Philip Gabel
- Department of Physiotherapy, Access Physiotherapy, Coolum Beach 4573, QLD, Australia
| | - Hamid Reza Mokhtarinia
- Department of Ergonomics, University of Social Welfare and Rehabilitation Sciences, Tehran 0001, Iran
- Department of Physiotherapy, University of Social Welfare and Rehabilitation Sciences, Tehran 0001, Iran
| | - Markus Melloh
- School of Health Professions, Zurich University of Applied Sciences, Winterthur 8310, Switzerland
| | - Sébastien Mateo
- INSERM U1028, CNRS UMR5292, Lyon Neuroscience Research Center, Université de Lyon, Lyon 69000, France
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Almond A, Zou Y, Forbes R. Navigating diagnostic uncertainty in musculoskeletal practice: The perspectives and experiences of new graduate physiotherapists. Musculoskelet Sci Pract 2021; 52:102354. [PMID: 33640659 DOI: 10.1016/j.msksp.2021.102354] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Diagnostic uncertainty in musculoskeletal pain presents as a frequent and challenging dilemma encountered by health professionals. Current literature indicates that diagnostic uncertainty impacts the clinical decision making of experienced physiotherapists. Despite this, the experiences and navigational strategies of new graduate physiotherapists, pertaining to this dilemma, are widely unknown. OBJECTIVES The aim of this study was to explore how new graduate physiotherapists experience and navigate diagnostic uncertainty when managing individuals with musculoskeletal pain. METHODS A qualitative study using a thematic analytical research approach was undertaken. A randomized sample of new graduate physiotherapists, working in musculoskeletal settings (n = 17), participated in semi-structured telephone interviews. Interview data was subsequently subject to thematic analysis. RESULTS Four key themes emerged from the data: 1) diagnostic uncertainty is fraught with challenges; 2) diagnosis is not the end game; 3) intrinsic strategies and extrinsic actions and 4) the imperative role of clinical practice. CONCLUSION New graduate physiotherapists frequently experience diagnostic uncertainty within musculoskeletal practice and are commonly challenged by this dilemma. Despite this, new graduates utilize several strategies to mitigate challenges including focusing on patient-centered care, maintaining transparency and relying on senior colleagues. Most strategies are directly attributed to clinical experiences. This study further outlines implications for physiotherapy curricula and workplace support.
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Affiliation(s)
- Allexandra Almond
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.
| | - Yixin Zou
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.
| | - Roma Forbes
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.
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