The Relation Between the Transversus Abdominis Muscles, Sacroiliac Joint Mechanics, and Low Back Pain Low back and lower-limb muscle performance in male and female recreational runners with chronic low back pain. Association between changes in abdominal and lumbar multifidus muscle thickness and clinical improvement after spinal manipulation. Segmental stabilization and muscular strengthening in chronic low back pain ‐ a comparative study Immediate effects of lumbar spine manipulation on the resting and contraction thickness of transversus abdominis in asymptomatic individuals. Effects of muscular stretching and segmental stabilization on functional disability and pain in patients with chronic low back pain: a randomized, controlled trial. Long-Term Effects of Specific Stabilizing Exercises for First-Episode Low Back Pain Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain Lumbar multifidus muscle thickness does not predict patients with low back pain who improve with trunk stabilization exercises. Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration The natural course of low back pain: a systematic critical literature review [Evaluation of specific stabilizing exercise in the treatment of low back pain and lumbar disk disease in outpatient rehabilitation]. Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. The association between dry needling-induced twitch response and change in pain and muscle function in patients with low back pain: a quasi-experimental study. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Relationship Between Low Back Pain and Lumbar Multifidus Size at Different Postures The Effects of Stabilization and Mckenzie Exercises on Transverse Abdominis and Multifidus Muscle Thickness, Pain, and Disability: A Randomized Controlled Trial in NonSpecific Chronic Low Back Pain Lumbar supports for prevention and treatment of low back pain: a systematic review within the framework of the Cochrane Back Review Group. Evaluation of perifacet injections and paraspinal muscle rehabilitation in treatment of low back pain. A randomised controlled trial. A review and proposal for a core set of factors for prospective cohorts in low back pain: a consensus statement. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews Effect of motor control training on muscle size and football games missed from injury. Preliminary Investigation of the Mechanisms Underlying the Effects of Manipulation: Exploration of a Multivariate Model Including Spinal Stiffness, Multifidus Recruitment, and Clinical Findings
Study Design . Two abdominal muscle patterns were tested in the same group of individuals , and their effects were compared in relation to sacroiliac joint laxity . One pattern was contraction of the transversus abdominis , independently of the other abdominals ; the other was a bracing action that used all the lateral abdominal muscles . Objectives . To demonstrate the biomechanical effect of the exercise for the transversus abdominis known to be effective in low back pain . Summary of Background Data . Drawing in the abdominal wall is a specific exercise for the transversus abdominis muscle ( in cocontraction with the multifidus ) , which is used in the treatment of back pain . Clinical effectiveness has been demonstrated to be a reduction of 3-year recurrence from 75 % to 35 % . To the authors ’ best knowledge , there is not yet in vivo proof of the biomechanical effect of this specific exercise . This study of a biomechanical model on the mechanics of the sacroiliac joint , however , predicted a significant effect of transversus abdominis muscle force . Methods . Thirteen healthy individuals who could perform the test patterns were included .  Sacroiliac joint laxity values were recorded with study participants in the prone position during the two abdominal muscle patterns . The values were recorded by means of Doppler imaging of vibrations . Simultaneous electromyographic recordings and ultrasound imaging were used to verify the two muscle patterns . Results . The range of sacroiliac joint laxity values observed in this study was comparable with levels found in earlier studies of healthy individuals . These values decreased significantly in all individuals during both muscle patterns ( P < 0.001 ) . The independent transversus abdominis contraction decreased sacroiliac joint laxity ( or rather increased sacroiliac joint stiffness ) to a significantly greater degree than the general abdominal exercise pattern ( P < 0.0260 ) . Conclusions . Contraction of the transversus abdominis significantly decreases the laxity of the sacroiliac joint . This decrease in laxity is larger than that caused by a bracing action using all the lateral abdominal muscles . These findings are in line with the authors ’ biomechanical model predictions and support the use of independent transversus abdominis contractions for the treatment of low back pain STUDY DESIGN Controlled laboratory study , cross-sectional . OBJECTIVE To compare lumbar extensor muscle fatigability , lumbar stabilizing muscle activation , and lower-limb strength between male and female runners with chronic low back pain ( LBP ) and healthy runners . BACKGROUND Little is known about muscle performance in runners with chronic LBP . METHODS Eighteen recreational runners with chronic LBP ( 9 men , 9 women ; mean age , 27.8 years ) and 18 healthy recreational runners ( 9 men , 9 women ; mean age , 24.6 years ) were recruited . The median frequency slopes for bilateral iliocostalis and longissimus were calculated from electromyographic signals captured during a 2-minute Sorensen test . The thickness changes of the transversus abdominis and lumbar multifidus between resting and contraction were measured using an ultrasound scanner .  Peak concentric torques  of the bilateral hip extensors , hip abductors , and knee extensors were measured using an isokinetic dynamometer at 60 ° /s . The average values for both sides were used for statistical analysis . RESULTS When averaged across sexes , peak knee extensor torque was 12.2 % lower in the LBP group compared to the healthy group ( mean difference , 0.29 Nm/kg ; 95 % confidence interval : 0.06 , 0.53 ; P = .016 ) . Male runners with chronic LBP exhibited smaller lumbar multifidus thickness changes compared to healthy male runners ( mean difference , 0.13 cm ; 95 % confidence interval : 0.01 , 0.25 ; P = .033 ) . No other group differences were observed . CONCLUSION Runners with chronic LBP exhibited diminished knee extensor strength compared to healthy runners . Male runners with chronic LBP demonstrated additional deficits in lumbar multifidus activation STUDY DESIGN Prospect i ve case series . OBJECTIVE To examine the relation between improved disability and changes in abdominal and lumbar multifidus ( LM ) thickness using ultrasound imaging following spinal manipulative therapy ( SMT ) in patients with low back pain ( LBP ) . BACKGROUND Although there is a growing body of literature demonstrating physiologic effects following the application of SMT , few studies have attempted to correlate these changes with clinical ly relevant outcomes . METHODS Eighty-one participants with LBP underwent 2 thrust SMT treatments and 3 assessment sessions within 1 week .  Transversus abdominis  ( TrA ) , internal oblique ( IO ) , and LM muscle thickness  was assessed during each session , using ultrasound imaging of the muscles at rest and during submaximal contractions . The Modified Oswestry Disability Index was used to quantify participants ' improvement in LBP-related disability . Stepwise hierarchical multiple linear regression and repeated- measures analysis of variance were performed to examine the multivariate relationship between change in muscle thickness and clinical improvement over time . RESULTS After controlling for the effects of age , sex , and body mass index , change in contracted LM muscle thickness was predictive of improved disability at 1 week ( P = .02 ) . As expected , larger increases in contracted LM muscle thickness at 1 week were associated with larger improvements in LBP-related disability . Contrary to our hypothesis , significant decreases in both contracted TrA and IO muscle thickness were observed immediately following SMT ; but these changes were transient and unrelated to whether participants experienced clinical improvements . CONCLUSION These findings provide evidence that clinical improvement following SMT is associated with increased thickening of the LM muscle during a submaximal task . LEVEL OF EVIDENCE Prognosis , level 4 OBJECTIVE : To contrast the efficacy of two exercise programs , segmental stabilization and strengthening of abdominal and trunk muscles , on pain , functional disability , and activation of the transversus abdominis muscle ( TrA ) , in individuals with chronic low back pain . DESIGN : Our sample consisted of 30 individuals , r and omly assigned to one of two treatment groups : segmental stabilization , where exercises focused on the TrA and lumbar multifidus muscles , and superficial strengthening , where exercises focused on the rectus abdominis , abdominus obliquus internus , abdominus obliquus externus , and erector spinae . Groups were examined to discovere whether the exercises created contrasts regarding pain ( visual analogical scale and McGill pain question naire ) , functional disability ( Oswestry disability question naire ) , and TrA muscle activation capacity ( Pressure Biofeedback Unit = PBU ) . The program lasted 6 weeks , and 30‐minute sessions occurred twice a week . Analysis of variance was used for inter‐ and intra‐group comparisons . The significance level was established at 5 % . RESULTS : As compared to baseline , both treatments were effective in relieving pain and improving disability ( p<0.001 ) . Those in the segmental stabilization group had significant gains for all variables when compared to the ST group ( p<0.001 ) , including TrA activation , where relative gains were 48.3 % and ‐5.1 % , respectively . CONCLUSION : Both techniques lessened pain and reduced disability . Segmental stabilization is superior to superficial strengthening for all variables . Superficial strengthening does not improve TrA activation capacity STUDY DESIGN R and omized , blinded , controlled crossover trial . OBJECTIVE To determine if thrust joint manipulation ( TJM ) to the lumbar spine would result in changes to the resting and contraction thickness of transversus abdominis ( TrA ) in healthy individuals . BACKGROUND Recent studies have demonstrated an immediate decrease in resting thickness and an increase in contraction thickness in TrA following lumbar TJM in patients with low back pain ( LBP ) who met a clinical prediction rule ( CPR ) for spinal manipulation . This observed phenomenon has not been investigated in healthy individuals . METHODS Thirty-five healthy participants were r and omly assigned to receive a TJM or sham manipulation treatment . All participants received instruction on how to produce an isolated concentric contraction of the TrA that involved visual ultrasound imaging biofeedback . Data were analyzed using ultrasound imaging to measure changes in thickness of the TrA at rest and during contraction , following the administration of each treatment . RESULTS There were no interactions observed between treatment and time for TrA muscle thickness at rest ( P = .351 ) and during the contracted state ( P = .761 ) . CONCLUSION Our results indicate that TJM to the lumbar spine does not appear to affect the resting or contraction thickness of TrA in healthy individuals . These findings are in contrast to previous research in which patients with LBP who met a CPR demonstrated an immediate decrease in resting thickness and an increase in contraction thickness in TrA following lumbar TJM OBJECTIVE The purpose of this study was to compare the effects of 2 exercise programs , segmental stabilization exercises ( SSEs ) and stretching of trunk and hamstrings muscles , on functional disability , pain , and activation of the transversus abdominis muscle ( TrA ) , in individuals with chronic low back pain . METHODS A total of 30 participants were enrolled in this study and r and omly assigned to 1 of 2 groups as a function of intervention . In the segmental stabilization group ( SS ) , exercises focused on the TrA and lumbar multifidus muscles , whereas in the stretching group ( ST ) , exercises focused on stretching the erector spinae , hamstrings , and triceps surae . Severity of pain ( visual analog scale and McGill pain question naire ) and functional disability ( Oswestry disability question naire ) and TrA muscle activation capacity ( Pressure Biofeedback Unit , or PBU ) were compared as a function of intervention . Interventions lasted 6 weeks , and sessions happened twice a week ( 30 minutes each ) . Analysis of variance was used for intergroup and intragroup comparisons . RESULTS As compared with baseline , both treatments were effective in relieving pain and improving disability ( P < .001 ) . Those in the SS group had significantly higher gains for all variables . The stretching group did not effectively activate the TrA ( P = .94 ) . CONCLUSION Both techniques improved pain and reduced disability . In this study , SS was superior to muscular stretching for the measured variables associated with chronic low back pain Study Design . A r and omized clinical trial with 1-year and 3-year telephone question naire follow-ups . Objective . To report a specific exercise intervention ’s long-term effects on recurrence rates in acute , first-episode low back pain patients . Summary of Background Data . The pain and disability associated with an initial episode of acute low back pain ( LBP ) is known to resolve spontaneously in the short-term in the majority of cases . However , the recurrence rate is high , and recurrent disabling episodes remain one of the most costly problems in LBP . A deficit in the multifidus muscle has been identified in acute LBP patients , and does not resolve spontaneously on resolution of painful symptoms and resumption of normal activity . Any relation between this deficit and recurrence rate was investigated in the long-term . Methods . Thirty-nine patients with acute , first-episode LBP were medically managed and r and omly allocated to either a control group or specific exercise group . Medical management included advice and use of medications . Intervention consisted of exercises aim ed at rehabilitating the multifidus in cocontraction with the transversus abdominis muscle . One year and three years after treatment , telephone question naires were conducted with patients . Results . Question naire results revealed that patients from the specific exercise group experienced fewer recurrences of LBP than patients from the control group . One year after treatment , specific exercise group recurrence was 30 % , and control group recurrence was 84 % ( P < 0.001 ) . Two to three years after treatment , specific exercise group recurrence was 35 % , and control group recurrence was 75 % ( P < 0.01 ) . Conclusion . Long-term results suggest that specific exercise therapy in addition to medical management and resumption of normal activity may be more effective in reducing low back pain recurrences than medical management and normal activity alone Objectives Although motor control exercises have been shown to be effective in the management of  low back pain ( LBP ) the mechanism of action is unclear . The current study investigated the relationship between the ability to recruit transversus abdominis and clinical outcomes of participants in a clinical trial . Methods Ultrasonography was used to assess the ability to recruit transversus abdominis in a nested design : a sample of 34 participants with chronic LBP was recruited from participants in a r and omised controlled trial comparing the efficacy of motor control exercise , general exercise and spinal manipulative therapy .  Perceived recovery , function , disability and pain were also assessed . Results Participants with chronic LBP receiving motor control exercise had a greater improvement in recruitment of transversus abdominis ( 7.8 % ) than participants receiving general exercise ( 4.9 % reduction ) or spinal manipulative therapy ( 3.7 % reduction ) . The effect of motor control exercise on pain reduction was greater in participants who had a poor ability to recruit transversus abdominis at baseline . There was a significant , moderate correlation between improved recruitment of transversus abdominis and a reduction in disability ( r = −0.35 ; 95 % CI 0.02 to 0.62 ) . Conclusion These data provide some support for the hypothesised mechanism of action of motor control exercise and suggest that the treatment may be more effective in those with a poor ability to recruit transversus abdominis OBJECTIVE To underst and lumbar multifidus ( LM ) muscle activation as a clinical feature to predict patients with low back pain ( LBP ) who are likely to benefit from stabilization ( STB ) exercises .  DESIGN Prospect i ve , cohort study . SETTING Outpatient physical therapy clinics . PARTICIPANTS Persons with LBP were recruited for this study . Subjects ( N=25 ) were classified as either eligible to receive STB exercises or ineligible on the basis of current clinical prediction rules . INTERVENTIONS Six weeks of STB treatment . MAIN OUTCOME MEASURES Before and after treatment , subjects underwent rehabilitative ultrasound imaging to quantify LM-muscle activation and completed disability and pain question naires . Analyses were performed to examine the ( 1 ) relation between LM-muscle activation and current clinical features used to predict patients with LBP likely to benefit from STB exercises , ( 2 ) LM-muscle activation between the STB-eligible and STB-ineligible groups before and after STB treatment , and ( 3 ) relation between LM-muscle activation before STB treatment and ( a ) disability and ( b ) pain outcomes after treatment for both groups . RESULTS No relation was found between LM-muscle activation and the number of clinical features . Before STB treatment , LM-muscle activation between the STB-eligible and STB-ineligible groups did not differ . After STB treatment , LM-muscle activation differed between the groups ; however , this interaction was because the LM-muscle activation for the STB-eligible group decreased after treatment while that for the STB-ineligible group increased after treatment . Finally , only the STB-eligible group had a significant reduction in disability following treatment ; however , no relation was found between LM-muscle activation before treatment and ( a ) disability or ( b ) pain outcomes after treatment in the STB-eligible group . CONCLUSIONS LM-muscle activation does not appear to be a clinical feature that predicts patients with LBP likely to benefit from STB exercises Abstract Purpose To evaluate the effectiveness of non-steroidal anti-inflammatory drugs ( NSAIDs ) for the management of neck pain and associated disorders ( NAD ) , whiplash-associated disorders , and non-specific low back pain ( LBP ) with or without radiculopathy . Methods We systematic ally search ed six data bases from 2000 to 2014 . R and om pairs of independent review ers critically appraised eligible systematic review s using the Scottish Intercollegiate Guidelines Network criteria . We included systematic review s with a low risk of bias in our best evidence synthesis . Results We screened 706 citations and 14 systematic review s were eligible for critical appraisal . Eight systematic review s had a low risk of bias . For recent-onset NAD , evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy . For NAD ( duration not specified ) , oral NSAIDs may be more effective than placebo . For recent-onset LBP , evidence suggests that : ( 1 ) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant ; and ( 2 ) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest . For persistent LBP , evidence suggests that : ( 1 ) oral NSAIDs are more effective than placebo ; and ( 2 ) oral NSAIDs may be more effective than acetaminophen . For recent-onset LBP with radiculopathy , there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo . Finally , different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy . Conclusions For NAD , oral NSAIDs may be more effective than placebo . Oral NSAIDs are more effective than placebo for persistent LBP , but not for recent-onset LBP . Different oral NSAIDs lead to similar outcomes for neck pain and LBP Background Most patients in the secondary care sector consulting for low back pain ( LBP ) seem to have a more or less constant course of pain during the ensuing year . Fewer patients with LBP in the primary care sector report continual pain over a one-year period . However , not much is known about the long-term course of LBP in the general population . A systematic critical literature review was undertaken in order to study the natural course of LBP over time in the general population . Methods A search of articles was performed in Pubmed , Cinahl and Psychinfo using the search terms ‘ epidemiology ’ ; ‘ low back pain ’ or ‘ back pain ’ ; ‘ prospect i ve study ’ or ‘ longitudinal study ’ ; ‘ follow-up ’ , ‘ natural course ’ , ‘ course ’ or ‘ natural history ’ ; ‘ general population ’ or ‘ working population ’ . Inclusion criteria were that one of the objectives was to study the course of (L)BP in the adult population , that the period of follow-up was at least 3 months , and that there were three points of observation or more . The review was undertaken by two independent review ers using three checklists relating to description of studies , quality and outcomes . The course of LBP was established in relation to those who , at baseline , were reported not to have LBP or to have LBP . Would this course be stable , fluctuating , worsening , or improving over time ? A synthesis of results in relation to common patterns was presented in a table and interpreted in a narrative form . Results Eight articles were included . Articles were different on time span , the number of surveys , and the definition of LBP . In six of the seven relevant studies , for those with no LBP at baseline , relatively substantial stable subgroups of people who continued to be LBP free were identified . In six of the seven relevant studies , definite stable subgroups of continued LBP were noted and improvement ( becoming pain free ) was never reported to be a common finding . Conclusion The status of LBP in individuals of the general population appears to be relatively stable over time , perhaps particularly so for those without LBP at baseline AIM The aim of the study was to evaluate the outcome of  outpatient rehabilitation in patients with low back pain and lumbar disk disease with a  specific stabilizing exercise of the M. multifidus and M. transversus abdominis . METHOD 99 out patients admitted to a rehabilitation unit were included in a prospect i ve r and omized controlled interventional trial . The interventional group consisted of 50 patients ( 34 male , 16 female ; mean age 41.1 + /- 9.1 , range ; 21 - 54 years ) , 49 patients ( 31 male , 18 female ; mean age 37.9 + /- 9.5 , range ; 19 - 55 years ) were in the control group . Outcomes were assessed at the beginning and the end of the treatment and at a three month follow-up with the Oswestry Low Back Pain Disability Question naire , the Hannover Functional Ability Question naire FFbH-R , the pain scale SES and a numeric rating scale . RESULTS In both groups there was a significant functional improvement as measured with the Oswestry Score and the FFbH-R. The interventional group showed better values at the end of the treatment . Pain as well could be reduced significantly by the treatment , but no differences were noted between the two groups . CONCLUSION Outpatient rehabilitation improved functional capacity and pain in both groups . Advantages could be seen in the interventional group concerning functional status . The specific stabilizing exercise approach appears to be effective in conservative treatment programs of low back pain and lumbar disk disease BACKGROUND CONTEXT Low back pain ( LBP ) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses . A common intervention for LBP is spinal manipulation , a technique that is not specific to one scope of practice or profession . PURPOSE The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain . METHODS A search of the current literature was conducted using PubMed , CINAHL , SPORTD iscus , Pro Quest Nursing and Allied Health Source , Scopus , and Cochrane Controlled Trials Register . Studies were included if each involved : 1 ) individuals with LBP ; 2 ) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations ; 3 ) measurable clinical outcomes or efficiency of treatment measures , and 4 ) r and omized control trials . The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Data base ( PEDro ) . RESULTS Six r and omized control trials met the inclusion criteria of this systematic review . The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes . Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events result ing from this intervention . Additionally , the manipulation group in one study reported statistically significantly less medication use , health care utilization , and lost work time . CONCLUSION Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice . Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain OBJECTIVE To investigate the relationship between dry needling-induced twitch response and change in pain , disability , nociceptive sensitivity , and lumbar multifidus muscle function , in patients with low back pain ( LBP ) . DESIGN Quasi-experimental study . SETTING Department of Defense Academic Institution . PARTICIPANTS Sixty-six patients with mechanical LBP ( 38 men , 28 women , age : 41.3 [ 9.2 ] years ) . INTERVENTIONS Dry needling treatment to the lumbar multifidus muscles between L3 and L5 bilaterally . MAIN OUTCOME MEASURES Examination procedures included numeric pain rating , the Modified Oswestry Disability Index , pressure algometry , and real-time ultrasound imaging assessment of lumbar multifidus muscle function before and after dry needling treatment . Pain pressure threshold ( PPT ) was used to measure nocioceptive sensitivity . The percent change in muscle thickness from rest to contraction was calculated to represent muscle function . Participants were dichotomized and compared based on whether or not they experienced at least one twitch response on the most painful side and spinal level during dry needling . RESULTS Participants experiencing local twitch response during dry needling exhibited greater immediate improvement in lumbar multifidus muscle function than participants who did not experience a twitch ( thickness change with twitch : 12.4 [6]% , thickness change without twitch : 5.7 [11]% , mean difference adjusted for baseline value , 95%CI : 4.4 [ 1 to 8]% ) . However , this difference was not present after 1-week , and there were no between-groups differences in disability , pain intensity , or nociceptive sensitivity . CONCLUSIONS The twitch response during dry needling might be clinical ly relevant , but should not be considered necessary for successful treatment Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied Study Design . A prospect i ve study of multifidus images . Objective . To compare the change of the cross-sectional area ( CSA ) of multifidus in subjects with and without chronic low back pain ( LBP ) at different postures . Summary of Background Data . Ultrasound imaging was shown to be useful in assessing acute LBP patients at rest only . Methods and Measures . Thirty-five male adults participated , including 19 normal and 16 chronic LBP patients . The CSAs of multifidus were assessed on ultrasound images acquired on both sides of the L4 and L5 levels with the subjects in prone lying , upright st and ing , and 25 ° and 45 ° forward stooping . Results . In the control group , the CSA of multifidus increased from prone lying to upright st and ing and then gradually decreased from 25 ° to 45 ° forward stooping . However , a reverse pattern of the CSA changes was identified in patients with chronic LBP . Conclusion . Multifidus contracts maximally at upright st and ing in the normal group , while maximum contraction of the muscle occurs at 25 ° forward stooping in the patient group . The role of multifidus may be altered in the stabilization of the lumbar spine of chronic LBP patients . Assessment of the change in muscle size reacting to different postures is found to be helpful [ Purpose ] This study compared the effectiveness of stabilization and McKenzie exercises on pain , disability , and thickness of the transverse abdominis and multifidus muscles in patients with nonspecific chronic low back pain . [ Subjects ] Thirty patients were r and omly assigned into two groups : the McKenzie and stabilization exercise groups . [ Methods ] Before and after intervention , pain , disability , and thickness of the transverse abdominis and multifidus muscles were evaluated by visual analogue scale , functional rating index , and sonography , respectively . The training program was 18 scheduled sessions of individual training for both groups . [ Results ] After interventions , the pain score decreased in both groups . The disability score decreased only in the stabilization group . The thickness of the left multifidus was significantly increased during resting and contracting states in the stabilization group . The thickness of the right transverse abdominis during the abdominal draw-in maneuver , and thickness of the left transverse abdominis during the active straight leg raising maneuver were significantly increased in the stabilization group . The intensity of pain , disability score , thickness of the right transverse abdominis during the abdominal draw-in manouver , and thickness of the left transverse abdominis during active straight leg raising in the stabilization group were greater than those on the Mackenzie . [ Conclusion ] Stabilization exercises are more effective than McKenzie exercises in improving the intensity of pain and function score and in increasing the thickness of the transverse abdominis muscle STUDY DESIGN A systematic review of r and omized and nonr and omized controlled trials . SUMMARY OF BACKGROUND DATA Lumbar supports are used in the treatment of low back pain , but also to prevent the onset ( primary prevention ) or recurrences of a low back pain episode ( secondary prevention ) . OBJECTIVES To assess the effects of lumbar sup-ports for prevention and treatment of nonspecific low back pain .  METHODS The Medline , Cinahl , and Current Contents data bases ; the Cochrane Controlled Trials Register up to September 1999 ; and the Embase data base up to September 1998 were all search ed . References of identified trials and systematic review s were review ed and the Science Citation Index used to identify additional trials . Method ologic quality assessment and data extraction were performed by two review ers independently . A quantitative analysis was performed in which the strength of evidence was classified as strong , moderate , limited or conflicting , and no evidence . RESULTS Five r and omized and two nonr and omized preventive trials and six r and omized therapeutic trials were included in the review . Only 4 of the 13 studies were of high quality . There was moderate evidence that lumbar supports are not effective for primary prevention . No evidence was found on the effectiveness of lumbar supports for secondary prevention . The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment , whereas it is still unclear whether lumbar supports are more effective than other interventions for treatment of low back pain . CONCLUSIONS There continues to be a need for high quality r and omized trials on the effectiveness of lumbar supports . One of the most essential issues to tackle in these future trials seems to be the realization of adequate compliance BACKGROUND Lumbar paraspinal muscle dysfunction and Low Back Pain are strongly correlated . The best treatment for non-specific Low Back Pain is still controversial . OBJECTIVE To evaluate the efficacy of lumbar multifidus muscle retraining exercises and perifacet multifidus injections in the treatment of Low Back Pain . MATERIAL AND METHODS 63 patients with non-specific LBP , with or without leg pain , and magnetic resonance images of paraspinal muscle degeneration only , were r and omised to one of three treatment groups : A- Back education and st and ard physiotherapy for 10 weeks , B- Back education and gym ball exercise for 10 weeks or C- Perifacet injection into the lumbar multifidus muscle with methylprednisolone . The Oswestry Disability Index was used as the primary outcome measure and the SF-36 , modified Zung depression index , modified somatic perception and McGill pain question naires were used as secondary outcome measures . RESULTS 56 patients completed the trial . The Oswestry Disability Index improved in general from a mean of 29.9 to 25.9 , but there were no statistically significant differences between the groups . Low back pain improved most in group C ( P<0.02 ) , while physical activities and social functioning were improved the most in group B ( P<0.03 ) . CONCLUSION Perifacet injection and back education including a gym ball exercise program may be more effective than back education alone in relieving pain and improving physical capacity respectively . Back education including gym ball exercise could be used for non-specific Low Back Pain , as the ultimate goal should be to restore function Introduction The Multinational Musculoskeletal Inception Cohort Study ( MMICS ) Statement is a consensus statement aim ed at improving the quality of prospect i ve investigations into the transition from early stages of low back pain ( LBP ) to persistent problems . The statement aims to help improve the quality of such studies by recommending an agreed minimal list of measures for inclusion in baseline data collection . The MMICS Statement is primarily aim ed at research ers who want to investigate prognosis in LBP , and this will allow data from cohorts to be pooled and will facilitate comparisons between different health care systems . One approach to preventing acute new episodes of LBP ( up to 3 weeks from onset ) from developing into persistent disabling pain is to identify those individuals with LBP who are most likely to progress to chronic disability . Targeting interventions at those at highest risk could reduce the population burden of chronic LBP . A wide range of baseline parameters have been associated with poor outcome in inception cohort studies ( 1–6 ) . Few existing studies have been of sufficient size and method ologic rigor to produce conclusive findings . Even in method ologically robust studies , baseline factors only account for a small proportion of the variance in outcome ( 7 ) , typically around 30 % . Systematic review s of the literature could not pool data because studies used different measurements ( 1–3 ) . Despite some information on physical , psychosocial , and work-related risk factors , it has not been possible to adequately estimate the comparative impact of individual psychosocial and societal factors on the transition from acute to persistent disabling LBP . How to address this problem was one focus of the VI International Forum for Primary Care Research in Low Back Pain held in April 2003 . A steering group for the collaboration was appointed , and 8 national team leaders volunteered to recruit teams of national experts . Three additional team leaders were recruited by the steering group ( Australia , France , and Germany ) . Independent experts were invited to advise on the quality of the MMICS process . The MMICS steering group , located in the UK , met regularly and included expert research ers in clinical and outcome factors in back pain ( AB ) , work-related issues in back pain ( AKB ) , psychosocial aspects of back pain ( TP and RS ) , and general practice aspects of back pain ( MU ) . The MMICS Statement set out to include 1 ) a minimal but comprehensive number of predictor factors based on current evidence and theory ; 2 ) appropriate measurement instruments for agreed predictor factors based on their clinometric properties , availability , and practical characteristics ; and 3 ) a minimum set of followup measures , including recommendations about measurement and timing BACKGROUND CONTEXT A range of morphologic and psychosocial variables has been suggested as risk factors for serious low back pain ( LBP ) illness . Although the relative contributions of structural and psychosocial variables are intensely debated , the validity of differing hypotheses has proven difficult to test because the incidence of serious disabling LBP illness is low in healthy subjects . These factors dictate the requirement for large sample sizes , extensive structural imaging and extended longitudinal study . Previous studies included either small cohorts with intensive imaging testing or large population studies that do not establish a detailed morphologic baseline . PURPOSE To establish , using a strict patient sample design , the relative contribution of structural and psychosocial determinants of serious LBP illness among subjects with no previous LBP disability or clinical LBP illness . STUDY DESIGN / SETTING A prospect i ve , longitudinal study of subjects with high risk factors for serious LBP as determined by structural and psychosocial characteristics . PATIENT SAMPLE One hundred subjects with known mild persistent low back pain and a 2:1 ratio of chronic ( non-lumbar ) pain syndrome were recruited from a study population with a predisposition to disc degenerative disease , to undergo baseline examination , testing and 5-year follow-up . OUTCOME MEASURES Observations were made at 6-month intervals over 4 to 6 years ( mean , 5.3 ) for the after primary outcomes measures : episodes of serious back pain ( visual analogue scale [ VAS ] > or = 6 ) , episodes of occupational disability less than 1 week , episodes of occupational disability for 1 week , remission episodes of all back pain symptoms at least 6 months and medical visits primarily for LBP evaluation and treatment . METHODS Lumbar magnetic resonance imaging ( MRI ) , lumbar provocative discography ( in psychometrically normal subjects ) , physical examinations , medical and work histories and psychometric testing were performed at baseline . Imaging and psychometric testing were grade d by blinded examiners . A scripted interview was conducted every 6 months during follow-up by independent research assistants who also were blinded to patient baseline data . The interview covered interval medical , occupational and accident or injury histories . RESULTS Psychosocial variables strongly predicted both long- and short-term disability events , duration and health-care visits for LBP problems ( p<0.0001 - 0.004 ) . The likelihood of a sustained remission from the baseline persistent ( sub clinical ) LBP appeared to be linked to occupation factors ( leaving a heavy labor occupation ; p=0.0001 ) , neurophysiologic variables ( chronic nonlumbar pain ; p=0.0002 ) and psychometric profiles at baseline ( DRAM and FABQ-PA ; p=0.003 - 0.002 ) . Of the structural findings measured only moderate or severe Modic changes of the vertebral end plate were weakly associated with an adverse outcome . A positive provocative discogram at baseline did not predict any future adverse event . CONCLUSION The development of serious LBP disability in a cohort of subjects with both structural and psychosocial risk factors was strongly predicted by baseline psychosocial variables . Structural variables on both MRI and discography testing at baseline had only weak association with back pain episodes and no association with disability or future medical care Abstract Objective : to review and up date the evidence for different forms of manual therapy ( MT ) for patients with different stages of non-specific low back pain ( LBP ) . Data sources : MEDLINE , Cochrane-Register-of-Controlled-Trials , PEDro , EMBASE . Method : A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent review ers according to Cochrane and PRISMA guidelines . A total of 360 studies were evaluated using qualitative criteria . Two stages of LBP were categorized ; combined acute – subacute and chronic . Further sub-classification was made according to MT intervention : MT1 ( manipulation ) ; MT2 ( mobilization and soft-tissue-techniques ) ; and MT3 ( MT1 combined with MT2 ) . In each sub-category , MT could be combined or not with exercise or usual medical care ( UMC ) . Consequently , quantitative evaluation criteria were applied to 56 eligible r and omized controlled trials ( RCTs ) , and hence 23 low-risk of bias RCTs were identified for review . Only studies providing new up date d information ( 11/23 RCTs ) are presented here . Results : Acute – subacute LBP : STRONG- evidence in favour of MT1 when compared to sham for pain , function and health improvements in the short-term ( 1–3 months ) . MODERATE- evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain , function and health improvements in the short-term . Chronic LBP : MODERATE to STRONG- evidence in favour of MT1 in comparison to sham for pain , function and overall-health in the short-term . MODERATE- evidence in favour of MT3 combined with exercise or UMC in comparison to  exercise  and back-school was established for pain , function and quality -of-life in the short and long-term . LIMITED- evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term . LIMITED- evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term . Conclusion : This systematic review up date s the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies PURPOSE This panel-r and omized intervention trial was design ed to examine the effect of a motor control training program for elite Australian Football League players with and without low back pain ( LBP ) . METHODS The outcome measures included cross-sectional area ( CSA ) and symmetry of multifidus , quadratus lumborum , and psoas muscles and the change in CSA of the trunk in response to an abdominal drawing-in task . These measures of muscle size and function were performed using magnetic resonance imaging . Availability of players for competition games was used to assess the effect of the intervention on the occurrence of injuries . The motor control program involved performance of voluntary contractions of the multifidus and transversus abdominis muscles while receiving feedback from ultrasound imaging . Because all players were to receive the intervention , the trial was delivered as a stepped-wedge design with three treatment arms ( a 15-wk intervention , a 8-wk intervention , and a waitlist control who received a 7-wk intervention toward the end of the playing season ) . Players participated in a Pilates program when they were not receiving the intervention . RESULTS The intervention program was associated with an increase in multifidus muscle size relative to results in the control group . The program was also associated with an improved ability to draw-in the abdominal wall . Intervention was commensurate with an increase in availability for games and a high level of perceived benefit . CONCLUSIONS The motor control program delivered to elite footballers was effective , with demonstrated changes in the size and control of the targeted muscles . In this study , footballers who received the intervention early in the season missed fewer games because of injury than those who received it late in the playing season Study Design . Prospect i ve case series . Objective . To examine spinal stiffness in patients with low back pain ( LBP ) receiving spinal manipulative therapy ( SMT )  , evaluate associations between stiffness characteristics and clinical outcome , and explore a multivariate model of SMT mechanisms as related to effects on stiffness , lumbar multifidus ( LM ) recruitment , and status on a  clinical prediction rule  ( CPR ) for SMT outcomes . Summary of Background Data . Mechanisms underlying the clinical effects of SMT are poorly understood . Many explanations have been proposed , but few studies have related potential mechanisms to clinical outcomes or considered multiple mechanisms concurrently . Methods . Patients with LBP were treated with two SMT sessions over 1 week . CPR status was assessed at baseline . Clinical outcome was based on the Oswestry disability index ( ODI ) . Mechanized indentation measures of spinal stiffness and ultrasonic measures of LM recruitment were taken before and after each SMT , and after 1 week . Global and terminal stiffness were calculated . Multivariate regression was used to evaluate the relationship between stiffness variables and percentage ODI improvement . Zero-order correlations among stiffness variables , LM recruitment changes , CPR status , and clinical outcome were examined . A path analysis was used to evaluate a multivariate model of SMT effects . Results . Forty-eight patients ( 54 % women ) had complete stiffness data . Significant immediate decreases in global and terminal stiffness occurred post-SMT regardless of outcome . ODI improvement was related to greater immediate decrease in global stiffness ( P = 0.025 ) , and less initial terminal stiffness ( P = 0.01 ) . Zero-order correlations and path analysis supported a multivariate model suggesting that clinical outcome of SMT is mediated by improvements in LM recruitment and immediate decrease in global stiffness . Initial terminal stiffness and CPR status may relate to outcome though their relationship with LM recruitment . Conclusion . The underlying mechanisms explaining the benefits of SMT appear to be multifactorial . Both spinal stiffness characteristics and LM recruitment changes appear to play a role
Evidence synthesis showed limited evidence supporting poor baseline transversus abdominis contraction thickness ratio as a treatment effect modifier favoring motor control exercise .
Limited evidence supported that high baseline transversus abdominis lateral slide was associated with higher pain intensity after various exercise interventions at 1-year follow-up .
However , there was limited evidence for the absence of relation between the contraction thickness ratio of transversus abdominis or anticipatory onset of lateral abdominal muscles at baseline and the short- or long-term LBP intensity after exercise interventions .
There was conflicting evidence for a relation between baseline percent thickness change of lumbar multifidus during contraction and the clinical outcomes of patients after various conservative treatments .
Although individual reports suggest that baseline morphometry or activity of transversus abdominis or lumbar multifidus predict clinical outcome of low back pain ( LBP ) , a related systematic review is unavailable .
Therefore , this review summarized evidence regarding the predictive value of these muscular characteristics .