A study of therapeutic ultrasound and exercise treatment for muscle fatigue in patients with chronic non specific low back pain: a preliminary report. Evidence-based medicine and the challenge of low back pain: where are we now? Specificity of a back muscle exercise machine in healthy and low back pain subjects. Course and prognosis of recovery for chronic non-specific low back pain: design, therapy program and baseline data of a prospective cohort study Prognosis and Course of Disability in Patients With Chronic Nonspecific Low Back Pain: A 5- and 12-Month Follow-up Cohort Study Specificity of a back muscle roman chair exercise in healthy and back pain subjects. The Effects of Dynamic Isolated Lumbar Extensor Training on Lumbar Multifidus Functional Cross-Sectional Area and Functional Status of Patients With Chronic Nonspecific Low Back Pain Quantifying the Lumbar Flexion–Relaxation Phenomenon: Theory, Normative Data, and Clinical Applications [Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance]. Functional multidisciplinary rehabilitation versus outpatient physiotherapy for non specific low back pain: randomized controlled trial. Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature.
AIM The aim of this study was to investigate the effect of continuous ultrasound ( US ) plus exercise on the endurance of paravertebral muscles of patients with chronic non specific low back pain ( CNSLBP ) . METHODS AND MATERIAL S In this pilot , pretest-posttest study , 22 patients with CNSLBP participated . Patients received 10 sessions of treatment , including continuous US plus exercise therapy , over a period of four consecutive weeks . Median frequency slopes of Iliocostalis and Multifidus muscles as well as holding time during Biering-Sorensen test were measured using surface electromyography . In addition , function and pain were measured using Functional Rating Index ( FRI ) question naire and VAS . RESULTS Five females and 15 males with a mean age of 31.7 years completed the treatment . Descriptive data showed a decrease of 0.01 and 0.02 mean in median frequency slope of right and left Iliocostalis respectively and a mean of 0.08 decrease for both right and left Multifidus muscles . Endurance time increased 1.8 seconds mean . Both function ( 17 % ) and pain ( 24 % ) improved post treatment . CONCLUSION Larger population studies in the context of high quality , r and omized clinical trial are needed to vali date the results Low  back pain  has long been described as a challenge for both primary care physicians and specialists . Management of  low back pain  has also been criticized as frequently arbitrary , inappropriate , or ineffective . Contributing factors have been an inadequate evidence base and a need for more rigorous appraisal s of the available literature . Evidence -based medicine , an approach to clinical problem solving , is predicated on the premise that high- quality health care will result from practice s consistent with the best evidence . In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion , authority , and un systematic clinical observations , evidence -based medicine emphasizes the need for rigorous critical appraisal s of the scientific literature to inform medical decision making . Evidence -based medicine places strong weight on the requirement for valid studies , particularly r and omized controlled trials , to appropriately evaluate the effectiveness of health care interventions . Because of the rapidly increasing volume of medical literature , however , most clinicians are unable to keep up-to- date with all the new data . Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic review s and evidence -based clinical practice guidelines . Like primary studies , systematic review s and clinical practice guidelines must adhere to high method ologic st and ards to reduce error and bias . As in other areas of medicine , the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings . In addition to more rigorous primary studies , an increasing number of high- quality systematic review s and evidence -based clinical practice guidelines for low back pain are also available . Although some research gaps and method ologic shortcomings persist , the richer evidence base has greatly improved our underst and ing of what does and does not work for low back pain . Despite these advances , the best available evidence often does not inform everyday clinical decisions for low back pain . Nonetheless , there is widespread agreement that adherence to evidence -based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care . This article review s basic principles of evidence -based medicine , discusses evidence -based medicine in the context of low back pain management , and summarizes some useful evidence -based medicine re sources PURPOSE To determine whether dynamic back muscle endurance exercises in a semisitting position induce more fatigue in back muscles than that in hip extensors in healthy controls as well as in patients with nonspecific chronic low back pain . METHODS Sixteen healthy volunteers and 18 volunteers with nonspecific chronic low back pain performed trunk flexion-extension cycles until exhaustion at 60 % of their strength in a machine design ed for back exercise in a semisitting position with knees ' angle at 135 degrees . The number of cycles and perceived muscle fatigue ( Borg CR-10 scale ) at five areas ( upper and lower back , gluteus , hamstrings , and quadriceps ) were used as fatigue criteria . EMG signals were recorded bilaterally on four back muscles , two hip extensors ( gluteus maximus and biceps femoris ) , and the vastus medialis . The slope values of the instantaneous median frequency values computed over time were retained as EMG indices of fatigue . RESULTS The number of cycles was equivalent in healthy controls ( n = 23 + /- 13 ) and patients with back pain ( n = 27 + /- 16 ) . EMG indices of fatigue disclosed evidence of muscle fatigue in all the back muscles and the vastus medialis , contrary to hip extensors . EMG revealed significantly more muscle fatigue of lower back muscles , which was further corroborated by the Borg scale assessment . No between-group difference was obtained in any EMG comparison . CONCLUSION These results showed that this type of exercise machine can specifically train the back muscles , and this as much in subjects with nonspecific chronic low back pain as in healthy controls . This has implication s for the training of back muscle endurance , especially in patients with back pain for whom poor back muscle endurance is sometimes of concern Background There has been increasing focus on factors predicting the development of chronic musculoskeletal disorders . For patients already experiencing chronic non-specific low back pain it is also relevant to investigate which prognostic factors predict recovery . We present the design of a cohort study that aims to determine the course and prognostic factors for recovery in patients with chronic non-specific low back pain . Methods / Design All participating patients were recruited ( Jan 2003-Dec 2008 ) from the same rehabilitation centre and were evaluated by means of ( postal ) question naires and physical examinations at baseline , during the 2-month therapy program , and at 5 and 12 months after start of therapy . The therapy protocol at the rehabilitation centre used a bio-psychosocial approach to stimulate patients to adopt adequate ( movement ) behaviour aim ed at physical and functional recovery . The program is part of regular care and consists of 16 sessions of 3 hours each , over an 8-week period ( in total 48 hours ) , followed by a 3-month self-management program . The primary outcomes are low back pain intensity , disability , quality of life , patient 's global perceived effect of recovery , and participation in work . Baseline characteristics include information on socio-demographics , low back pain , employment status , and additional clinical items status such as fatigue , duration of activities , and fear of kinesiophobia . Prognostic variables are determined for recovery at short-term ( 5 months ) and long-term ( 12 months ) follow-up after start of therapy . Discussion In a routine clinical setting it is important to provide patients suffering from chronic non-specific low back pain with adequate information about the prognosis of their complaint Background Few data are available on the course of and predictors for disability in patients with chronic nonspecific low back pain ( CNSLBP ) . Objective The purpose of this study was to describe the course of disability and identify clinical ly important prognostic factors of low-back-pain – specific disability in patients with CNSLBP receiving multidisciplinary therapy .  Design A prospect i ve cohort study was conducted . Methods A total of 1,760 patients with CNSLBP who received multidisciplinary therapy  were evaluated for their course of disability and prognostic factors at baseline and at 2- , 5- , and 12-month follow-ups . Recovery was defined as 30 % reduction in low back pain – specific disability at follow-up compared with baseline and as absolute recovery if the score on the Quebec Back Pain Disability Scale ( QBPDS ) was ≤20 points at follow-up . Potential prognostic factors were identified using multivariable logistic regression analysis . Results Mean patient-reported disability scores on the QBPDS ranged from 51.7 ( SD=15.6 ) at baseline to 31.7 ( SD=15.2 ) , 31.1 ( SD=18.2 ) , and 29.1 ( SD=20.0 ) at 2 , 5 , and 12 months , respectively . The prognostic factors identified for recovery at 5 and 12 months were younger age and high scores on disability and on the 36-Item Short-Form Health Survey ( SF-36 ) ( Physical and Mental Component Summaries ) at baseline . In addition , at 5-month follow-up , a shorter duration of complaints was a positive predictor , and having no comorbidity and less pain at baseline were additional predictors at 12-month follow-up . Limitations Missing values at 5- and 12-month follow-ups were 11.1 % and 45.2 % , respectively . Conclusion After multidisciplinary treatment , the course of disability in patients with CNSLBP continued to decline over a 12-month period . At 5- and 12-month follow-ups , prognostic factors were identified for a clinical ly relevant decrease in disability scores on the QBPDS PURPOSE Roman chair exercises are popular for improving back muscle endurance but do not specifically target back muscles . This study aim ed to determine whether an adaptation of the Roman chair exercise would induce more fatigue in back muscles than in hip extensors . METHODS For this study , 16 healthy subjects and 18 patients with nonspecific chronic low back pain performed trunk flexion-extension cycles until exhaustion in a Roman chair with hips flexed at 40 ° . Surface EMG signals  were recorded bilaterally on four back muscles and two hip extensors ( gluteus maximus and biceps femoris ) . Motion analysis of the trunk segments ( pelvis , lumbar , and thoracic spines ) was also carried out . RESULTS In both groups , EMG revealed clear evidence of muscle fatigue for the gluteus maximus , less clear evidence of fatigue for the lower back muscles , and motor unit recruitment ( without fatigue ) for the upper back muscles and biceps femoris . A change of muscle activation pattern was emphasized throughout the exercise bout , with some lower back muscles showing an increase followed by a decrease or leveling off of activation and with upper back muscles showing an increased activation at the end . Kinematic analyses revealed a progressive decrease ( 11 ° ) in the lumbar range of motion ( ROM ) and a progressive increase in hip ( 2 ° ) and thoracic ( 7 ° ) ROM during the exercise bout . CONCLUSIONS Roman chairs allow more freedom to change the kinematics of the spine during the exercise ( less lumbar and more thoracic motion ) to delay lower back muscle fatigue by sharing the load between the lower and upper back muscles . Even with adaptations to reduce hip extensors fatigue , this may make this exercise not as specific as wanted for fatiguing lower back muscles Study Design . A prospect i ve single-arm trial . Objective . To investigate whether dynamic isolated resistance training of global lumbar extensor muscles leads to changes in lumbar multifidus ( LM ) morphology in terms of cross-sectional muscle , and , if so , whether these changes are associated with observed changes in self-experienced functional status of chronic nonspecific low back pain ( CNSLBP ) . Summary of Background Data . LM morphology is associated with the recurrence of CNSLBP . Methods . Sixteen male patients underwent a dynamic isolated resistance-training program for the lower back muscles of approximately 10 sessions in 12 weeks . In the next 12 weeks , frequency of training was tailored to the patients ' need . Participants underwent lumbar magnetic resonance imaging at baseline ( T0 ) , after 12 weeks ( T12 ) , and after 24 weeks ( T24 ) . Functional cross-sectional area was obtained by analyzing the magnetic resonance images . Functional status was assessed using the patient-specific functional scale , Rol and -Morris disability question naire , and global perceived effect scale . Results . Rol and -Morris disability question naire and patient-specific functional scale scores showed significant and clinical ly relevant improvements between baseline and T12 , with 44 % and 39 % , respectively . Between T12 and T24 , these scores did not change significantly . Seven participants ( 44 % ) reported clinical ly relevant improvements in global perceived effect at T12 . At T24 , 1 more participant reported a relevant global perceived effect improvement , whereas 2 participants ( 13 % ) reported worsening of their condition . The magnetic resonance imaging analysis showed minor nonsignificant changes in functional cross-sectional area . Conclusion . Our study shows that 10 weeks of dynamic isolated training of the lumbar extensors , once a week , leads to clinical ly relevant improvements in functional status of men with CNSLBP , without accompanying improvements in functional cross-sectional area of LM . These findings suggest that improvement in LM morphology is not a critical success factor in restoring functional status of patients with CNSLBP , at least in the short term ( 6 mo ) Study Design . A two-part investigation was conducted : 1 ) a prospect i ve study of asymptomatic subjects quantitatively comparing trunk mobility to surface electromyographic ( sEMG ) signals from the erector spinae during trunk flexion ; and 2 ) a prospect i ve repeated- measures cohort study of patients with chronic disabled work-related spinal disorder tested for the flexion – relaxation ( FR ) phenomenon while measured simultaneously for lumbar spine inclinometric range of motion ( ROM ) . Objectives . To describe a theoretical model for the potential use of FR unloaded in assessing patients with chronic low back pain patients before and after rehabilitation , and to establish a normative data base ( Part 1 ) for subsequent use in comparison to patients with chronic low back pain ( Part 2 ) . The second part of the study assessed the clinical utility of combined sEMG and ROM measurements  for assessing the FR phenomenon as a test to assist potentially in planning rehabilitation programs , guiding patients ’ individual rehabilitation progress , and identifying early posttreatment outcome failures . Summary of Background Data . The FR phenomenon has been recognized since 1951 , and it can be reproducibly assessed in normal subjects with FR unloaded . It can be found intermittently in patients with chronic low back pain . Recent studies have moved toward deriving formulas to identify FR , but only a few have examined a potential relation between inclinometric lumbar motion measures and the sEMG signal . No previous studies have developed normative data potentially useful for objective ly assessing nonoperative treatment progress , effort , or the validity of permanent impairment rating measures . Methods . In Part 1 , 12 asymptomatic subjects were evaluated in an intra- and interrater repeated- measures protocol to examine reliability of sEMG signal readings in FR , as well as ROM measures at FR and maximum voluntary flexion . The mean sEMG signal averaging right – left electrode recordings , as well as the gross , true , and sacral lumbar ROM measurements , were recorded as normative data . In Part 2 , 54 patients with chronic disabled work-related spinal disorder referred as c and i date s for tertiary functional restoration rehabilitation participated in a st and ardized assessment protocol for sEMG and ROM measurement before rehabilitation . Those who completed the program were retested with the identical methodology after rehabilitation ( n = 34 ) using the empirically derived cutoff scores for sEMG readings at FR and ROM from Part 1 and prior scientific literature . Pain disability self-reported scores were correlated with sEMG and ROM . Sensitivity and specificity of the sEMG for identifying abnormal motion were assessed . Results . In Part 1 , the ability of the experienced testers to measure ROM and sEMG reliably at FR was high ( r ≥ 0.92 ; P < 0.001 ) . All asymptomatic subjects achieved FR at a tightly clustered range of mean sEMG signals from 1 to 2.3 & mgr;V. Most of the variation between motion at FR and maximum voluntary flexion occurred through the hip ( sacral ) motion component of the gross ( or total ) motion measured at T12 . In Part 2 , posttreatment reliability for ROM , sEMG , and the ability to detect the FR point was high ( r ≥ 0.82 ; P < 0.001 ) . More than 30 % of the 54 patients tested before treatment demonstrated ability to achieve FR , with FR usually associated with higher ROM than in the non-FR patients . After treatment , 94 % of those who completed the program achieved FR , including all those who achieved FR before treatment . Flexion – relaxation was associated with major improvement in ROM and pain disability self-report . Conclusions . Flexion – relaxation measures a point at which true lumbar flexion ROM approaches its maximum in asymptomatic subjects . This also is the point at which lumbar extensor muscle contraction relaxes , allowing the lumbar spine to hang on its posterior ligaments . The gluteal and hamstring muscles then lower the flexed trunk even further by allowing the pelvis to rotate around the hips . This phenomenon was subsequently found in Part 2 to offer a potentially promising method for individualizing rehabilitation treatment , decreasing unnecessary utilization , identifying potential postrehabilitation treatment failures , and assessing permanent impairment rating validity . Moreover , this is the first study to demonstrate systematic ally that an absence of FR in patients with chronic low back pain can be corrected with treatment INTRODUCTION Active treatments are advocated for the management of  non-specific chronic low back pain ( CLBP ) , although few studies have documented the relative efficacy of differing types of programme . A number of the available treatments comprise exercise routines on specially design ed training machines , which are ostensibly better disposed to reverse the compromised trunk muscle function displayed by these patients than are ' free exercise ' programmes . However , in using these muscle-training programmes , the physiological or anatomical adaptations that might account for the improved performance are rarely investigated , let alone identified . This is an important issue , because if the ' newly-acquired strength ' is mostly specific to performance on the devices on which the patient has trained and been tested , and reflects the skill in executing these particular tasks , this will not necessarily assist the patient during performance of his/her everyday activities . The aims of the present study were ( 1 ) to quantify the changes in back muscle performance in chronic LBP patients following 3 months active therapy , and ( 2 ) to analyse the corresponding changes in activation and cross-sectional area of the paraspinal muscles . METHODS 148 individuals ( 57 % women ) with CLBP ( age 45.0+/-10.0 years ; duration of LBP 10.9+/-9.5 years ) were r and omised to a treatment which they attended 2/week for 3 months : active physiotherapy , muscle reconditioning on training devices , or low-impact aerobics . Pre- and post-therapy , assessment s were made of isometric trunk muscle strength in each plane of movement and of erector spinae activation ( using surface electromyography ) during back extension . In a sub-group of 56 patients , the cross-sectional area of the paravertebral muscles was determined using magnetic resonance imaging ( MRI ) . In all patients , self-rated pain intensity , pain frequency and disability were assessed before and after therapy . RESULTS 132/148 patients completed the therapy .  Isometric strength in each movement plane increased significantly in all groups post-therapy . Apart from trunk extension , the changes were significantly greater in the devices group than in the other two groups ( Fig 1 ) . Activation of the paraspinal muscles during back extension also increased significantly in all groups ( Fig 2 ) and was weakly , but significantly ( r = 0.37 ; p = 0.0001 ) correlated with increased strength in back extension . Although , at baseline , highly significant correlations were observed between the size of the paraspinal muscles ( at L3/4 and at L4/5 ) and isometric back extension strength ( r=0.75 ; p < 0.0001 ) , post-training increases in strength were not accompanied by corresponding changes in muscle size . None of the improvements in strength showed any relationship with the clinical changes in pain and disability , regardless of whether the latter were examined on an individual basis or in relation to ' outcome groups ' . CONCLUSION The superior trunk strength shown by the devices group post-therapy was considered to be attributable , in part , to a ' learning effect ' , of the type often seen when training and testing are carried out on the same machines . These gains are considered to be mostly ' task-specific ' . However , part of the improvement in strength after active therapy ( in all groups ) also appeared to be due to an increased neural activation of the trunk muscles . These positive effects should be transferable to the performance of everyday activities for which the same muscles are employed , although the percentage improvement is probably not as high as the measured increase in strength might suggest . Possible roles for improved co-ordination and changes in motivation and /or pain tolerance after therapy can not be excluded . No differences in the clinical outcome were observed between the three therapy groups , and the changes in physical performance after therapy did not correlate with the clinical outcome . It is therefore question able whether strength measurements have any clinical significance in documenting the success of rehabilitation programmes , other than on a motivational basis . The results of the present study suggest that the value of supervised active therapy programmes does not reside in the reversal of specific muscular deficiencies , but rather in the provision of a source of confirmation/encouragement for the patient , that movement is not harmful , and a foundation upon which to further build . Whether the utilisation of specific training devices , or individual instruction , is necessary to elicit these particular effects is question able INTRODUCTION In recent decades the treatment of non-specific low back pain has turned to active modalities , some of which were based on cognitive-behavioural principles . Non-r and omised studies clearly favour functional multidisciplinary rehabilitation over outpatient physiotherapy . However , systematic review s and meta- analysis provide contradictory evidence regarding the effects on return to work and functional status . The aim of the present r and omised study was to compare long-term functional and work status after 3-week functional multidisciplinary rehabilitation or 18 supervised outpatient physiotherapy sessions . METHODS 109 patients with non-specific low back pain were r and omised to either a 3-week functional multidisciplinary rehabilitation programme , including physical and ergonomic training , psychological pain management , back school and information , or 18 sessions of active outpatient physiotherapy over 9 weeks . Primary outcomes were functional disability ( Oswestry ) and work status . Secondary outcomes were lifting capacity ( Spinal Function Sort and PILE test ) , lumbar range-of-motion ( modified-modified Schöber and fingertip-to-floor tests ) , trunk muscle endurance ( Shirado and Biering-Sörensen tests ) and aerobic capacity ( modified Bruce test ) . RESULTS Oswestry disability index was improved to a significantly greater extent after functional multidisciplinary rehabilitation compared to outpatient physiotherapy at follow-up of 9 weeks ( P = 0.012 ) , 9 months ( P = 0.023 ) and 12 months ( P = 0.011 ) . Work status was significantly improved after functional multidisciplinary rehabilitation only ( P = 0.012 ) , result ing in a significant difference compared to outpatient physiotherapy at 12 months ' follow-up ( P = 0.012 ) . Secondary outcome results were more contrasted . CONCLUSIONS Functional multidisciplinary rehabilitation was better than outpatient physiotherapy in improving functional and work status . From an economic point of view , these results should be backed up by a cost-effectiveness study 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
We found conflicting data regarding the validity of methods used to examine back muscle fatigue .
The Biering-Sorensen test  , performed in conjunction with surface electromyography spectral analysis , turned out to be the most widely used and comparatively , the most optimal modality currently available to assess objective back muscle fatigue in daily clinical practise , even though critical limitations are discussed .
Implication s for Rehabilitation Despite its limitations , the Biering-Sorensen test is currently the most used , convenient and easily available fatiguing test for lumbar muscles .
Pooled mean frequency and half-width of the spectrum are currently the most valid electromyographic parameters to assess fatigue in chronic non-specific low back pain .
PURPOSE This systematic literature review aim ed at examining the validity and applicability in everyday clinical rehabilitation practise of methods for the assessment of back muscle fatiguability in patients with chronic non-specific low back pain ( CNSLBP ) .