Recovery of the lumbar multifidus muscle size in chronic low back pain patients by strengthening hip abductors: A randomized clinical trial

IntroductionDecrease in cross-sectional thickness of lumbar multifidus (MF) muscles during prolonged low back pain episodes commonly occurs. Restoration of the MF muscle size can be an effective way of treating chronic low back pain (CLBP) patients. Traditionally, clinicians apply muscle stabilization exercises for these patients. Recent studies support the need for active strengthening exercises for treatment of the CLBP patients.ObjectiveThe MF muscles provide lumbar stability, and therefore we hypothesized that strengthening of these muscles can be more effective than the MF muscle stabilization exercises in restoration of the muscle size.DesignStudy design was a randomized allocation control trial with two groups of adult female CLBP patients (n = 12 each; age range of 20–45). Patients in the control group underwent stabilization exercises and the patients in the intervention group underwent the hip abductor strengthening exercises.SettingFor all subjects of each group, the trials continued in 24 sessions distributed over 8 weeks and the MF muscles were measured in the beginning of the first session and one week after completion of the last session.Main outcome measuresStatistical significance (p-value) of the change in the average MF muscle thickness, pain, and disability scores along with for each group were estimated.ResultsBoth regimens of exercises can significantly decrease the pain and disability: average pain and disability reductions of 46% (p-value of 0.001) and 33% (p-value of 0.02) via stabilization versus average pain and disability reductions of 65% (p-value of 0.001) and 59% (p-value of 0.001) via hip abductor strengthening. However, the hip abductor strengthening is the sole statistically significant exercise regimen (p-value of 0.014 vs 0.94) for increasing the MF muscle size.ConclusionReplacement of the traditional stabilization exercises with the hip abductor strengthening exercises for effective treatment of female adults with CLBP is recommended.     

The influence of home exercise programs for patients with non-specific or specific neck pain: a systematic review of the literature

Abstract

Study design: Systematic review of randomized controlled trials (RCT).

Objectives: To examine the effects of a therapeutic home exercise program (HEP) for patients with neck pain (associated with whiplash, non-specific, or specific neck pain, with or without radiculopathy, or cervicogenic headache) on pain, function, and disability. Our secondary aim was to describe the design, dosage, and adherence of the prescribed HEPs.

Background: Neck pain is a leading cause of disability that affects 22–70% of the population. Different techniques have been found effective for the treatment of neck pain. However, there is conflicting evidence to support the role of a therapeutic HEP to reduce pain, disability, and improve function and quality of life (QOL).

Methods: A systematic review in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement for reporting systematic reviews. The full-text review utilized the Maastricht–Amsterdam assessment tool to assess quality among RCTs.

Results: A total of 1927 subjects included within seven full-text articles met our specific search strategy. It was found that HEPs with a focus on strength and endurance-training exercises, as well as self- mobilization, have a positive effect when used in combination with other conservative treatments or alone.

Conclusions: Home exercise programs that utilize either self-mobilizations within an augmented HEP to address specific spinal levels, or strengthening, and/or endurance exercise are effective at reducing neck pain, function, and disability and improving QOL. The benefit of HEPs in combination with other conservative interventions yields some benefit with a range of effect sizes.     

Effects of lumbar stabilization exercise on functional disability and lumbar lordosis angle in patients with chronic low back pain

[Purpose] This study examined the effects of lumbar stabilization exercises on the functional disability and lumbar lordosis angles in patients with chronic low back pain. [Subjects] The subjects were 30 patients with chronic low back pain divided into a lumbar stabilization exercise group (n = 15) and a conservative treatment group (n = 15). [Methods] The lumbar stabilization exercise and conservative treatment groups performed an exercise program and conservative physical treatment, respectively. Both programs were performed 3 times a week for 6 weeks. The degree of functional disability was assessed by the Oswestry disability index, and lumbar lordosis angles were measured by plain radiography. [Results] The Oswestry disability index decreased significantly in the both groups; however, it was significantly lower in the lumbar stabilization exercise group. The lumbar lordosis angle increased significantly in the lumbar stabilization exercise group after treatment and was also significantly greater than that in the conservative treatment group. [Conclusion] Lumbar stabilization exercise is more effective than conservative treatment for improving functional disability and lumbar lordosis angles.Key words: Lumbar stabilization exercise, Lumbar lordosis angle, Chronic low back pain     

Effect of different exercise programs on non-specific chronic low back pain and disability in people who perform sedentary work

BackgroundThis study compared the short- and long-term effects of different exercise programs on lumbar muscle function, cross-sectional area of the multifidus muscle, functional disability and low back pain in people who perform sedentary work.MethodsA total of 70 volunteer women with sedentary occupations suffering from low back pain were randomized to either the lumbar stabilization exercise program group or the lumbar muscle strengthening exercise program group. All subjects entered the 20-week exercise programs. The measurement of the cross-sectional area of the multifidus muscle was executed by using an ultrasound system, isokinetic peak torque was measured applying an isokinetic dynamometer.FindingsThe results indicated that the 20-week exercise programs reduced low back pain and functional disability. Positive effects for the cross-sectional area of the multifidus muscle, functional disability and low back pain lasted for 4 weeks after the application of lumbar muscle strengthening exercise program and for 12 weeks after the application of lumbar stabilization exercise program. The lumbar muscle strength increased and lasted for 8 weeks after both exercise programs.InterpretationThe 20-week lumbar stabilization exercise and muscle strengthening exercise programs were efficacious in decreasing LBP and functional disability in people performing sedentary work, however the lumbar stabilization exercise program was more effective, and this effect lasted for 12 weeks after completion of the program.     

The impact of hip strengthening and/or neuromuscular control on frontal plane knee kinematics and kinetics in females: a systematic review

Background: Physical therapists commonly treat individuals with anterior knee pain (AKP) and anterior cruciate ligament (ACL) injuries. Despite the suggestion for including hip strengthening or neuromuscular control exercises in preventative programs to change knee mechanics and reduce AKP and ACL injuries and in the treatment of AKP, no previous systematic review has addressed the impact of these exercises on frontal plane knee mechanics.

Objective: The purpose of this systematic review was to determine the level of evidence associated with hip strengthening or neuromuscular control exercises as an intervention to improve frontal plane knee mechanics during dynamic activity in females.

Methods: Databases searched included PubMed, CINAHL Plus with full text, and SportDiscus with full text; specific search terms were used. All studies were to include females without any current knee pain or injury. Studies had to investigate the impact of a hip strengthening or a hip neuromuscular control program or a combination of strengthening and neuromuscular control. The primary outcome measure of interest was frontal plane knee mechanics.

Results: A total of 414 articles were identified. Eight additional articles were identified using other sources. Fourteen studies were ultimately included in the qualitative analysis. There was support for neuromuscular control exercises as well as neuromuscular control plus strengthening exercises to improve frontal plane knee mechanics during dynamic activity in females. Strengthening alone was not supported.

Conclusion: Clinically, one should consider either a neuromuscular control program or a combined neuromuscular control plus strength training program for females to improve frontal plane knee mechanics during dynamic activity. This may be particularly relevant in prevention of ACL injuries and AKP.     

Effects of individual strengthening exercises for the stabilization muscles on the nutation torque of the sacroiliac joint in a sedentary worker with nonspecific sacroiliac joint pain

[Purpose] We investigated the effects of individual strengthening exercises for the stabilization muscles on the nutation torque of the sacroiliac joint in a sedentary worker with nonspecific sacroiliac joint pain. [Subject] A 36-year-old female complained of pain in the sacroiliac joints. [Methods] The subject performed individual strengthening exercises for the stabilization muscles for nutation torque of the sacroiliac joint for 3 weeks. Pain-provocation tests and visual analog scale (VAS) scores were evaluated before and after the exercises. [Results] After performing the individual strengthening exercises for the erector spinae, rectus abdominis, and biceps femoris muscles for 3 weeks, the subject displayed no pain in the pain provocation tests, and the VAS score was 2/10. [Conclusion] The individual strengthening exercises for the stabilization muscles of the sacroiliac joint performed in the present study appear to be effective for sedentary workers with sacroiliac joint pain.Key words: Nutation torque, Pain provocation tests, Sacroiliac joint stabilization     

The effectiveness of a multimodal approach in the treatment of patients with upper crossed syndrome: A randomized controlled trial

ObjectivesConsidering the multitude of contributing factors to upper crossed syndrome (UCS), a multimodal treatment may be an effective therapeutic option. This study aimed to examine the effectiveness of the multimodal approach, including muscle energy technique (MET), cervical and scapulothoracic stabilization exercises, and postural correction training with ergonomic advice, in the treatment of patients with UCS.MethodsThis randomized controlled trial randomly assigned 40 patients with UCS aged 30–55 years to either group A (intervention group, n = 20) who received the multimodal approach or group B (control group, n = 20) who received MET only. The trial evaluated the craniovertebral angle (CVA) and sagittal shoulder angle (SSA) measured by photogrammetry, pain intensity estimated using the visual analog scale (VAS), and functional disability evaluated using the Arabic version of the neck disability index (ANDI) pretreatment and four weeks after intervention.ResultsThe within-group analysis demonstrated a substantial decrease in VAS and ANDI and an increase in CVA post-intervention (P < 0.001). Only the multimodal group exhibited a significant change in SSA (P < 0.0001). Between-group differences were noteworthy, favoring the multimodal intervention (P < 0.0001).ConclusionsA 4-week multimodal approach that comprises MET, cervical and scapulothoracic stabilization exercises, and postural correction training with ergonomic advice has remarkable improvements in CVA, SSA, pain intensity, and functional disability in patients with UCS, highlighting it as a superior choice.     

Rehabilitation for Clinical Lumbar Instability in a Female Adolescent Competitive Diver with Spondylolisthesis

Abstract

Few studies have investigated conservative lumbar stabilization approaches with adolescent athletes, specifically those with radiographic evidence of a unilateral pars interarticularis fracture. The purpose of this case study was to describe a lumbar stabilization strengthening intervention for an adolescent competitive diver. A 12-year-old female was diagnosed with a grade-I, traumatic, unilateral, dysplastic spondylolisthesis, accompanied by ensuing symptoms of lumbar spine instability. Symptom provocation occurred during extension and torsion motions as well as long-term sitting and standing. A comprehensive lumbar stabilization program was associated with a reduction of symptoms, improvement in trunk stabilization, and a quick return to competitive diving. Because the case report involved one highly motivated subject, the results are not generalizable to all adolescent divers. Future studies should investigate the treatment of spine instability on a sample of adolescent athletes.     

Effects of scapular stabilization and upper limb proprioception as an adjunct to cervical stabilization in chronic neck pain patients: A randomized controlled trial

BackgroundChronic neck pain is a prevalent health condition and a leading cause of disability worldwide. Prompt therapeutic measures are required to overcome this condition.ObjectivesTo evaluate the efficacy of incorporation of scapular stabilization and upper limb proprioceptive exercises to cervical stabilization exercises in patients with chronic neck pain (CNP).DesignA single-blinded randomized controlled design.MethodsA sample of convenience was deployed to recruit twenty-eight patients having CNP (18–45 years) and was randomized into two groups: group A (cervical stabilization exercises group) and group B (scapular stabilization and upper limb proprioceptive exercises group + cervical stabilization exercises). Pain intensity, disability, sleep quality, quality of life, scapular muscles strength and proprioception were assessed at 4 weeks follow up to determine the efficacy of the intervention.ResultsA mixed model ANOVA was used. A statistically significant (p < 0.05) group by time interaction for pain intensity (p = 0.000), scapular muscles strength of all muscles (p = 0.000) was observed. Significant group interaction for absolute error (p = 0.00), for pain (p = 0.001), disability (p = 0.04) and scapular muscle's strength (p = 0.000) was also demonstrated.ConclusionThe results indicated that scapular stabilization and upper limb proprioceptive exercises when combined with cervical stabilization exercises are more beneficial in alleviating pain and disability and improving scapular muscle strength and proprioception in patients with CNP.     

Does adding hip strengthening exercises to manual therapy and segmental stabilization improve outcomes in patients with nonspecific low back pain? A randomized controlled trial

BackgroundThe literature is unclear on the need for hip strengthening in persons with low back pain (LBP).ObjectivesTo investigate the effectiveness of hip strengthening exercises when added to manual therapy and lumbar segmental stabilization in patients with chronic nonspecific LBP.MethodsSeventy patients with chronic nonspecific LBP were randomly assigned to either the manual therapy and lumbar segmental stabilization group or the manual therapy and lumbar segmental stabilization plus specific hip strengthening group. A 10 cm visual analogue scale and the Rolland-Morris Questionnaire were the primary clinical outcome measures at baseline, at the end of treatment (posttreatment), and 6- and 12-months posttreatment. Hip strength and kinematics were measured as secondary outcomes .ResultsWhile within-group improvements in pain, disability, and hip extensors strength occurred in both groups, there were no significant between-group differences at posttreatment or follow-ups. Mean difference in changes in pain level between groups at posttreatment and at 6- and 12-month follow-up were 0.5 points (95% confidence interval [CI]: -0.5, 1.5), 0.3 points (95% CI: -0.9, 1.5), and 0.0 points (95% CI: -1.1, 1.1), respectively. The mean differences in changes in disability were 0.8 points (95% CI: -1.3, 2.7), 0.0 points (95% CI: -2.4, 2.4), and 0.4 points (95% CI: -2.0, 2.8), respectively. Finally, we did not observe any between-group differences for any of the other outcomes at any timepoint.ConclusionThe addition of specific hip strengthening does not appear to result in improved clinical outcomes for patients with nonspecific LBP.     

Limited scientific evidence supports the use of conservative treatment interventions for pain and function in patients with subacromial impingement syndrome: randomized control trials

Abstract

Background: Different conservative treatment interventions are often used to decrease pain and improve function in patients with subacromial impingement syndrome (SAIS). However, the current evidence to support the use of these interventions has not been established.

Objectives: To determine the evidence for conservative treatment interventions regarding pain and function compared to any intervention for SAIS patients.

Methods: A systematic review of randomized controlled trials, published in English between 1 January 1999 and 31 May 2010, was performed using PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and manual searching. The methodological quality (PEDro scale) and evidence grade (SBU) were rated. Eight studies were of high quality, four were medium quality, and eight were low quality. Various conservative treatment interventions were evaluated: acupuncture, electrotherapy modalities, exercises, mixed modalities, changing posture, and use of a functional brace.

Results: Limited scientific evidence (LSE) indicates positive effects of exercise and mixed modalities regarding pain and function and high-intensity laser therapy (HILT) regarding pain in SAIS patients. LSE also indicate no effect of electrotherapy modalities, apart from HILT, as treatment for SAIS.

Conclusions: The lack of high quality interventions limits the ability to draw conclusions regarding efficacy from several of the included studies. However, exercise may be as efficient as surgery, manual therapy in combination with exercise seems to be more effective than exercise alone and high-dose exercises seem to be more effective than low-dose exercises. Furthermore, there is contradictory evidence to support the use of acupuncture.     

Isolated greater tuberosity fracture: Short-term functional outcome following a specific rehabilitation program

BackgroundEvaluate the functional outcome of a specific program of rehabilitation during conservative treatment of fracture of the greater tuberosity.MethodsWe retrospectively studied the records of 22 patients, with minimally displaced greater tuberosity fracture, according to inclusion criteria. All patients have received an early (one week after the injury) rehabilitation program based on physical analgesic therapy means, techniques for recovering range of motion, strengthening exercises, proprioceptive stabilization exercises and usability advices. The evaluation was done at baseline, one, two and three months of the end of physical treatment.ResultsPain, perceived disability and range of motion were improved significantly since the end of rehabilitation. The improvement of function (Constant score) was significant at different evaluation times. The functional result seems to be poor when patients are aged and pain is severe at baseline.ConclusionDuring conservative treatment of fracture of the greater tuberosity, earlier rehabilitation allows rapid range of motion and functional recovery limiting care duration. After fracture healing, the rehabilitation program becomes similar to that advocated in rotator cuff disease. Whatever the initial treatment choice, rehabilitation must be considered at the waning of the first week.     

A comparison of water-based and land-based core stability exercises in patients with lumbar disc herniation: a pilot study

Purpose: To determine and compare the effects of core stability exercise programs performed in two different environments in lumbar disc herniation (LDH) patients. Method: Thirty-one patients who were diagnosed with LDH and were experiencing pain or functional disability for at least 3 months were randomly divided into two groups as land-based exercises or water specific therapy. Also, 15 age–sex-matched healthy individuals were recruited as healthy controls. Both groups underwent an 8-week (3 times/week) core stabilization exercise program. Primary outcomes were pain, trunk muscle static endurance and perceived disability level. The secondary outcome was health-related quality of life. Results: Level of static endurance of trunk muscles was found to be lower in the patients compared to the controls at baseline (p?p?p?>?0.05). After the treatment, static endurance of trunk muscles of the LDH patients became similar to controls (p?>?0.05). Conclusion: According to these results, core stabilization exercise training performed on land or in water both could be beneficial in LDH patients and there is no difference between the environments.

• Implications for Rehabilitation

• An 8-week core stabilization program performed in water or on land decrease pain level and improve functional status in LDH patients.

• Both programs seem beneficial to increase health-related quality of life and static endurance of trunk muscles.

• Core stability exercises could be performed in water as well, no differences were found between methods due to environment.

     

Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury

Objectives: Standard therapy in Germany for acute whiplash injury has traditionally included a soft collar (cervical orthosis), an approach that is passive compared with early exercise and mobilisation. The purpose of this study is to examine the recovery in the first six weeks of groups of acute whiplash injury patients subjected to two different treatment approaches, the traditional approach of a collar compared with active, early mobilisation.

Methods: Between August 1997 and February 2000 a randomised clinical trial with a total of 200 patients was performed. A total of 97 were randomly assigned to a collar therapy group, and 103 to the exercise group, treated by a physiotherapist. Study participants recorded average pain and disability twice (baseline and six week follow up) during a one week period by diary, using numeric visual analogue (VAS) rating scales ranging from 0 to 10.

Results: The initial mean VAS pain intensity and VAS disability reported by the collar therapy group and the exercise group showed no statistical difference. The mean VAS pain rating reported by the collar therapy group after six weeks was 1.60 and mean VAS disability rating was 1.56. The mean VAS pain intensity of the exercise group was 1.04 and mean VAS disability was 0.92. These differences between the groups were both significant, as was the reduction in the prevalence of symptoms in the exercise therapy group compared with the collar group at six weeks.

Conclusions: Early exercise therapy is superior to the collar therapy in reducing pain intensity and disability for whiplash injury.

     

Lumbar spondylolisthesis: retrospective comparison and three-year follow-up of two conservative treatment programs

Forty-eight patients with symptomatic back pain secondary to spondylolisthesis who were treated conservatively were followed for three years after initial examination to compare the outcomes of two exercise programs. The patients were divided into two groups--those doing flexion and those doing extension back strengthening exercises. All patients received instructions on posture, lifting techniques, and the use of heat for relief of symptoms. After three months, only 27% of patients who were instructed in flexion exercises had moderate or severe pain and only 32% were unable to work or had limited their work. Of the patients who were instructed in extension exercises, 67% had moderate or severe pain and 61% were unable to work or had limited their work. At three-year follow-up, only 19% of the flexion group had moderate or severe pain and 24% were unable to work or had limited their work. The respective figures for the extension group were 67% and 61%. The overall recovery rate after three months was 58% for the flexion group and 6% for the extension group. At three years these figures improved to 62% for the flexion group and dropped to 0% for the extension group. The literature is scarce regarding the applicability of conservative treatment programs for lumbar spondylolisthesis. On the basis of our findings, we suggest that if a conservative treatment program is elected, back flexion or isometric back strengthening exercises should be considered. The three-year follow-up data presented here lend support to this point of view.     

Effects of core stabilization exercises on thickness and activity of trunk and hip muscles in subjects with nonspecific chronic low back pain

BackgroundChanges in trunk and hip muscles are believed to be important in subjects with nonspecific chronic low back pain (NSCLBP), but little is known about specific changes, or how they might be affected by core stabilization exercises. The aim of this study was to compare six key muscles before and after these exercises.MethodsThirty two NSCLBP patients were assigned randomly into two groups: exercise (n = 17) and control (n = 15). On 5 days per week for 4 weeks, the Exercise group performed 16 core stabilization exercises and the Control group received transcutaneous electrical nerve stimulation and a ‘hot-pack’. Surface electromyography (EMG) was used to assess maximum bilateral activity of transversus abdominis (TrA), multifidus (MF) and gluteus maximus (Gmax) muscles. Ultrasound imaging was used to measure the rest and contracted thickness of these muscles. Pain and disability were assessed using a visual analogue scale (VAS) and the Oswestry Disability Index.ResultsWhen left and right-side muscle data were combined, two-way ANOVAs showed a nonsignificant interaction effect for all dependent variables (P > 0.05), significant time effects on resting muscle thickness for TrA (P = 0.01), MF (P = 0.041) and Gmax (P = 0.003), EMG signals of TrA (P = 0.038), pain and disability (P = 0.000). There were a significant group effect on contracted thickness for TrA (P = 0.032) and Gmax (P = 0.026) and disability (P = 0.017).ConclusionsCore stabilization exercises increased contracted thickness of TrA and Gmax muscles and decreased disability in subjects with NSCLBP.     

Reduction of cervical and respiratory muscle strength in patients with chronic nonspecific neck pain and having moderate to severe disability

Purpose: To investigate whether patients with chronic nonspecific neck pain and having moderate to severe disability have a greater cervical motor function impairment and respiratory disturbances compared with patients with chronic nonspecific neck pain having mild disability and asymptomatic subjects; and the association between these outcomes in patients with chronic nonspecific neck pain and healthy controls.

Methods: Cross-sectional study, 44 patients with chronic nonspecific neck pain and 31 healthy subjects participated. The neck disability index was used to divide the patients into 2 groups: 1) mild disability group (scores between 5 and 14 points); and 2) moderate to severe disability group (scores?>14 points). Cervical motor function was measured by cervical range of motion, forward head posture, neck flexor, and extensor muscle strength. Respiratory function and maximum respiratory pressures were also measured.

Results: Statistically differences were found between the patients with chronic nonspecific neck pain having a moderate to severe disability and the asymptomatic subjects for cervical and respiratory muscle strength. Comparisons between chronic nonspecific neck pain and the asymptomatic groups showed differences for all the variables, except for forward head posture. The regression model determined that strength of cervical flexion explained 36.4 and 45.6% of the variance of maximum inspiratory pressures and maximum expiratory pressures, respectively.

Conclusions: Only the chronic nonspecific neck pain group with moderate to severe disability showed differences compared with the healthy subjects. Neck muscle strength could be a good predictor of respiratory muscle function.

• Implications for rehabilitation

• Neck pain severity could be closely associated with decreased respiratory pressure in patients with chronic nonspecific neck pain.

• These findings suggest a new therapeutic approach for patients with moderate to severe disability, such as respiratory muscle training.

• The regression models show that a simple measurement of neck muscle strength could provide a reasonably accurate prediction for the respiratory function of these patients. Hence, this could provide an easy tool to assess respiratory function to physiotherapists without the need for sophisticated instrumentation.