Extrinsic feedback and management of low back pain: A critical review of the literature

Effective intervention for low back pain (LBP) can include feedback in one form or other. Although extrinsic feedback (EF) can be provided in a number of ways, most research has not considered how different EF characteristics (e.g. timing and content) influence treatment outcomes. A systematic search related to feedback and LBP was performed on relevant electronic databases. This narrative review aims to describe the forms of feedback provision in the literature regarding management of LBP, and to discuss these in light of previously recommended principles for the use of extrinsic feedback. The present review found support for the provision of EF that focuses on content characteristics including program feedback, summary results feedback, and external focus of attention. Temporal characteristics should enhance the use of intermittent or self-selected feedback. The literature does not support the provision of concurrent or constant EF. As much of the literature related to EF in the management of LBP has not considered content and timing characteristics we have identified future research directions that will clarify the use of content and timing characteristics of EF relative to the management of LBP.     

Motor control problems in patients with spinal pain: a new direction for therapeutic exercise

Recent research into muscle dysfunction in patients with low back pain has led to discoveries of impairments in deep muscles of the trunk and back. These muscles have a functional role in enhancing spinal segmental support and control. The muscle impairments are not those of strength but rather problems in motor control. These findings call for a different approach in therapeutic exercise, namely a motor learning exercise protocol. The specific exercise approach has an initial focus on retraining the cocontraction of the deep muscles (ie, the transversus abdominis and lumbar multi-fidus Initial clinical trials point to the effectiveness of the approach in patients with both acute and chronic low back pain in terms of reducing the neuromuscular impairment and in control of pain.     

Is It Reasonable to Use an Individual Patient's Progress After Treatment as a Guide to Ongoing Clinical Reasoning?

Systematic assessment of a patient's progress after an intervention is frequently used to inform decision making in ongoing conservative management of patients with musculoskeletal symptoms. Although reassessment of impairments immediately after treatment is commonplace in clinical practice, relatively little research has considered whether this method is reasonable. The history of, rationale behind, and evidence for the use of patient responses to inform clinical reasoning are explored in this commentary. Although the evidence is not conclusive, an argument is presented suggesting it is more reasonable to use a patient's response to treatment to inform ongoing clinical reasoning than to follow predetermined protocols. A methodical approach that considers change in parameters such as patient impairments is likely to be a useful guide for decision making during ongoing patient management but only when the change being reassessed can be directly linked to functional goals. Changes in active range of movement or centralization of pain appear to be better indicators of treatment effectiveness than changes in either pain intensity or assessment of joint position. There is limited evidence to support the use of changes in segmental stiffness to guide ongoing management. Although reassessment of some impairments has been found to be useful, the author suggests that care is required in the selection of reassessments used to guide ongoing management. The usefulness of any reassessment is considered to rely on how well a change in the selected impairment predicts that individual patient's ability to achieve their goals.     

The use of an eclectic approach for the treatment of low back pain: a case study.

The purposes of this case report are (1) to describe an examination approach that relates identification of an impairment to a disability and (2) to describe an eclectic treatment approach for an individual with low back pain (LBP). The individual described in this case report is an intercollegiate athlete who, because of chronic LBP, was unable to perform his sport of pole vaulting. The findings of the physical therapy examination suggested that an impairment of lumbar motion prevented the patient from assuming the spinal position necessary for pole vaulting. The goals of the treatment consisted of increasing the patient's lumbar motion to that required for pole vaulting and to have the patient pole vault without pain or stiffness. The treatment approach that was used combined procedures described by Maitland, McKenzie, and others. The rationale for the use of these procedures and their limitations are discussed.     

Lumbar functional instability: a critical appraisal of the literature.

The goals of this paper were to define the concept of instability, to describe the way it can be assessed, to report on impairments of the spine stabilization system in patients with low back pain (LBP), to cite the recommended exercises and, lastly, to examine the results of programs based on lumbar stabilization. Patients suffering from lumbar instability appear to belong to a particular subgroup of subjects with LBP. In the literature, several definitions of lumbar instability have been proposed. Radiological instability, for instance, differs from functional instability. Diagnosis remains difficult: the relevance of static and dynamic radiographs appears limited whereas several signs and clinical instability tests have been described in the literature but remain controversial. The functional stability system of the spine consists of three interdependent components: the passive, the active and the neuromuscular subsystems. The benefits of lumbar stabilization programs for LBP patients have been underlined. Lumbar stabilization exercises are aimed at sensorimotor reprogrammation of spine stabilizer muscles intended to improve their motor control skill and delay of response and consequently to compensate for weakness of the passive stabilization system.     

Effects of tactile feedback on lumbar multifidus muscle activity in asymptomatic healthy adults and patients with low back pain

Background

Reduced lumbar multifidus (LM) muscle contraction has been observed in patients with low back pain (LBP). Clinicians often use various strategies to ensure LM activation, including tactile feedback and verbal instruction. However, the effects of tactile feedback on muscle activation have not been studied previously. Therefore, the purpose of this study was to investigate whether or not tactile feedback would increase LM muscle activity in adults with and without LBP.

Patient-reported perception of difficulty as a clinical indicator of dysfunctional neuromuscular control during the prone hip extension test and active straight leg raise test

Two clinical tests used to assess for neuromuscular control deficits in patients with low back pain (LBP) are the prone hip extension (PHE) test and active straight leg raise (ASLR) test. For these tests, it has been suggested that patients be classified as “positive” if they demonstrate specific “abnormal” lumbopelvic motion patterns. For the ASLR test, the use of patient-reported perception of difficulty is also used to assess neuromuscular control. Thirty participants with LBP and 40 asymptomatic controls took part in this cross-sectional observational study. Participants performed both tests and were classified as “positive” or “negative” based on the presence or absence (respectively) of specific “abnormal” motion patterns. The participants also rated their perceived difficulty in performing the tests using a six-point scale. A two-way analysis of covariance (ANCOVA) was used to examine the effects of group (LBP/control) and examiner classification (positive/negative) on the perceived difficulty scores for each test. The LBP group perceived greater difficulty in performing both tests compared to the control group. Conversely, there was no significant difference in the perceived difficulties of the positive and negative examiner classifications for either test. Additional investigation is required to comment further on the relative usefulness of the perceived difficulty and observable motion patterns during these tests in assessing the neuromuscular control strategies of the lumbopelvic region, and their potential as a diagnostic tool or treatment outcome.     

Altered postural responses persist following physical therapy of general versus specific trunk exercises in people with low back pain

Interventions that target trunk muscle impairments in people with LBP have been promoted; however, the treatment effects on muscle activation impairments during postural tasks remain unclear. Thus, our objective was to evaluate the effects trunk stabilization vs. general strength and conditioning exercises on the automatic postural response in persons with chronic low back pain (LBP).Fifty-eight subjects with chronic, recurrent LBP (n = 58) (i.e., longer than six months) were recruited and randomly assigned to one of two, 10-week physical therapy programs: stabilization (n = 29) or strength and conditioning (n = 29). Pain and function were measured at 11 weeks and 6 months post-treatment initiation. To quantify postural following support surface perturbations, surface electrodes recorded electromyography (EMG) of trunk and leg muscles and force plates recorded forces under the feet, to calculate the center of pressure.Both groups demonstrated significant improvements in pain and function out to 6 months. There were also changes in muscle activation patterns immediately post-treatment, but not at 6 months. However, changes in center of pressure (COP) responses were treatment specific. Following treatment, the stabilization group demonstrated later onset of COP displacement, while the onset of COP displacement in the strengthening group was significantly earlier following treatment.Despite two different treatments, clinical improvements and muscle activation patterns were similar for both groups, indicating that the stabilization treatment protocol does not preferentially improve treatment outcomes or inter-muscle postural coordination patterns for persons with LBP.Clinical Trial Registration NumberNCT01611792.     

Pain coping strategies in a Dutch population of chronic low back pain patients

The use of strategies for coping with chronic pain was assessed by means of the Coping Strategy Questionnaire (CSQ) in a Dutch sample of 108 chronic low back pain (LBP) patients referred for behavioral treatment. The 3 factors of the CSQ were related to measurements of behavioral and emotional adjustment to LBP above and beyond the effects of demographic and medical status variables. Especially patients high on the factor Helplessness reported higher levels of pain, functional impairment, anxiety, depression and psychoneuroticism, while patients high on the factor Perceived Control reported lower levels of pain, functional impairment and also manifested a higher level of uptime. The causal role of coping strategies in adjustment to pain, the selectivity of focusing on LBP patients selected through referral and implications for pain management are discussed.     

Multiple sclerosis and spasticity

Spasticity is a common impairment in MS. It can result in significant medical complications and is associated with increased disability. Treatment strategies include skilled rehabilitation strategies, neuromuscular blocks, oral agents, intrathecal management, and surgery. Rehabilitation strategies are central, whereas other strategies are added based on the level of impairment and functional loss. Treatment strategies for spasticity management are far from optimal and are complicated in MS as a result of lesions in the brain and the spinal cord. Pharmaceutical management in MS is complicated by the numerous secondary impairments in MS and its associated polypharmacy.Head-to-head studies of the various agents are rare. The studies that exist are small and do not point to any one strategy over another. Although management is difficult, it is essential for the health, functional status, and well-being of the individual who has MS. Providers must use well-developed clinical skills to arrive at optimal individualized treatment programs and monitor them frequently. For spasticity that is unresponsive, referral to a MS Center with a spasticity program is ideal.     

The influence of specific training on trunk muscle recruitment patterns in healthy subjects during stabilization exercises

Low back pain is a major problem involving high medical costs, therefore effective prevention strategies are essential. Stabilization exercises seem to facilitate the neuromuscular control of the lumbar spine and may be useful in prevention programs. To investigate whether specific lumbar stabilization training has an effect on muscle recruitment patterns in a healthy population, in the present study 30 subjects were recruited to perform two types of testing exercises, i.e. bridging exercises and exercises in four-point kneeling, both before and after training. Surface electromyographic data of different abdominal and back muscles were obtained. After training, analysis of the relative muscle activity levels (percentage of maximal voluntary isometric contraction) showed a higher activity of the local (segmental-stabilizing) abdominal muscles, but not of the local back muscles; minimal changes in global (torque-producing) muscle activity also occurred. Analysis of the local/global relative muscle activity ratios revealed higher ratios during all exercises after training, although not all differences were significant. These results indicate that muscle recruitment patterns can be changed in healthy subjects by means of a training program that focuses on neuromuscular control. Additional studies are needed to evaluate this type of training as a prevention strategy.     

Outcomes of the Bobath concept on upper limb recovery following stroke

OBJECTIVE: To determine the effectiveness of the Bobath concept at reducing upper limb impairments, activity limitations and participation restrictions after stroke. METHODS: Electronic databases were searched to identify relevant trials published between 1966 and 2003. Two reviewers independently assessed articles for the following inclusion criteria: population of adults with upper limb disability after stroke; stated use of the Bobath concept aimed at improving upper limb disability in isolation from other approaches; outcomes reflecting changes in upper limb impairment, activity limitation or participation restriction. RESULTS: Of the 688 articles initially identified, eight met the inclusion criteria. Five were randomized controlled trials, one used a single-group crossover design and two were single-case design studies. Five studies measured impairments including shoulder pain, tone, muscle strength and motor control. The Bobath concept was found to reduce shoulder pain better than cryotherapy, and to reduce tone compared to no intervention and compared to proprioceptive neuromuscular facilitation (PNF). However, no difference was detected for changes in tone between the Bobath concept and a functional approach. Differences did not reach significance for measures of muscle strength and motor control. Six studies measured activity limitations, none of these found the Bobath concept was superior to other therapy approaches. Two studies measured changes in participation restriction and both found equivocal results. CONCLUSIONS: Comparisons of the Bobath concept with other approaches do not demonstrate superiority of one approach over the other at improving upper limb impairment, activity or participation. However, study limitations relating to methodological quality, the outcome measures used and contextual factors investigated limit the ability to draw conclusions. Future research should use sensitive upper limb measures, trained Bobath therapists and homogeneous samples to identify the influence of patient factors on the response to therapy approaches.     

Functional rehabilitation of low back disorders

Musculoskeletal disorders of which low back pain (LBP) accounts for more than 50% are now the most common cause of chronic incapacity in industrialized countries. The traditional approach in looking for the reason (etiology) for musculoskeletal disorders is to search structural failures but, in most cases, it is difficult to find an explicit reason for back pain. Many scientists now consider spine disorders as multifactorial, bio-psycho-social problems. Pain has clear effects on motor control. Therefore, LBP can also induce changes in neuromuscular control and motor performance, i.e., causing various functional deficits. Another feature, which deserves special consideration with reference to back problems, concerns the numerous psychological factors, which are involved in mediating the relationships between physical impairment, pain and disability. The new scientific knowledge on functional deficits is increasingly being transferred to clinical applications, where the aim is to reverse them with physical rehabilitation. As a result of the recognition of the behavioral (psychological) problems with LBP, psychological, behavioral and educational interventions are commonly combined with the physical rehabilitation for LBP also. Basically, functional rehabilitation includes systematic quantification of both the physical function and psychological factors, which drive the therapeutic process. The exercises used in the functional rehabilitation usually revolve around the treatment of the spine as a functional unit. Thus many programs for functional rehabilitation use rehabilitation equipment (iso-inertial/isokinetic) by properly trained physiotherapists. However, some centers use regular fitness equipment or aerobics-type exercises. Furthermore, some relaxation and ergonomic exercises are typically proposed, and psychological support provided along the treatment. There exists both an outpatient and an inpatient functional rehabilitation approach. They are described in the paper together with the first results obtained in Italy with the outpatient approach.     

Prolonged paralysis after treatment with neuromuscular junction blocking agents.

OBJECTIVES: Previous reports have described prolonged paralysis after treatment with neuromuscular junction blocking agents in critically ill patients. The purpose of this study was to further describe a group of patients who developed prolonged weakness after treatment with these agents. DESIGN: Clinical information, electrodiagnostic and muscle pathology results are described in this group of patients. Clinical information includes diagnoses, dosage of neuromuscular junction blocker, other medications affecting the neuromuscular system, and neuromuscular examination and clinical course. SETTING: All patients were seen in the ICUs of three local hospitals. PATIENTS: Included were critically ill patients with a variety of diagnoses, all of whom developed severe weakness after discontinuation of neuromuscular junction blocking agents. INTERVENTIONS: Electrodiagnostic studies and muscle biopsies were performed on several of the patients. MEASUREMENTS AND MAIN RESULTS: All patients had pronounced weakness without sensory loss. Electrodiagnostic and muscle pathology findings were consistent with failed neuromuscular transmission. Although many patients had disorders or were taking medications that can injure the neuromuscular system, no disorder or medication was common to all. Recovery of strength often took several months and most patients were slow to wean from mechanical ventilator support. CONCLUSIONS: Although alternative explanations cannot be excluded with certainty, the use of neuromuscular junction blocking agents may lead to neurogenic atrophy and care must be taken when using them.     

Management of work-related low back pain: a population-based survey of physical therapists

BACKGROUND AND PURPOSE: Physical therapy often is used in the management of work-related low back pain (LBP). Little information, however, is known about the types of interventions used by physical therapists in the management of this condition. The objective of this study was to describe the interventions used by physical therapists in the treatment of workers with acute or subacute LBP, with or without radiating pain below the knee. SUBJECTS: Clinical management questionnaires for workers without and with radiating pain were returned by 190 and 139 physical therapists, respectively. METHODS: For each treatment session, therapists recorded treatment objectives, interventions, and education provided to 2 workers with LBP, 1 with radiating pain and 1 without radiating pain. RESULTS: The majority of physical therapists used stretching and strengthening exercises, spinal mobilization, soft tissue mobilization and massage, manual traction, posture correction, interferential current, ultrasound, heat, and functional activities education. With radiating pain, the majority of the therapists also used cold and the McKenzie approach. Treatment objectives pursued by the majority of the therapists were decrease of pain, increase of range of motion, increase of muscle strength (force-generating capacity of muscle), decrease of muscle tension, and worker education. DISCUSSION AND CONCLUSION: Physical therapists use an array of interventions with workers with LBP. The effectiveness of most interventions reported has not been well studied.     

Exercise assessment and training in pulmonary rehabilitation for patients with COPD

Chronic obstructive pulmonary disease (COPD) is a common condition with a growing impact on global health services. Patients with COPD frequently complain of dyspnoea and leg fatigue on exertion. Pulmonary rehabilitation (PR) is an established intervention for the management of patients with COPD. There is clear evidence for the benefit in this population. The purpose of this article is to describe the assessment process, exercise intervention and its anticipated benefits, in the context of a rehabilitation programme for individuals with COPD. This has been sub-divided into aerobic, skeletal muscle resistance and inspiratory muscle rationale, assessment and training. The evidence supporting the incorporation of aerobic and skeletal muscle resistance training in PR is well established. The benefit of including inspiratory muscle training (IMT) as an adjunct to PR is less clear.     

Exercise therapy for shoulder pain aimed at restoring neuromuscular control: a randomized comparative clinical trial.

OBJECTIVE: To compare the effectiveness of exercise therapy aimed at restoring neuromuscular control mechanisms at the shoulder with other conservative interventions for the treatment of chronic shoulder pain with and without accompanying stiffness. DESIGN: Randomized control trial. Patients: A total of 138 volunteers with unilateral shoulder pain of local mechanical origin. METHODS: Subjects were randomly allocated to receive exercise therapy aimed at restoring dynamic stabilizing mechanisms and muscle co-ordination at the shoulder; or subacromial corticosteroid injection; or a combination of physical modalities and range of motion exercises. Outcome measurements of pain intensity, functional impairment, active range of motion, isometric muscle force and self-assessed improvement were taken at baseline and after 5 weeks of treatment. RESULTS: The mean/median changes in all outcome measurements at 5 weeks indicated that subjects in each treatment group, improved significantly with no difference between the treatment groups. Comparison with an earlier no-treatment trial would suggest that this improvement is greater than that which could be expected by natural recovery. CONCLUSION: Exercise therapy aimed at restoring neuromuscular control, corticosteroid injection and multiple physical modalities and range of motion exercises are equally effective in the short-term treatment of shoulder pain, with exercise therapy and corticosteroid injection being less costly to administer.     

Forefoot Injuries in Athletes: Integration of the Movement System

Despite the prevalence of forefoot related problems in athletes, there are few comprehensive summaries on examination and intervention strategies for those with forefoot related symptoms. While many factors may contribute to pathology and injury, the presence of abnormal foot alignment can negatively affect lower extremity biomechanics and be associated with injuries. Physical therapists may use the characteristics associated abnormal pronation or abnormal supination to describe the movement system disorder and serve as a guide for evaluating and managing athletes with forefoot pathologies. Athletes with an abnormal pronation movement system diagnosis typically demonstrate foot hypermobility, have decreased strength of the tibialis posterior muscle, and present with a medially rotated lower extremity position. Athletes with abnormal supination movement system diagnosis typically demonstrate foot hypomobility, decreased strength of the fibularis muscles, and a laterally rotated lower extremity position. Interventions of manual therapy, taping, strengthening exercises, and neuromuscular reeducation can be directed at the identified impairments and abnormal movements. The purpose of this clinical commentary is to integrate a movement system approach in pathoanatomical, evaluation, and intervention considerations for athletes with common forefoot pathologies, including stress fractures, metatarsalgia, neuroma, turf toe, and sesamoiditis. By applying a prioritized, objective problem list and movement system diagnosis, emphasis is shifted from a pathoanatomical diagnosis-based treatment plan to a more impairment and movement focused treatment.Level of Evidence5     

Paralumbar muscle activity in chronic low back pain

Muscle spasm is often considered to be a prominent feature operating in chronic low back spin syndrome (LBP). The present study compared levels of paralumbar muscle activity, determined by an electromyogram (EMG), for LBP patients and normal subjects during periods of rest and voluntary muscular contraction. The resting state EMG measure did not differ in the 2 groups. However, when attempting to relax the low back while contracting other muscle groups, LBP patients exhibited higher mean levels of low back muscle activity as compared to the non-pain group. These results would suggest that such "cocontraction relaxation" procedures may provide a viable behavioral technique for assessing and possibly treating functional backache thought to be symptomatic of muscle spasm. Previous studies employing feedback and progressive relaxation techniques have trained subjects to reduce muscle tension in the resting state. Results of the present study suggest that the acquisition of "resting level" relaxation may be of little benefit to patients who exhibit excessive muscular tension while performing daily tasks. Rather, to maximize the likelihood of beneficial results, training would be better directed at relaxation of the low back during activity of other muscle groups.