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Individualized Low-Load Motor Control Exercises and Education Versus a High-Load Lifting Exercise and Education to Improve Activity, Pain Intensity, and Physical Performance in Patients With Low Back Pain: A Randomized Controlled Trial

STUDY DESIGN Randomized controlled trial. BACKGROUND Low back pain is a common disorder. Patients with low back pain frequently have aberrant and pain-provocative movement patterns that often are addressed with motor control exercises. OBJECTIVE To compare the effects of low-load motor control (LMC) exercise and those of a high-load lifting (HLL) exercise. METHODS Seventy participants with recurrent low back pain, who were diagnosed with nociceptive mechanical pain as their dominating pain pattern, were randomized to either LMC or HLL exercise treatments. Participants were offered 12 treatment sessions over an 8-week period. All participants were also provided with education regarding pain mechanisms. METHODS Participants were assessed prior to and following treatment. The primary outcome measures were activity (the Patient-Specific Functional Scale) and average pain intensity over the last 7 days (visual analog scale). The secondary outcome measure was a physical performance test battery that included 1 strength, 3 endurance, and 7 movement control tests for the lumbopelvic region. RESULTS Both interventions resulted in significant within-group improvements in pain intensity, strength, and endurance. The LMC group showed significantly greater improvement on the Patient-Specific Functional Scale (4.2 points) compared with the HLL group (2.5 points) (P<.001). There were no significant between-group differences in pain intensity (P=.505), strength, and 1 of the 3 endurance tests. However, the LMC group showed an increase (from 2.9 to 5.9) on the movement control test subscale, whereas the HLL group showed no change (from 3.9 to 3.1) (P<.001). CONCLUSION An LMC intervention may result in superior outcomes in activity, movement control, and muscle endurance compared to an HLL intervention, but not in pain intensity, strength, or endurance. Registered at ClinicalTrials.gov (NCT01061632). LEVEL OF EVIDENCE Therapy, level 2b-.

Which patients with low back pain benefit from deadlift training

Abstract Berglund, L, Aasa, B, Hellqvist, J, Michaelson, P, and Aasa, U. Which patients with low back pain benefit from deadlift training? J Strength Cond Res 29(7): 1803–1811, 2015—Recent studies have indicated that the deadlift exercise may be effective in decreasing pain intensity and increasing activity for most, but not all, patients with a dominating pattern of mechanical low back pain. This study aimed to evaluate which individual factors measured at baseline could predict activity, disability, and pain intensity in patients with mechanical low back pain after an 8-week training period involving the deadlift as a rehabilitative exercise. Thirty-five participants performed deadlift training under the supervision of a physical therapist with powerlifting experience. Measures of pain-related fear of movement, hip and trunk muscle endurance, and lumbopelvic movement control were collected at baseline. Measures of activity, disability, and pain intensity were collected at baseline and at follow-up. Linear regression analyses were used to create models to predict activity, disability, and pain intensity at follow-up. Results showed that participants with less disability, less pain intensity, and higher performance on the Biering-Sørensen test, which tests the endurance of hip and back extensor muscles, at baseline benefit from deadlift training. The Biering-Sørensen test was the most robust predictor because it was included in all predictive models. Pain intensity was the next best predictor as it was included in 2 predictive models. Thus, for strength and conditioning professionals who use the deadlift as a rehabilitative exercise for individuals with mechanical low back pain, it is important to ensure that clients have sufficient back extensor strength and endurance and a sufficiently low pain intensity level to benefit from training involving the deadlift exercise.

Effects of Low-load Motor Control Exercises and a High-load Lifting Exercise on Lumbar Multifidus Thickness: A Randomized Controlled Trial

Study Design. Randomized controlled trial. Objective. The aim of this study was to compare the effects of low-load motor control (LMC) exercises and a high-load lifting (HLL) exercise, on lumbar multifidus (LM) thickness on either side of the spine and whether the effects were affected by pain intensity or change in pain intensity. Summary of Background Data. There is evidence that patients with low back pain (LBP) may have a decreased size of the LM muscles with an asymmetry between sides in the lower back. It has also been shown that LMC training can affect this asymmetry. It is, however, not known whether a high-load exercise has the same effect. Methods. Sixty-five participants diagnosed with nociceptive mechanical LBP were included and randomized into LMC exercises or a HLL exercise, the deadlift. The LM thickness was measured using rehabilitative ultrasound imaging (RUSI), at baseline and after a 2-month training period. Results. There were no differences between interventions regarding effect on LM muscle thickness. However, the analysis showed a significant effect for asymmetry. The thickness of the LM muscle on the small side increased significantly compared with the large side in both intervention groups, without influence of pain at baseline, or change in pain intensity. Conclusion. At baseline, there was a difference in thickness of the LM muscles between sides. It seems that exercises focusing on spinal alignment may increase the thickness of the LM muscles on the small side, irrespective of exercise load. The increase in LM thickness does not appear to be mediated by either current pain intensity or the magnitude of change in pain intensity. Level of Evidence: 2

High load lifting exercise and low load motor control exercises as interventions for patients with mechanical low back pain : a randomized controlled trial with 24-month follow-up

OBJECTIVE The aim of this study was to compare the effects of a high load lifting exercise with low load motor control exercises on pain intensity, disability and health-related quality of life for patients with mechanical low back pain. DESIGN A randomized controlled trial. SUBJECTS Patients with mechanical low back pain as their dominating pain mechanism. METHODS The intervention programme consisted of a high load lifting exercise, while the control group received low load motor control exercises over 8 weeks (12 sessions) with pain education included in both intervention arms. The primary outcome was pain intensity and disability, and the secondary outcome was health-related quality of life. RESULTS Each intervention arm included 35 participants, analysed following 2-, 12- and 24-month follow-up. There was no significant difference between the high load lifting and low load motor control interventions for the primary or secondary outcome measures. Between 50% and 80% of participants reported a decrease in perceived pain intensity and disability for both short- and long-term follow-up. CONCLUSION No difference was observed between the high low load lifting and low load motor control interventions. Both interventions included retraining of movement patterns and pain education, which might explain the positive results over time.

Physical Activity Might Be of Greater Importance for Good Spinal Control Than If You Have Had Pain or Not : A Longitudinal Study

Study Design. Longitudinal design. A cohort followed in 3 waves of data collection. Objective. The aim of the study was to describe the relationships between the performance of 2 tests of spinal control at the age of 52 years and low back pain, physical activity level, and fitness earlier in life, as well as to describe the cross-sectional relationships between these measures. Summary of Background Data. Altered spinal control has been linked to pain; however, other stimuli may also lead to inability to control the movements of the spine. Methods. Participants answered questions about physical activity and low back pain, and performed physical fitness tests at the age of 16, 34, and 52 years. The fitness test battery included tests of endurance in the back and abdominal muscles, a submaximal bicycle ergometer test to estimate maximal oxygen uptake, and measurements of hip flexion, thoracic spine flexibility, and anthropometrics. Two tests were aggregated to a physical fitness index. At the age of 52, also 2 tests of spinal control, the standing Waiters bow (WB) and the supine double leg lower (LL) were performed. Results. Logistic regression analyses showed that higher back muscle endurance at the age of 34 years could positively predict WB performance at 52 years and higher physical fitness at the age of 34 could positively predict LL performance at 52 years. Regarding cross-sectional relationships, an inability to perform the WB correctly was associated with lower physical fitness, flexibility and physical activity, and larger waist circumference. An inability to correctly perform the LL was associated with lower physical fitness. One-year prevalence of pain was not significantly associated with WB or LL test performance. Conclusion. An active life resulting in higher physical fitness is related to better spinal control in middle-aged men and women. This further strengthens the importance of physical activity throughout the life span. Level of Evidence: 3

Do we see the same movement impairments? The inter-rater reliability of movement tests for experienced and novice physiotherapists

Abstract Study design: Inter-rater reliability study. Background: Physiotherapists (PTs) use clinical tests including movement tests to identify faulty movement patterns. Aims: To investigate the inter-rater-reliability of active movement tests in the cervical spine, shoulder joint and scapulo-thoracic joint, and to describe the reasons for judgment of a positive test. Methodology: Four PTs, two experienced and two recently educated (novice), rated performance of five movement tests for 36 participants. Twenty-one of the participants were patients under treatment because of neck and/or shoulder problems, while 15 participants declared no problem from this region of the body. All tests were video recorded and the ratings were done by observing the video recordings. First, the PTs judged the tests as negative (the movement being ideally performed) or positive (the movement not being ideally performed). Then, the PTs described why the movements that they judged positive were not being ideally performed, using a predefined protocol, which represented different movement quality aspects. The inter-rater reliability was calculated for each test using Kappa statistics between the two experienced and the two novice PTs, respectively, and between each of the experienced and each of the novice PTs. Major findings: The experienced PTs had a higher inter-rater reliability than the novice PTs. The reasons for considering a movement test being positive differed highly between the (novice) PTs. Principal conclusion: This study supports previous studies concluding that the observation of active movement tests is reliable when assessed by experienced PTs. Novice PTs might benefit from further supervision.

Sagittal lumbopelvic alignment in patients with low back pain and the effects of a high-load lifting exercise and individualized low-load motor control exercises—a randomized controlled trial

BACKGROUND CONTEXT Assessment of posture and lumbopelvic alignment is often the main focus in the classification and treatment of patients with low back pain (LBP). However, little is known regarding the effects of motor control interventions on objective measures of lumbopelvic alignment. PURPOSE The primary aim of this study was to describe the variation of sagittal lumbopelvic alignment in patients with nociceptive mechanical LBP. The secondary aim was to compare the effects of a high-load lifting exercise (HLL) and low-load motor control exercises (LMC) on the change in lumbopelvic alignment with a special emphasis on patients with high and low degrees of lumbar lordosis (lu) and sacral angle (sa). STUDY DESIGN This study is a secondary analysis of a randomized controlled trial evaluating the effects of HLL and LMC. PATIENT SAMPLE Patients from the primary study, that is, patients categorized with nociceptive mechanical LBP, who agreed to participate in the radiographic examination were included (n=66). OUTCOME MEASURES Lateral plain radiographic images were used to evaluate lumbopelvic alignment regarding the lumbar lordosis and the sacral angle as outcomes, with posterior bend as an explanatory variable. MATERIALS AND METHODS The participants were recruited to the study from two occupational health-care facilities. They were randomized to either the HLL or the LMC intervention group and offered 12 supervised exercise sessions. Outcome measures were collected at baseline and following the end of intervention period 2 months after baseline. Between- and within-group analyses of intervention groups and subgroups based on the distribution of the baseline values for the lumbar lordosis and the sacral angle, respectively (LOW, MID, and HIGH), were performed using both parametric and non-parametric statistics. RESULTS The ranges of values for the present sample were 26.9-91.6° (M=59.0°, standard deviation [SD]=11.5°) for the lumbar lordosis and 18.2-72.1° (M=42.0°, SD=9.6°) for the sacral angle. There were no significant differences between the intervention groups in the percent change of eitheroutcome measure. Neither did any outcome change significantly over time within the intervention groups. In the subgroups, based on the distribution of respective baseline values, LOWlu showed a significantly increased lumbar lordosis, whereas HIGHsa showed a significantly decreased sacral angle following intervention. CONCLUSIONS This study describes the wide distribution of values for lumbopelvic alignment for patients with nociceptive mechanical LBP. Further research is needed to investigate subgroups of other types of LBP and contrast findings to those presented in this study. Our results also suggest that retraining of the lumbopelvic alignment could be possible for patients with LBP.

A characterisation of pain, disability, kinesiophobia and physical capacity in patients with predominantly peripherally mediated mechanical low back pain

Purpose: The purpose of this studywas to investigate disease specific and respiratory function measures that may influence physical activity levels and exercise capacity in people with Huntington’s disease. Relevance: Huntington’s disease (HD) is a neurodegenerative condition resulting in motor, cognitive and behavioural dysfunction. As with Parkinson’s disease and multiple sclerosis,physiotherapy management focuses on maintaining functional ability as long as possible. Ability to function and participate in activities of daily life will depend upon the pathophysiology of the condition as well as respiratory function. There is limited evidence concerning factors that influence physical activity levels and exercise capacity in people with HD. The results of this study will enable physiotherapists to use an evidence-based approach to the assessment and management of patients’ problems. Participants: Eighteen (7 female; mean (SD) age 51.2 (13.6) patients with HD were selected from a HD research and management clinic. Inclusion criteria were: symptomatic of HD;able to walk with or without assistance. Methods: A cross-sectional observational method was used. Descriptive data collected were: age; total functional capacity (TFC) from standardised questionnaire. Dependant variables measured were: physical activity level (MET-minutes/week)from International Physical Activity Questionnaire (IPAQ)short form; exercise capacity (meters) measured by six minute walk test (6 MWT). Independent variables measured were: Forced Vital Capacity in litres (FVC), a global measure of respiratory function measured following American Thoracic Society Guidelines; Unified Huntington’s Disease Rating Scale-Total Motor Score (UHDRS-TMS), a disease specific measure of motor function. Analysis: Data were analysed using Pearson’s correlations and where appropriate stepwise linear regression. Results: Descriptive data of all variables are as follows: mean (SD) TFC was 4.35 (2.4) (available range 0–14, higher scores indicate greater functional level); IPAQ median 328MET-minutes/week (low activity level); 6MWT mean (SD) was 191.95 meters (105.78); UHDRS-TMS mean (SD) 61.73 (12.02) (available range 0–120, higher scores indicating decreased motor function); FVC mean (SD) 2.19 L (1.00). FVC correlated with 6MWTand IPAQ (r = 0.44, 0.61 respectively); UHDRS correlated negatively with 6MWT and IPAQ (r =−0.63, r =−0.42 respectively). Linear regression results: UHDRS-TMS predicted 6MWT (R2 = 0.40, 6MWT= 536.1–5.6 (UHDRS-TMS), FVC was excluded; FVC predicted IPAQ (R2 = 0.37, IPAQ=−135.2 + 225.6 (FVC), UHDRS-TMS was excluded. Conclusions: In patients with HD, 6MWT is more influenced by UHDRS-TMS than respiratory function, however respiratory function predicted self-reported physical activity level. Slow gait due to motor function impairment may curtail 6MWTcompletion, while respiratory function may limit daily activities. Based on this study, it appears that the ability to function and participate in activities is multifactorial which requires consideration for physiotherapy management of people with neurodegenerative conditions. The results of this study are limited to patients who reported low activity levels and lowTFC scores; but are part of a larger study which will increase the power of the study. Implications: Ability to function and participate in activities is dependent on underlying disease process and respiratory function, and both elements should be considered when assessing and developing management strategies for people with neurodegenerative conditions.Purpose: To investigate the effects of three cueing devices (visual, auditory, and somatosensory) on movement and muscular control during gait initiation in people with Parkinson’s disease who experience freezing and to ascertain the acceptability of these cueing devices to novice users. Relevance: Over six million people worldwide are affected by Parkinson’s disease. It is estimated that thirty percent may experience freezing (an inability to produce effective steps) and have difficulty initiating gait, and maintaining gait whilst negotiating obstacles. This limits their capacity for physical activity and ability to participate in usual activities, and can result in social isolation. Various sensory cues have been shown to improve on-going gait in people with Parkinson’s Disease, but there is limited evidence on their effectiveness for people with gait initiation difficulties. Jiang and Norman (2006) found that transverse line visual cues improved gait initiation, while auditory cues had no effect. Dibble et al. (2004), using auditory and cutaneous cues during maximal speed gait initiation found an adverse effect on movement outcomes. Portable cueing devices are commercially available, however their influence in gait initiation and acceptability to users is currently unknown. InformaWPT2011, Research Report Abstracts eS773 tion on their effectiveness would enable physical therapists to provide better informed advice to potential purchasers. Participants: Twenty participants with idiopathic Parkinson’s disease and a history of freezing of gait (evaluated using item 14 of the Unified Parkinson’s Disease Rating Scale) were recruited; 14 males and 6 females, mean age 68 years and 11.5 years since diagnosis. Methods: An experimental trial of five randomised conditions: laser cane, sound metronome, vibrating metronome, walking stick and uncued. After using each cue participants’ opinions were obtained via a questionnaire. Motion data were collected using a 10 camera motion analysis system, force platforms and surface Electromyography. Analysis: Questionnaire responses from twelve participants who experienced freezing during testing were analysed using a Wilcoxon signed ranks test. Motion data from these participants were analysed using one-way ANOVA tests with post-hoc pair-wise comparisons to test for differences between conditions. Results: Significant differences were seen in step length, Centre of Mass and Centre of Pressure movement in the anterior/ posterior and medial/lateral directions between freezing and non-freezing episodes. The post hoc pair-wise comparisons showed significant improvements in the Centre of Mass and Centre of Pressure movement when using the laser cane and the walking stick and greater step length when using the laser cane. Participants rated the perceived effectiveness of the devices, theWilcoxon test showed a significant improvement in satisfaction when using the laser cane for both starting and maintaining walking (p < 0.05). Conclusions: The laser cane was overall the most effective cueing device for people with Parkinson’s disease and gait initiation difficulties in both user’s perception and efficacy tested in the gait laboratory. However the longer term effectiveness and acceptability of cueing devices at home and outdoors requires further investigation. Implications: This study would support the use of the laser cane as a relatively cheap intervention for people with Parkinson’s disease who experience spontaneous freezing.Purpose: This study investigated the effect of an elasticated tubular bandage and neutral patella taping on the threedimensional mechanics of the knee during slow step descent in a group of subjects suffering from Patellofemoral Pain Syndrome (PFPS). Relevance: A number of studies have demonstrated that subjects with patellofemoral pain syndrome have poor eccentric control at the knee. Most previous studies have focused on the use of taping, braces or neoprene knee sleeves; this is the first study to investigate the effect of the low cost alternative of an elasticated tubular bandage on eccentric control during step descent in a PFPS population. Participants: Ten subjects (4 men:6 women) with a diagnosis of patellofemoral pain syndrome referred to a Primary Care Musculoskeletal physiotherapy service (NHS Central Lancashire) for treatment were recruited (Mean: age = 28; Modified Functional Index Questionnaire score = 26; Visual Analogue Scale for Usual Pain in the past week = 29 mm). Inclusion criteria were; presence of traumatic or idiopathic peripatellar pain and pain provoked by deep squatting, kneeling, ascending or descending stairs; alone or in combination. Exclusion criteria; any history of knee surgery. Methods: Slow step descent was used to assess the control of the knee under three randomised conditions: (a) no intervention, (b) elasticated tubular bandage, and (c) neutral patella taping. Kinematic and kinetic data were collected using a ten camera Oqus (Qualisys) motion analysis system and two AMTI force platforms. The segments of the lower limbs were modelled in six-degrees of freedom and joint kinematics and moments were calculated at the knee. Post testing, subjects were asked to rank the test conditions in order of preference. Analysis: A repeated measures (RM) ANOVA was performed together with post hoc pairwise comparison for the coronal and transverse plane knee angles and moments about the knee, comparing the three randomised conditions. A further RMANOVA was conducted to investigate differences in the sagittal plane knee angular velocity in order to confirm that observed differences were not artefacts of descent velocity. Significance was set to P≤0.05. Results: The coronal plane knee range of motion was significantly reduced with taping (P = 0.032) and the tubular bandage (P = 0.006). No significant differences were seen in any other plane or for knee angular velocity or moments. Subjects ranking preference of the test conditionswas evenly split between the two interventions: neutral patella taping (N=5) and elasticated tubular bandage (N= 4); only one subject stated they would prefer to have nothing on their knee. Conclusions: The use of an elasticated tubular bandage and a neutral patella taping technique actually produced a measurable change in the control mechanism of the knee and resulted in subjects with PFPS demonstrating greater knee control and less pain during a step descent when compared to no intervention. The tubular bandage had the greatest mechanical effect, reducing movement in the coronal plane by 30% when compared to no intervention. Implications: An elasticated tubular bandage and neutral patellar taping may represent low cost, convenient interventions in the management of mild Patellofemoral Pain Syndrome.Purpose: Patients with juvenile idiopathic arthritis (JIA) are less physically active than healthy peers. Therefore we developed an internet-based intervention to improve physical activity (PA). The aim of the study was to examine the effectiveness of the program in improving PA. Relevance: Evidence is accumulating that PA is effective in the primary and secondary prevention of several chronic conditions. PA is also associated with a reduction in all-cause mortality. There is evidence that in youth aged 6-16 years, PA controls body weight, reduces blood pressure in hypertensive youth, improves aerobic capacity, muscular strength, endurance and skeletal health, reduces anxiety and depression and improves self concept. PA also has a positive effect on academic performance, concentration, memory and classroom behavior. For children with JIA and other chronic diseases it is recognized that they could take advantage of the same health benefits. Participants: All patients with JIA, registered in the University Medical Center Groningen, the Netherlands and aged 8-12 years, were selected for this study. Inclusion criteria were a diagnosis of JIA, a good comprehension of the Dutch language and the availability of a home-based computer with an internet connection. Methods: PA was determined by activity-related energy expenditure (AEE), PA level, time spent on moderate to vigorous PA and the number of days with 1 hour or more of moderate to vigorous PAand was assessed with a 7-day activity diary. Aerobic exercise capacity was assessed by means of a Bruce treadmill test and recorded as maximum endurance time. Disease activity was assessed by using the JIA core set. Adherence was electronically monitored. Analysis: Descriptive statistics were used for patients characteristics. The Kolmogorov-Smirnov test was used to test variables for normality of distribution. Paired samples t-test was used for within group differences. Results: Out of 59 patients 33 eligible patients were included and randomized in an intervention (n = 17, mean±SD age 10.6±1.5 years) and control waiting list group (n = 16, mean±SD age 10.8±1.4 years). All patients completed baseline and t = 1 testing. PA significantly improved in both groups. Maximum endurance time significantly improved in the intervention but not in the control group. In a subgroup analysis for patients with low PA (intervention n = 7 and control n = 5), PA improved in the intervention but not in the control group. The intervention was safe, feasible and showed a good adherence. Conclusions: An internet-based program for children with JIA, aged 8-12 years, directed at promoting PA in daily life, effectively improves PA in those patients with low PA levels. It can also improve endurance while it is safe, feasible and has a good adherence. Implications: PA in JIA can be improved through internet based interventions. Similar programs can be developed for other chronic conditions.Purpose: The specific objectives were to: 1) describe the level of pain intensity, disability, activity limitation, kinesiophobia and physical capacity in patients with predominantly peripherally m ...