Duncan Critchley

Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation.

Study Design. Pragmatic, randomized, assessor blinded, clinical trial with economic analysis. Objective. To compare the effectiveness and cost-effectiveness of three kinds of physiotherapy commonly used to reduce disability in chronic low back pain. Summary of Background Data. Physiotherapy reduces disability in chronic back pain, but there are several forms of physiotherapy and it is unclear which is most effective or cost effective. Methods. A total of 212 patients referred to physiotherapy with chronic low back pain were randomized to receive usual outpatient physiotherapy, spinal stabilization classes, or physiotherapist-led pain management classes. Primary outcome was Roland Disability Questionnaire score 18 months from baseline; secondary measures were pain, health-related quality of life, and time off work. Healthcare costs associated with low back pain and quality-adjusted life years (QALYs) were also measured. Results. A total of 71 participants were assigned to usual outpatient physiotherapy, 72 to spinal stabilization, and 69 to physiotherapist-led pain management. A total of 160 (75%) provided follow-up data at 18 months, showing similar improvements with all interventions: mean (95% confidence intervals) Roland Disability Questionnaire score improved from 11.1 (9.6–12.6) to 6.9 (5.3–8.4) with usual outpatient physiotherapy, 12.8 (11.4−14.2) to 6.8 (4.9–8.6) with spinal stabilization, and 11.5 (9.8–13.1) to 6.5 (4.5–8.6) following pain management classes. Pain, quality of life, and time off work also improved within all groups with no between-group differences. Mean (SD) healthcare costs and QALY gain were £474 (840) and 0.99 (0.27) for individual physiotherapy, £379 (1040) and 0.90 (0.37) for spinal stabilization, and £165 (202) and 1.00 (0.28) for pain management. Conclusions. For chronic low back pain, all three physiotherapy regimens improved disability and other relevant health outcomes, regardless of their content. Physiotherapist-led pain management classes offer a cost-effective alternative to usual outpatient physiotherapy and are associated with less healthcare use. A more widespread adoption of physiotherapist-led pain management could result in considerable cost savings for healthcare providers.

Transversus Abdominis and Obliquus Internus Activity During Pilates Exercises: Measurement With Ultrasound Scanning

OBJECTIVE To assess activity of transversus abdominis (TrA) and obliquus internus abdominis (OI) muscles during classical Pilates exercises performed correctly and incorrectly, and with or without equipment. DESIGN Repeated-measures descriptive study. SETTING Pilates studio. PARTICIPANTS A volunteer sample of women (n=18) and men (n=8), mean age +/- SD (43+/-14y), with more than 6 months classical Pilates training and no back pain or other condition likely to influence abdominal muscle activity. INTERVENTIONS Participants performed Pilates imprint, hundreds A and B, roll-up, and leg-circle exercises on a mat. The hundreds exercise was also performed on a reformer (sliding platform). Mat imprint and hundreds exercises were instructed to be performed correctly (with abdominal drawing-in) or incorrectly (without drawing-in). MAIN OUTCOME MEASURE Thickness of TrA and OI middle fibers measured with ultrasound imaging. RESULTS TrA thickness increased during the mat imprint, hundreds A, hundreds B, leg-circle, and roll-up exercises (all P=.001) compared with resting. OI thickness increased during the mat imprint, hundreds A, hundreds B, leg-circle (all P=.001), and roll-up exercises (P=.002) compared with resting. TrA thickness during reformer hundreds B was greater than during mat hundreds B (P=.011); OI thicknesses were not different for this comparison. During incorrect imprint, neither TrA or OI thicknesses were different to resting. TrA and OI muscle thicknesses were moderately correlated (R=.410; P=.001). CONCLUSIONS This study provides the first evidence that a selection of classic Pilates exercises activates TrA and OI. Use of the reformer exercise machine can result in greater TrA activation in some exercises. TrA and OI did not function independently during these exercises. Research into the training effects of Pilates or in patient populations can be undertaken using ultrasonography in submaximal exercises.

Mechanism of Action of Spinal Mobilizations: A Systematic Review.

Study design. Systematic review. Objective. To review the evidence regarding the mechanism of action of mobilizations. Summary of background data. Spinal mobilizations—low velocity passive oscillatory movements—reduce spinal pain in some patient subgroups. Identifying patients likely to respond remains a challenge since mobilizations’ mechanism(s) of action are unclear. Methods. Medline, Web of Science, Cinahl, Embase, and Scopus databases were searched for relevant studies. Reference lists of included studies were hand searched. Studies were included if the intervention was passive spinal mobilizations, participants were symptomatic, and outcomes evaluated possible mechanisms of action. Methodological quality was independently assessed by two assessors using a modified Cochrane Back Review Group tool. Results. Twenty-four studies were included in the review. Four were classified high risk, 14 moderate risk, and four low risk of bias. Commonest methodological limitations were lack of participant blinding, adequate randomization and allocation concealment, and sample size calculation. Evidence suggests that spinal mobilizations cause neurophysiological effects resulting in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation, and improved muscle function. Mobilizations have no effect on temperature pain threshold. Three of four studies reported reduction in spinal stiffness, heterogeneous in location and timing. There is limited evidence (one study in each case) to suggest that mobilizations produce increased nociceptive flexion reflex threshold, improved posture, decreased concentration of substance P in saliva, and improved sway index measured in cervical extension. Evidence does not support an effect on segmental vertebral movement. Two studies investigated correlations between hypoalgesia and mechanism: one found a correlation with sympathoexcitatory changes, whereas the other found no correlation with change in stiffness. Conclusion. These findings suggest involvement of an endogenous pain inhibition system mediated by the central nervous system, although this is yet to be investigated directly. There is limited evidence regarding other possible mechanisms. Level of Evidence: 3

Effectiveness of Rocker Sole Shoes in the Management of Chronic Low Back Pain A Randomized Clinical Trial

Study Design. Multicenter, assessor-blind, randomized, clinical trial. Objective. To compare the effectiveness of rocker sole footwear to traditional flat sole footwear as part of the management for people with low back pain (LBP). Summary of Background Data. During the past decade, persistent advertising has claimed that footwear constructed with a rocker sole will reduce LBP. However, there is no robust evidence to support these claims. Methods. One hundred fifteen people with chronic LBP were randomized to wear rocker sole shoes or flat sole shoes for a minimum of 2 hours each day while standing and walking. Primary outcome was the Roland Morris Disability Questionnaire (RMDQ). In addition, participants attended an exercise and education program once a week for 4 weeks and wore their assigned shoes during these sessions. Participants were assessed without their knowledge of group allocation prerandomization, and at 6 weeks, 6 months, and 1 year (main outcome point). Analysis was by intention-to-treat method. Results. At 12 months, data from 44 of 58 (77.2%) of the rocker sole group and 49 of 57 (84.5%) of the flat sole group were available for analysis. In the rocker sole group, mean reduction in RMDQ was −3.1 (95% CI [confidence interval], −4.5 to −1.6), and in the flat sole group, it was −4.4 (95% CI, −5.8 to −3.1) (a greater negative value represents a greater reduction in disability). At 6 months, more people wearing flat shoes compared with those wearing rocker shoes demonstrated a minimal clinically important improvement in disability (53.2% and 31.1%, respectively; P = 0.03). Between-group differences were not significant for RMDQ or any secondary outcomes (e.g., pain) at any time. People reporting pain when standing and walking at baseline (n = 59) reported a greater reduction in RMDQ at 12 months in the flat sole group (−4.4 [95% CI, −6.0 to −2.8], n = 29) than the rocker sole group (−2.0 [95% CI, −3.6 to −0.4], n = 30) (P < 0.05). Conclusion. Rocker sole shoes seem to be no more beneficial than flat sole shoes in affecting disability and pain outcomes in people with chronic LBP. Flat shoes are more beneficial for LBP aggravated by standing or walking. Level of Evidence: N/A

Cross-cultural Translation, Adaptation, and Psychometric Testing of the Roland-Morris Disability Questionnaire Into Modern Standard Arabic

Study Design. Cross-cultural translation, adaptation, and psychometric testing. Objective. To cross-culturally translate and adapt the Roland-Morris Disability Questionnaire (RMDQ) into Modern Standard Arabic and examine its validity with Arabic-speaking patients with low back pain (LBP). Summary of Background Data. The English RMDQ is valid, reliable, and commonly used to assess LBP disability in clinical practice and research. There is no valid and reliable version of the RMDQ in Modern Standard Arabic. Methods. The RMDQ was forward translated and back translated. An expert committee of musculoskeletal physiotherapists reviewed the translation. Eight patients with LBP evaluated item-by-item comprehensibility. Ten patients piloted the RMDQ for overall comprehensibility and acceptability. Seventeen bilingual patients tested the agreement of the Arabic and English RMDQs. Two-hundred one patients completed the RMDQ and the visual analogue scale. Sixty-four patients were followed-up for test-retest reliability. Results. Translation of most items was uncontroversial. The expert committee found the Arabic RMDQ clinically and culturally appropriate. They reviewed item 11, addressing bending and kneeling, because this has a clinical significance and cultural/religious implication regarding prayer positions. All patients reported that it was easy to understand and complete. The Arabic RMDQ had high overall agreement with the English RMDQ for the global score (intraclass correlation coefficient [ICC] = 0.925; 0.811–0.972). Kappa statistics showed good item-by-item agreement (none ⩽0.30). Mean (SD) RMDQ and visual analog scale scores of 201 patients were 10.53 (4.80) and 5.11 (2.28), respectively. The RMDQ had a low correlation against pain intensity (r = 0.259; P < 0.01). A Cronbach &agr; of 0.729 showed high internal consistency. Test-retest reliability of the Arabic RMDQ was good (ICC = 0.900; 95% confidence interval, 0.753–0.951). Kappa statistics were high for 18 items and fair for 6. Conclusion. The Arabic version of the RMDQ has good comprehensibility and acceptability, high internal consistency and reliability, low correlation against pain intensity, and good agreement with the English RMDQ. We recommend its use with Arabic-speaking patients with LBP. Level of Evidence: 3

Physiotherapy informed by Acceptance and Commitment Therapy (PACT): protocol for a randomised controlled trial of PACT versus usual physiotherapy care for adults with chronic low back pain

Introduction Chronic low back pain (CLBP) is a common condition and source of significant suffering, disability and healthcare costs. Current physiotherapy treatment is moderately effective. Combining theory-based psychological methods with physiotherapy could improve outcomes for people with CLBP. The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of Physiotherapy informed by Acceptance and Commitment Therapy (PACT) on functioning in patients with CLBP. Methods and analysis The PACT trial is a two-armed, parallel-group, multicentre RCT to assess the efficacy of PACT in comparison with usual physiotherapy care (UC). 240 patients referred to physiotherapy with CLBP will be recruited from three National Health Service (NHS) hospitals trusts. Inclusion criteria are: age ≥18 years, CLBP ≥12-week duration, scoring ≥3 points on the Roland-Morris Disability Questionnaire (RMDQ) and adequate understanding of spoken and written English to participate. Patients will be randomised to PACT or UC (120 per arm stratified by centre) by an independent randomisation service and followed up at 3 and 12 months post randomisation. The sample size of 240 will provide adequate power to detect a standardised mean difference of 0.40 in the primary outcome (RMDQ; 5% significance, 80% power) assuming attrition of 20%. Analysis will be by intention to treat conducted by the trial statistician, blind to treatment group, following a prespecified analysis plan. Estimates of treatment effect at the follow-up assessments will use an intention-to-treat framework, implemented using a linear mixed-effects model. Ethics and dissemination This trial has full ethical approval (14/SC/0277). It will be disseminated via peer-reviewed publications and conference presentations. The results will enable clinicians, patients and health service managers to make informed decisions regarding the efficacy of PACT for patients with CLBP. Trial registration number ISRCTN95392287; Pre-results.

Do isometric pull-down exercises increase the acromio-humeral distance?

OBJECTIVES To evaluate the effect of isometric shoulder extension in 90° shoulder flexion on the acromio-humeral distance, to establish the force required to achieve a clinically important increase in the acromio-humeral distance, and to investigate the practicality and reliability of real-time ultrasound measurement of the acromio-humeral distance in 90° shoulder forward flexion. DESIGN Prospective single-group intervention. SETTING Kings College London, Guys Campus. PARTICIPANTS Twenty healthy volunteers [five males and 15 females (40 shoulders)] with a mean age of 32 (standard deviation 10, range 19 to 55) years were recruited from the faculty and staff at Kings College London. INTERVENTIONS The acromio-humeral distance in asymptomatic participants was measured using real-time ultrasound in the neutral position at rest, at 90° shoulder flexion at rest, and while performing an isometric pull-down exercise at 100%, 50%, 30% and 10% maximal voluntary isometric contraction. MAIN OUTCOME MEASURES Real-time ultrasound measures of the acromio-humeral distance. RESULTS Of the 20 participants, 38 shoulders were imaged. In 90° shoulder flexion, pull-down exercises at all levels of force increased the acromio-humeral distance compared with no pull-down (P<0.05), but this was only clinically significant in males. Measures had excellent short-term intra-operator reliability. CONCLUSIONS Isometric pull-down exercises lead to an increase in the acromio-humeral distance in asymptomatic males that may be clinically important, and therefore may be an appropriate exercise for patients with shoulder pathology. Ultrasound measurement of the acromio-humeral distance in 90° shoulder flexion is practical and reliable.

Immediate effects of cervical mobilisations on global perceived effect, movement associated pain and neck kinematics in patients with non-specific neck pain. A double blind placebo randomised controlled trial

BACKGROUND Neck pain is prevalent, costly and disabling. Cervical mobilisations are frequently used to treat it but their effectiveness has been questioned by several systematic reviews. Evidence suggests that better outcomes are achieved with mobilisations when they are applied to specific patient subgroups. A criteria for patients suitable for neck mobilisations has been proposed, but the effectiveness on this patient subgroup has not been tested. OBJECTIVE To assess the effectiveness of cervical mobilisations applied to a subgroup of patients with neck pain who fulfil specific criteria. DESIGN Randomised controlled trial. METHOD 40 patients with neck pain attending a Physiotherapy clinic were recruited and randomised to a single session of either cervical mobilisations or motionless manual contact placebo. The immediate effects on global perceived effect, range of movement (ROM), movement velocity and movement associated pain were assessed. RESULTS mobilisation participants reported significantly better global perceived effect (p˂0.001) and improvements in movement associated pain (p = 0.041). Mobilisations produced a significant increase in ROM in side flexion (p = 0.006) and rotation (p = 0.044) when compared with placebo, but only in patients with pre-intervention ROM restriction. 29-47% of all movement associated pains were resolved following mobilisations and 11-27% following placebo. Patients in both groups showed a significant (p < 0.05) increase in movement velocity, but only in those who had a velocity restriction pre-intervention. CONCLUSIONS Cervical mobilisations are effective in improving movement-associated pain, increasing ROM and velocity, and patient perceived improvement when applied to patients with neck pain that fulfil a criteria. Their use should be advocated.

Reliability of a Method to Measure Neck Surface Electromyography, Kinematics, and Pain Occurrence in Participants With Neck Pain

Objective: To investigate the reliability of a novel method to measure neck surface electromyography (SEMG), kinematics, and pain during active movements in participants with neck pain. Methods: This test‐retest study evaluated 23 participants with chronic neck pain. Each was measured twice within a single session. Three‐dimensional kinematics and SEMG were recorded in 10° increments during forward and side flexion, extension, and rotation of the neck. Neck position during pain occurrence was also measured. Results: Intraclass correlation coefficients were >0.80 for 96% and 100% of SEMG and kinematic data, respectively. The percentage of standard error of the measurement (SEM) values were <25% for 91% of all SEMG measures; most were <15%, and some were <10%. For ranges of motion in the primary plane, percentage of SEM values were all <6% (SEM 1°‐3°). Intraclass correlation coefficients for neck position during pain occurrence were all >0.60, except for right rotation (0.48) (SEM values 2°‐8°). Pain occurred approximately 59% to 75% into the total range of motion and persisted to its end. Conclusions: This methodology showed good reliability. It may be suitable for neck pain subclassification to evaluate the effects of treatment on pain, kinematics, and muscle activity during functional neck movements. The point of pain occurrence suggests increasing mechanical load on tissues may be one of the causative factors for movement‐associated neck pain.

Differences in neck surface electromyography, kinematics and pain occurrence during physiological neck movements between neck pain and asymptomatic participants: A cross-sectional study

Background: Neck pain has been associated with altered muscle activity and impaired kinematics. Patients frequently report pain during physiological neck movements. Previously, the average muscle activity during these movements has been measured. However, muscle activity is modulated by the position in the range of movement, hence the study of neck muscle activity in discrete sections of the range of movement is warranted. Evidence is conflicting regarding range of movement restriction in neck pain. No study has assessed the point in the range of movement at which pain occurs. This study aimed to investigate neck kinematics, muscle activity and pain during physiological neck movements in participants with and without neck pain. Methods: Neck kinematics and surface electromyography were recorded continuously and analysed in 10° increments during forward and side flexion, extension and rotation of the neck in 20 neck pain and 20 asymptomatic participants. Point of pain occurrence in the range of movement was recorded. Findings: Neck pain participants demonstrated significantly lower activity of scalene during flexion and extension, and a non‐significant higher activity in sternocleidomastoids during rotation. No differences in neck kinematics were observed. 65% of neck pain participants reported pain during at least one neck movement. Pain was reported in the last ≈20–40% of the range of movement. Interpretation: Exercises used in current practice to minimise scalene activity may not be appropriate for all neck pain patients. Restricted range of movement is not a consistent feature of neck pain. Movement associated neck pain is present at the end of range of movement, which has implications for the study of neck pain and rehabilitation. HIGHLIGHTSPeople with neck pain show decreased activity of the scalene.Treatments to reduce scalene muscle activity are not supported by the current study.Range of movement reduction is not a consistent feature of neck pain.Movement associated neck pain is present only at the end of range.