Gabriel Peixoto Leão Almeida

The short-term effects of graded activity versus physiotherapy in patients with chronic low back pain: A randomized controlled trial

BACKGROUND Chronic low back pain is one of the most common problematic health conditions worldwide and is highly associated with disability, quality of life, emotional changes, and work absenteeism. Graded activity programs, based on cognitive behavioral therapy, and exercises are common treatments for patients with low back pain. However, recent evidence has shown that there is no evidence to support graded activity for patients with chronic nonspecific low back pain. AIM to compare the effectiveness of graded activity and physiotherapy in patients with chronic nonspecific low back pain. METHODS A total of 66 patients with chronic nonspecific low back pain were randomized to perform either graded activity (moderate intensity treadmill walking, brief education and strength exercises) or physiotherapy (strengthening, stretching and motor control). These patients received individual sessions twice a week for six weeks. The primary measures were intensity of pain (Pain Numerical Rating Scale) and disability (Rolland Morris Disability Questionnaire). RESULTS After six weeks, significant improvements have been observed in all outcome measures of both groups, with a non-significant difference between the groups. For intensity of pain (mean difference = 0.1 points, 95% confidence interval [CI] = -1.1-1.3) and disability (mean difference = 0.8 points, 95% confidence interval [CI] = -2.6-4.2). No differences were found in the remaining outcomes. CONCLUSION The results of this study suggest that graded activity and physiotherapy showed to be effective and have similar effects for patients with chronic nonspecific low back pain.

Efficacy of graded activity versus supervised exercises in patients with chronic non-specific low back pain: protocol of a randomised controlled trial.

BackgroundLow back pain is a relevant public health problem, being an important cause of work absenteeism worldwide, as well as affecting the quality of life of sufferers and their individual functional performances. Supervised active physical routines and of cognitive-behavioral therapies are recommended for the treatment of chronic Low back pain, although evidence to support the effectiveness of different techniques is missing. Accordingly, the aim of this study is to contrast the effectiveness of two types of exercises, graded activity or supervised, in decreasing symptoms of chronic low back pain.Methods/designSample will consist of 66 patients, blindly allocated into one of two groups: 1) Graded activity which, based on an operant approach, will use time-contingent methods aiming to increase participants’ activity levels; 2) Supervised exercise, where participants will be trained for strengthening, stretching, and motor control targeting different muscle groups. Interventions will last one hour, and will happen twice a week for 6 weeks. Outcomes (pain, disability, quality of life, global perceived effect, return to work, physical activity, physical capacity, and kinesiophobia) will be assessed at baseline, at treatment end, and three and six months after treatment end. Data collection will be conducted by an investigator blinded to treatment allocation.DiscussionThis project describes the randomisation method that will be used to compare the effectiveness of two different treatments for chronic low back pain: graded activity and supervised exercises. Since optimal approach for patients with chronic back pain have yet not been defined based on evidence, good quality studies on the subject are necessary.Trial registrationNCT01719276

Q-angle in patellofemoral pain: relationship with dynamic knee valgus, hip abductor torque, pain and function

Objective To investigate the relationship between the q-angle and anterior knee pain severity, functional capacity, dynamic knee valgus and hip abductor torque in women with patellofemoral pain syndrome (PFPS). Methods This study included 22 women with PFPS. The q-angle was assessed using goniometry: the participants were positioned in dorsal decubitus with the knee and hip extended, and the hip and foot in neutral rotation. Anterior knee pain severity was assessed using a visual analog scale, and functional capacity was assessed using the anterior knee pain scale. Dynamic valgus was evaluated using the frontal plane projection angle (FPPA) of the knee, which was recorded using a digital camera during step down, and hip abductor peak torque was recorded using a handheld dynamometer. Results The q-angle did not present any significant correlation with severity of knee pain (r = −0.29; p = 0.19), functional capacity (r = −0.08; p = 0.72), FPPA (r = −0.28; p = 0.19) or isometric peak torque of the abductor muscles (r = −0.21; p = 0.35). Conclusion The q-angle did not present any relationship with pain intensity, functional capacity, FPPA, or hip abductor peak torque in the patients with PFPS.

Does anterior knee pain severity and function relate to the frontal plane projection angle and trunk and hip strength in women with patellofemoral pain

The aim of the present study was to determine the relationship between knee pain severity and function with the frontal plane projection angle (FPPA) and trunk and hip peak torque (PT) in women with patellofemoral pain (PFPS). Twenty-two women with PFPS were assessed. Knee pain severity (KPS) was assessed with an 11-point visual analog scale and function with an Anterior Knee Pain Scale. The FPPA was recorded with a digital camera. PT of extensors, abductors, and the lateral rotators of hip and lateral core stability were measured with a handheld dynamometer. FPPA was the only predictor for the KPS. Regarding predictors of function, PT of lateral core stability and the extensor and abductor of the hip explained 41.4% of the function. Increase in FPPA was associated with greater KPS, and the lowest PT of lateral core stability, hip abductors, and extensors was associated with lower function in women with PFPS.

Efeitos da dominância unilateral dos membros inferiores na flexibilidade e no desempenho isocinético em mulheres saudáveis

INTRODUCTION: The unilateral dominance of the lower limbs can cause asymmetries between the contralateral muscle groups, predisposing both legs to possible injury. Thus, knowledge of unilateral deficits is important in the prevention and outcomes. OBJECTIVE: To assess the difference of daily activities on the dominant (DL) and non-dominant (NDL) limb as flexibility, peak torque (PT), maximum work (MW), maximum power (MP) for flexors and extensors of the knee. METHOD: 23 healthy women without symptoms. Flexibility was assessed using the popliteal angle test (PAT) for hamstring and Thomas test (TT) for quadriceps, the isokinetic assessment was carried out for the concentric extension and flexion of the knee. For the PT and MW were performed five repetitions at an angular velocity of 60o/sec, and for MP, 15 repetitions at 240o/sec. All evaluations were performed by the same researcher. RESULTS: No statistically significant difference as the bilateral flexibility through the TAP and TT (p > 0.05). However, all the isokinetic variables were assessed with a significant difference between the DL and NDL (p < 0.01), with an average of limb symmetry index exceeding 10%. CONCLUSION: According to the data, the daily activities in healthy women cause differences between the DL and NDL, as evidenced by the isokinetic evaluation as to the PT, MW and MP; however, these differences were not viewed as flexibility.

Dynamic postural stability and muscle strength in patellofemoral pain: Is there a correlation?

BACKGROUND Although females with patellofemoral pain (PFP) show a decrease in hip and knee muscle strength, there is a lack of studies that associates this with postural stability. The purpose of this study was to assess the dynamic postural stability and muscle strength in the hips and knees of females with and without PFP, and to verify the association between the postural stability and the muscle strength in the PFP group. METHODS Two groups were tested: one with 25 PFP and one with 25 asymptomatic. Postural stability was evaluated during stepping up down tasks using a force platform to determine the center of pressure (COP) excursion and velocity. A handheld dynamometer was used to assess the muscles strength. The correlation analysis was conducted between the COP variables and the muscle strength. RESULTS The PFP group demonstrated greater total and medial-lateral COP displacement (8887.7±761.7 vs. 8129.4±691.9mm, P<0.001; 32.3±5.5 vs. 21.7±2.7mm, P<0.001) and a higher total of medial-lateral COP velocity (22.2±5.2 vs. 17.0±1.6 P=0.001). The PFP group showed weaknesses in all muscles (P<0.05), and there was a good positive correlation between the anterior-posterior displacement and the velocity of the extensor hip muscle (r=0.52, P<0.01; r=0.55, P<0.001). CONCLUSIONS Subjects with PFP have frontal dynamic postural stability deficit and show an association between hip extensor and sagittal plane stability.

Relationship between frontal plane projection angle of the knee and hip and trunk strength in women with and without patellofemoral pain

BACKGROUND It is theorized that increased dynamic knee valgus relates to decreased hip posterolateral muscle strength. OBJECTIVE The aim here was to assess the relationship between the frontal plane projection angle (FPPA) of the knee and hip and trunk muscle strength in women with and without patellofemoral pain (PFP). METHODS The sample comprised 43 women: Patellofemoral Pain Group (PPG, n = 22) and Control Group (CG, n = 21). Muscle strength for hip abduction, extension, external rotation and lateral core were measured using a handheld dynamometer. The FPPA was recorded during step-down. RESULTS The PPG showed a deficit for hip muscles torque and increased FPPA (P < 0.05). Negative correlation of the FPPA-Peak was found in the CG for the hip abductor (r = -0.31) and posterolateral complex (r = -0.32) (P < 0.05). In the PPG, the FPPA-Peak showed a moderate negative correlation to the torque of external rotators and posterolateral hip muscles, although this correlation did not reach statistical significance. CONCLUSIONS These findings suggest that women with patellofemoral pain present greater dynamic knee valgus and hip muscle weakness. Abductor and posterolateral hip muscles strength are associated with increased FPPA only in the pain-free population.

Manual therapy and therapeutic exercise in patient with symptomatic cervical spondylotic myelopathy: a case report.

Cervical spondylotic myelopathy (CSM) is caused by narrowing of the cervical spinal canal, although surgical decompression is an obvious indication for spinal cord stenosis, there are not enough data to determine that surgery is the most indicated intervention for milder forms. The purpose of the present case report was to describe the outcomes results of the physical therapy treatment with emphasis on manual therapy and therapeutic exercise for a patient with CSM. A 58-year-old male patient attended the physical therapy clinic due to pain and paresthesia in the upper and lower limbs. The magnetic resonance imaging was compatible with spondylotic myelopathy. Following physical therapy treatment, the patient exhibited an improvement in functional capacity (triangle step test and timed 10-m walk), pain, paresthesia, mJOA scale and Neck Disability Index. Based on the lack of rapid evolution of neurological impairment, physical therapy treatment was indicated, which achieved satisfactory results.

Comparison Between Transcutaneous Electrical Nerve Stimulation and Stabilization Exercises in Fatigue and Transversus Abdominis Activation in Patients With Lumbar Disk Herniation: A Randomized Study

Objective: The purpose of this study was to compare transcutaneous electrical nerve stimulation (TENS) and stabilization exercises in an attempt to prevent fatigue and improve muscle activation in patients with lumbar disk herniation associated with low back pain. Methods: This study involved 29 patients (age range 25–58 years) randomized into 2 groups: the segmental stabilization group (n = 15), who received stabilization exercises on the transversus abdominis (TrA) and lumbar multifidus muscles; and the TENS group (n = 14), who received electrotherapy. Groups underwent 16 sessions, for 60 minutes, twice per week, and they were evaluated before and after intervention. Pain was measured using a visual analog scale, functional disability using the Oswestry Disability Index, muscle activation and fatigue with electromyography, and patients’ ability to contract the TrA with a pressure biofeedback unit. Analyses within and between groups were performed. Results: The stabilization group improved lumbar multifidus fatigue (median frequency [MF] initial [P = .002], MF final [P < .001], MF slope [P = .001], and resistance time [P < .001]), ability to contract the TrA (P < .001), pain (P < .001), and functional disability (P < .001). TENS only was effective for pain (P = .012). Conclusion: Although it relieved pain, TENS was not effective as a single treatment to prevent fatigue, increase TrA contraction, and reduce functional disability in herniated disk patients. Stabilization exercises alone improved all measured outcomes.

AB1165-HPR Relationship between Anterior Knee Pain Severity, Functional Capacity, Frontal Plane Projection Angle, Trunk and Hip Strength in Patellofemoral Pain

Background Patellofemoral Pain Syndrome (PFPS) is characterized by anterior knee pain most commonly on the patella lateral facet. Although the increased Frontal Plane Projection Angle (FPPA), core deficit and hip strength have been reported, there are no studies on the relationship of the anterior knee pain severity and functional capacity with the FPPA, core and hip strength1. Knowledge of the contribution of the FPPA, hip lateral rotator, extensor and abductor muscles strength to the pain level and functional capacity would provide an insight into factors associated with symptom severity in patients with PFPS, and help to provide a better treatment approach in subjects with this knee disorder. Objectives The objective of the present study was to determine the relationships between isometric torque (hip lateral rotator, extensor and abductor muscles strength) and FPPA, symptom severity and functional capacity in females with PFPS. Methods This cross-sectional study enrolled 22 women with age ranging from 18 to 45 years. Anterior knee pain was assessed using an 11-point visual analog scale (VAS) for pain. Functional capacity was using the Anterior Knee Pain Scale (AKPS). The FPPA was recorded using three adhesive markers were placed on the midpoint of the ankle malleoli, midpoint of the femoral condyles, and on the proximal thigh along a line from the ASIS to approximately 30 cm above the knee marker2. The height of the step was customized as being 10% of subjects height. The digital camera was positioned 2 m ahead of the subject2. A Nicholas handheld dynamometer was used to measure strength. To mitigate the influence of the examiner, a strap was used for all tests. Participants were instructed to push the dynamometer for 5 seconds, as hard as they could sustain. Three tests were performed, with 30-seconds between measures. Results The FPPA showed moderate positive correlation with the intensity of pain (r=0.55; p=0.008), functional capacity moderate positive correlation with peak torque of hip abductor (r=0.46; P=0.03), hip extensor (r=0.49; p=0.02) and trunk side flexion (r=0.63; p=0.002). In the multiple regression model, the only predictor for the severity of knee pain was FPPA (r2=0.31; p=0.008). Regarding predictors of functional capacity, the peak torque of trunk side flexion, hip extensor and hip abductor explain 41.4% of the functional capacity of the knee in women with PFPS (r2=0.41; p=0.02). Conclusions The increased FPPA was associated with greater anterior knee pain severity and lower peak torque of trunk side flexion, hip extensor and hip abductor was associated with lesser functional capacity in women with PFPS. References Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther 40: 42-51, 2010. Willson JD and Davis IS. Utility of the frontal plane projection angle in females with patellofemoral pain. J Orthop Sports Phys Ther 38: 606-615, 2008. Acknowledgements À Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2908