John M. Mayer

Recommendations for the Pharmacological Management of Neuropathic Pain: An Overview and Literature Update

The Neuropathic Pain Special Interest Group of the International Association for the Study of Pain recently sponsored the development of evidence-based guidelines for the pharmacological treatment of neuropathic pain. Tricyclic antidepressants, dual reuptake inhibitors of serotonin and norepinephrine, calcium channel alpha(2)-delta ligands (ie, gabapentin and pregabalin), and topical lidocaine were recommended as first-line treatment options on the basis of the results of randomized clinical trials. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in certain clinical circumstances. Results of several recent clinical trials have become available since the development of these guidelines. These studies have examined botulinum toxin, high-concentration capsaicin patch, lacosamide, selective serotonin reuptake inhibitors, and combination therapies in various neuropathic pain conditions. The increasing number of negative clinical trials of pharmacological treatments for neuropathic pain and ambiguities in the interpretation of these negative trials must also be considered in developing treatment guidelines. The objectives of the current article are to review the Neuropathic Pain Special Interest Group guidelines for the pharmacological management of neuropathic pain and to provide a brief overview of these recent studies.

Back Extension Endurance and Strength : The Effect of Variable-Angle Roman Chair Exercise Training

Study Design. A pre- and postintervention randomized, controlled trial was conducted. Objective. To evaluate the effect of progressive resistance exercise training using a variable-angle Roman chair on the development of lumbar extensor endurance and strength. Summary of Background Data. Progressive resistance exercise for the lumbar extensors has been used successfully for low back pain rehabilitation, but the limitations of currently available back exercise devices have negatively affected its use. Methods. For this study, 36 healthy volunteers were randomized into one of two groups: a variable-angle Roman chair exercise group (n = 18) that performed one set of 15 to 25 repetitions of dynamic progressive resistance back extension exercise on a variable-angle Roman chair three times per week for 8 weeks or a control group (n = 18) that did not perform resistance exercise. Before training and after 4 and 8 weeks of training, static back extension endurance (seconds) and isometric lumbar extension strength (Newton·meters) were recorded. Results. The variable-angle Roman chair exercise group displayed a 42% increase in static back extension endurance at the 4-week and 8-week tests relative to the pretraining measure (P < 0.05). The control group did not increase back endurance time at either the 4-week or 8-week tests (P > 0.05). Neither the variable-angle Roman chair exercise group nor the control group displayed an increase in lumbar extension strength at the 4-week or 8-week tests (P > 0.05). Conclusions. Dynamic progressive resistance exercise training on a variable-angle Roman chair is capable of developing back extension endurance. Future research is needed to determine the clinical applicability of variable-angle Roman chair exercise training for patients with low back pain patients.

NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain

BACKGROUND CONTEXT Low back pain (LBP) continues to be a very prevalent, disabling, and costly spinal disorder. Numerous interventions are routinely used for symptoms of acute LBP. One of the most common approaches is spinal manipulation therapy (SMT). PURPOSE To assess the current scientific literature related to SMT for acute LBP. PATIENT SAMPLE Not applicable. OUTCOME MEASURES Not applicable. DESIGN Systematic review (SR). METHODS Literature was identified by searching MEDLINE using indexed and free text terms. Studies were included if they were randomized controlled trials (RCTs) published in English, and SMT was administered to a group of patients with LBP of less than 3 months. RCTs included in two previous SRs were also screened, as were reference lists of included studies. Combined search results were screened for relevance by two reviewers. Data related to methods, risk of bias, harms, and results were abstracted independently by two reviewers. RESULTS The MEDLINE search returned 699 studies, of which six were included; an additional eight studies were identified from two previous SRs. There were 2,027 participants in the 14 included RCTs, which combined SMT with education (n=5), mobilization (MOB) (n=4), exercise (n=3), modalities (n=3), or medication (n=2). The groups that received SMT were most commonly compared with those receiving physical modalities (n=7), education (n=6), medication (n=5), exercise (n=5), MOB (n=3), or sham SMT (n=2). The most common providers of SMT were chiropractors (n=5) and physical therapists (n=5). Most studies (n=6) administered 5 to 10 sessions of SMT over 2 to 4 weeks for acute LBP. Outcomes measured included pain (n=10), function (n=10), health-care utilization (n=6), and global effect (n=5). Studies had a follow-up of less than 1 month (n=7), 3 months (n=1), 6 months (n=3), 1 year (n=2), or 2 years (n=1). When compared with various control groups, results for improvement in pain in the SMT groups were superior in three RCTs and equivalent in three RCTs in the short term, equivalent in four RCTs in the intermediate term, and equivalent in two RCTs in the long term. For improvement in function, results from the SMT groups were superior in one RCT and equivalent in four RCTs in the short term, superior in one RCT and equivalent in one RCT in the intermediate term, and equivalent in one RCT and inferior in one RCT in the long term. No harms related to SMT were reported in these RCTs. CONCLUSIONS Several RCTs have been conducted to assess the efficacy of SMT for acute LBP using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone.

Systematic Review of Core Muscle Activity During Physical Fitness Exercises

Abstract Martuscello, JM, Nuzzo, JL, Ashley, CD, Campbell, BI, Orriola, JJ, and Mayer, JM. Systematic review of core muscle activity during physical fitness exercises. J Strength Cond Res 27(6): 1684–1698, 2013—A consensus has not been reached among strength and conditioning specialists regarding what physical fitness exercises are most effective to stimulate activity of the core muscles. Thus, the purpose of this article was to systematically review the literature on the electromyographic (EMG) activity of 3 core muscles (lumbar multifidus, transverse abdominis, quadratus lumborum) during physical fitness exercises in healthy adults. CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, PubMed, SPORTdiscus, and Web of Science databases were searched for relevant articles using a search strategy designed by the investigators. Seventeen studies enrolling 252 participants met the reviews inclusion/exclusion criteria. Physical fitness exercises were partitioned into 5 major types: traditional core, core stability, ball/device, free weight, and noncore free weight. Strength of evidence was assessed and summarized for comparisons among exercise types. The major findings of this review with moderate levels of evidence indicate that lumbar multifidus EMG activity is greater during free weight exercises compared with ball/device exercises and is similar during core stability and ball/device exercises. Transverse abdominis EMG activity is similar during core stability and ball/device exercises. No studies were uncovered for quadratus lumborum EMG activity during physical fitness exercises. The available evidence suggests that strength and conditioning specialists should focus on implementing multijoint free weight exercises, rather than core-specific exercises, to adequately train the core muscles in their athletes and clients.

Effects Of Pelvic Stabilization On Lumbar Muscle Activity During Dynamic Exercise

Many commonly utilized lowback exercise devices offer mechanisms to stabilize the pelvis and to isolate the lumbar spine, but the value of these mechanisms remains unclear. The purpose of this study was to examine the effect of pelvic stabilization on the activity of the lumbar and hip extensor muscles during dynamic back extension exercise. Fifteen volunteers in good general health performed dynamic extension exercise in a seated upright position on a lumbar extension machine with and without pelvic stabilization. During exercise, surface electromyographic activity of the lumbar multifidus and biceps femoris was recorded. The activity of the multifidus was 51% greater during the stabilized condition, whereas there was no difference in the activity of the biceps femoris between conditions. This study demonstrates that pelvic stabilization enhances lumbar muscle recruitment during dynamic exercise on machines. Exercise specialists can use these data when designing exercise programs to develop low back strength.

Management of chronic low back pain in active individuals.

Chronic low back pain (LBP) is a common and potentially disabling condition in all adults, including those who are physically active. It currently is challenging for clinicians and patients to choose among the numerous treatment options. This review summarizes recommendations from recent clinical practice guidelines and systematic reviews about common primary care and secondary care approaches to the management of chronic LBP. The best available evidence currently suggests that in the absence of serious spinal pathology, nonspinal causes, or progressive or severe neurologic deficits, the management of chronic LBP should focus on patient education, self-care, common analgesics, and back exercises. Short-term pain relief may be obtained from spinal manipulative therapy or acupuncture. For patients with psychological comorbidities, adjunctive analgesics, behavioral therapy, or multidisciplinary rehabilitation also may be appropriate. Given the importance of active participation in recovery, patient preference should be sought to help select from among the recommended treatment options.

The Impact of Obesity on Back and Core Muscular Endurance in Firefighters

The purpose of this study was to assess the relationships between obesity and measures of back and core muscular endurance in firefighters. Methods. A cross-sectional study was conducted in career firefighters without low back pain. Obesity measures included body mass index (BMI) and body fat percentage assessed with air displacement plethysmography. Muscular endurance was assessed with the Modified Biering Sorensen (back) and Plank (core) tests. Relationships were explored using t-tests and regression analyses. Results. Of the 83 participants enrolled, 24 (29%) were obese (BMI ≥ 30). Back and core muscular endurance was 27% lower for obese participants. Significant negative correlations were observed for BMI and body fat percentage with back and core endurance (r = −0.42 to −0.52). Stepwise regression models including one obesity measure (BMI, body fat percentage, and fat mass/fat-free mass), along with age and self-reported physical exercise, accounted for 17–19% of the variance in back muscular endurance and 29–37% of the variance in core muscular endurance. Conclusions. Obesity is associated with reduced back and core muscular endurance in firefighters, which may increase the risk of musculoskeletal injuries. Obesity should be considered along with back and core muscular endurance when designing exercise programs for back pain prevention in firefighters.

Body mass normalisation for ultrasound measurements of lumbar multifidus and abdominal muscle size

The purpose of this study was to determine if ratio scaling or allometric scaling is the more appropriate method for normalising ultrasound measurements of lumbar multifidus and abdominal muscle size to body mass. In a convenience sample of 62 male career firefighters, cross-sectional area and thickness of the lumbar multifidus, as well as, thicknesses of the external oblique, internal oblique, and transverse abdominal muscles were assessed with ultrasonography. Ratio scaling entailed dividing muscle size by body mass, while allometric scaling entailed dividing muscle size by body mass raised to a power. Significant positive correlations (r = 0.25 to 0.49, p < 0.05) existed between body mass and all muscle size measurements, except for transverse abdominal thickness (r = 0.21, p = 0.100). Ratio scaling was deemed inappropriate for normalising the muscle size measurements, because it merely reversed the direction of the correlations between body mass and the muscle size measurements (r = -0.31 to -0.50, p < 0.05), with external oblique abdominal thickness representing the only exception (r = -0.17, p = 0.192). Allometric scaling with derived allometric parameters was deemed appropriate for normalising muscle size measurements, because it caused the correlations between body mass and muscle size to become insignificant and near to zero (r = -0.06 to 0.00, p > 0.05). The current study provides allometric parameters that can be used to normalise muscle size measurements to body mass in male firefighters. Future research is needed to establish reference databases of population-specific allometric parameters in other groups.

Development of lumbar extension strength: Effect of pelvic stabilization during resistance training

The purpose of this studywas to determine the effect of pelvic stabilization during resistance training on the development of isometric lumbar extension strength (torque output) when testing and training are conducted on a lumbar dynamometer. Eighteen healthy volunteers were randomly assigned to one of two groups that trained on a lumbar extension dynamometer: One trained with pelvic stabilization (n = 9) and the other trained without pelvic stabilization (n = 9). Peak isometric lumbar extension torque was measured on the dynamometer at seven angles over the full range of lumbar flexion, before and after a twelve-week, one time per week dynamic progressive resistance exercise program. Following training, peak isometric torque increased for the stabilization and without stabilization groups (average increase of 15.8 ± 11.8% and 20.6 ± ;17.2%, respectively; p ≤ 0.05), while there was no difference in torque production between the groups (p > 0.05). This study demonstrates that pelvic stabilization is not required during training to develop lumbar extension strength when testing and training are conducted on the same machine.

Recommendations for the pharmacological management of neuropathic pain

The Neuropathic Pain Special Interest Group of the International Association for the Study of Pain recently sponsored the development of evidence-based guidelines for the pharmacological treatment of neuropathic pain. Tricyclic antidepressants, dual reuptake inhibitors of serotonin and norepinephrine, calcium channel alpha(2)-delta ligands (ie, gabapentin and pregabalin), and topical lidocaine were recommended as first-line treatment options on the basis of the results of randomized clinical trials. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in certain clinical circumstances. Results of several recent clinical trials have become available since the development of these guidelines. These studies have examined botulinum toxin, high-concentration capsaicin patch, lacosamide, selective serotonin reuptake inhibitors, and combination therapies in various neuropathic pain conditions. The increasing number of negative clinical trials of pharmacological treatments for neuropathic pain and ambiguities in the interpretation of these negative trials must also be considered in developing treatment guidelines. The objectives of the current article are to review the Neuropathic Pain Special Interest Group guidelines for the pharmacological management of neuropathic pain and to provide a brief overview of these recent studies.