Kieran O’Sullivan

Can we reduce the effort of maintaining a neutral sitting posture? A pilot study

Neutral sitting postures encouraging lumbar lordosis have been recommended in the management of sitting-related low back pain (LBP). However, prolonged lordotic sitting postures can be associated with increased fatigue and discomfort. This pilot study investigated whether changing the type of chair used in sitting can reduce the effort of maintaining a neutral sitting posture. The muscle activation of six trunk muscles was recorded using surface electromyography in 12 painfree participants. Participants were facilitated into a neutral sitting posture for 1 min on both a standard backless office chair and a dynamic, forward-inclined chair (Back App). Lumbar multifidus activity was significantly lower on the Back App chair (p=0.013). None of the other five trunk muscles measured demonstrated a significant difference in activity between the chairs. There was no significant difference (p=0.108) in the perceived effort of maintaining the neutral sitting posture on the two chairs. This study suggests that the lumbar multifidus activation required to maintain a neutral sitting posture can be reduced by considering the type of chair used. The mechanism through which the Back App chair reduces lumbar multifidus activation is unclear, but the greatest difference between chairs is the degree of hip flexion. The ability to maintain a neutral lumbar posture with less lumbar multifidus activation is potentially advantageous during prolonged sitting. Further investigations of the effects of chair design on longer duration sitting, and among LBP subjects, are warranted.

Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain

&NA; Biomedical approaches for diagnosing and managing disabling low back pain (LBP) have failed to arrest the exponential increase in health care costs, with a concurrent increase in disability and chronicity. Health messages regarding the vulnerability of the spine and a failure to target the interplay among multiple factors that contribute to pain and disability may partly explain this situation. Although many approaches and subgrouping systems for disabling LBP have been proposed in an attempt to deal with this complexity, they have been criticized for being unidimensional and reductionist and for not improving outcomes. Cognitive functional therapy was developed as a flexible integrated behavioral approach for individualizing the management of disabling LBP. This approach has evolved from an integration of foundational behavioral psychology and neuroscience within physical therapist practice. It is underpinned by a multidimensional clinical reasoning framework in order to identify the modifiable and nonmodifiable factors associated with an individuals disabling LBP. This article illustrates the application of cognitive functional therapy to provide care that can be adapted to an individual with disabling LBP.

The efficacy of interventions for low back pain in nurses: A systematic review

OBJECTIVES To investigate the efficacy of interventions for the prevention and treatment of low back pain in nurses. DESIGN Systematic review. DATA SOURCES The review was registered on the PROSPERO database (CRD42015026941) and followed the PRISMA statement guidelines. A two phase approach was used. In phase one, all randomised controlled trials included in the systematic review of Dawson et al. (2007) which reviewed interventions for low back pain in nurses until 2004 were selected. In phase two, relevant randomised controlled trials and cluster randomised controlled trials published from 2004 until December 2015 were identified by an electronic search of nine databases (Embase, CINAHL, SPORTDiscus, PsycARTICLES, Cochrane Library, Web of Science, PEDro, Scopus and MEDLINE). To be eligible, trials had to examine the efficacy of interventions either for the prevention or treatment of low back pain in nurses. Primary outcomes of interest were any measure of pain and/or disability. REVIEW METHODS Three reviewers independently assessed eligibility and two reviewers independently conducted a risk of bias assessment (Cochrane Back and Neck Group). RESULTS Four studies were retrieved from phase one. In phase two, 15,628 titles and abstracts were scanned. From these, 150 full-text studies were retrieved and ten were eligible. Fourteen studies (four from phase one, ten from phase two) were eligible for risk of bias assessment. The included trials were highly heterogeneous, differing in pain and disability outcome measures, types of intervention, types of control group and follow-up durations. Only four of the included studies (n=644 subjects) had a low risk of bias (≥6/12). Manual handling training and stress management in isolation were not effective in nurses with and without low back pain (risk of bias, 7/12, n=210); the addition of a stretching exercise intervention was better than only performing usual activities (risk of bias, 6/12, n=127); combining manual handling training and back school was better than passive physiotherapy (risk of bias, 7/12, n=124); and a multidimensional intervention (risk of bias, 7/12, n=183) was not superior to a general exercise program in reducing low back pain in nurses. CONCLUSIONS Only four relevant low risk of bias randomised controlled trials were found. At present there is no strong evidence of efficacy for any intervention in preventing or treating low back pain in nurses. Additional high quality randomised controlled trials are required. It may be worth exploring the efficacy of more individualised multidimensional interventions for low back pain in the nursing population.

Pain and fatigue in sport: are they so different?

Pain and fatigue are common reasons for athletes to avoid, or reduce, sporting participation. Despite commonly coexisting, they are usually treated as distinct entities. Both sensations are often interpreted by medical staff as indicating that physical activity should be reduced or avoided, either due to tissue damage (pain) or excessive training (fatigue). But paradoxically, that management plan—relative rest—means that athletes avoid what keeps them healthy, fit and resilient—physical activity. Coaches sometimes view the sensations of pain and fatigue as indicators of physical and/or psychological weakness; they should be ignored to ‘toughen up’ athletes, sometimes leading to athletes unhelpfully provoking symptoms. These opposing views between medical staff and coaches—which often reflect limited understanding regarding the interaction of training load, beliefs and other external factors on pain and fatigue—often place the athlete in a conflicted state. ‘Should I tell (the medical team) or should I remain stoic’ (figure 1). We discuss the parallels between pain and fatigue, and how their management reflects the lens through which these …

Validation of the manual inclinometer and flexicurve for the measurement of thoracic kyphosis

ABSTRACT Introduction: Physiotherapists commonly use the manual inclinometer and Flexicurve for the clinical measurement of thoracic spinal posture. The aim of this study is to examine the concurrent validity of the Flexicurve and manual inclinometer in relation to the radiographic Cobb angle for the measurement of thoracic kyphosis. Methods: Eleven subjects (seven males, four females) underwent a sagittal plane spinal radiograph. Immediately following the radiograph, a physiotherapist measured thoracic kyphosis using the Flexicurve and manual inclinometer before the subjects moved from position. Cobb angles were subsequently measured from the radiographs by an independent examiner. Results: A strong correlation was demonstrated between both the Cobb angle and the Flexicurve angle (r = 0.96) and the Cobb angle and the manual inclinometer angle (r = 0.86). On observation of the Bland–Altman plots, the inclinometer showed good agreement with the Cobb angle (mean difference 4.8 ° ± 8.9 °). However, the Flexicurve angle was systematically smaller than the Cobb angle (mean difference 20.3 ° ± 6.1 °), which reduces its validity. Conclusion: The manual inclinometer is recommended as a valid instrument for measuring thoracic kyphosis, with good agreement with the gold standard. While the Flexicurve is highly correlated to the gold standard, they have poor agreement. Therefore, physiotherapists should take caution when interpreting its results.

The associations between training load and baseline characteristics on musculoskeletal injury and pain in endurance sport populations: A systematic review

OBJECTIVES To determine the associations between training load, baseline characteristics (e.g. age or previous injury) and rate of musculoskeletal injury and/or pain specifically within an Endurance Sporting Population (ESP). DESIGN Prospectively registered systematic review. METHODS Eight electronic databases were searched by two independent reviewers. Studies were required to prospectively monitor both (i) training loads and (ii) musculoskeletal injury and/or pain for >3 months. Methodological quality and risk of bias were determined utilising the Critical Skills Appraisal Program (CASP). Reported effect sizes were categorised as small, medium or large. RESULTS Twelve endurance sport studies were eligible (running, triathlon, rowing). Increased injury and/or pain risk was associated with: (i) high total training distances per week/month (medium effect size) (ii) training frequency <2 sessions/week (medium effect size) and (iii) both low weekly (<2hours/week) and high monthly (large effect size) training durations. None of the studies reported internal training load data or acute:chronic workload ratios. Baseline characteristics found to increase the rate of injury and/or pain included: (i) a history of previous injury (medium effect size), (ii) age >45 years (small effect size), (iii) non-musculoskeletal comorbidities (large effect size), (iv) using older running shoes (small effect size) and (v) non-competitive behaviour. CONCLUSIONS This review identifies a range of external training load factors and baseline characteristics associated with an increased rate of injury and/or pain within ESPs. There is an absence of research relating to internal training loads and acute:chronic workload ratios in relation to rate of injury and/or pain within ESPs.

Biopsychosocial Factors Associated with Foot and Ankle Pain and Injury in Irish Dance: A Prospective Study

BACKGROUND Foot and ankle pain/injury (FAPI) is the most common musculoskeletal problem suffered in Irish dancing. A prospective examination of risk factors for FAPI in this cohort has never been performed. STUDY DESIGN Prospective study over 1-year. METHODS 85 elite adult Irish dancers were screened at baseline for biopsychosocial factors and followed up prospectively each month for 1 year to evaluate FAPI rates and potential risk factors. Subjects who suffered from multiple incidences of FAPI (with no pain/injury reported elsewhere in the body) or at least one moderate episode of FAPI were allocated to the foot/ankle-injured (FAI) group (n=28, 25 F/3 M). Subjects reporting no pain/injury or only one minor FAPI were allocated to the non-injured group (n=21, 14 F/7 M). Baseline differences in variables between groups were tested with the independent samples t-test, Mann-Whitney U-test for skewed data, and Fishers exact test for categorical variables. RESULTS Baseline factors significantly associated with the FAI group included failing to always perform a warm-up (p=0.042), lower levels of energy (p=0.013), and more bothersome pain (p=0.021). Subjects also scored worse on two dimensions of the Athletic Coping Skills Inventory: i.e., coping with adversity (p=0.035) and goal setting and mental preparation (p=0.009). CONCLUSION Several biopsychosocial factors appear to be associated with FAPI in Irish dancers. Biopsychosocial screening protocols and prevention strategies may best identify and support at-risk dancers.

NICE low back pain guidelines: opportunities and obstacles to change practice

The National Institute for Health and Care Excellence recently updated its low back pain (LBP) guidelines,1 with the associated infographic developed to assist interpretation of the recommendations. The guidelines are more consistently aligned with Cochrane systematic reviews than the previous version. The guidelines contain several key directives, which, if widely implemented, could significantly impact on the care of individuals with LBP. Established evidence-based messages, including the need for more cautious referral for some investigations and treatments including imaging, medication and surgery, are reinforced, with a clear emphasis on facilitating self-management strategies. Considering psychosocial factors at an early stage is also advocated, rather than waiting for usual care to fail. There is a timely shift to targeting care based on a person’s multidimensional risk profile, rather than merely symptom duration. 1. Which treatment option for whom?

Evaluation of the within- and between-day intra-tester and inter-tester reliability of positioning subjects into neutral and lordotic sitting postures

Abstract Purpose: To assess the reliability of postural positioning in two different sitting postures (SP), within- and between-days, as well as intra-tester and inter-tester. Methods: Twenty six individuals were facilitated into lordotic (LSP) and neutral (NSP) SP on two different days by four physiotherapists, while kinematic data were collected. Intra-tester and inter-tester reliability were assessed using measures of relative reliability (intra-class correlation coefficients, ICC) and absolute reliability (standard error of measurement-SEM; minimal detectable change; mean difference; limits of agreement). Results: Substantial or almost perfect relative reliability (ICC >0.67), with very good absolute reliability (SEM <2.7°) was found for both intra- and inter-tester (within- and between-day) reliability. However, likely due to methodological variation affecting head angles on Day 2, the reliability of head/neck angles were poor (ICC as low as −0.11, SEM ≤5.71°). Conclusion: This study suggests that postural positioning of asymptomatic individuals into NSP and LSP can be performed with very good reliability for most spinal angles. Therefore, clinicians can have some confidence that positioning in SPs can be done reliably. However, while the degree of error is typically small, the small range of movement occurring at many spinal angles suggests that determining what is a clinically meaningful change in posture is difficult.

Effectiveness of Therapeutic Exercise on Forward Head Posture: A Systematic Review and Meta-analysis

Objective: The purpose of this systematic review and meta‐analysis was to summarize the results related to the effects of corrective exercises on postural variables in individuals with forward head posture (FHP). Methods: A systematic review of the electronic literature through February 2017 was independently performed by 2 investigators. The electronic databases searched included PubMed, MEDLINE, Web of Science, ScienceDirect, Cochrane Central Register of Controlled Clinical Trials, Google Scholar, and Scopus. Methodological quality was evaluated using the Physiotherapy Evidence Database scale. Meta‐analyses were carried out for craniovertebral angle (CVA), cranial angle (CA), and pain intensity. Results: Seven randomized clinical trials comprising 627 participants met the study criteria. The between‐groups pooled random odds ratios for CVA, CA, and pain were 6.7 (confidence interval [CI] = 2.53–17.9, P = .0005), 0.7 (CI = 0.43–1.2, P = .2), and 0.3 (95% CI = 0.13–0.42, P < .001), respectively. No publication bias was observed. Level 1a evidence (strong) indicates exercise training can effectively modify CVA, and level 1b evidence (moderate) indicates exercise may improve pain but not CA. Conclusion: The findings suggest that therapeutic exercises may result in large changes in CVA and moderate improvement in neck pain in participants with FHP. The precise nature of the relationship between FHP and musculoskeletal pain, and improvements in both after therapeutic exercise, remains to be established.