Luiz Armando Vidal Ramos

Effects of Muscular Stretching and Segmental Stabilization on Functional Disability and Pain in Patients with Chronic Low Back Pain: A Randomized, Controlled Trial

OBJECTIVE The purpose of this study was to compare the effects of 2 exercise programs, segmental stabilization exercises (SSEs) and stretching of trunk and hamstrings muscles, on functional disability, pain, and activation of the transversus abdominis muscle (TrA), in individuals with chronic low back pain. METHODS A total of 30 participants were enrolled in this study and randomly assigned to 1 of 2 groups as a function of intervention. In the segmental stabilization group (SS), exercises focused on the TrA and lumbar multifidus muscles, whereas in the stretching group (ST), exercises focused on stretching the erector spinae, hamstrings, and triceps surae. Severity of pain (visual analog scale and McGill pain questionnaire) and functional disability (Oswestry disability questionnaire) and TrA muscle activation capacity (Pressure Biofeedback Unit, or PBU) were compared as a function of intervention. Interventions lasted 6 weeks, and sessions happened twice a week (30 minutes each). Analysis of variance was used for intergroup and intragroup comparisons. RESULTS As compared with baseline, both treatments were effective in relieving pain and improving disability (P < .001). Those in the SS group had significantly higher gains for all variables. The stretching group did not effectively activate the TrA (P = .94). CONCLUSION Both techniques improved pain and reduced disability. In this study, SS was superior to muscular stretching for the measured variables associated with chronic low back pain.

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

Atividade eletromiográfica durante exercícios de propriocepção de tornozelo em apoio unipodal

Propriocepcao refere-se a percepcao dos mecanorreceptores para discriminar a posicao do corpo e movimentos articulares, bem como tensoes sobre os tendoes na fase estatica ou dinâmica da marcha. Objetivou-se avaliar por eletromiografia a ativacao muscular do gastrocnemio e tibial anterior em diferentes exercicios de propriocepcao do tornozelo em apoio unipodal, comparando graus de dificuldade. Foram selecionados 54 voluntarios, sedentarios, destros, do sexo masculino (20-35 anos). Exercicios foram feitos no balancinho, prancha de equilibrio, cama elastica e solo, a razao de tres repeticoes de 15 segundos cada, com intervalo de 15 segundos entre as repeticoes. Ao final dos testes os voluntarios indicaram a maior dificuldade. A atividade eletrica de ambos os musculos foi significativamente maior durante o teste no balancinho. No solo, ambos os musculos apresentaram menor atividade, mas apenas no gastrocnemio essa diferenca foi significativa. No exercicio na prancha de equilibrio e na cama elastica nao se encontrou diferenca quanto a ativacao dos musculos. Na analise intermusculo foi observada maior atividade do tibial anterior, exceto no balancinho. Assim, para o treino do apoio unipodal na aquisicao do ganho proprioceptivo, o equipamento adotado deve ser escolhido com cuidado: no balancinho e maior o recrutamento dos musculos tibial anterior e gastrocnemio, assim como e maior o grau de dificuldade para manutencao do equilibrio.

Efficacy of acupuncture and electroacupuncture in patients with nonspecific low back pain: study protocol for a randomized controlled trial

BackgroundPrevious studies have shown that acupuncture and electroacupuncture (EA) are effective in the treatment of patients with low back pain. However, there is little evidence to support the use of one intervention over the other. The aim of this study is to compare the effect of acupuncture and electroacupuncture in the treatment of pain and disability in patients with chronic nonspecific low back pain.Methods/designThe study design is a randomized controlled trial. Patients with nonspecific chronic low back pain of more than three months duration are recruited at Rehabilitation Center of Taboao da Serra - SP (Brazil). After examination, sixty-six patients will be randomized into one of two groups: acupuncture group (AG) (n = 33) and electroacupuncture group (EG) (n = 33). Interventions will last one hour, and will happen twice a week for 6 weeks. The primary clinical outcomes will be pain intensity as measured and functional disability. Secondary outcomes: quality of pain, quality of life. perception of the overall effect, depressive state, flexibility and kinesiophobia. All the outcomes will be assessed will be assessed at baseline, at treatment end, and three months after treatment end. Significance level will be determined at the 5 % level. Results of this trial will help clarify the value of acupuncture and electroacupuncture as a treatment for chronic low back pain and if they are different.DiscussionResults of this trial will help clarify the value of acupuncture needling and electroacupuncture stimulation of specific points on the body as a treatment for chronic low back pain.Trial RegistrationClinicaltrials.gov: NCT02039037. Register October 30, 2013.

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.

FRI0561-HPR Effect of Cognitive Behavioral Therapy and Exercise versus Supervised Exercise Program in Patients with Chronic Nonspecific Low Back Pain: A Randomized Controlled: Table 1.

Background Low back pain (LBP) is a major health problem that is associated with reduced functional performance and biopsychosocial factors. The practice of supervised exercise has shown positive results in reducing pain and disability, but we still have inconclusive results regarding the graded activity in patients with LBP. Objectives Evaluate the effect of gradual activity and exercise versus supervised exercises in patients with chronic nonspecific low back pain in the outcomes pain, functional disability, Global Perceived effect and kinesiophobia. Methods This study examined 66 patients with low back pain: Graded Activity Group (GA) n=33 mean age 47 (10.7) BMI 28.4 (3.9) kg/m2 and Supervised Exercise Group (SE) n=33 mean age 47 (8.6), BMI 26.7 (4.2) kg/m2. The interventions were individualized, one hour per session, for six weeks and often twice a week. Patients in the GA was based in the protocol described by Macedo (1), which are based on individualized, progressive and sub-maximal exercises aiming to improve physical fitness and stimulate changes in behavioral and attitudes due to pain. The Supervised Exercised group was based in the protocol described by França (3) using stretching, strengthening and motor control exercises. Intergroup statistical analysis was performed using the t test and Mann- Whitney for data with normal and without normal distribution respectively. α=0.05. Results Patients improved outcome for pain intensity (mean difference -0.3 points and 95% CI -1.62 to 1.02) and for functional disability (mean difference -1.5 and both IC 95% -4.32 to 1.32). No statistically significant difference for all outcome variables was observed. Table 1. Difference between groups after six weeks of intervention Comparison of treatment effect between groups Difference between groups (95% CI) Graded activity P* Supervised exercise P* Mean (SD) Mean (SD) Pain: NRS (0–10 cm)# 4.8 (2.7) <0.001 5.1 (2.4) <0.001 −0.3 (−1.62, 1.02) Functional Disability (0–24) 6.3 (5.1) <0.001 7.8 (5.8) <0.001 −1.5 (−4.32, 1.32) Pain: McGill total (0–77)# 16.4 (18.1) <0.001 22.2 (17.4) <0.001 −5.8 (−14.98, 3.38) Global perceived effect (−5, +5)# −6.4 (2.2) <0.001 −6.44 (3.5) < .001 −12 (−21.50, 21.58) Kinesiophobia (17–68)# 6.2 (10.0) <0.001 8.0 (5.2) <0.001 −1.8 ( −5.92, 2.32) 95% CI, Confidence interval; NRS, Numerical rating scale. # Score; * P value for the T test. Conclusions No statistically significant difference between groups, so both treatments have benefits for patients with LBP. References Macedo LG, Latimer J, Maher CG, Hodges PW, Nicholas M, Tonkin L, et al. Motor control or graded activity exercises for chronic low back pain? A randomised controlled trial. BMC Musculoskelet Disord 2008;9:65. França FR, Burke TN, Caffaro RR, Ramos LA, Marques AP. Effects of muscular stretching and segmental stabilization on functional disability and pain in patients with chronic low back pain: a randomized, controlled trial. J Manipulative Physiol Ther 2012 May;35(4):279-85. Acknowledgements FAPESP – Fundação de Amparo à Pesquisa do Estado de São Paulo Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3670

AB1163-HPR Effect of Stabilizing Exercises versus Tens in Fatigue of the Lumbar Multifidus Muscle and the Ability to Activate the Transversus Abdominis: A Preliminary Study

Background Chronic low back pain (cLBP) is defined as back pain lasting more than 12 weeks in the lumbar and sacral levels of the spine. The intervertebral disc herniation into the vertebral canal may cause pain and affects the transversus abdominis (TrA) and Lumbar Multifidus (ML) muscles that are preferentially attacked in episodes of nonspecific low back pain. Objectives Compare the effect of stabilizing exercises versus TENS in fatigue of the lumbar multifidus muscle (LM) and the ability to activate the transversus abdominis (TrA) in patients with lumbar disc herniation (LDH). Methods This study involved 29 patients (age range 25–58 years) randomised into two groups: Stabilisation group (SG: n=15); which received of stabilization exercises (transversus abdominis and lumbar multifidus muscles) and TENS group (TG: n=14), which received electrotherapy. Groups underwent 16 sessions, for 60 minutes, twice a week and they were evaluated before and after eight weeks. The following instruments were used: visual analogue pain scale and McGill Pain Questionnaire for pain, Oswestry Disability Index for functional disability, electromyography (EMG) to evaluate the LM and pressure biofeedback unit (PBU) for ability to contract the TrA. Analyses within and between groups were performed after treatment. One-way analysis of variance was used for intergroup and intragroup comparisons. Results The stabilisation group was superior to TENS in terms of improvements in fatigue of ML, pain, functional disability and ability to contract the TrA. There were no significant differences in TENS group in terms of disability or ability to contract the TrA muscle. Conclusions The stabilisation group was superior to TENS in improvements fatigue of ML, pain, functional disability and ability to contract the TrA. References Dedering A, Ringdahl KH, Ne`meth G. Back extensor muscle fatigue in patients with lumbar disc herniation, pre-operative and post-operative analysis of electromyography, endurance time and subjective factors, Eur Spine J, 2006, 15: 559–569. Cairms MC, Harrison K, Wright C. Pressure biofeedback: a useful tool in the quantification of abdominal muscular dysfunction? Physiother, 2000, 86(3): 127-38. Acknowledgements CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2927