Maurício Oliveira Magalhães

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.

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.

Effectiveness of graded activity versus physiotherapy in patients with chronic nonspecific low back pain: midterm follow up results of a randomized controlled trial

Highlights • Graded activity and physiotherapy have similar effects in terms of reducing pain and disability.• Healthcare professionals may identify inadequate beliefs in patients with low back pain.• It is important to stimulate patients with LBP return to work.

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.

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