PURPOSE:

To assess response to osteopathic manual treatment (OMT) according to baseline severity of chronic low back pain (LBP).

METHODS:

The OSTEOPATHIC Trial used a randomized, double-blind, sham-controlled, 2×2 factorial design to study OMT for chronic LBP. A total of 269 (59%) patients reported low baseline pain severity (LBPS) (<50mm/100mm), whereas 186 (41%) patients reported high baseline pain severity (HBPS) (≥50mm/100mm). Six OMT sessions were provided over eight weeks and outcomes were assessed at week 12. The primary outcome was substantial LBP improvement (≥50% pain reduction). The Roland-Morris Disability Questionnaire (RMDQ) and eight other secondary outcomes were also studied. Response ratios (RRs) and 95% confidence intervals (CIs) were used in conjunction with Cochrane Back Review Group criteria to determine OMT effects.

RESULTS:

There was a large effect size for OMT in providing substantial LBP improvement in patients with HBPS (RR, 2.04; 95% CI, 1.36-3.05; P<0.001). This was accompanied by clinically important improvement in back-specific functioning on the RMDQ (RR, 1.80; 95% CI, 1.08-3.01; P=0.02). Both RRs were significantly greater than those observed in patients with LBPS. Osteopathic manual treatment was consistently associated with benefits in all other secondary outcomes in patients with HBPS, although the statistical significance and clinical relevance of results varied.

CONCLUSIONS:

The large effect size for OMT in providing substantial pain reduction in patients with chronic LBP of high severity was associated with clinically important improvement in back-specific functioning. Thus, OMT may be an attractive option in such patients before proceeding to more invasive and costly treatments.

Studies examining repositioning error (RE) in non-specific chronic low back pain (NSCLBP) demonstrate contradictory results, with most studies not correlating RE deficits with measures of pain, disability or fear. This study examined if RE deficits exist among a subgroup of patients with NSCLBP whose symptoms are provoked by flexion, and how such deficits relate to measures of pain, disability, fear-avoidance and kinesiophobia. 15 patients with NSCLBP were matched (age, gender, and body mass index) with 15 painfree participants. Lumbo-pelvic RE, pain, functional disability, fear-avoidance and kinesiophobia were evaluated. Participants were asked to reproduce a target position (neutral lumbo-pelvic posture) after 5 s of slump sitting. RE in each group was compared by evaluating constant error (CE), absolute error (AE) and variable error (VE). Both AE (p = 0.002) and CE (p = 0.006) were significantly larger in the NSCLBP group, unlike VE (p = 0.165) which did not differ between the groups. There were significant, moderate correlations in the NSCLBP group between AE and functional disability (r = 0.601, p = 0.018), and between CE and fear-avoidance (r = -0.577, p = 0.0024), but all other correlations were weak (r < 0.337, rs < 0.377) or non-significant (p > 0.05). The results demonstrate increased lumbo-pelvic RE in a subgroup of NSCLBP patients, with the selected subgroup undershooting the target position. Overall, RE was only weakly to moderately correlated with measures of pain, disability or fear. The deficits observed are consistent with findings of altered motor control in patients with NSCLBP. The mechanisms underlying these RE deficits, and the most effective method of addressing these deficits, require further study.

Chronic low back pain (CLBP) is a common, yet challenging condition for both patients and clinicians. Several studies have demonstrated a strong association between CLBP and psychological factors such as anxiety, fear-avoidance, self-efficacy, catastrophizing and depression. These factors are closely linked with emotional states; however, it is unknown whether CLBP patients process their emotions differently from asymptomatic individuals. The aim of this case-control study was to investigate the relationship between CLBP and emotional processing. A sample of 110 participants comprising of 55 patients with chronic back pain and 55 individuals without a history of CLBP were assessed using the Emotional Processing Scale (EPS-25). The EPS-25 generates an overall score, and also scores pertaining to five individual emotional processing factors - avoidance, suppression, unregulated emotion, impoverished emotional experience and signs of unprocessed emotion. Chronic back pain patients scored significantly higher in the overall EPS-25 score (p < 0.001) with an effect size of 0.33. In addition, there were significant differences in four factors - impoverished emotional experience, unregulated emotion, unprocessed emotion, and suppression, with effect sizes ranging from 0.20 to 0.44. The results suggest that dysfunctional emotional processing, particularly with regard to the suppression of emotions, is associated with CLBP. Clinicians should critically consider the role of emotional processing in their patients' evaluation and management. Future research using a prospective cohort should assess the role of emotional processing as a predictor in the development of chronic back pain.

Hip strength impairments have been established as risk factors for lower limb injuries. Hip muscles strength might be influenced by foot misalignments, however this has not yet been verified. Forefoot varus (FV) has been shown to cause subtalar joint hyperpronation. Subtalar hyperpronation has been associated with excessive lower limb internal rotation in weight-bearing activities. Also, subtalar hyperpronation might result in greater ground reaction force dissipation at the foot. Consequently, there would be less demand for force dissipation at the hip joint, which could reduce the capacity for hip eccentric torque in these subjects. Therefore, the purpose of this study was to determine if FV influences the eccentric hip torque generation of young subjects. Forty-four sedentary, healthy adolescents were divided into 2 groups: subjects with FV (VG, n = 22) and subjects with neutral forefoot alignment (CG, n = 22). An isokinetic dynamometer was used to assess the eccentric torque generated in hip extension and external rotation in these subjects. Group differences were assessed using a one-way multivariate analysis of variance. The VG presented smaller eccentric torque for hip extension (P = 0.014) when compared to the CG, with no difference between groups in external rotation torque (P = 0.433). These results indicate that FV influences hip eccentric torque generation of young subjects. Considering that the muscles involved in hip extension are related to the stabilization of the lumbar spine, hip and knee, these findings bring further enlightenment to the role of foot misalignments as risk factors for injuries in the lower limbs and lumbo-pelvic complex in young subjects.

AIMS:

The main aim of the case series was to inform further experimental research to determine the effectiveness of myofascial trigger point (MTrP) therapy for the treatment of triceps surae dysfunction.

PARTICIPANTS:

Ten participants with triceps surae dysfunction were recruited (4 females and 6 males); mean age±standard deviation=43±7.1 years.

METHODS:

Participants were screened for inclusion/exclusion criteria and the following outcomes measures were assessed at baseline and discharge; lower extremity functional scale (LEFS), verbal numerical rating scale (NRS), MTrP prevalence, ankle dorsiflexion range of movement (ROM) and pressure pain threshold (PPT). Intervention involved trigger point (TrP) pressure release, self MTrP release and a home stretching programme.

RESULTS:

There was a high prevalence of active/latent MTrPs and possible myofascial pain syndrome (MPS) for all 10 participants at baseline. Active MTrP prevalence decreased to 0%, while latent MTrPs were still present at discharge. There were positive changes in most outcome measures (LEFS, NRS, ROM and PPT) for all 10 participants. Short term to medium term treatment outcomes (6 week post discharge) showed an overall mean LEFS increase of 11 points from 61/80 at baseline to 72/80 at discharge.

CONCLUSION:

This case series suggests that a brief course of multimodal MTrP therapy would be helpful for some patients with sub-acute or chronic calf pain. Important preliminary data was gathered, that will inform more rigorous research in this under investigated area.

STUDY DESIGN:

Reliability study.

OBJECTIVE:

To investigate the inter-session reliability of measuring the thickness of deep (dMF) and superficial layer of lumbar multifidus (sMF) using ultrasonography for participants with and without low back pain (LBP).

BACKGROUND:

The lumbar multifidus is an important muscle in maintaining spinal stability. The dMF is considered important in maintaining tonic contraction and joint stability. Motor control impairment is also discovered in patients with LBP. However, no study to date has investigated the method of observing both the sMF and dMF through ultrasound imaging (USI).

METHODS:

Twenty subjects aged 18-35 years old with LBP (N=10) and without LBP (N=10) were recruited. Every subject extended the upper trunk in prone lying with maximal isometric contraction. Simultaneously, the examiner measured the thickness of the dMF and the sMF using ultrasonography after ensuring the muscle belly was located. The participants performed three trials of isometric trunk extension in each session, with 30min between each session. The reliability of measuring the change of thickness is represented by the intra-class correlation coefficient (ICC).

RESULTS:

Through averaging three trials of measurement, the reliability of measuring the thickness of the dMF or the sMF in static or in the contracted condition, and the change of the thickness during contraction, is reliable (ICC=0.84-1.00).

CONCLUSIONS:

The intra-rater inter-session reliability of measurement of the dMF and the sMF with USI has been established. This method could be applied to the qualification of the activation level of the dMF and the sMF with specific tasks.

Electromagnetic devices allow the non invasive and accurate measurement of 3D scapula kinematics. The acromial method allows continuous dynamic measurement using a skin surface sensor fixed to the acromion. Inter-session intra and inter-observer repeatability of 3D scapular kinematics have only been partially assessed for analytical movements and never for functional tasks. Inter-session intra and inter-observer repeatability of 3D scapular kinematics were assessed for arm elevation in the sagittal and frontal planes and for two activities of daily living (ADL), hair combing and back washing, in both shoulders of 15 healthy subjects, using the intraclass correlation coefficient (ICC), the standard error of measurement (SEM), the small real difference (SRD) and the Bland and Altman's graphical method. Intra-observer repeatability was good to excellent for every scapular rotation for both arm elevation in isolated planes and ADL (ICC ranged from 0.64 to 0.95). Inter-observer repeatability of scapular rotations was fair to excellent for arm elevation in isolated planes (ICC ranged from 0.49 to 0.92) and poor to excellent for ADL (ICC ranged from 0.35 to 0.89). Inter-observer repeatability of scapular protraction/retraction had the lowest ICC. For both inter-session intra and inter-observer reliability, the SEM and SRD remained low and Bland and Altman's graphical method showed a good repeatability of the measurement method. Longitudinal monitoring of a subject's scapular kinematics by a trained observer is reliable. The inter-observer repeatability of scapular protraction/retraction must be improved.

Patients with neck disorders can report difficulties with functional use of their upper limb because of their neck pain. Yet, there is little information on the frequency and specifically, the nature of these upper limb activities. This study surveyed patients with neck pain disorders (n = 103) presenting for management at private physiotherapy clinics in a large metropolitan area to investigate the frequency and nature of reduced upper limb function. Participants were asked to complete four questionnaires, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Neck Disability Index (NDI), Pictorial Fear of Activity Scale-Cervical (PFActS-C) and Patient Specific Functional Scale (PSFS). Approximately 80% of patients spontaneously reported that upper limb activities aggravated their neck pain (PSFS). Most frequently, these activities involved loading of the upper limb such as lifting. Eight activity items on the DASH were scored positive by ≥50% of participants. Participants had mild to moderately severe neck pain (NDI: range 2-68%). The DASH and NDI were moderately-highly correlated (ρ = 0.669; p < 0.001), indicating the higher the neck pain severity the greater the upper limb functional restrictions. There was a low correlation between the NDI and PFActS-C (ρ = 0.319; p = 0.001). These findings provide evidence that upper limb function is often impaired in association with neck pain disorders and suggest clinicians should routinely question patients regarding upper limb function. The DASH could be used as a suitable outcome measure in its current or possibly a modified form.

Surface electromyographic response of the middle, lower serratus anterior, and the upper trapezius muscles was investigated within a number of exercises. In total, 16 healthy, physically active volunteers completed three individual trials consisting of arm elevation above 120°, diagonal elevation, dynamic hug, dynamic hug plus, and push-up plus while surface electromyography was used to record muscle activity in the lower and middle serratus anterior (LSA, MSA) and upper trapezius (UT) muscles. The dynamic hug plus exercise caused significant increases in the activity of the MSA compared with the other exercises (P < 0.05). The diagonal elevation, dynamic hug plus, and push up plus showed significantly higher activation in the LSA compared with the arm elevation above 120° and the dynamic hug (P < 0.05). The activation of the UT and the UT/MSA and UT/LSA ratios in both the arm elevation and diagonal shoulder flexion exercises was significantly higher than that for the dynamic hug, dynamic hug plus, and push-up plus exercises (P < 0.05). The present study showed that the dynamic hug plus exercise could be used for activating MSA and LSA. Selective activation of the LSA and MSA is better achieved with exercises that include a scapular protraction component.