A study of therapeutic ultrasound and exercise treatment for muscle fatigue in patients with chronic non specific low back pain: a preliminary report. Evidence-based medicine and the challenge of low back pain: where are we now? Specificity of a back muscle exercise machine in healthy and low back pain subjects. Course and prognosis of recovery for chronic non-specific low back pain: design, therapy program and baseline data of a prospective cohort study Prognosis and Course of Disability in Patients With Chronic Nonspecific Low Back Pain: A 5- and 12-Month Follow-up Cohort Study Specificity of a back muscle roman chair exercise in healthy and back pain subjects. The Effects of Dynamic Isolated Lumbar Extensor Training on Lumbar Multifidus Functional Cross-Sectional Area and Functional Status of Patients With Chronic Nonspecific Low Back Pain Quantifying the Lumbar Flexion–Relaxation Phenomenon: Theory, Normative Data, and Clinical Applications [Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance]. Functional multidisciplinary rehabilitation versus outpatient physiotherapy for non specific low back pain: randomized controlled trial. Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. Stretching in the Rehabilitation of Low-Back Pain Patients Effectiveness of Back School program versus hydrotherapy in elderly patients with chronic non-specific low back pain: a randomized clinical trial. Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Effects of long-term corset wearing on chronic low back pain. Medial branch neurotomy in management of chronic spinal pain: systematic review of the evidence. Massage for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Back Review Group Effects of preferred-exercise prescription compared to usual exercise prescription on outcomes for people with non-specific low back pain: a randomized controlled trial [ACTRN12608000524392] Psychological features and outcomes of the Back School treatment in patients with chronic non-specific low back pain. A randomized controlled study. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Yoga as a treatment for chronic low back pain: A systematic review of the literature The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews Kinesio Taping applied to lumbar muscles influences clinical and electromyographic characteristics in chronic low back pain patients.
AIM The aim of this study was to investigate the effect of continuous ultrasound ( US ) plus exercise on the endurance of paravertebral muscles of patients with chronic non specific low back pain ( CNSLBP ) . METHODS AND MATERIAL S In this pilot , pretest-posttest study , 22 patients with CNSLBP participated . Patients received 10 sessions of treatment , including continuous US plus exercise therapy , over a period of four consecutive weeks . Median frequency slopes of Iliocostalis and Multifidus muscles as well as holding time during Biering-Sorensen test were measured using surface electromyography . In addition , function and pain were measured using Functional Rating Index ( FRI ) question naire and VAS . RESULTS Five females and 15 males with a mean age of 31.7 years completed the treatment . Descriptive data showed a decrease of 0.01 and 0.02 mean in median frequency slope of right and left Iliocostalis respectively and a mean of 0.08 decrease for both right and left Multifidus muscles . Endurance time increased 1.8 seconds mean . Both function ( 17 % ) and pain ( 24 % ) improved post treatment . CONCLUSION Larger population studies in the context of high quality , r and omized clinical trial are needed to vali date the results Low  back pain  has long been described as a challenge for both primary care physicians and specialists . Management of  low back pain  has also been criticized as frequently arbitrary , inappropriate , or ineffective . Contributing factors have been an inadequate evidence base and a need for more rigorous appraisal s of the available literature . Evidence -based medicine , an approach to clinical problem solving , is predicated on the premise that high- quality health care will result from practice s consistent with the best evidence . In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion , authority , and un systematic clinical observations , evidence -based medicine emphasizes the need for rigorous critical appraisal s of the scientific literature to inform medical decision making . Evidence -based medicine places strong weight on the requirement for valid studies , particularly r and omized controlled trials , to appropriately evaluate the effectiveness of health care interventions . Because of the rapidly increasing volume of medical literature , however , most clinicians are unable to keep up-to- date with all the new data . Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic review s and evidence -based clinical practice guidelines . Like primary studies , systematic review s and clinical practice guidelines must adhere to high method ologic st and ards to reduce error and bias . As in other areas of medicine , the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings . In addition to more rigorous primary studies , an increasing number of high- quality systematic review s and evidence -based clinical practice guidelines for low back pain are also available . Although some research gaps and method ologic shortcomings persist , the richer evidence base has greatly improved our underst and ing of what does and does not work for low back pain . Despite these advances , the best available evidence often does not inform everyday clinical decisions for low back pain . Nonetheless , there is widespread agreement that adherence to evidence -based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care . This article review s basic principles of evidence -based medicine , discusses evidence -based medicine in the context of low back pain management , and summarizes some useful evidence -based medicine re sources PURPOSE To determine whether dynamic back muscle endurance exercises in a semisitting position induce more fatigue in back muscles than that in hip extensors in healthy controls as well as in patients with nonspecific chronic low back pain . METHODS Sixteen healthy volunteers and 18 volunteers with nonspecific chronic low back pain performed trunk flexion-extension cycles until exhaustion at 60 % of their strength in a machine design ed for back exercise in a semisitting position with knees ' angle at 135 degrees . The number of cycles and perceived muscle fatigue ( Borg CR-10 scale ) at five areas ( upper and lower back , gluteus , hamstrings , and quadriceps ) were used as fatigue criteria . EMG signals were recorded bilaterally on four back muscles , two hip extensors ( gluteus maximus and biceps femoris ) , and the vastus medialis . The slope values of the instantaneous median frequency values computed over time were retained as EMG indices of fatigue . RESULTS The number of cycles was equivalent in healthy controls ( n = 23 + /- 13 ) and patients with back pain ( n = 27 + /- 16 ) . EMG indices of fatigue disclosed evidence of muscle fatigue in all the back muscles and the vastus medialis , contrary to hip extensors . EMG revealed significantly more muscle fatigue of lower back muscles , which was further corroborated by the Borg scale assessment . No between-group difference was obtained in any EMG comparison . CONCLUSION These results showed that this type of exercise machine can specifically train the back muscles , and this as much in subjects with nonspecific chronic low back pain as in healthy controls . This has implication s for the training of back muscle endurance , especially in patients with back pain for whom poor back muscle endurance is sometimes of concern Background There has been increasing focus on factors predicting the development of chronic musculoskeletal disorders . For patients already experiencing chronic non-specific low back pain it is also relevant to investigate which prognostic factors predict recovery . We present the design of a cohort study that aims to determine the course and prognostic factors for recovery in patients with chronic non-specific low back pain . Methods / Design All participating patients were recruited ( Jan 2003-Dec 2008 ) from the same rehabilitation centre and were evaluated by means of ( postal ) question naires and physical examinations at baseline , during the 2-month therapy program , and at 5 and 12 months after start of therapy . The therapy protocol at the rehabilitation centre used a bio-psychosocial approach to stimulate patients to adopt adequate ( movement ) behaviour aim ed at physical and functional recovery . The program is part of regular care and consists of 16 sessions of 3 hours each , over an 8-week period ( in total 48 hours ) , followed by a 3-month self-management program . The primary outcomes are low back pain intensity , disability , quality of life , patient 's global perceived effect of recovery , and participation in work . Baseline characteristics include information on socio-demographics , low back pain , employment status , and additional clinical items status such as fatigue , duration of activities , and fear of kinesiophobia . Prognostic variables are determined for recovery at short-term ( 5 months ) and long-term ( 12 months ) follow-up after start of therapy . Discussion In a routine clinical setting it is important to provide patients suffering from chronic non-specific low back pain with adequate information about the prognosis of their complaint Background Few data are available on the course of and predictors for disability in patients with chronic nonspecific low back pain ( CNSLBP ) . Objective The purpose of this study was to describe the course of disability and identify clinical ly important prognostic factors of low-back-pain – specific disability in patients with CNSLBP receiving multidisciplinary therapy .  Design A prospect i ve cohort study was conducted . Methods A total of 1,760 patients with CNSLBP who received multidisciplinary therapy  were evaluated for their course of disability and prognostic factors at baseline and at 2- , 5- , and 12-month follow-ups . Recovery was defined as 30 % reduction in low back pain – specific disability at follow-up compared with baseline and as absolute recovery if the score on the Quebec Back Pain Disability Scale ( QBPDS ) was ≤20 points at follow-up . Potential prognostic factors were identified using multivariable logistic regression analysis . Results Mean patient-reported disability scores on the QBPDS ranged from 51.7 ( SD=15.6 ) at baseline to 31.7 ( SD=15.2 ) , 31.1 ( SD=18.2 ) , and 29.1 ( SD=20.0 ) at 2 , 5 , and 12 months , respectively . The prognostic factors identified for recovery at 5 and 12 months were younger age and high scores on disability and on the 36-Item Short-Form Health Survey ( SF-36 ) ( Physical and Mental Component Summaries ) at baseline . In addition , at 5-month follow-up , a shorter duration of complaints was a positive predictor , and having no comorbidity and less pain at baseline were additional predictors at 12-month follow-up . Limitations Missing values at 5- and 12-month follow-ups were 11.1 % and 45.2 % , respectively . Conclusion After multidisciplinary treatment , the course of disability in patients with CNSLBP continued to decline over a 12-month period . At 5- and 12-month follow-ups , prognostic factors were identified for a clinical ly relevant decrease in disability scores on the QBPDS PURPOSE Roman chair exercises are popular for improving back muscle endurance but do not specifically target back muscles . This study aim ed to determine whether an adaptation of the Roman chair exercise would induce more fatigue in back muscles than in hip extensors . METHODS For this study , 16 healthy subjects and 18 patients with nonspecific chronic low back pain performed trunk flexion-extension cycles until exhaustion in a Roman chair with hips flexed at 40 ° . Surface EMG signals  were recorded bilaterally on four back muscles and two hip extensors ( gluteus maximus and biceps femoris ) . Motion analysis of the trunk segments ( pelvis , lumbar , and thoracic spines ) was also carried out . RESULTS In both groups , EMG revealed clear evidence of muscle fatigue for the gluteus maximus , less clear evidence of fatigue for the lower back muscles , and motor unit recruitment ( without fatigue ) for the upper back muscles and biceps femoris . A change of muscle activation pattern was emphasized throughout the exercise bout , with some lower back muscles showing an increase followed by a decrease or leveling off of activation and with upper back muscles showing an increased activation at the end . Kinematic analyses revealed a progressive decrease ( 11 ° ) in the lumbar range of motion ( ROM ) and a progressive increase in hip ( 2 ° ) and thoracic ( 7 ° ) ROM during the exercise bout . CONCLUSIONS Roman chairs allow more freedom to change the kinematics of the spine during the exercise ( less lumbar and more thoracic motion ) to delay lower back muscle fatigue by sharing the load between the lower and upper back muscles . Even with adaptations to reduce hip extensors fatigue , this may make this exercise not as specific as wanted for fatiguing lower back muscles Study Design . A prospect i ve single-arm trial . Objective . To investigate whether dynamic isolated resistance training of global lumbar extensor muscles leads to changes in lumbar multifidus ( LM ) morphology in terms of cross-sectional muscle , and , if so , whether these changes are associated with observed changes in self-experienced functional status of chronic nonspecific low back pain ( CNSLBP ) . Summary of Background Data . LM morphology is associated with the recurrence of CNSLBP . Methods . Sixteen male patients underwent a dynamic isolated resistance-training program for the lower back muscles of approximately 10 sessions in 12 weeks . In the next 12 weeks , frequency of training was tailored to the patients ' need . Participants underwent lumbar magnetic resonance imaging at baseline ( T0 ) , after 12 weeks ( T12 ) , and after 24 weeks ( T24 ) . Functional cross-sectional area was obtained by analyzing the magnetic resonance images . Functional status was assessed using the patient-specific functional scale , Rol and -Morris disability question naire , and global perceived effect scale . Results . Rol and -Morris disability question naire and patient-specific functional scale scores showed significant and clinical ly relevant improvements between baseline and T12 , with 44 % and 39 % , respectively . Between T12 and T24 , these scores did not change significantly . Seven participants ( 44 % ) reported clinical ly relevant improvements in global perceived effect at T12 . At T24 , 1 more participant reported a relevant global perceived effect improvement , whereas 2 participants ( 13 % ) reported worsening of their condition . The magnetic resonance imaging analysis showed minor nonsignificant changes in functional cross-sectional area . Conclusion . Our study shows that 10 weeks of dynamic isolated training of the lumbar extensors , once a week , leads to clinical ly relevant improvements in functional status of men with CNSLBP , without accompanying improvements in functional cross-sectional area of LM . These findings suggest that improvement in LM morphology is not a critical success factor in restoring functional status of patients with CNSLBP , at least in the short term ( 6 mo ) Study Design . A two-part investigation was conducted : 1 ) a prospect i ve study of asymptomatic subjects quantitatively comparing trunk mobility to surface electromyographic ( sEMG ) signals from the erector spinae during trunk flexion ; and 2 ) a prospect i ve repeated- measures cohort study of patients with chronic disabled work-related spinal disorder tested for the flexion – relaxation ( FR ) phenomenon while measured simultaneously for lumbar spine inclinometric range of motion ( ROM ) . Objectives . To describe a theoretical model for the potential use of FR unloaded in assessing patients with chronic low back pain patients before and after rehabilitation , and to establish a normative data base ( Part 1 ) for subsequent use in comparison to patients with chronic low back pain ( Part 2 ) . The second part of the study assessed the clinical utility of combined sEMG and ROM measurements  for assessing the FR phenomenon as a test to assist potentially in planning rehabilitation programs , guiding patients ’ individual rehabilitation progress , and identifying early posttreatment outcome failures . Summary of Background Data . The FR phenomenon has been recognized since 1951 , and it can be reproducibly assessed in normal subjects with FR unloaded . It can be found intermittently in patients with chronic low back pain . Recent studies have moved toward deriving formulas to identify FR , but only a few have examined a potential relation between inclinometric lumbar motion measures and the sEMG signal . No previous studies have developed normative data potentially useful for objective ly assessing nonoperative treatment progress , effort , or the validity of permanent impairment rating measures . Methods . In Part 1 , 12 asymptomatic subjects were evaluated in an intra- and interrater repeated- measures protocol to examine reliability of sEMG signal readings in FR , as well as ROM measures at FR and maximum voluntary flexion . The mean sEMG signal averaging right – left electrode recordings , as well as the gross , true , and sacral lumbar ROM measurements , were recorded as normative data . In Part 2 , 54 patients with chronic disabled work-related spinal disorder referred as c and i date s for tertiary functional restoration rehabilitation participated in a st and ardized assessment protocol for sEMG and ROM measurement before rehabilitation . Those who completed the program were retested with the identical methodology after rehabilitation ( n = 34 ) using the empirically derived cutoff scores for sEMG readings at FR and ROM from Part 1 and prior scientific literature . Pain disability self-reported scores were correlated with sEMG and ROM . Sensitivity and specificity of the sEMG for identifying abnormal motion were assessed . Results . In Part 1 , the ability of the experienced testers to measure ROM and sEMG reliably at FR was high ( r ≥ 0.92 ; P < 0.001 ) . All asymptomatic subjects achieved FR at a tightly clustered range of mean sEMG signals from 1 to 2.3 & mgr;V. Most of the variation between motion at FR and maximum voluntary flexion occurred through the hip ( sacral ) motion component of the gross ( or total ) motion measured at T12 . In Part 2 , posttreatment reliability for ROM , sEMG , and the ability to detect the FR point was high ( r ≥ 0.82 ; P < 0.001 ) . More than 30 % of the 54 patients tested before treatment demonstrated ability to achieve FR , with FR usually associated with higher ROM than in the non-FR patients . After treatment , 94 % of those who completed the program achieved FR , including all those who achieved FR before treatment . Flexion – relaxation was associated with major improvement in ROM and pain disability self-report . Conclusions . Flexion – relaxation measures a point at which true lumbar flexion ROM approaches its maximum in asymptomatic subjects . This also is the point at which lumbar extensor muscle contraction relaxes , allowing the lumbar spine to hang on its posterior ligaments . The gluteal and hamstring muscles then lower the flexed trunk even further by allowing the pelvis to rotate around the hips . This phenomenon was subsequently found in Part 2 to offer a potentially promising method for individualizing rehabilitation treatment , decreasing unnecessary utilization , identifying potential postrehabilitation treatment failures , and assessing permanent impairment rating validity . Moreover , this is the first study to demonstrate systematic ally that an absence of FR in patients with chronic low back pain can be corrected with treatment INTRODUCTION Active treatments are advocated for the management of  non-specific chronic low back pain ( CLBP ) , although few studies have documented the relative efficacy of differing types of programme . A number of the available treatments comprise exercise routines on specially design ed training machines , which are ostensibly better disposed to reverse the compromised trunk muscle function displayed by these patients than are ' free exercise ' programmes . However , in using these muscle-training programmes , the physiological or anatomical adaptations that might account for the improved performance are rarely investigated , let alone identified . This is an important issue , because if the ' newly-acquired strength ' is mostly specific to performance on the devices on which the patient has trained and been tested , and reflects the skill in executing these particular tasks , this will not necessarily assist the patient during performance of his/her everyday activities . The aims of the present study were ( 1 ) to quantify the changes in back muscle performance in chronic LBP patients following 3 months active therapy , and ( 2 ) to analyse the corresponding changes in activation and cross-sectional area of the paraspinal muscles . METHODS 148 individuals ( 57 % women ) with CLBP ( age 45.0+/-10.0 years ; duration of LBP 10.9+/-9.5 years ) were r and omised to a treatment which they attended 2/week for 3 months : active physiotherapy , muscle reconditioning on training devices , or low-impact aerobics . Pre- and post-therapy , assessment s were made of isometric trunk muscle strength in each plane of movement and of erector spinae activation ( using surface electromyography ) during back extension . In a sub-group of 56 patients , the cross-sectional area of the paravertebral muscles was determined using magnetic resonance imaging ( MRI ) . In all patients , self-rated pain intensity , pain frequency and disability were assessed before and after therapy . RESULTS 132/148 patients completed the therapy .  Isometric strength in each movement plane increased significantly in all groups post-therapy . Apart from trunk extension , the changes were significantly greater in the devices group than in the other two groups ( Fig 1 ) . Activation of the paraspinal muscles during back extension also increased significantly in all groups ( Fig 2 ) and was weakly , but significantly ( r = 0.37 ; p = 0.0001 ) correlated with increased strength in back extension . Although , at baseline , highly significant correlations were observed between the size of the paraspinal muscles ( at L3/4 and at L4/5 ) and isometric back extension strength ( r=0.75 ; p < 0.0001 ) , post-training increases in strength were not accompanied by corresponding changes in muscle size . None of the improvements in strength showed any relationship with the clinical changes in pain and disability , regardless of whether the latter were examined on an individual basis or in relation to ' outcome groups ' . CONCLUSION The superior trunk strength shown by the devices group post-therapy was considered to be attributable , in part , to a ' learning effect ' , of the type often seen when training and testing are carried out on the same machines . These gains are considered to be mostly ' task-specific ' . However , part of the improvement in strength after active therapy ( in all groups ) also appeared to be due to an increased neural activation of the trunk muscles . These positive effects should be transferable to the performance of everyday activities for which the same muscles are employed , although the percentage improvement is probably not as high as the measured increase in strength might suggest . Possible roles for improved co-ordination and changes in motivation and /or pain tolerance after therapy can not be excluded . No differences in the clinical outcome were observed between the three therapy groups , and the changes in physical performance after therapy did not correlate with the clinical outcome . It is therefore question able whether strength measurements have any clinical significance in documenting the success of rehabilitation programmes , other than on a motivational basis . The results of the present study suggest that the value of supervised active therapy programmes does not reside in the reversal of specific muscular deficiencies , but rather in the provision of a source of confirmation/encouragement for the patient , that movement is not harmful , and a foundation upon which to further build . Whether the utilisation of specific training devices , or individual instruction , is necessary to elicit these particular effects is question able INTRODUCTION In recent decades the treatment of non-specific low back pain has turned to active modalities , some of which were based on cognitive-behavioural principles . Non-r and omised studies clearly favour functional multidisciplinary rehabilitation over outpatient physiotherapy . However , systematic review s and meta- analysis provide contradictory evidence regarding the effects on return to work and functional status . The aim of the present r and omised study was to compare long-term functional and work status after 3-week functional multidisciplinary rehabilitation or 18 supervised outpatient physiotherapy sessions . METHODS 109 patients with non-specific low back pain were r and omised to either a 3-week functional multidisciplinary rehabilitation programme , including physical and ergonomic training , psychological pain management , back school and information , or 18 sessions of active outpatient physiotherapy over 9 weeks . Primary outcomes were functional disability ( Oswestry ) and work status . Secondary outcomes were lifting capacity ( Spinal Function Sort and PILE test ) , lumbar range-of-motion ( modified-modified Schöber and fingertip-to-floor tests ) , trunk muscle endurance ( Shirado and Biering-Sörensen tests ) and aerobic capacity ( modified Bruce test ) . RESULTS Oswestry disability index was improved to a significantly greater extent after functional multidisciplinary rehabilitation compared to outpatient physiotherapy at follow-up of 9 weeks ( P = 0.012 ) , 9 months ( P = 0.023 ) and 12 months ( P = 0.011 ) . Work status was significantly improved after functional multidisciplinary rehabilitation only ( P = 0.012 ) , result ing in a significant difference compared to outpatient physiotherapy at 12 months ' follow-up ( P = 0.012 ) . Secondary outcome results were more contrasted . CONCLUSIONS Functional multidisciplinary rehabilitation was better than outpatient physiotherapy in improving functional and work status . From an economic point of view , these results should be backed up by a cost-effectiveness study BACKGROUND CONTEXT Low back pain ( LBP ) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses . A common intervention for LBP is spinal manipulation , a technique that is not specific to one scope of practice or profession . PURPOSE The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain . METHODS A search of the current literature was conducted using PubMed , CINAHL , SPORTD iscus , Pro Quest Nursing and Allied Health Source , Scopus , and Cochrane Controlled Trials Register . Studies were included if each involved : 1 ) individuals with LBP ; 2 ) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations ; 3 ) measurable clinical outcomes or efficiency of treatment measures , and 4 ) r and omized control trials . The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Data base ( PEDro ) . RESULTS Six r and omized control trials met the inclusion criteria of this systematic review . The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes . Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events result ing from this intervention . Additionally , the manipulation group in one study reported statistically significantly less medication use , health care utilization , and lost work time . CONCLUSION Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice . Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain The major objective of this investigation was to study the effectiveness of the physical conditioning program used at the University of Miami Comprehensive Pain and Rehabilitation Center in restoring certain elements of the functional abilities of individuals suffering from chronic low-back pain and to evaluate the effectiveness of using a systematic ally applied , aggressive stretching maneuver as an add-on therapy in the treatment of chronic low-back pain patients . The effect(s ) of the proposed stretching maneuver was evaluated . Twenty-eight chronic low-back pain patients were r and omly assigned to one of two groups . The control group underwent a multimodal rehabilitation program , and the experimental group underwent the same rehabilitation program in addition to the systematic stretching maneuver under investigation . The results obtained showed that patients undergoing the multimodal rehabilitation program with and without the proposed systematic stretching maneuver showed a significant improvement in their functional abilities as seen from the significant increase in the static strength of the back extensors , with corresponding significant increase in back muscle myoelectric signals . Also , a significant decrease in their pain level was reported after 2 weeks of continuous treatment . The use of the systematic stretching maneuver enhanced the functional gains of chronic low-back pain patients compared to the control group BACKGROUND AND AIM OF THE WORK Chronic low back pain ( CLBP ) is a major cause of disability , for which clinical practice guidelines suggest exercise programs , such as Back School program ( stretching and selective muscle reinforcement techniques ) and Hydrotherapy technique , as an effective treatment to reduce pain intensity and disability . METHODS We enrolled 56 elderly individuals , affected by non-specific CLBP , whose pain had worsened in the last three months , which were r and omly allocated to Back School ( group A ) or to Hydrotherapy program ( group B ) . Each group underwent two one-hour-treatment sessions per week , over a 12-week period . Each patient was evaluated using the Rol and Morris Disability Question naire ( RMDQ ) and the 36-Item Short Form Health Survey ( SF-36 ) V2.0 at the beginning ( T0 ) , at the end of treatment ( T1 ) and at the 3-month follow-up ( T2 ) . RESULTS At T1 and T2 we observed a highly significant statistical difference in the values measured in both groups : at T1 in group A RMDQ improvement of 3.26±1.02 ( p<0.001 ) and SF-36 of 13.30±1.44 ( p<0.001 ) ; in group B RMDQ improvement of 4.96±0.71 ( p<0.001 ) and SF-36 of 14.19±1.98 ( p<0.001 ) . We have also evaluated the difference in effectiveness of the two programs and no significant statistical differences were found between the two groups . CONCLUSIONS Back School program and Hydrotherapy could be valid treatment options in the rehabilitation of non-specific CLBP in elderly people . Both therapies proved to be effective and can be used in association with other rehabilitation programs . We believe that Back School program should be favored for its simplicity and the small number of re sources required Abstract Purpose To evaluate the effectiveness of non-steroidal anti-inflammatory drugs ( NSAIDs ) for the management of neck pain and associated disorders ( NAD ) , whiplash-associated disorders , and non-specific low back pain ( LBP ) with or without radiculopathy . Methods We systematic ally search ed six data bases from 2000 to 2014 . R and om pairs of independent review ers critically appraised eligible systematic review s using the Scottish Intercollegiate Guidelines Network criteria . We included systematic review s with a low risk of bias in our best evidence synthesis . Results We screened 706 citations and 14 systematic review s were eligible for critical appraisal . Eight systematic review s had a low risk of bias . For recent-onset NAD , evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy . For NAD ( duration not specified ) , oral NSAIDs may be more effective than placebo . For recent-onset LBP , evidence suggests that : ( 1 ) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant ; and ( 2 ) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest . For persistent LBP , evidence suggests that : ( 1 ) oral NSAIDs are more effective than placebo ; and ( 2 ) oral NSAIDs may be more effective than acetaminophen . For recent-onset LBP with radiculopathy , there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo . Finally , different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy . Conclusions For NAD , oral NSAIDs may be more effective than placebo . Oral NSAIDs are more effective than placebo for persistent LBP , but not for recent-onset LBP . Different oral NSAIDs lead to similar outcomes for neck pain and LBP There are few studies of the therapeutic effects of long-term corset wearing in patients with chronic low back pain . The aim of this study was to evaluate the effects of long-term corset wearing on chronic low back pain and to examine the myoelectrical activities of the paravertebral muscles . Forty subjects with chronic low back pain were enrolled and r and omly divided into two groups : a group wearing corsets for 6 months ( CW ) group and a group not wearing corsets ( NW ) . The treatment effects were measured using the Japanese Orthopaedic Association ( JOA ) score . Muscle endurance was evaluated during the Biering-Sorensen test ( S-test ) , and the degree of muscle fatigue was evaluated by the change in percent mean power frequency ( % MPF ) of the paravertebral muscles . Corset treatment for chronic low back pain improved low back pain and increased muscle endurance for a short period of time . Paravertebral muscle fatigue was not increased by long-term corset wearing for chronic low back pain , and weakening of the paravertebral muscles was not observed up to 6 months after the start of corset wearing Zygapophysial or facet joints have been implicated as cause of low back , mid back , upper back and neck pain with referred pain . Cervical , thoracic and lumbar facet joints are innervated by the medial branches of the dorsal rami . Zygapophysial ( facet ) joints have been implicated as the source of chronic pain in 15 % to 45 % of the patients with chronic low back pain , 54 % to 60 % of the patients with chronic neck pain and 48 % of the patients with thoracic pain . A systematic review of the evidence of effectiveness of radiofrequency denervation in the management of chronic spinal pain was undertaken . This review included r and omized clinical trials , as well as non-r and omized or observational studies in the analysis . Literature search included MEDLINE , EMBASE , systematic review s , narrative review s , cross-references to the review s and various published trials ; and peer review ed abstract s from scientific meetings during the past two years . An algorithmic approach was followed in study evaluation with a description of inclusion and exclusion criteria . A set of high-performing scales or checklists pertaining to r and omized clinical trials and observational trials derived from the Agency for Healthcare Research and Quality ( AHRQ ) was utilized ; Systems to Rate the Strength of Scientific Evidence . Qualitative analysis was conducted , using five levels of evidence for effectiveness of medial branch neurotomy . Our search strategy identified over 1,000 citations as the result of electronic and manual screening . A total of 7 r and omized trials of radiofrequency neurotomy for spinal pain were identified . However , only 4 related to medial branch neurotomy . Two of the four met the inclusion criteria . Among the multiple observational studies considered for inclusion , 4 prospect i ve evaluations were included in the systematic review . In addition , 3 retrospective evaluations were also included . Two r and omized trials comprised of 27 patients receiving active treatment . The first study consisted of cervical facet joint pain and the second consisted of lumbar facet joint pain . Both studies showed positive results . Similar to r and omized trials , prospect i ve , as well as retrospective evaluations showed positive evidence , both in short-term and long-term . The results of this systematic review of 2 well- design ed r and omized trials , 4 prospect i ve well- design ed trials without r and omization and 3 retrospective evaluations provided strong evidence that radiofrequency denervation offers short-term relief and moderate evidence of long-term pain relief of facet joint origin Study Design . Systematic Review . Objectives . To assess the effects of massage therapy for nonspecific low back pain . Summary of Background Data . Low back pain is one of the most common and costly musculoskeletal problems in modern society . Proponents of massage therapy cl aim it can minimize pain and disability , and speed return to normal function . Methods . We search ed MEDLINE , EMBASE , CINAHL from their beginning to May 2008 . We also search ed the Cochrane Central Register of Controlled Trials ( The Cochrane Library 2006 , issue 3 ) , HealthSTAR and Dissertation abstract s up to 2006 . There were no language restrictions . References in the included studies and in review s of the literature were screened . The studies had to be r and omized or quasi-r and omized trials investigating the use of any type of massage ( using the h and s or a mechanical device ) as a treatment for nonspecific low back pain . Two review authors selected the studies , assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group , and extracted the data using st and ardized forms . Both qualitative and meta-analyses were performed . Results . Thirteen r and omized trials were included . Eight had a high risk and 5 had a low risk of bias . One study was published in German and the rest in English . Massage was compared to an inert therapy ( sham treatment ) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups . In 8 studies , massage was compared to other active treatments . They showed that massage was similar to exercises , and massage was superior to joint mobilization , relaxation therapy , physical therapy , acupuncture , and self-care education . One study showed that reflexology on the feet had no effect on pain and functioning . The beneficial effects of massage in patients with chronic low back pain  lasted at least 1 year after the end of the treatment . Two studies compared 2 different techniques of massage . One concluded that acupuncture massage produces better results than classic ( Swedish ) massage and another concluded that Thai massage produces similar results to classic ( Swedish ) massage . Conclusion . Massage might be beneficial for patients with subacute and chronic nonspecific low back pain , especially when combined with exercises and education . The evidence suggests that acupuncture massage is more effective than classic massage , but this need confirmation . More studies are needed to confirm these conclusions , to assess the impact of massage on return-to-work , and to determine cost-effectiveness of massage  as an intervention for low back pain Background Non-specific chronic low back pain ( NSCLBP ) has become a significant problem due to high healthcare utilization , rising costs of care and perceived limitations of effectiveness of many current treatments . Systematic review s have repeatedly concluded that , on average across participants , exercise for NSCLBP appears effective in decreasing pain and improving function . Not all people with NSCLBP benefit from exercise programs and it would assist care-providers and care-seekers if factors that impact on program effectiveness and success were identified . Methods and design The study will be a r and omised controlled trial comparing an exercise rehabilitation program informed by a participant preferences question naire compared to a program without this guideline for patients with chronic low back pain . A sample of 150 patients will be recruited in Melbourne , Australia through community-based healthcare clinics that provide supervised exercise rehabilitation programs for people with non-specific chronic low back pain . Clinicians will be r and omly assigned to exercise preferences question naire or no question naire and participants will be allocated in a concealed manner . A qualitative focus group study of exercise instructor feedback about the exercise preferences instrument will be embedded in the research design . Two qualitative focus group studies will also be conducted for participants in the intervention and the control groups to obtain feedback about participants ' experiences of the two types of exercise programs . The primary outcomes will be functional ability , pain , fear avoidance , exercise adherence . Discussion This trial will evaluate the effectiveness of individualised exercise prescription compared to usual exercise prescription for NSCLP and , using feedback following the trial , refine the exercise preferences question naire BACKGROUND Low back pain is a worldwide health problem , affecting up to 80 % of adult population . Psychological factors are involved in its development and maintenance . Many clinical trials have evaluated the efficacy of different interventions for chronic non-specific low back pain . In this field , Back School program has been demonstrated effective for people with chronic non-specific low back . AIM To evaluate the relationship between the effects of the Back School treatment and psychological features measured by MMPI-II of patients with chronic non-specific low back pain . DESIGN A r and omised controlled trial with three and six-month follow-up . SETTING Ambulatory rehabilitative university centre . POPULATION Fifty patients with chronic non-specific low back pain out of 77 screened patients . METHODS Patients were r and omly placed in a 3:2 form and were allocated into two groups ( Treatment versus Control ) . The Treatment Group participated to an intensive multidisciplinary Back School program ( BSG , N.=29 ) , while the Control Group received medical assistance ( CG , N.=21 ) . Medication was the same in both groups . Then , patients were subgrouped in those with at least an elevation in one scale of MMPI-II , and those without it . The Short Form 36 Health Status Survey for the assessment of quality of life ( primary outcome measure ) , pain Visual Analogue Scale , Waddel Index and Oswestry Disability Index were collected at baseline , at the end of treatment , and at the three and six-month follow-up . RESULTS Only the two treated subgroups showed a significant improvements in terms of quality of life , disability and pain . Among treated subjects , only those with at least one scale elevation in MMPI-II showed also a significant improvement in terms of Short Form 36 mental composite score and relevant subscores . CONCLUSION These results suggest that Back School program has positive effects , even in terms of mental components of quality of life in patients with scale elevations of MMPI-II . Probably these findings are due to its educational and cognitive-behavioural characteristics . CLINICAL REHABILITATION IMPACT Because of its educational purpose s , the Back School treatment can have positive effects also on the mental status of patients with low back pain when it affects their psychological features Description The American College of Physicians ( ACP ) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain . Methods Using the ACP grading system , the committee based these recommendations on a systematic review of r and omized , controlled trials and systematic review s published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain . Up date d search es were performed through November 2016 . Clinical outcomes evaluated included reduction or elimination of low back pain , improvement in back-specific and overall function , improvement in health-related quality of life , reduction in work disability and return to work , global improvement , number of back pain episodes or time between episodes , patient satisfaction , and adverse effects . Target Audience and Patient Population The target audience for this guideline includes all clinicians , and the target patient population includes adults with acute , subacute , or chronic low back pain . Recommendation 1 Given that most patients with acute or subacute low back pain improve over time regardless of treatment , clinicians and patients should select nonpharmacologic treatment with superficial heat ( moderate- quality evidence ) , massage , acupuncture , or spinal manipulation ( low- quality evidence ) . If pharmacologic treatment is desired , clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants ( moderate- quality evidence ) . ( Grade : strong recommendation ) . Recommendation 2 For patients with chronic low back pain , clinicians and patients should initially select nonpharmacologic treatment with exercise , multidisciplinary rehabilitation , acupuncture , mindfulness-based stress reduction ( moderate- quality evidence ) , tai chi , yoga , motor control exercise , progressive relaxation , electromyography biofeedback , low-level laser therapy , operant therapy , cognitive behavioral therapy , or spinal manipulation ( low- quality evidence ) . ( Grade : strong recommendation ) . Recommendation 3 In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy  , clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy , or tramadol or duloxetine as second-line therapy . Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients . ( Grade : weak recommendation , moderate- quality evidence ) Objectives Chronic low back pain ( CLBP ) affects millions of people worldwide , and appears to be increasing in prevalence . It is associated not only with pain , but also with increased disability , psychological symptoms , and reduced quality of life . There are various treatment options for CLBP , but no single therapy st and s out as being the most effective . In the past 10 years , yoga interventions have been studied as a CLBP treatment approach . The objective of this paper is to review the current literature supporting the efficacy of yoga for CLBP . Methods A literature search through the beginning of 2015 was conducted in Pub Med for r and omized control trials addressing treatment of CLBP with yoga . Results In this review we evaluate the use of yoga as a treatment for CLBP . Specifically we evaluate how yoga impacts physical functioning and disability , pain , and associated psychological symptoms . We also evaluate possible mediators of the effect of yoga and the safety of yoga . Discussion With few exceptions , previous studies and the recent r and omized control trials ( RCTs ) indicate that yoga can reduce pain and disability , can be practice d safely , and is well received by participants . Some studies also indicate that yoga may improve psychological symptoms , but these effects are currently not as well established Abstract Objective : to review and up date the evidence for different forms of manual therapy ( MT ) for patients with different stages of non-specific low back pain ( LBP ) . Data sources : MEDLINE , Cochrane-Register-of-Controlled-Trials , PEDro , EMBASE . Method : A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent review ers according to Cochrane and PRISMA guidelines . A total of 360 studies were evaluated using qualitative criteria . Two stages of LBP were categorized ; combined acute – subacute and chronic . Further sub-classification was made according to MT intervention : MT1 ( manipulation ) ; MT2 ( mobilization and soft-tissue-techniques ) ; and MT3 ( MT1 combined with MT2 ) . In each sub-category , MT could be combined or not with exercise or usual medical care ( UMC ) . Consequently , quantitative evaluation criteria were applied to 56 eligible r and omized controlled trials ( RCTs ) , and hence 23 low-risk of bias RCTs were identified for review . Only studies providing new up date d information ( 11/23 RCTs ) are presented here . Results : Acute – subacute LBP : STRONG- evidence in favour of MT1 when compared to sham for pain , function and health improvements in the short-term ( 1–3 months ) . MODERATE- evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain , function and health improvements in the short-term . Chronic LBP : MODERATE to STRONG- evidence in favour of MT1 in comparison to sham for pain , function and overall-health in the short-term . MODERATE- evidence in favour of MT3 combined with exercise or UMC in comparison to  exercise  and back-school was established for pain , function and quality -of-life in the short and long-term . LIMITED- evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term . LIMITED- evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term . Conclusion : This systematic review up date s the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies BACKGROUND Kinesio Taping ( KT ) has proved to be effective in various musculoskeletal conditions . Although its precise working mechanism has yet to be fully understood , it is believed to interact with neuromuscular function through mechanoceptor activation . No studies design ed to assess the effects of KT in chronic low back pain ( CLBP ) patients have yet been conducted . AIM The aim of this study was to determine the effects of KT on pain , disability and lumbar muscle function in sufferers of CLBP , both immediately and at a one-month follow-up examination . DESIGN The study consisted of two phases : phase I was based on an intra-subject pre-test/post-test procedure ; phase II was based on a r and omized , single-blinded controlled trial . SETTING Outpatient facility . POPULATION Thirty-nine CLBP patients were enrolled . METHODS KT plus exercise , KT alone or exercise alone have been used for four weeks . Pain , disability and lumbar muscle function were evaluated before and after the treatment period . RESULTS The patients in all three groups displayed a significant reduction in pain after treatment , though only the exercise-alone group displayed reduced disability . A return to normal lumbar muscle function was observed in 28 % of patients , but was not related to a reduction in pain . CONCLUSION When applied to CLBP patients , KT leads to pain relief and lumbar muscle function normalization shortly after its application ; these effects persist over a short follow-up period . CLINICAL REHABILITATION IMPACT KT may represent an effective adjunct therapy in the physical rehabilitation program of CLBP patients for immediate and acute pain control
We found conflicting data regarding the validity of methods used to examine back muscle fatigue .
The Biering-Sorensen test  , performed in conjunction with surface electromyography spectral analysis , turned out to be the most widely used and comparatively , the most optimal modality currently available to assess objective back muscle fatigue in daily clinical practise , even though critical limitations are discussed .
Implication s for Rehabilitation Despite its limitations , the Biering-Sorensen test is currently the most used , convenient and easily available fatiguing test for lumbar muscles .
Pooled mean frequency and half-width of the spectrum are currently the most valid electromyographic parameters to assess fatigue in chronic non-specific low back pain .
PURPOSE This systematic literature review aim ed at examining the validity and applicability in everyday clinical rehabilitation practise of methods for the assessment of back muscle fatiguability in patients with chronic non-specific low back pain ( CNSLBP ) .