Journal of Back and Musculoskeletal Rehabilitation - Volume 26, issue 2
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Journal of Back and Musculoskeletal Rehabilitation is a journal whose main focus is to present relevant information about the interdisciplinary approach to musculoskeletal rehabilitation for clinicians who treat patients with back and musculoskeletal pain complaints. It will provide readers with both 1) a general fund of knowledge on the assessment and management of specific problems and 2) new information considered to be state-of-the-art in the field. The intended audience is multidisciplinary as well as multi-specialty.
In each issue clinicians can find information which they can use in their patient setting the very next day. Manuscripts are provided from a range of health care providers including those in physical medicine, orthopedic surgery, rheumatology, neurosurgery, physical therapy, radiology, osteopathy, chiropractic and nursing on topics ranging from chronic pain to sports medicine. Diagnostic decision trees and treatment algorithms are encouraged in each manuscript. Controversial topics are discussed in commentaries and rebuttals. Associated areas such as medical-legal, worker's compensation and practice guidelines are included.
The journal publishes original research papers, review articles, programme descriptions and cast studies. Letters to the editors, commentaries, and editorials are also welcomed. Manuscripts are peer reviewed. Constructive critiques are given to each author. Suggestions for thematic issues and proposed manuscripts are welcomed.
Abstract: Background: This paper reviews various methods for the assessment and management of the coccygodynia. It included review of both conservative as well as operative methods. Goal of conservative methods in coccygodynia is to restore the functional status of the patients and to eliminate or at least minimize the discomfort associated with this disabling condition. Though various conservative methods have been used traditionally, yet not all patients respond positively to them. In such cases operative interventions are used, yet previous literature does suggest that even this method is not absolutely promising as not all patients do respond positively to it.…Methodology: The purpose of this article is to review various literatures available for the assessment and the management of coccygodynia. It tends to identify the factors which could guide the selection of best intervention strategy for its management. English literature databases were searched to find the studies matching the predetermined inclusion criteria. Conclusion: Multiple factors (pathology, duration of pain, Body mass index, neurotic personality, associated disc pathologies, amount of inter-coccygeal movement) influence the outcomes of the remedial interventions. This study highlights multiple treatment approaches for the rehabilitation of the coccygodynia management.
Abstract: Lower back pain (LBP) is a widespread, expensive, and debilitating problem in Western industrialized countries. Though LBP can be caused by acute injuries, biomechanical discrepancies have also been indicated to cause chronic LBP. A possible link between podiatrical deviations and LBP has been established in the literature; yet, no comprehensive review investigating the effects of foot and ankle deviations on low back pain has been published. The aim of this study was to assess the relevant literature concerning the effects of foot and ankle deviations on LBP. After review, it was determined that there is limited research regarding ankle and…foot deviations and their connection to LBP. Reviewed studies have linked flat feet, ankle instability, sagittal plane blockage and excessive pronation to LBP. Specifically, excessive pronation has been shown to cause leg length discrepancies leading to pelvic tilts and LBP. Based on these results, ankle and foot deviations can be considered a potential cause for LBP due to the disruption of the kinetic chain from the foot to the back. Clinicians should consider the foot and ankle when addressing LBP, especially if more conventional etiologies fail to describe the condition.
Keywords: Low back pain, kinetic dysfunction, ankle, foot, excessive pronation, leg length discrepancy
Abstract: Purpose: This systematic review aimed to assess changes on spatiotemporal gait parameters due to fatigue. Material and Method: A search was carried out in literature published from 1950 to December 2010 and retrieved 771 articles using terms referring to walking and fatigue in the title, abstract or keywords. Two researchers assessed the selection and quality of each article independently. Results: Seven studies were selected for this systematic review, two of which reported on the same data set. Several spatiotemporal parameters were reported to change with fatigue, but the few variables studied in multiple studies, gait speed…and stride or step length and stride time, were affected only in single studies. Fatigue appears to modulate spatiotemporal gait parameters, but the effects of fatigue appear to be dependent on the muscles that were fatigued, and age that appears to be a moderator of the effects of fatigue on gait.
Keywords: Gait, muscle fatigue, spatiotemporal parameters, motor control
Abstract: Objective: Pelvic girdle pain is a common complaint of pregnant women. There are limited data on comparison between the effectiveness of stabilizing exercises and lumbopelvic belt on the treatment of these patients. The objective of this study was to compare the effect of lumbopelvic belt plus information, home based pelvic girdle stabilizing exercises plus information and information alone on pain intensity, functional status and quality of life of pregnant women with pelvic girdle pain. Methods: In this randomized clinical trial pregnant women with pelvic girdle pain (n = 105 ) were randomly allocated to three groups;…Control group (n = 35 ) that received general information, exercise group (n = 31 ) that in addition to general information were asked to perform specific pelvic stabilizing exercises at home and belt group (n = 31 ) that received non-rigid lumbopelvic belt and the information. The primary outcome variables were pain intensity and functional status of the participants which were measured using visual analogue scale and Oswestry Disability Index (ODI) respectively. Quality of life of participants was measured using WHOQOL-BREF questionnaire. All measurements were performed at baseline, 3 and 6 weeks after the study conduction. Results: The pain intensity of patients in belt group in comparison to other groups was decreased significantly at both 3 and 6 weeks follow-ups. The mean score of ODI of patients in belt group was also improved more than exercise and control groups significantly. Conclusions: On base of our results, it can be found that in short term lumbopelvic belt and information in treatment of pregnant women with pelvic girdle pain is superior to exercise plus information or information alone.
Abstract: Purpose: To investigate the reliability and validity of the Electronic Cervical Range of Motion (CROM) Goniometer in measurement of cervical spine mobility in adults with and without neck pain. Methods: A cross-sectional reliability study was conducted on 54 subjects (26 neck pain and 26 non-neck pain) aged from 20–70 years old. The Numerical Pain Rating Scale and Chinese version of Northwick Park Neck Pain Questionnaire were used to assess neck pain severity and disability respectively. The CROM was measured in sitting position except left to right rotation was measured in supine lying. All the cervical active movements were…measured by using the Electronic CROM Goniometer from ARCON TM Functional Capacity Evaluation (FCE) systems. Results: The intra-tester and inter-tester reliability were high in both normal and chronic neck pain groups with ICC coefficients ranged from 0.75-*0.92. There was significant difference in the total CROM between the normal (374.7°) and chronic neck pain group (292.6°). Conclusion: The ACRON cervical goniometer was found to be reliable for measuring cervical mobility in 3 planes for both normal and patient subjects. Construct validity of the goniometer was supported as the test’s result documented significant difference in CROM between the control and the neck pain groups.
Keywords: Cervical range of motion, neck pain, electronic goniometer, reliability, validity
Abstract: Background: The most common instruments developed to assess the functional status of patients with Non specific low back pain is the Roland-Morris Disability Questionnaire (RMDQ). Clinical and epidemiological research related to low back pain in the Gujarati population would be facilitated by the availability of well-established outcome measures. AIM: To find the reliability, validity, sensitivity and specificity of the Gujarati version of the RMDQ for use in Non Specific Chronic low back pain. Study Design: A reliability, validity, sensitivity and specificity study of Gujarati version of the Roland-Morris Disability Questionnaire (RMDQ). Methodology: Thirty out…patients with Non Specific Chronic low back pain were assessed by the RMDQ. Reliability is assessed by using internal consistency and the intra-class correlation coefficient (ICC). Internal construct validity is assessed by RASCH Analysis and external construct validity is assessed by association with pain and spinal movement. Clinical calculator was used to determine the sensitivity and specificity. Results: Internal consistency of the RMDQ is found to be adequate (> 0.65 ) at both times, with high ICC’s also at both time points. Internal construct validity of the scale is good, indicating a single underlying construct. Expected associations with pain and spinal movement confirm external construct validity. The Sensitivity and Specificity at cut off point of 0.5 was 80% and 84% with respectively positive predictive value (PPV) of 83.33% and negative predictive value (NPV) of 80.76%. The Questionnaire is at the ordinal level. Conclusion: The RMDQ is a one-dimensional, ordinal measure, which works well in the Gujarati population.
Keywords: Low back pain, RMDQ, disability, ICC, RASCH
Abstract: We report herein a 35-year-old man who suffered from pain at his left elbow and numbness in his left hand. Electromyographic studies demonstrated a localized nerve conduction block in the left elbow region. Ultrasonographic evaluation revealed enlargement of the ulnar nerve at the level of the medial epicondyle as well as bilateral anconeus epitrochlearis muscles, one of which was hypertrophic, causing the ulnar neuropathy at the symptomatic site. We emphasize with this case report the complementary role of ultrasound in peripheral nerve pathologies, as it confirmed the entrapment and determined the underlying cause.
Abstract: Background and Objectives: This study aims to analyze muscle activity of the lower limbs during stance phase of gait in accordance with the application of various vertical loadings. Material and Methods: Participants who met the criterion for this study (n = 11 ). During their gait, various vertical loadings (0 kg, 0.5 kg, 1 kg) were provided and their muscle activities in the lower limbs during stance phase were measured. In order to accurately measure their gait, they were instructed to walk 5 gait cycles, and 3 gait cycles excluding the front and back 1 cycle…were used for analysis. For the objectivity of data, measurements were made three times under each condition and average values were employed for statistic analysis. Results: The intervention of applying various vertical loadings of 0 kg, 0.5 kg, 1 kg to the lower limbs during swing phase in order to compare muscle activities of the lower limbs during stance phase of gait resulted in the following outcomes. Tibialis anterior and peroneus longus muscle activities did not significantly differ with the application of various vertical loadings to the lower limbs during swing phase, while gluteus medius muscle activities significantly differed according to the levels of loadings applied. There were significant differences in muscle activities between the loading of 0 kg and the loading of 0.5 kg. Conclusions: Clinicians may use these results to effectively progress strengthening for gluteus medius in the rehabilitation of lower extremity injuries.
Abstract: Background and Objective: Muscle imbalance between the abductor hallucis (AbdH) and adductor hallucis (AddH) has been demonstrated in hallux valgus (HV). Clinically, the short-foot (SF) is performed for strengthening foot intrinsic muscle. The toes-spread-out (TSO), the newly introduced, was devised to correct HV deformity. However, there was no study to determine which exercise is effective in balancing the ratio of activation between AbdH and AddH muscles. The purpose of this study was to compare the muscle activities of the AbdH and AddH between SF and TSO exercises in subjects with mild HV. Methods: Eighteen subjects with mild HV…participated. The muscle activity of AbdH and AddH and the angle of first metatarsophalangeal (MTP) joint in the horizontal plane were measured during the SF and TSO exercises. Values of dependent variables were compared using a paired t-test between the SF and TSO exercises. Results: The TSO exercise showed significantly greater activation of the AbdH than did the SF exercise (mean difference=44.96% of maximum voluntary isometric contraction; p < 0.001 ). There was no significant difference between the SF and TSO exercises in activating the AddH (mean difference=8.28% of maximum voluntary isometric contraction; p = 0.271 ). The ratio of AbdH to AddH muscle activity was significantly higher in the TSO exercise than in the SF exercise (mean difference=0.54; p = 0.001 ). The angle of the first MTP joint in the horizontal plane during the TSO was significantly greater than that in the SF exercise (mean difference=9.60°; p < 0.001 ). Conclusions: These results suggest that the TSO exercise can be recommended for preventing or correcting HV deformity at an early stage.
Abstract: Cervical and lumbar roots may be irritated or compressed due to the pathological conditions such as disc herniations, degenerative foraminal stenosis, trauma and tumors. Electrophysiologic tests are frequently used in conjunction with imaging modalities for evaluation of low back and neck pain radiating to extremities, primarily for the purpose of establishing the presence or absence of a radiculopathy. In this study, we aimed to evalulate the relationship between clinic and electroneuromyographic (ENMG) findings in patients with suspected radiculopathies. Forty one patients with radicular complaints in the upper extremities and 51 patients with radicular complaints in the lower extremities were included…in this study. McNemar test and Kappa coefficients between the two methods were applied to each group of patients, in order to test the significance of the difference between the two diagnostic procedures’ ability on finding out the pathology. The McNemar test identified a significant difference between the two diagnostic approaches both for cervical and lumbar radiculopathies (p < 0.001 ). The Kappa coefficients between the two methods were determined as 0.08 and 0.07, respectively. This means, efficacy of anamnesis and neurological examination for the prediction of electrodiagnostic tests was found to be limited. Normal neurological examination results in a patient with suspected radiculopathy can not eliminate abnormal electrodiagnostic test results; likewise, abnormal findings in the neurological examination would not mean finding pathologies in the electrodiagnostic tests. For more accurate approach to a patient, neurological examination and electrodiagnostic tests must be used and interpreted together.
Abstract: Background and Objectives: Many studies have evaluated factors related to lumbar multifidus (MF) muscle atrophy. However, few studies have investigated radiculopathy and the MF muscle. In this study, the association between radiculopathy and lumbar MF muscle atrophy in magnetic resonance imaging (MRI) was evaluated. Materials and Methods: In total, 100 patients with low back pain or radiating leg pain were examined. Their lumbar MRIs were visually analyzed semi-quantitatively for signs of lumbar MF muscle atrophy. The severity and extent of MF atrophy were compared between non-radiculopathy (Non-rad) and radiculopathy (Rad) groups. Asymmetry of MF atrophy was also compared…between unilateral radiculopathy (UniR) and bilateral radiculopathy (BiR) groups. Results: Significantly more severe and extensive MF atrophy was observed in the Rad group than in the Non-rad group (p < 0.01 ). However, no difference in the asymmetry of MF atrophy was found between the UniR and BiR groups (p > 0.05 ). Conclusion: More severe and extensive atrophy in the lumbar MF muscle was associated with radiculopathy. Thus, we might consider the presence of radiculopathy when severe and extensive multi-level involvement of MF atrophy is seen in MRI.
Keywords: Multifidus, low back pain, magnetic resonance imaging, radiculopathy
Abstract: Background and Objectives: Current evidence suggests that lumbosacral transforaminal epidural steroid injection (TFESI) is an effective treatment for lumbosacral radicular pain. However, practitioners may be reluctant to attempt this intervention in obese patients because of a perceived reduction in the chance of providing pain relief due to the increased technical difficulty of TFESI in individuals with a larger body habitus. No study to date has compared the effectiveness of TFESI in groups stratified by BMI. We report pilot data addressing whether lumbosacral transforaminal epidural steroid injection is as effective in treating lumbosacral radicular pain in the obese and overweight population…as it is in the non-overweight population. Material and Methods: This study consisted of 9 normal weight (18.5 < BMI < 25), 9 overweight (25 < BMI < 30), and 6 obese (BMI > 30) patients who presented with lumbosacral radicular pain and received a TFESI. For each group, percent reduction in pain and the proportion of individuals with a 50% or greater reduction in pain 2–4 weeks after TFESI was determined. Results: Comparing the overweight and obese groups to the normal weight group, no significant differences were found in the percent improvement in pain after TFESI (p = 0.7154 , p = 0.4566 ) or in the proportion of each group with a 50% or greater reduction in lower back pain after TFESI (p = 0.2968 ). Conclusion: Our pilot data indicates that lumbosacral TFESI is as effective in providing short-term relief of lumbosacral radicular pain in obese and overweight patients as it is in non-overweight patients. However, our sample size was not large enough to find a significant difference at a power of 80%. We plan to perform a larger prospective study to confirm the findings of this study. Level of Evidence: Case-control study, Level II-2.
Keywords: Epidural injection, BMI, body mass index, obese, radiculopathy
Abstract: Objectives: To investigate training effects of two different resistance and proprioceptive exercising concepts of neck muscles. Material and Method: Twenty-six healthy women participated in a randomized pilot trial. The test persons were randomized to two different neck-training programs (resistance training (RT) and proprioceptive resistance training (PRT)). They performed a standardized training program for the duration of ten weeks two times weekly. The neck strength, the cross-sectional area of three neck muscle groups (1. sternocleidomastoid muscles; 2. multifidus and semispinalis cervicis muscles; 3. semispinalis capitis and splenius muscles) and the proprioceptive capability evaluated by the dynamic joint repositioning error…(DJRE) of the head were assessed pre- and post-intervention. Results: Strength gain did not differ significantly between the two resistance training groups (PRT group: 8.2% to 29.3%; RT group: 1.4% to 19.8%). Change of hypertrophy of all neck muscle groups was significantly (p < 0.001 to p = 0.013 ) greater in the PRT group (18.9% to 32.3%) than in the RT group (1.5% to 12.9%). The DJRE deteriorated with 35% in the RT group and did not change in PRT group (−2.0%). Conclusion: In combination with resistance training, proprioceptive training led to a significantly higher muscle hypertrophy and didn’t effect a significant deterioration of the proprioceptive capability compared to isolated resistance training.
Keywords: Cervical spine, visual motion control, training efficacy, cervicocephalic kinaesthesia
Abstract: Objective: Patients with osteoporotic vertebral compression fracture (OVCF) have postural changes and increased risk of falling. The aim of this study is to compare balance characteristics between patients with OVCF and healthy control subjects. Methods: Patients with severe OVCF and control subjects underwent computerised dynamic posturography (CDP) in this case-control study. Results: Forty-seven OVCF patients and 45 controls were recruited. Compared with the control group, the OVCF group had significantly decreased average stability; maximal stability under the ‘eye open with swayed support surface’ (CDP subtest 4) and ‘eye closed with swayed support surface’ conditions (subtest 5);…and decreased ankle strategy during subtests 4 and 5 and under the ‘swayed vision with swayed support surface’ condition (subtest 6). The OVCF group fell more frequently during subtests 5 and 6 and had longer overall reaction time and longer reaction time when moving backward during the directional control test. Conclusion: OVCF patients had poorer static and dynamic balance performance compared with normal control. They had decreased postural stability and ankle strategy with increased fall frequency on a swayed surface; they also had longer reaction times overall and in the backward direction. Therefore, we suggest balance rehabilitation for patients with OVCF to prevent fall.
Keywords: Osteoporosis, vertebral compression fracture, balance, computerised dynamic posturography, sensory organization test, motor control test
Abstract: Background and Objective: To investigate the effects of knee osteoarthritis (OA) on activities of daily living and motor and functional improvement in stroke patients with hemiparesis. Methods: This prospective case-controlled study included 60 inpatients (44 women, 16 men; mean age 66.1 ± 7.6 years, range 51–79 years) with hemiparesis after stroke. Main outcome measures included the Brunnstrom motor recovery stages of the lower extremity, Functional Ambulation Category (FAC), Barthel index, knee pain as assessed by a VAS, and radiographic severity of knee OA based on the Kellgren-Lawrence (K/L) criteria. Results: Between improvements in FAC score and…time since stroke, Barthel score, knee pain at rest, K/L radiological grade revealed weak but significant correlations (r : 0.254–0.393) (p < 0.05 ). Regression analysis revealed that time since stroke, knee pain at rest and radiologically knee ostearthritis had a significant effect on the improvement in ambulation level (r = 0.134 , p = 0.001 ; r = 0.137 , p < 0.05 ; r = − 0.007 , p < 0.05 ; respectively). Conclusions: The present study shows that knee OA had a negative effect on ambulation levels in hemiplegic patients after stroke. Thus, knee pain at rest and knee ostearthritis could be evaluated as a functional outcome factor for the improvement of the ambulation levels within stroke patients.
Abstract: Background: There is growing interest in the role of abnormal asymmetrical posture, which is considered one of the most important etiological factors reported to be associated with mechanical low back pain. Objective: This study was conducted to investigate the effect of lumbar extension traction on the pain, function and whole spine sagittal balance as represented in lumbar curvature, thoracic curvature, C7 plumb line, and sacral slope. Methods: Eighty patients with chronic mechanical low back pain (CMLBP) and definite hypolordosis were randomly assigned to traction or a control group. The control group (n = 40…) received stretching exercises and infrared radiation, whereas the traction group (n = 40 ) received lumbar extension traction in addition to stretching exercises and infrared radiation three times a week for 10 weeks. Back pain rating scale, Oswestry Disability Index, and radiological spine sagittal balance parameters in terms of lumbar lordosis, thoracic kyphosis, sacral slope, and positioning of C7 plumb line were measured for all patients at three intervals (before treatment, after 10 weeks of treatment, and at six months follow-up). Results: There was a significant difference between the traction and control groups adjusted to baseline value of outcome at 10 weeks post treatment with respect to lumbar lordotic curve (P = 0.000 ), thoracic kyphosis (P = 0.013 ), sacral slope (P = 0.001 ), C7 plump line distance (p = 0.001 ), while there was no significant difference with respect to pain (p = 0.29 ) and Oswestry Disability Index (ODI) (p = 0.1 ). At 6-months follow-up, there were significant differences between both groups for all the previous variables (p < 0.05 ). Conclusions: Lumbar extension traction in addition to stretching exercises and infrared radiation improved the spine sagittal balance parameters and decreased the pain and disability in CMLBP.
Keywords: Traction, mechanical low back pain, randomized controlled trial
Abstract: 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 Materials: 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)…questionnaire 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, randomized clinical trial are needed to validate the results.
Keywords: Chronic low back pain, fatigue, endurance, ultrasound, exercise