ArticlePDF Available

The measurable impact of a protocoled multimodal physiotherapeutic intervention on the quality of life in patients with non-specific chronic low back pain. A RCT study

Authors:

Figures

Original Research Open Access
The measurable impact of a protocoled multimodal
physiotherapeutic intervention on the quality of life in
patients with non-specic chronic low back pain.
A RCT study
Robbert Nimal van Amstel1*, Peter Vaes2 and Shaun Malone3
1Graduate student (at time of study), University of Brussels, faculty of Rehabilitation science and physical therapy, faculty of Pharmacy and
medicine, Brussels, Belgium.
2Professor (at time of study), University of Brussels, faculty of Rehabilitation science and physical therapy, faculty of Pharmacy and medi-
cine, Brussels, Belgium.
3Senior Lecturer, Assistant Professor (at time of study), University of Brussels, faculty of Rehabilitation science and physical therapy, faculty
of Pharmacy and medicine, Brussels, Belgium.
*Correspondence: Robbert.Van.Amstel@vub.be
Abstract
Study design: One-way, mixed, real experimental RCT study.
Background: A multimodal physiotherapeutic approach to treat non-specific (NSP) Chronic Low Back Pain
(CLBP), may affect the quality of life (QoL), pain intensity (PI) and active range of motion (AROM).
The 4 X T method by orthopaedic disorder® (4MTOR®) is a decision tree to guide the physical therapist to
t r eat N SP- CL BP.
Objectives: To investigate the measureable impact on the QoL, PI and the AROM in patients with NSP-
CLBP, after physiotherapeutic back rehabilitation care according to the 4MTOR® , twice a week during a
6 weeks period.
Methods: This was a RCT, where the experimental group (EGR) received the 4MTOR® compared to an
control group (CGR) who received exercise therapy with sham application. The subjects were randomly
assigned to one of the two groups. Both groups received physiotherapeutic intervention twice a week for a
period of six weeks.
Results: The QoL in the EGR significantly improved on the EQ-5D-index p=0.001. The QoL mea-
sured with the EQ-VAS, did significantly improve in both groups p<0.001. However, only a clinically
important change was found for the EGR (W0= 59.72±SD15.43 to W7=78.63± SD17.14). The f lexion
AROM increased significantly (p< 0.005) in the EGR (W0=87.53±SD20.45, W3=96.29±SD16.34, W7=
98.28±SD17.01). A significant (p<0.01) change was also seen for the extension AROM in the EGR (W0=
19.36±SD9.27,W3= 22.25±SD5.99, W7=25.55±SD7.30). The PI reduced only significantly in the EGR
during active flexion (p<0.001). The extension PI did not significantly decrease in both groups, however, a
clinically important change was found in the EGR.
Conclusion: The positive effects of the 4MTOR® on the Qol, PI and AROM in NSP-CLBP exceeded the
effect of exercise therapy with sham application. Further research is required.
Keywords: Low back/lumbar spine, Multimodal Physical therapy interventions, Quality of life, Range of
Motion, Pain. Chronic complaints
© 2018 Amstel et al; licensee Herbert Publications Ltd. is is an Open Access article distributed under the terms of Creative Commons Attribution License
(http://creativecommons.org/licenses/by/3.0). is permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Physical erapy and Rehabilitation
ISSN 2055-2386 | Volume 5 | Article 2
CrossMark
Click for updates
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
2
doi: 10.7243/2055-2386-5-2
Introduction chronic low back pain
Low back pain (LBP) is a common back complaint and is 8th
in the ranking of Disability Adjusted Life Years (DALYs) [
36
].
In 2015, The Netherlands estimates, 1,982,300 people with
diagnosis of neck and back complaints: 832,700 men and
1,149,600 women [37]. The RIVM reports that low back pain
(LBP) is most common in musculoskeletal disorder, with a
prevalence rate of 43.9% and a point of prevalence 26,9%,
21.2% of the LBP were chronic low back complaints [37].
Over 80% of low back pain is constantly present or consists
of recurrent pain. Apparently, according to this report, 20.8%
of adults have chronic low back pain [65]. Mobility of the spine
is expressed in Range of Motion (ROM), which is measured
during active trunk flexion and extension. The cause of LBP
in non-specific chronic low back pain (NSP-CLBP) patients
is unknown. Systematic review shows that the lumbar ROM
is reduced in patients with low back pain [42]. However, a
considerable variability was measured, this may be possible
by using different measuring instruments, measurement
method and margin of error, but also because LBP can
come without ROM reduction [
76
]. The reduced ROM may
adversely affect quality of life (QoL) [
31
]. We speak of chro-
nicity if this statement is exclusively based on the duration
of symptoms of low back pain. Continuous LBP episodes
longer than 12 weeks called CLBP [
37
]. The first episode of
low back pain usually occur in people between the age of
22 and 55 years. The LBP can be classified by duration; acute
(0-6 weeks), subacute (7-12 weeks) and chronic (12> weeks)
[
73
]. Several studies have investigated the effect of using a
multimodal physiotherapeutic intervention the QoL, pain
intensity (PI) and active ROM (AROM) in NSP-CLBP patients
[
20
-
22
,
24
,
40
,
59
,
81
]. From these studies, it is apparent that the
use of a multimodal physiotherapeutic approach combining
various physiotherapeutic interventions in NSP-CLBP patients
can positively affect the QoL, PI and ROM. The organized
multimodal intervention according to the 4 x T method at
orthopaedic rehabilitation
®
(4MTOR
®
), is a decision tree as
main goal to guide the therapist in choosing the best possible
intervention and the right location, direction and intensity of
the selected intervention. 4MTOR
®
has not been investigated
before. This study will compare the 4MTOR®to a exercise program
with sham application on the Qol, PI and AROM in NSP-CLBP.
Methods
Research design
Objective
This study investigated the impact of the physiotherapeutic
back rehabilitation care according to the 4MTOR® on NSP-
CLBP patients. We measured the QoL, PI and the AROM, after
a period of 6 weeks twice a week physical therapy. The results
in this research were analysed and reported. We hypothesized
that the 4MTOR
®
can positively influence the QoL, PI and
the AROM in NSP-CLBP patients. An statistically significant
effect was found when a p value < α=0.05 was achieved [
75
].
Primary variable was the QoL, this was measured by using
the EQ-5D-3L consisting of an EQ-5D-index and an EQ visual
analogue scale (EQ-VAS). The EQ-5D-3L questionnaire was
developed by Euroqol Group. Secondary outcome measures
were the AROM of the active trunk flexion and trunk extension
measured with a bubble inclinometer. Also, the PI was scored
by the patient during active flexion and extension by means of
the Verbal Rating Scale scaled 0-10 (VRS). The measurements
took place during week 0 the baseline measurement (W0),
week 3 the intermediate measurement (W3) and finally week
7 the post measurement (W7). All participants were informed
for the research and agreed by signing the “informed consent”
The research was approved by the Committee of Medical Ethics
University Hospital University of Brussels, B.U.N. 143201627110.
Participants
Inclusion and exclusion criteria
Participants were included when they met the following
criteria: NSP-CLBP from 12 weeks and longer, continuously
present (with and without recurrent complaints), Age between
20 and 60 years, untreated with 4MTOR®.
Participants were excluded when they met the following
criteria: Radiating disturbing pain beyond the knee, neuro-
logical disorder symptoms, overall malaise, spinal cord ma-
lignancy, unexplained weight loss, prolonged corticosteroid
use, osteoporotic vertebral fracture, spondylitis ankylopoetics,
spinal stenosis, rheumatic arthritis, vertebral fracture and
severe deformity of the spinal cord.
Recruitment
Patients recruitment
The subjects were recruited from orthopaedic hospitals
departments in Utrecht the Netherlands. Participants were
asked to refer NSP-CLBP patients for this research and by ad-
vertisement in an Dutch-language newspaper. Also, NSP-CLBP
patients, who applied for physical therapy, were required
to participate in this research. A call form was prepared for
this purpose. All subjects were asked if they would like to
participate in this research. The subjects were authorized to
perform medical physiotherapeutic treatment by signing a
statement of agreement, as previously stated. Personal data
will not be included in this research and are protected by
researchers and the Committee of Medical Ethics University
Hospital University of Brussels.
erapist recruitment Experimental intervention group
This physiotherapist has been educated and qualified in the
KNGF accredited multimodal intervention according to the
4MTOR®. The physiotherapist has at least 2 years of work
experience with the use of the 4MTOR® decision tree.
erapist recruitment SHAM intervention group
This is a Health Care registered physiotherapist and has at least
3 years work experience and is familiar with the KNGF Low
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
3
doi: 10.7243/2055-2386-5-2
Back pain, 2013 guidelines (KNGF_LBP) [74]. Both therapists
were informed about their work protocol and have agreed
to the implementation of the interventions by signing an
informed consent.
Intervention
Evidence Based Practice EGR
In the experimental group (EGR), the 4MTOR
®
treatment
method was used for LBP. This 4MTOR® uses the following
steps in a decision tree: T1 Testing (Physiotherapeutic exami-
nation), T2 Triggering (Manual Techniques), T3 Taping (Elastic
Tape) and T4 Training (medical rehabilitation exercises).
T1: The 4MTOR
®
tests consist of the diagnostic process
as described in the KNGF_LBP [74], and mapping the health
profile [
78
]. In addition, a mechanical diagnostic examination
is performed. A mechanical approach was previously used in
the McKenzie Classification Mechanical Diagnostic Research
[50]. In the mechanical diagnostic examination by 4MTOR®,
the physiotherapist analyses the active movement to find
the direction that elicits the most recognizable complaints.
According to 4MTOR
®
, the directions for applying the manual
interventions and tape should be determined [58]. Noten [58]
developed the Dynamic Arthro-Myofascial Translation Test
®
(DAMT
®
Test) for the 4MTOR
®
. The DAMT
®
Test is a quick
test to investigate and determine the direction of manual
interventions and taping. There is no validity and reliability
known for this quick test, since it was never tested before.
T2 : The myofascial structures are released to the results of
the DAMT®Test, after this that direction was mobilized and
impulse mobilization was given on a hypomobile joint, where
required. T3 : After applying T2 interventions the tape was
adjusted. T4: The 4MTOR® uses various fitness exercises and
homework assignments in their rehabilitation training plan
at NSP-CLBP, which are divided into extension - and flexion
based exercises. The training in 4MTOR
®
will be within the
pain free movement, as well as in the least painful direction.
The choice of parameters (frequency, intensity, volume and
duration) of the training is adjusted by the physiotherapist and
always takes place according to the result of de DAMT
®
Test.
Therefore, initially is chosen for high volume training with low
intensity. Gradually, these parameters will change during the
physiotherapy care. The endurance training includes cycling
on a home trainer, walking on a treadmill , cross-training on a
cross trainer of the brand MATRIX™. Muscle training includes
abdominal training on an abdominal crunch machine of the
brand MATRIX™ . Back muscle training with Pilates exercises,
Brügger back school and on the low-back extension machine
of the brand MATRIX™ [
35
,
57
]. Finally, spine mobility was
trained with Pilates exercises [57].
Evidence Based Practice CGR
The participants in the CGR received a sham multimodal physi-
otherapeutic intervention as controlled intervention, in which
sham techniques were applied. The interventions consisted of
combining sham manual mobilisations, paravertebral elastic
taping according to Kaze [
32
] and Evidence Based Practice
Therapy. The protocol in the CGR followed the similar steps:
Testing, Taping, Triggering and Training like the 4MTOR
®
. The
trunk flexion and extension were tested for treatment (T1),
after which a Sham intervention was performed by applying
sham elastic tape (ET) and rubbing softly the skin. In this
study, similar sham tape technique is used as in the studies
of [2,64], wherein the tape was applied paravertebral with
0% elongation (T2). The shrinkage and lift is the main effect
of the ET [
32
]. Current science cannot support this claim [
79
].
The sham myofascial release techniques were performed by
using sham soft skin rubbing technique. Instead of (impulse)
mobilization techniques on the spine, three times ten seconds
pressure felt by the subject on the hypomobile vertebra and
pain location (T3). In addition, control intervention consisted
of an evidence-based practice medical training schedule
(EBP-MET) using scientifically proven physiotherapy interven-
tions for LBP [23,53,71]. The EBP-MET consists of core stability
training, back and abdominal exercises in Matrix™ fitness
machines and muscle stretch exercises. Core stability in back
pain is a widely used method in physiotherapy. The aim of
core stability training is to recruit effectively the m. multifidus,
m. transversus abdominis, pelvic floor and diaphragm. It ap-
pears, that the feedforward mechanism of the internal units
has been delayed at LBP [25,26,28]. Our systematic review has
been documented that strength training, in which abdominal
and back muscles were trained, including stretching/mobili-
zation of the hamstring, mm abductors and m. tensor fascia
latae has a positive effect on the ROM at (C) LBP [4]. Effective
studies of such programs have not made it clear what type of
exercises are the best. The KNGF_LBP therefore recommend
a varied exercise program that matches the CLBP patient’s
need, which is time congestion [74].
Randomization and observer
The Randomization procedure was performed using the list
option in the UX Random Number Generator 1.2.4
©
. The simple
random allocation method was used to assign the participants
to one of the groups. The randomization was performed by
an independent person under supervision of the investigator.
The randomization process was thereby concealed.
The bubble inclinometer measurement was performed
by a trained researcher and was read by a ‘blinded’ observer
who was masked to allocation of subjects.
Outcome measures
Times pad registration: The measurements were performed
on: W0, W3 and finally W7.
Primary outcome measures
In this study, the participants’ QOL was analysed with EQ-5D-3L-
index and EQ-VAS. Each question in EQ-5D-3L-index, included
one dimension of QoL: mobility, self-care, daily activities, pain/
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
4
doi: 10.7243/2055-2386-5-2
discomfort & anxiety/depression. Each dimension has 3 levels
(having no problems, having some or moderate problems,
being unable to do/having extreme problems) and gets a
separate score. The scores can be combined in combination
with an assessment of the health status they represent, this
rating is expressed in weight or utility. Description of the
QoL can be transformed into a QoL assessment by means
of a formula. These ratings are based on judgments of the
general population of all possible combinations of QoL on
the different dimensions (euroqol.org).
The EQ-5D has a good construct validity in chronic com-
plaints and is able to detect changes for the subjective QoL
[
60
]. The study of Soer et al [
72
], showed that changes in
CLBP patients can also be well detected with EQ-5D. In addi-
tion, they found a good (criterion) concurrent validity versus
multiple gold standards. According to Chapman et al [15], QoL
should be measured more often at CLBP, they indicate that
EQ-5D is a good method for analysing this. Before EQ-5D-3L
was taken, the following question was asked ‘Compare your
current status with the status of your first measurement of
QoL. The minimal clinically important change (MCIC) for EQ-
5D-3L-index in CLBP with a 12 week follow- up is between
0.09-0.2866. For EQ-VAS we used the minimum important
change (MIC) for VAS 15 points [61]. The use of EQ-5D-3L
has been approved and registered by the EuroQol Research
Foundation.
Secondary outcome measures
The AROM: of the lumbar vertebral column was measured
with the BASELINE®BUBBLE®INCLINOMETER (
Figure 1
). The
AROM consisted of active spine flexion and extension. The
bubble inclinometer is a very good, reliable and valid measur-
Figure 1. Baseline®bubble®inclinometer.
ing instrument, provided this is done by a trained researcher
[
51
]. Three different AROM tests were tested: thoracolumbar-
pelvic flexion (TLPF), thoracolumbar- pelvic extension (TLPE)
and isolated lumbar flexion (ILF) as described in [
38
]. This
measurement was performed in several studies [
69
,
70
,
83
].
For clinical relevance, the minimum detectable change (MDC)
for the BASELINE®BUBBLE®INCLINOMETER has been taken
into account. The MDC TLPF is 7° ≤ and for TLPE 6° ≤. Finally,
the ILF has a MCD of 9° ≤ [
38
]. The detailed description of
the operarationalization of the performance is described in
section below and the footnotes of the relevant figures.
The VRS: was also measured during spine flexion and exten-
sion to observe the participant PI. Studies have shown that
a score of 0-10 must be at least 30% reduction with a range
between 1 to 4.5 on a maximum of 10 points [
12
]. In this study,
a Minimal Important Change (MIC) of 2 points (4.5 <) were
chosen as described [
61
]. Before the participant gave a PI
number to the active flexion or extension, the VRS scale was
shown. Thereafter, the movement was performed as described
in the footnotes. After completing the active flexion or exten-
sion , the participant gave a VRS score regarding the PI.
Standard procedure inclinometer measurement (Short
description)
Preparation of test: S1/2 and L1/ T12 were marked with the
dermatological pencil and labelled with tape (Figure 2).
Test performance: The examination was carried out bare
footed, the active tests were performed with the head roll-
ing down to the trunk. First, the subjects are actively raising
their knees 10 times before adopting their starting position.
The inclinometer was placed on the marked point, so the
tape was between the inclinometer arcus and was set to 0°.
Instruction was given as described in the footnotes, X° was
noted by the ‘blinded’ observer who was masked for alloca-
tion of the subjects. The formula was used - as described in
Kolber et al [38] . For detail see Figures 3-6.
Statistical analysis
In this study we used a p value <α=0.05 to show statistical
significance. The outcome variables from the measurements,
Figure 2. Spinosis landmarks. Spinosis S1/2 and L1/T12.
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
5
doi: 10.7243/2055-2386-5-2
Figure 3. Starting position. Before the subjects adopting
their starting position for the thoracolumbar -pelvic exion
and extension test, the subject raised actively their knees 10
times. en, they were instructed to stand tall, feet hipwidth
apart, arms straight along the body, thumbs forward, and
forward focus.
Figure 5. AROM oracolumbar-pelvic extension. e
inclinometer placed on L1/T12 with the tape between the
inclinometer arcus and was set to 0 °. During the test, the
investigator kept the inclinometer on L1/T12 while instructing
the subject to put his hands on his pelvis and bend backwards.
Figure 4. AROM oracolumbar-pelvic exion. e
inclinometer placed on L1/T12 with the tape between
the inclinometer arcus and was set to 0 °. During the test,
the investigator kept the inclinometer on L1/T12 while
instructing the subject to bend forward with the arms in
hanging position.
Figure 6. AROM Isolated lumbar exion test. e inclinometer
was moved to labelled S1/S2 and the inclinometer was set to 0
°. During the test, the investigator held the inclinometer on S1/
S2 while instructing the subject to bend forward. e formula
∑T12/L1-S1/S2 was used.
was used in the SPSS program to calculate the sample mean,
standard deviation and confidence interval. In order to compare
the two groups or distinguish them significantly, the Repeated
Measure Analysis of variance mixed design (RMANOVA-MD)
was used. Within factor were analysed between: W0-W3 and
W7. Between factor were analysed between: experimental
group versus Sham group. Finally, interaction between groups
x time was analysed.
Sample size
The sample analysis was performed for the RMANOVA-MD
with the Gpower
©
program. The RMANOVA-MD power analysis
was performed using the following values: Power.81, Alpha
0.50, Sample size effect f2=.25, resulting in a minimum of
28 participants, Fcritical=3.175 and an actual power of .82 .
Cohen [18] advised a medium-sized effect size (f2 = .25) in a
RMANOVA-MD. 10% was added to these 28 participants (n =
30), towards the possible dropouts. The NSP-CLBP participants
are divided into two groups.
Results
In total, 53 participants in the first round had been registered
for participation in this study, of which 11 were directly ex-
cluded by telephone screening, because they scored positively
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
6
doi: 10.7243/2055-2386-5-2
on the call form. 6 Participants had independently decided
to retreat from participating after informative conversation. 1
Participant had signed off for participation, because she had
become pregnant. 3 Participants were excluded during the
screening for the study, one of them had a radicular pathology
L5/S1, which was later confirmed by MRI. Another participant
appeared to have had recent trauma with a vertebral fracture
T12/L1 and was diagnosed with partial sacralisation. The last
one was excluded due to general malaise complaints after a
stomach correction and placement of osteosynthetic material
L4/L5/S1. Finally, 2 participants had been unsubscribed for
reasons unknown. A total of 30 subjects participated in this
research. The randomization was performed by a ‘blinded’
observer, with respect to allocation of subjects under the
supervision of the investigator. A total of 15 subjects were
randomized to the CGR and 15 subjects for the EGR. In the
CGR, 14 subjects followed the therapy, one of the subjects
didn’t show up at his first appointment for unknown reason.
Three subjects stopped during the first three weeks and
did not complete the follow-up measurements, because
of conflict in activity of daily life (ADL), which led to once
a week treatment. In the EGR, 15 subjects have undergone
therapy, of which two subjects have not been able to meet
the follow-up measurements. One subject stopped because
of conflict ADL schedule. The other subject was included in
a mental hospital (Figure 7).
Analysis
Since the intention was to treat, all randomized participants
were included in the analysis. For the non- completers, an
expectation-maximization intention algorithm was used with
the built-in program of SPSS® statistical software for Windows.
The expectation-maximization is a better method than a last
Figure 7. Prisma owchart diagram.
observation carrying forward technique for non-completers
[
10
,
14
]. An analysis was conducted for a total of 29 subjects. In
order to analyse the homogeneity of baseline characteristics
in W0, the independent sample t-test or Mann Withney U test
was preformed. Homogeneity was accepted at a Levenes F
test p> α=0.01. The groups were homogeneous for all mea-
surements during the baseline measurement (W0).
The VRS_Classification was calculated by (Table 1).
Primary and secondary outcome measures
The changes in our variables were analysed within time:
W0-W3, W0-W7 and W3-W7 and for between groups: EGR
versus CGR. The results are shown for all variables in a table.
The analysis for all variables were significant when p<α=0.05.
e quality of life EQ 5D 3L and EQ VAS
After analysing the data, there appears to be a significant in-
teraction effect between time and groups (F=4.425, p=0.022)
(Graph 1). This means that the effect on the dependent, variable
QoL measured by EQ-5D-3L-index, depends on the therapy
used in the groups and follow up measurement in time, but
that both independent variables (groups x time) depend on
each other. Interpreting the main effects is not possible. The
data was therefore divided into groups, to analyse where
the difference was. After splitting files into groups, there
appears to be no significant changes within time in CGR for
the QoL measured by EQ-5D-3L-index score (0.565 ±SD 0.298,
F=2.167, p=0.157). However, when comparing follow-ups in
EGR, a significant difference was found within time for: W0-W3,
W0-W7 & W3-W7 (F=13.786, p=0.001). This means that the
QoL, measured by the EQ-5D-3L-index in this group, shows
Variabeles Experimental
group (n=15)
Control group
(n=14)
p_ value
Age 45.2 ±SD 11.28 44.9 ±SD 10.93 p= 0.477
EQ 5D 3L index 0.466 ±SD 0.29 0.565 ±SD 0.29 p= 0.660
EQ 5D 3L VAS 59.72 ±SD 15.43 56.00 ±SD 17.66 p= 0.702
FL_AROM° 87.53 ±SD 20.43 98.07 ±SD 18.35 p= 0.658
ET_AROM° 19.36 ±SD 9.30 19.57 ±SD 7.34 p= 0.187
FL_Pain_VRS 5.03 ±SD 2.31 3.5 ±SD 2.80 p= 0,513
ET_Pain_VRS 4.60 ±SD 2.60 4.10 ±SD 3.00 p= 0.322
Gender Man n=19 Female n=10 p= 0 .368
*VRS classication 2.60 ±SD 0.82 2.46 ±SD 77.62 p= 0.780
Table 1. Baseline Characteristics.
Data is displayed as mean ± SD and p-value.
a. p-value of independent sample t-test
b. p-value of Mann Whitney U test
c. FL = exion, ET = extension, AROM = active range of motion in
degrees°
d. VRS = verbal rating score, Vas = visual analogue scale
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
7
doi: 10.7243/2055-2386-5-2
Graph 1. Interaction EQ-5D-3L-index.
Experimental group Control group
Week Mean 95% CI Mean dierent Within
p_value
Mean 95% CI Within
p_ value
W0 0.466±SD0.286 .308 .625 -- p=0.005 0.565±SD0.298 .393 .738 p=NS
W3 0.678±SD0.264 .532 .825 -- p=0.005 0.506±SD0.270 .350 .662 p=NS
W7 0.783±SD0.191 .677 .890 -- p=0.005 0.619±SD0.209 .498 .740 p=NS
W0-W3 -- -.388 -.037 -.213 p=0.016 -- -- -- --
W0-W7 -- -.486 -.148 -.317 p>0.001 -- -- -- --
W3-W7 -- -.105 -.200 -.009 p=0.030 -- -- -- --
Table 2. Quality of life EQ-5D-3L-index results.
Data is displayed as mean ± SD and p- value.
a. p- value of RMANOVA mix design & Bonferroni post hoc
b. W0=week 0/baseline measurement, W3= week 3/intermediate measurement, W7= week 7/ post measurement
c. NS= not signicant
Data is displayed as mean ± SD and p- value.
a. p- value of RMANOVA mix design
b. W0=week 0/baseline measurement, W3= week 3/intermediate measurement, W7= week 7/ post
measurement
c. CI=condence interval
d. NS= not signicant
Experimental group Control group
Week Mean 95% CI Mean 95% CI Between p_value
W0 59.72±SD15.43 51.74 68.26 56.00±SD17.66 .393 .738 p=NS
W3 71.54±SD15.42 63.00 80.09 59.20±SD14.84 .350 .662 p=NS
W7 78.63±SD17.14 69.03 88.02 66.65±SD13.54 .498 .740 p=NS
Within p_value p<0.001 p<0.001
Table 3. Quality of life EQ-VAS results.
a positive evolution in time. To correct for increased chance
of finding an incorrect, significant effect (Type 1 error), we
used the Bonferroni post hoc test. This analysis shows that
there was a significant difference between the follow-up
measurements: W0-W3, W0-W7 & W3-W7 (
Table 2
). The QoL
measured by EQ-VAS shows a significant improvement within
both groups for follow-up measurements (F=19.162, p<0.001),
therefore, it appears that a positive evolution has been found
in both groups. There is no significant difference between the
groups on EQ-VAS score (F=3.426, p= 0.075> α=0.05). It was
apparent from this analysis that EQ-VAS score is not dependent
on the therapy used in both groups. EQ-VAS score was the
same, and there was a positive evolution in QoL measured
with EQ-VAS scores for both groups (
Table 3
). The Minimal
Important Change (MIC) for a Visual Analog Score (VAS) is 15
points [61]. When we looked at our data, it appears that this
had only been achieved by the EGR between W0-W7 (
Table 4
).
AROM exion and extension (Inclinometer)
A significant interaction effect was found between the time
and the groups in the TLPF AROM (F=2.401, p=0.027) (Graph 2).
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
8
doi: 10.7243/2055-2386-5-2
Experimental group Control group
Week 95% CI MD MIC 95% CI MD MIC
W0-W3 -19.11 -4.54 -11.82 11.82<15 -18.55 12.15 -3.20 3.20 <15
W0-W7 -28.44 -9.17 -18.81 18.81 >15 -23.35 2.04 -10.65 10.65<15
W3-W7 -12.66 -1.30 -6.98 6.98 <15 -13.98 -.91 -7.45 7.45 <15
Table 4. MIC EQ-VAS.
Data is displayed as condence interval mean dierent vs MIC
a. MD=mean dierent
b. MIC= minimal important change, minimal mean full change for patient
c. CI= Condence interval
d. Vas= visual analogue scale
e. W0=week 0/baseline measurement, W3= week 3/intermediate
measurement, W7= week 7/post measurement
Graph 2. Interaction active exion ROM°.
Experimental group Control group
Week Mean 95% CI Mean
dierent
Within
p_value
Mean 95% CI Within
p_value
W0 87.53±SD20.45 76.21 98.84 -- p=0.005 98.07±SD18.34 87.47 108.6 p=NS
W3 96.29±SD16.34 87.24 105.3 -- p=0.005 96.60±SD19.72 85.51 108.3 p=NS
W7 98.28±SD17.01 88.86 107.7 -- p=0.005 96.03±SD18.73 85.22 106.9 p=NS
W0-W3 -- -14.64 -2.88 8,76 p=0.002 -- -- -- --
W0-W7 -- -21.66 -160 -10.75 p=0.015 -- -- -- --
W3-W7 -- -8.85 4.87 -1.99 P= NS -- -- -- --
Table 5. Active range of motion° thoracolumbar-pelvic exion inclinometer results.
Data is displayed as mean ± SD and p- value.
a. p- value of RMANOVA mix design & Bonferroni post hoc
b. W0=week 0/baseline measurement, W3= week 3/intermediate measurement, W7= week 7/post measurement
c. CI= Condence interval
d. NS=not signicant
This shows that the effect on the dependent variable AROM
measured by the inclinometer, was dependent on the therapy
used in the groups and the independent variables time, but
that both independent variables depend on each other. Inter-
preting the main effects was not realistic. In order to properly
interpret the data, a split file into groups had been used. After
analysis the data, no significant differences were found in the
CGR for TLPF AROM measured by the inclinometer (F=0.182,
p=0.836). However, the TLPF AROM increased significantly in
the EGR (F=8.304, p=0.005). A Bonferroni post hoc analysis
had been performed to see if there was a difference between
the follow-up measurements and to exclude a Type 1 error.
This analysis shows that there was a significant difference
between W0-W3 and W0-W7, no significant difference was
found between W3-W7 (
Table 5
). This observation is confirmed
when we looked at the MDC for the TLPF. Between W0-W3 and
W0-W7 , MDC was exceeded, the opposite we see for W3-W7
where MDC was not reached. This conclusion corresponds to
the post hoc results. Also a significant interaction effect was
found between time measurements and the groups for the
TLPE AROM measured by the inclinometer (F=3.382, p=0.049)
(
Graph 3
). This shows that the effect on the dependent vari-
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
9
doi: 10.7243/2055-2386-5-2
Graph 3. Interaction active extension rom°.
Experimental group Control group
Week Mean 95% CI Mean
dierent
Within
p_value
Mean 95% CI Within
p_value
W0 19.36±SD9.27 14.22 24.50 -- p=0.014 19.57±SD7.35 15.33 23.81 p=NS
W3 22.25±SD5.99 21.93 28.57 -- p=0.014 18.83±SD6.14 15.29 22.38 p=NS
W7 25.55±SD7.30 21.51 29.60 -- P=0.014 19.81±SD5.61 16.57 23.05 p=NS
W0-W3 -- -10.34 1.42 -5.88 p=0.009 -- -- -- --
W0-W7 -- -11.40 -982 -6.19 p=0.018 -- -- -- --
W3-W7 -- -1.89 2.50 -.306 p=NS -- -- -- --
Table 6. Active range of motion° thoracolumbar- pelvic extension inclinometer results.
Data is displayed as mean ± SD and p- value.
a. p- value of RMANOVA mix design & Bonferroni post hoc
b. W0=week 0/baseline measurement, W3= week 3/intermediate measurement, W7= week 7/ post measurement;
c. CI= condence interval
d. NS= not signicant
of 6° only exceeded between W0-W7 (
Table 8
). Finally, the
ILF AROM was analysed, a significant main effect was found
(F4.185, p=0.027).
According to the analysis, an improvement could be seen
in both groups, there is no significant difference between the
groups (F=0.0102, p=0.775> α=0.05) (
Table 7
). The difference
was so small, that it was very difficult to correctly interpret
this analysis. If there was an improvement, this would be in
favour of the CGR, because it had exceeded the MCD° of 9°
between W0-W7.
Pain intensity, exion and extension (Verbal Rating Scale)
The PI during active flexion measured by the VRS scale was de
-
pendent on the intervention used (F=7.118, p=0.037) (Graph 4).
This means that the analysed effect on the PI during the ac-
tive flexion measured by the VRS scale was dependent on the
therapy used in the groups and the measurements in time,
but that both independent variables depend on each other.
Interpreting the main effects could be false and needed to
be split into groups. After splitting files into groups, there
appeared to be no significant changes in the CGR in the PI
able AROM measured by the inclinometer is dependent on
the therapy used in the groups and the independent variables
time, but that both independent variables depend on each
other. The main effects cannot be interpreted. No significant
changes appeared to be in the CGR in the ROM for the TLPE
AROM measured by the inclinometer, after performing a
RMANOVA split files into groups (F=0.418, p=0.668> α=0.05).
Significant evolution was found in the EGR (F=5.970, p= 0.014),
a Bonferroni post hoc analysis had been performed to see if
there was a difference between the follow-up measurements
and to exclude a Type 1 error. This analysis shows that there
had been a significant improvement between W0-W3 and
W0-W7, no significant difference was found between W3-W7
(Table 6). When we looked at the descriptive data the MDC
Experimental group Control group
Week Mean Mean Between
p_value
W0 36.03±SD13.43 42.42±10.40 p=NS
W3 34.96±SD11.95 34.87±11.91 p=NS
W7 34.29±SD10.93 31.35±7.22 p=NS
Within p_value p= 0.027
Table 7. Isolated lumbar exion active range of motion°
inclinometer results.
Data is displayed as mean ± SD and p- value.
a. p- value of RMANOVA mix design & Bonferroni post hoc
b. W0=week 0/baseline measurement, W3= week 3/intermediate
measurement, W7= week 7/ post measurement
c. CI= condence interval
d. NS= not signicant
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
10
doi: 10.7243/2055-2386-5-2
Graph 4. Pain intensity active exion.
Total thoracolumbar-pelvic exion Total thoracolumbar-pelvic extension
Week 95% CI MD MDC° 95% CI MD MDC°
W0-W3 -14.64 -2.88 8.76 8.76> 7° -10.34 1.42 -5.88 -5.88< 6°
W0-W7 -21.66 -160 -10.75 10.75> 7° -11.40 -982 -6.19 6.19> 6°
W3-W7 -8.85 4.87 -1.99 1.99< 7° -1.89 2.50 -.306 -.306< 6°
Table 8. MDC° AROM experimental group.
Table 9. Active exion pain intensity VRS.
Data is displayed as condence interval mean dierent vs MIC
a. CI=condence interval
b. MD= mean dierent
c. MDC= minimal detectable change, minimum change in a patient’s score that ensures
the change isn’t the result of measurement error.
Data is displayed as mean ± SD and p- value.
a. p- value of RMANOVA mix design & Bonferroni post hoc
b. W0=week 0/baseline measurement, W3= week 3/intermediate measurement, W7= week 7/ post measurement
c. CI= condence interval
d. NS= not signicant
e. VRS= Verbal Rating Scale, Pain Scale
during the active flexion (F=0.502, p=0.617). Although the
PI decreased significantly in the EGR (F=16.906, p<0.001). In
order to correct for the increased chance of finding a type
1 error, we used the Bonferroni post hoc test. This analysis
shows a significant difference between W0-W3 and W0-W7,
but no significant difference between W3-W7 (
Tables 9
and
11
).
The PI during the extension did not significantly decrease in
both groups (F=2.880, p=0.074) (
Table 10
). However, it seems
that we had a trend in favour of the EGR, which could also
be seen in (Graph 5). We are talking about a trend when the
p value is just not smaller than α=0.05. The descriptive data
for the EGR show that the MIC of 2 points has been exceeded
between W0-W7 (Table 12). There may be a small beneficial
effect in the EGR that was valuable for NSP-CLBP patient on
the PI during active extension.
Discussion
One of the purposes of this study was to report the results
and to investigate the effect of the 4MTOR
®
method on QoL,
PI and the AROM in patients with NSP-CLBP, after a period of
six weeks of physiotherapeutic back rehabilitation care, twice
a week, according to the 4MTOR
®
. Another purpose was to
Experimental group Control group
Week Mean 95% CI Mean dierent p_value Mean 95% CI p_value
W0 5.03±SD2.3 3.75 6.31 -- p<0.001 3.46±SD2.8 1.85 5.07 p=NS
W3 3.20±SD2.7 1.73 4.69 -- p<0.001 3.44±SD2.8 1.84 5.04 p=NS
W7 1.75±SD2.4 0.395 3.10 -- p<0.001 2.70±SD3.6 .636 4.77 p=NS
W0-W3 -- 0.77 2.87 1.8 p=0.001 -- -- -- --
W0-W7 -- 1.619 4.94 3.3 p<0.001 -- -- -- --
W3-W7 -- -.105 3.01 1.4 p=NS -- -- -- --
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
11
doi: 10.7243/2055-2386-5-2
determine whether further investigation into this 4MTOR®
method could have an added value. A total of 30 subjects
had been randomized in this research, however, a total of 6
participants dropped out for several reasons. Due to these
dropouts, we dived under our power of 82% and we should
Experimentele groep Controle groep
Week Mean 95% CI Mean 95% CI Between p_value
W0 4.60±SD2.59 3.16 6.03 4.07±SD2.03 2.34 5.80 p=NS
W3 2.92±SD2.06 1.78 4.06 4.67±SD2.48 3.24 6.10 p=NS
W7 2.08±SD2.67 .60 3.56 4.15±SD2.93 2.46 5.85 p=NS
Whthin p_value p=NS p=NS
Table 10. Extension pain intensity VRS.
Data is displayed as mean ± SD and p- value.
a. p- value of RMANOVA mix design
b. W0=week 0/baseline measurement, W3= week 3/intermediate measurement,
W7= week 7/ post measurement
c. CI= condence interval
d. NS= not signicant
e. VRS= Verbal Rating Scale, Pain Scale
Data is displayed as condence interval mean dierent vs MIC
a. MD = mean dierent
b. MIC= minimal important change, minimal mean full change for patient.
Experimentele groep Controle groep
Week 95% CI MD MIC 95% CI MD MIC
W0-W3 -.214 3.57 1.7 1.7< 2 2.83 1.63 -.600 -.600 <2
W0-W7 -.418 4.61 2.5 2.5>2 2.30 2.12 -.886 -.886<2
W3-W7 -.362 2.04 .84 .84< 2 -1.08 2.11 -.514 -.514<2
Table 11. Active exion pain intensity VRS, minimal important change.
Graph 5. Pain intensity active extension.
Experimentele groep
Week 95% CI MD MIC
W0-W3 0.77 2.87 1.8 1.8<2
W0-W7 1.619 4.94 3.3 3.3>2
W3-W7 -.105 3.01 1.4 1.4<2
Tab1e 12. Active extension pain intensity VRS, minimal
important change.
Data is displayed as condence interval mean dierent vs
MIC
a. MD = mean dierent
b. MIC = minimal important change
c. W0=week 0/baseline measurement, W3= week
3/intermediate measurement, W7= week 7/ post
measurement
d. CI= condence interval
be careful about interpreting our data. The effect on QoL, PI
and AROM have not previously been investigated in NSP-
CLBP by this 4MTOR
®
method. The 4MTOR
®
consists of 4
dimensions, Testing, Triggering, Taping and Training, and was
compared to an control group who received exercise therapy
with sham manual intervention and sham ET. The costs of care
for neck and back is 1.3 billion euros a year. The proportion of
care costs for neck and back problems is greater for women
(61%) than for men (39%) [
36
]. In this study, the proportion
of women (n=10) was lower than men (n=19), which could
distort the reality.
Quality of life
QoL is an important outcome in chronic complaints, and is
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
12
doi: 10.7243/2055-2386-5-2
therefore often used in the analysis of chronic conditions,
including cardiac, lung-and cancer patients. From current
science it is advised to measure the QoL in CLBP [
15
]. However,
there are few effects studies measured the QoL in patients
with CLBP. The Cochrane review of Rubinstein et al [68] shows
that physiotherapeutic manual interventions don’t affect
the QoL and PI. In this study, the QoL seems to be positively
influenced in the EGR. The QoL only increases significantly
in the CGR measured with EQ-VAS. In previous studies, it was
shown that various exercise/training therapy can contribute
to improving QoL measured between week 0 - week 8, this
was not analysed by EQ-5D [19,39]. Hurley et al [27] analysed
the QoL with the EQ-5D at n= 246 subjects. Firstly they com-
pared three interventions: running program, training class
and physiotherapy. All interventions showed a significant
difference on the EQ-5D-3L-index (p<0.05). Whynes et al [
84
]
using the EQ-5D-3L-index and the EQ-VAS to evaluate the
QoL in CLPB patients, they concluded that EQ-5D-3L-index
measures other conceptual changes than EQ-VAS. This could
maybe also been the case in this research. Secondly, they
measured the responsiveness of the EQ-5D-3L based on 3
measure moments: week 0, week 2 and week 12. We also used
three measure moments: week 0, week 3, week 7. The major
question is, whether this research was representative for this
NSP-CLBP population, was the follow-up long enough? In ad
-
dition, the EQ-5D was evaluated during the therapy period,
but what if NSP-CLBP patients do not get treatments. What
will happen between week 7 and week 12 with QoL? These are
important factors which remain unanswered in this research.
Active Range of motion° exion and extension (Incli-
nometer)
In this study, only the AROM improved significantly in the
EGR and not in the CGR. In this study, a bubble inclinometer
was used. The bubble inclinometer uses a fixed reference
point that has been determined in advance. The data is
represented by gravity. Before the data can and may be de-
termined, the inclinometer is always set to zero. When the
subject is moving forward or backward at one of the AROM
tests, the skin shifts; this may be resulting in errors during
the analysis. The AROM extension is more difficult to measure
than the AROM flexion and will show less rapid significant
improvements [70]. This could also be seen in our research.
The technique for holding the bubble inclinometer must be
practiced, hence the researcher must be trained in using the
bubble inclinometer. Measuring the spinal movement may
be problematic in a clinical setting, which may be due to the
limitations of simple measuring instruments as a inclinometer
[
62
]. The blinded’ observer who was masked for allocation of
the subjects did not know whether the subject had physi-
otherapeutic care in CGR or EGR. The observer’s task was to
read the inclinometer during these tests with the placement
of the inclinometer performed by a trained researcher . We
did not analyse the inter-assessment reliability between the
investigator and the ‘blinded’ observer who was masked for
allocation of the subjects.
Verbal rating scores VRS
The VRS was used to score the PI by the participant during
active flexion and extension. The VRS and Verbal Numeric
Rating Scale (VNRS) are both practically easier to use than
a Visual Analogue Scale (VAS) [
29
]. It also appears that VAS
and NRS can detect better a difference in PI than the VRS
[12]. In this study, we see no significant improvement in PI
during extension, but the MIC of 2 points has been exceeded
between W0-W7 in favour of EGR. This may be due to the less
ability to detect a change of the VRS.
Conclusion
The QoL was positively influenced, measured with EQ-5D-
3L-index and the EQ-VAS within W0-W3, W0-W7 and W3-W7
in the EGR (p<0.005). The QoL was positively influenced
during a 6-week intervention according to the 4MTOR®. The
biggest effect was measured in the first 3 weeks, when they
had received a total of 6 treatments (W0 =0.466 ±SD 0.286 to
W3=0. 678 ±SD 0.264, p<0.005). The AROM increased signifi-
cantly and clinically for the TLPF AROM in W0= 87.53° ±SD
20.45° to W3 =96.29° ±SD 16.34° to W7 =98.28° ±SD 17.01°,
p<0.005. We can conclude that the lumbar spinal mobility
significantly increased in flexion direction of the subjects in
this study, who have had physical therapy according to the
4MTOR
®
. The TLPE AROM increased significantly over time
in the EGR, however, the MCD was reached between W0-W7
(ROM=6.19°> MDC 6°). This shows that the TLPE mobility is
clinically relevant for practice only after 12 treatments. The
PI 0-10 points significantly reduced during active flexion
in time, clinical relevance was observed between W0-W7
(W0=5.03 ±SD 2,3 to W7=1.75 ±SD 2.45, p=0.001 / VRS 6.1>
MDC 2). This means that the patient actually experiences
less pain during active flexion after 12 treatments with the
4MTOR® in this research. The PI didn’t significantly decrease
for extension, but a clinical relevance was found between
W0-W7. The PI can therefore be positively influenced by the
4MTOR
®
. We could conclude from the data in this research
that the 4MTOR®
according to Noten [58] offers possibilities
for positively influencing the QoL, the movement outcome
and the active pain experience in CLBP. To see if a protocol-
based multimodal physiotherapy intervention, according to
the 4MTOR®, gives a better result than unimodal intervention
based physiotherapy, further investigation is required. This
sample is too small to make an actual statement about the
achieved result of the increased QoL, AROM and reduced PI.
Further research has to be carried out on this method, with
more statistical power.
Competing interests
The authors declare that they have no competing interests.
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
13
doi: 10.7243/2055-2386-5-2
Authors’ contributions
Acknowledgement
I would like to thank Anne Pijpers for the ne cooperation.
She helped very well and assisted in organizing this research.
In this respect she was the link between me and the
organisation of Sport Medical Expertise and Rehabilitation
Centre. In particular, I would like to express my gratitude to
my promoter Professor Doctor Vaes. I would like to thank
him for the ne cooperation and in particular, for giving me
the opportunity to do this research. In addition, I would like
to thank my script counsellor assistant professor Master of
science S. Malone for the good guidance. You have given me
the right handles in order to choose the right direction.
Publication history
Editor: Mohammad H. Hadadzadeh, Wheeling Jesuit University, USA.
Received: 15-Dec-2017 Final Revised: 12-Mar-2018
Accepted: 20-Mar-2018 Published: 08-Apr-2018
Authors’ contributions RVM PV SM
Research concept and design ✓ ✓ --
Collection and/or assembly of data ✓ -- --
Data analysis and interpretation ✓ -- --
Writing the article ✓ -- --
Critical revision of the article ✓ ✓ ✓
Final approval of article ✓ ✓ ✓
Statistical analysis ✓ -- --
References
1. Added MA, Costa LO, Fukuda TY, de Freitas DG, Salomao EC, Monteiro
RL and Costa Lda C. Ecacy of adding the Kinesio Taping method
to guideline-endorsed convenonal physiotherapy in paents with
chronic nonspecic low back pain: a randomised controlled trial. BMC
Musculoskelet Disord. 2013; 14:301. | Arcle | PubMed Abstract |
PubMed FullText
2. Added MA, Costa LO, de Freitas DG, Fukuda TY, Monteiro RL, Salomao
EC, de Medeiros FC and Costa Lda C. Kinesio Taping Does Not Provide
Addional Benets in Paents With Chronic Low Back Pain Who
Receive Exercise and Manual Therapy: A Randomized Controlled Trial. J
Orthop Sports Phys Ther. 2016; 46:506-13. | Arcle | PubMed
3. Ajimsha MS, Daniel B and Chithra S. Eecveness of myofascial release
in the management of chronic low back pain in nursing professionals. J
Bodyw Mov Ther. 2014; 18:273-81. | Arcle | PubMed
4. van Amstel R.N, Vaes P and Malone S. Flexibility aer physiotherapeuc
intervenon in chronic low back pain: A systemac review, [thesis].
Rehabilitaon en movement science, The University of Brussels. 2014.
5. Areeudomwong P, Wongrat W, Neammesri N and Thongsakul T. A
randomized controlled trial on the long-term eects of propriocepve
neuromuscular facilitaon training, on pain-related outcomes and back
muscle acvity, in paents with chronic low back pain. Musculoskeletal
Care. 2017; 15:218-229. | Arcle | PubMed
6. Arguisuelas M.D.. Lisón, J.F. Sánchez-Zuriaga D, Marnez-Hurtado I and
Doménech-Fernández J. Eects of Myofascial Release in Nonspecic
Chronic Low Back Pain: A Randomized Clinical Trial, Spine (Phila Pa
1976), 2017; 42:627-634.. | Arcle
7. Bae SH, Lee JH, Oh KA and Kim KY. The eects of kinesio taping on
potenal in chronic low back pain paents ancipatory postural
control and cerebral cortex. J Phys Ther Sci. 2013; 25:1367-71. | Arcle |
PubMed Abstract | PubMed FullText
8. Bialosky JE, George SZ, Horn ME, Price DD, Staud R and Robinson ME.
Spinal manipulave therapy-specic changes in pain sensivity in
individuals with low back pain (NCT01168999). J Pain. 2014; 15:136-48.
| Arcle | PubMed Abstract | PubMed FullText
9. Bicalho E, Se JA, Macagnan J, Cano JL and Manra EF. Immediate
eects of a high-velocity spine manipulaon in paraspinal muscles
acvity of nonspecic chronic low-back pain subjects. Man Ther. 2010;
15:469-75. | Arcle | PubMed
10. Blankers M, Koeter MW and Schippers GM. Missing data
approaches in eHealth research: simulaon study and a tutorial for
nonmathemacally inclined researchers. J Med Internet Res. 2010;
12:e54. | Arcle | PubMed Abstract | PubMed FullText
11. Borges J, Bapsta AF, Santana N, Souza I, Kruschewsky RA, Galvao-Castro
B and Sa KN. Pilates exercises improve low back pain and quality of life
in paents with HTLV-1 virus: a randomized crossover clinical trial. J
Bodyw Mov Ther. 2014; 18:68-74. | Arcle | PubMed
12. Breivik H, Borchgrevink P.C, Allen S.M, Rosseland L.A, Romundstad L, Hals
E.K, Kvarstein G and Stubhaug A. Assessment of pain. Brish Journal of
Anaesthesia. 2008; 101:17-24. | Arcle
13. Bronfort G, Haas M, Evans RL and Bouter LM. Ecacy of spinal
manipulaon and mobilizaon for low back pain and neck pain: a
systemac review and best evidence synthesis. Spine J. 2004; 4:335-56.
| Arcle | PubMed
14. Jo B, Asparouhov T and Muthen BO. Intenon-to-treat analysis in cluster
randomized trials with noncompliance. Stat Med. 2008; 27:5565-77. |
Arcle | PubMed Abstract | PubMed FullText
15. Chapman JR, Norvell DC, Hermsmeyer JT, Bransford RJ, DeVine J, McGirt
MJ and Lee MJ. Evaluang common outcomes for measuring treatment
success for chronic low back pain. Spine (Phila Pa 1976). 2011; 36:S54-
68. | Arcle | PubMed
16. Chen YH, Chai HM, Shau YW, Wang CL and Wang SF. Increased sliding
of transverse abdominis during contracon aer myofascial release in
paents with chronic low back pain. Man Ther. 2016; 23:69-75. | Arcle
| PubMed
17. Clare HA, Adams R and Maher CG. Reliability of McKenzie classicaon
of paents with cervical or lumbar pain. J Manipulave Physiol Ther.
2005; 28:122-7. | Arcle | PubMed
18. Cohen J. Stascal power analysis for the behavioral sciences (2nd ed.).
Hillsdale, NJ: Erlbaum. 1988.
19. Coulombe BJ, Games KE, Neil ER and Eberman LE. Core Stability Exercise
Versus General Exercise for Chronic Low Back Pain. J Athl Train. 2017;
52:71-72. | Arcle | PubMed Abstract | PubMed FullText
20. Cuesta-Vargas AI, Garcia-Romero JC, Arroyo-Morales M, Diego-Acosta AM
and Daly DJ. Exercise, manual therapy, and educaon with or without
high-intensity deep-water running for nonspecic chronic low back
pain: a pragmac randomized controlled trial. Am J Phys Med Rehabil.
2011; 90:526-34; quiz 535-8. | Arcle | PubMed
21. Cuesta-Vargas AI, Gonzalez-Sanchez M and Casuso-Holgado MJ. Eect on
health-related quality of life of a mulmodal physiotherapy program
in paents with chronic musculoskeletal disorders. Health Qual Life
Outcomes. 2013; 11:19. | Arcle | PubMed Abstract | PubMed FullText
22. Cuesta-Vargas AI, White M, Gonzalez-Sanchez M and Kuisma R. The
opmal frequency of aquac physiotherapy for individuals with chronic
musculoskeletal pain: a randomised controlled trial. Disabil Rehabil.
2015; 37:311-8. | Arcle | PubMed
23. Davin J and Callaghan M. Towards evidence based emergency medicine:
Best BETs from the Manchester Royal Inrmary. BET 2: Core stability
versus convenonal exercise for treang non-specic low back pain.
Emerg Med J. 2016; 33:162-3. | Arcle | PubMed
24. George JW, Skaggs CD, Thompson PA, Nelson DM, Gavard JA and Gross
GA. A randomized controlled trial comparing a mulmodal intervenon
and standard obstetrics care for low back and pelvic pain in pregnancy.
Am J Obstet Gynecol. 2013; 208:295 e1-7. | Arcle | PubMed
25. Hodges PW. Core stability exercise in chronic low back pain. Orthop Clin
North Am. 2003; 34:245-54. | Arcle | PubMed
26. Hodges PW and Richardson CA. Inecient muscular stabilizaon of the
lumbar spine associated with low back pain. A motor control evaluaon
of transversus abdominis. Spine (Phila Pa 1976). 1996; 21:2640-50. |
Arcle | PubMed
27. Hurley DA, Tully MA, Lonsdale C, Boreham CA, van Mechelen W, Daly L,
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
14
doi: 10.7243/2055-2386-5-2
Tynan A and McDonough SM. Supervised walking in comparison with
tness training for chronic back pain in physiotherapy: results of the
SWIFT single-blinded randomized controlled trial (ISRCTN17592092).
Pain. 2015; 156:131-47. | Arcle | PubMed
28. Hides J, Stanton W, Mendis MD and Sexton M. The relaonship of
transversus abdominis and lumbar muldus clinical muscle tests in
paents with chronic low back pain. Man Ther. 2011; 16:573-7. | Arcle
| PubMed
29. Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH,
Fainsinger R, Aass N and Kaasa S. Studies comparing Numerical Rang
Scales, Verbal Rang Scales, and Visual Analogue Scales for assessment
of pain intensity in adults: a systemac literature review. J Pain
Symptom Manage. 2011; 41:1073-93. | Arcle | PubMed
30. Jorritsma W and Mulder B. Anatomie in vivo : handleiding bij het
Anatomie in vivo-onderwijs aan Academies voor Fysiotherapie.
Uitgever onbekend. 1984.
31. Imagama S, Matsuyama Y, Hasegawa Y, Sakai Y, Ito Z, Ishiguro N and
Hamajima N. Back muscle strength and spinal mobility are predictors
of quality of life in middle-aged and elderly males. Eur Spine J. 2011;
20:954-61. | Arcle | PubMed Abstract | PubMed FullText
32. Kase K, Wallis J and Kase T. Clinical Therapeuc Applicaons of the
Kinesio Taping Method. Tokyo,Japan, Ken Ikai Co Ltd. 13-14; 2003.
33. Kent P, Mjosund HL and Petersen DH. Does targeng manual therapy
and/or exercise improve paent outcomes in nonspecic low back
pain? A systemac review. BMC Med. 2010; 8:22. | Arcle | PubMed
Abstract | PubMed FullText
34. Krismer M and van Tulder M. Strategies for prevenon and management
of musculoskeletal condions. Low back pain (non-specic). Best Pract
Res Clin Rheumatol. 2007; 21:77-91. | Arcle | PubMed
35. Koch-Remmele C. Funkonskrankheiten des Bewegungssystems nach
Brügger,Diagnosk, Therapie, Eigentherapie, Springer. Heidelberg. 2007.
36. Koes, B.W. Nek-en rugklachten Cijfers & Context Oorzaken en gevolgen.
Volksgezondheidenzorg.info. 2 017 . | Website
37. Koes B.W and van Tulder M.W. Nek- en rugklachten samengevat.
In: Volksgezondheid Toekomst Verkenning, Naonaal Kompas
Volksgezondheid. Bilthoven. RIVM. Het Rijksinstuut voor
Volksgezondheid en Milieu. 2017. | Website
38. Kolber MJ, Pizzini M, Robinson A, Yanez D and Hanney WJ. The reliability
and concurrent validity of measurements used to quanfy lumbar spine
mobility: an analysis of an iphone(R) applicaon and gravity based
inclinometry. Int J Sports Phys Ther. 2013; 8:129-37. | PubMed Abstract
| PubMed FullText
39. Kofotolis N, Kellis E, Vlachopoulos SP, Gouitas I and Theodorakis Y. Eects
of Pilates and trunk strengthening exercises on health-related quality of
life in women with chronic low back pain. J Back Musculoskelet Rehabil.
2016; 29:649-659. | Arcle | PubMed
40. Kumar S, Negi MP, Sharma VP, Shukla R, Dev R and Mishra UK. Ecacy
of two mulmodal treatments on physical strength of occupaonally
subgrouped male with low back pain. J Back Musculoskelet Rehabil.
2009; 22:179-88. | Arcle | PubMed
41. Kumar S, Sharma VP, Shukla R and Dev R. Comparave ecacy of two
mulmodal treatments on male and female sub-groups with low back
pain (part II). J Back Musculoskelet Rehabil. 2010; 23:1-9. | Arcle |
PubMed
42. Laird RA, Gilbert J, Kent P and Keang JL. Comparing lumbo-pelvic
kinemacs in people with and without back pain: a systemac review
and meta-analysis. BMC Musculoskelet Disord. 2014; 15:229. | Arcle |
PubMed Abstract | PubMed FullText
43. Lara-Munoz C, De Leon SP, Feinstein AR, Puente A and Wells CK.
Comparison of three rang scales for measuring subjecve phenomena
in clinical research. I. Use of experimentally controlled auditory smuli.
Arch Med Res. 2004; 35:43-8. | Arcle | PubMed
44. Lee CW, Hyun J and Kim SG. Inuence of pilates mat and apparatus
exercises on pain and balance of businesswomen with chronic low
back pain. J Phys Ther Sci. 2014; 26:475-7. | Arcle | PubMed Abstract |
PubMed FullText
45. Lee CW, Hwangbo K and Lee IS. The eects of combinaon paerns of
propriocepve neuromuscular facilitaon and ball exercise on pain and
muscle acvity of chronic low back pain paents. J Phys Ther Sci. 2014;
26:93-6. | Arcle | PubMed Abstract | PubMed FullText
46. Lim EC and Tay MG. Kinesio taping in musculoskeletal pain and disability
that lasts for more than 4 weeks: is it me to peel o the tape and
throw it out with the sweat? A systemac review with meta-analysis
focused on pain and also methods of tape applicaon. Br J Sports Med.
2015; 49:1558-66. | Arcle | PubMed
47. Machado LA, de Souza M, Ferreira PH and Ferreira ML. The McKenzie
method for low back pain: a systemac review of the literature with
a meta-analysis approach. Spine (Phila Pa 1976). 2006; 31:E254-62. |
Arcle | PubMed
48. Machado LA, Maher CG, Herbert RD, Clare H and McAuley JH. The
eecveness of the McKenzie method in addion to rst-line care for
acute low back pain: a randomized controlled trial. BMC Med. 2010;
8:10. | Arcle | PubMed Abstract | PubMed FullText
49. May S and Ross J. The McKenzie classicaon system in the extremies:
a reliability study using Mckenzie assessment forms and experienced
clinicians. J Manipulave Physiol Ther. 2009; 32:556-63. | Arcle |
PubMed
50. McKenzie R.A and May S. The Lumbar Spine. Mechanical Diagnosis and
Therapy. (Vol. 1 and 2) Spinal Publicaons, 2nd Edion, New Zealand:
Spinal Publicaons. 2003.
51. MacDermid JC, Arumugam V, Vincent JI and Carroll KL. The reliability and
validity of the computerized double inclinometer in measuring lumbar
mobility. Open Orthop J. 2014; 8:355-60. | Arcle | PubMed Abstract |
PubMed FullText
52. Meeusen R. Funconal trainingstherapy. College lecturers. University
Brussel. 2014.
53. Meeus M, Roussel NA, Truijen S and Nijs J. Reduced pressure pain
thresholds in response to exercise in chronic fague syndrome but not
in chronic low back pain: an experimental study. J Rehabil Med. 2010;
42:884-90. | Arcle | PubMed
54. Miro J, Castarlenas E, de la Vega R, Sole E, Tome-Pires C, Jensen MP, Engel
JM and Racine M. Validity of three rang scales for measuring pain
intensity in youths with physical disabilies. Eur J Pain. 2016; 20:130-7.
| Arcle | PubMed Abstract | PubMed FullText
55. Morris D, Jones D, Ryan H and Ryan CG. The clinical eects of Kinesio(R)
Tex taping: A systemac review. Physiother Theory Pract. 2013; 29:259-
70. | Arcle | PubMed
56. Mostafavifar M, Wertz J and Borchers J. A systemac review of the
eecveness of kinesio taping for musculoskeletal injury. Phys
Sportsmed. 2012; 40:33-40. | Arcle | PubMed
57. Noten K. De beste oefeningen bij rugklachten. 1e druk
,Uithoorn:Karakter Uitgevers B.V. 2007.
58. Noten K. Orthopedische revalidae 4xt-methode. College lecturers.
Fysio Physics, IJsselstein. 2012.
59. Neubauer E, Zahlten-Hinguranage A, Schiltenwolf M and Buchner
M. Mulmodale Therapie bei chronischem HWS und LWS-Schmerz.
Schmerz. 2006; 20:210-8.
60. Obradovic M, Lal A and Liedgens H. Validity and responsiveness of
EuroQol-5 dimension (EQ-5D) versus Short Form-6 dimension (SF-6D)
quesonnaire in chronic pain. Health Qual Life Outcomes. 2013; 11:110.
| Arcle | PubMed Abstract | PubMed FullText
61. Ostelo RW, Deyo RA, Straord P, Waddell G, Cro P, Von Kor M, Bouter
LM and de Vet HC. Interpreng change scores for pain and funconal
status in low back pain: towards internaonal consensus regarding
minimal important change. Spine (Phila Pa 1976). 2008; 33:90-4. |
Arcle | PubMed
62. O’Sullivan P. Diagnosis and classicaon of chronic low back pain
disorders: maladapve movement and motor control impairments as
underlying mechanism. Man Ther. 2005; 10:242-55. | Arcle | PubMed
63. Panjabi MM. The stabilizing system of the spine. Part I. Funcon,
dysfuncon, adaptaon, and enhancement. J Spinal Disord. 1992;
5:383-9. | PubMed
Amstel et al, Physical erapy and Rehabilitation 2018,
http://www.hoajonline.com/journals/pdf/2055-2386-5-2.pdf
15
doi: 10.7243/2055-2386-5-2
64. Parreira Pdo C, Costa Lda C, Hespanhol LC, Jr., Lopes AD and Costa LO.
Current evidence does not support the use of Kinesio Taping in clinical
pracce: a systemac review. J Physiother. 2014; 60:31-9. | Arcle |
PubMed
65. Picavet & verschuren. Aspecieke lage rugklachten: omvang en
gevolgen. 2016.
66. van der Roer N, Ostelo RW, Bekkering GE, van Tulder MW and de Vet HC.
Minimal clinically important change for pain intensity, funconal status,
and general health status in paents with nonspecic low back pain.
Spine (Phila Pa 1976). 2006; 31:578-82. | Arcle | PubMed
67. Pool-Goudzwaard AL, Vleeming A, Stoeckart R, Snijders CJ and Mens
JM. Insucient lumbopelvic stability: a clinical, anatomical and
biomechanical approach to ‘a-specic’ low back pain. Man Ther. 1998;
3:12-20. | Arcle | PubMed
68. Rubinstein SM, van Middelkoop M, Assendel WJ, de Boer MR and van
Tulder MW. Spinal manipulave therapy for chronic low-back pain: an
update of a Cochrane review. Spine (Phila Pa 1976). 2011; 36:E825-46. |
Arcle | PubMed
69. Salamh PA and Kolber M. The reliability, minimal detectable change and
concurrent validity of a gravity-based bubble inclinometer and iphone
applicaon for measuring standing lumbar lordosis. Physiother Theory
Pract. 2014; 30:62-7. | Arcle | PubMed
70. Saur PM, Ensink FB, Frese K, Seeger D and Hildebrandt J. Lumbar range
of moon: reliability and validity of the inclinometer technique in the
clinical measurement of trunk exibility. Spine (Phila Pa 1976). 1996;
21:1332-8. | Arcle | PubMed
71. Shamsi M, Sarrafzadeh J, Jamshidi A, Zarabi V and Pourahmadi MR.
The eect of core stability and general exercise on abdominal muscle
thickness in non-specic chronic low back pain using ultrasound
imaging. Physiother Theory Pract. 2016; 32:277-83. | Arcle | PubMed
72. Soer R, Reneman MF, Speijer BL, Coppes MH and Vroomen PC.
Clinimetric properes of the EuroQol-5D in paents with chronic low
back pain. Spine J. 2012; 12:1035-9. | Arcle | PubMed
73. Shega JW, Tiedt AD, Grant K and Dale W. Pain measurement in the
Naonal Social Life, Health, and Aging Project: presence, intensity, and
locaon. J Gerontol B Psychol Sci Soc Sci. 2014; 69 Suppl 2:S191-7. |
Arcle | PubMed Abstract | PubMed FullText
74. Staal J.B, Hendriks J.E.M, Heijmans M, Kiers, Lutgers-Boomsma H.A,
Ruen V.G, van Tulder M.W, den Boer J, Ostelo R and Custer J.W.H. KNGF-
richtlijn Lage rugpijn. 2013.
75. Thabane L, Ma J, Chu R, Cheng J, Ismaila A, Rios LP, Robson R, Thabane
M, Giangregorio L and Goldsmith CH. A tutorial on pilot studies: the
what, why and how. BMC Med Res Methodol. 2010; 10:1. | Arcle |
PubMed Abstract | PubMed FullText
76. Mannion A and Troke M. A comparison of two moon analysis devices
used in the measurement of lumbar spinal mobility. Clin Biomech
(Bristol, Avon). 1999; 14:612-9. | Arcle | PubMed
77. Tozzi P, Bongiorno D and Viurini C. Fascial release eects on paents
with non-specic cervical or lumbar pain. J Bodyw Mov Ther. 2011;
15:405-16. | Arcle | PubMed
78. Vaes P, Kerckhofs E and Beckwee D. Het gezondheidsproel. Anamnese
en diagnose in de kinesitherapie/fysiotherapie. Standaard Uitgeverij /
WPG Uitgevers België. 2011.
79. Van C, Bertozzi L, Gardenghi I, Turoni F, Guccione AA and Pillastrini P.
Eect of taping on spinal pain and disability: systemac review and
meta-analysis of randomized trials. Phys Ther. 2015; 95:493-506. |
Arcle | PubMed
80. Vieira-Pellenz F, Oliva-Pascual-Vaca A, Rodriguez-Blanco C, Heredia-
Rizo AM, Ricard F and Almazan-Campos G. Short-term eect of spinal
manipulaon on pain percepon, spinal mobility, and full height
recovery in male subjects with degenerave disk disease: a randomized
controlled trial. Arch Phys Med Rehabil. 2014; 95:1613-9. | Arcle |
PubMed
81. Vijayakumar P, Nagarajan M and Ramli A. Mulmodal physiotherapeuc
management for stage-IV osteis pubis in a 15-year old soccer athlete:
a case report. J Back Musculoskelet Rehabil. 2012; 25:225-30. | Arcle |
PubMed
82. Vicenzino G and Twomey L. Sideexion induced lumbar spine conjunct
rotaon and its inuencing factors. Aust J Physiother. 1993; 39:299-306.
| Arcle | PubMed
83. Waddell G. Evaluaon of results in lumbar spine surgery. Clinical
outcome measures--assessment of severity. Acta Orthop Scand Suppl.
1993; 251:134-7. | PubMed
84. Whynes DK, McCahon RA, Ravenscro A, Hodgkinson V, Evley R and
Hardman JG. Responsiveness of the EQ-5D health-related quality-of-life
instrument in assessing low back pain. Value Health. 2013; 16:124-32. |
Arcle | PubMed
Citation:
van Amstel RN, Vaes P and Malone S. e measurable
impact of a protocoled multimodal physiotherapeutic
intervention on the quality of life in patients with non-
specic chronic low back pain. A RCT study.
Phys er Rehabil. 2018; 5:2.
http://dx.doi.org/10.7243/2055-2386-5-2
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Data sources: The authors searched the following databases: China Biological Medicine disc, Cochrane Library, Embase, and PubMed from 1970 through 2011. The key medical subject headings searched were chronic pain, exercise, LBP, lumbosacral region, and sciatica. Study selection: Randomized controlled trials comparing core stability exercise with general exercise in the treatment of chronic LBP were investigated. Participants were male and female adults with LBP for at least 3 months that was not caused by a specific known condition. A control group receiving general exercise and an experimental group receiving core stability exercise were required for inclusion in the meta-analysis. Core stability was defined as the ability to ensure a stable neutral spine position but the type of exercise was not specified. Outcome measures of pain intensity, back-specific functional status, quality of life, and work absenteeism were recorded at 3-, 6-, and 12-month intervals. Data extraction: The study design, participant information, description of interventions in the control and experimental groups, outcome measures, and follow-up period were extracted. The mean difference (MD) and 95% confidence interval (CI) were calculated to evaluate statistical significance. Risk of bias was assessed using the Cochrane Collaboration Recommendations, and all articles were rated as high risk for other bias with no further explanation given. Main results: Five studies involving 414 patients were included. Four studies assessed pain intensity using the visual analog scale or numeric rating scale. In the core stability exercise group, the reduction in pain was significant at 3 months (MD = -1.29, 95% CI = -2.47, -0.11; P = .003) but not at 6 months (MD = -0.50, 95% CI = -1.36, 0.35; P = .26). Functional status was improved at 3 months (MD = -7.14, 95% CI = -11.64, -2.65; P = .002) but not at 6 months (MD = -0.50, 95% CI = .36, 0.35; P = .26) or 12 months (MD = -0.32, 95% CI = -0.87, 0.23; P = .25). All of the included studies assessed back-specific functional status: 4 used the Oswestry Disability Index and 1 used the Roland-Morris Disability Questionnaire. Patients in the core stability exercise groups experienced improved functional status versus the general exercise group at 3 months (MD = -7.14, 95% CI = -11.64, -2.65; P = .002); no results were recorded at 6 or 12 months. Conclusions: In the short term, core stability exercise was more effective than general exercise for decreasing pain and increasing back-specific functional status in patients with LBP.
Article
Full-text available
Background: The role of exercise therapy in improving pain-related clinical outcomes and trunk muscle activity in patients with chronic low back pain (CLBP) has been widely reported. There is little information on the effect of proprioceptive neuromuscular facilitation (PNF) training in patients with CLBP. The purpose of the present study was therefore to investigate the persistence of the effects of PNF training on pain intensity, functional disability, patient satisfaction, health-related quality of life (HRQOL) and lower back muscle activity in patients with CLBP. Methods: Forty-two participants with CLBP were randomly assigned either to 4-week PNF training or to a control group receiving a Low back pain educational booklet. Pain-related outcomes, including pain intensity, functional disability, patient satisfaction, HRQOL and lumbar erector spinae (LES) muscle activity, were measured before and after the intervention, and at a follow-up session 12 weeks after the last intervention session. Results: Compared with the control group, after undergoing a 4-week PNF training intervention, participants showed a significant reduction in pain intensity and functional disability, and improved patient satisfaction and HRQOL (p < 0.01). These effects were still significant at the 12-week follow-up assessment (p < 0.01). LES muscle activity in the PNF training group was significantly increased throughout the measurement periods compared with controls (p < 0.01). Conclusions: The study found that 4-week PNF training has positive long-term effects on pain-related outcomes, and increases lower back muscle activity in patients with CLBP.
Article
Full-text available
Study Design Randomized controlled trial. Background Many clinical practice guidelines endorses that both manual therapy and exercise are effective treatment options for patients with low back pain. To optimize the effects of the treatments recommended by the guidelines, a new intervention known as kinesio Taping is being widely used in these patients. Objective To determine the effectiveness of adding the use of Kinesio Taping in patients with chronic nonspecific low back pain who receive physical therapy program consisting of exercise and manual therapy. Methods 148 patients with chronic nonspecific low back pain were randomly allocated to receive ten twice-weekly sessions of physical therapy consisting of exercise and manual therapy or the same treatment with the addition of kinesio Taping applied to the lower back. The primary outcomes were pain intensity and disability (5 weeks after randomization) and the secondary outcomes were pain intensity, disability (3 months and 6 months after randomization), and satisfaction with care (5 weeks after treatment). Data were collected by a blinded assessor. Results No between-group differences in the primary outcomes pain intensity (mean difference = -0.01 points; 95% CI -0.88 to 0.85) and disability (mean difference = 1.14 points, 95% CI -0.84 to 3.13) were observed. In addition, no between-group differences were observed for any of the other outcomes evaluated, except disability 6 months after randomization (mean difference = 2.01 points, 95% CI 0.03 to 4.00) in favor of the control group. Conclusion Patients who received a physical therapy program consisting of exercise and manual therapy did not get additional benefit from the use of Kinesio Taping. Level of Evidence Therapy, level 1b. J Orthop Sports Phys Ther, Epub 6 Jun 2016. doi:10.2519/jospt.2016.6590.
Article
Study design: Double-blind, randomized parallel sham-controlled trial with concealed allocation and intention-to treat analysis. Objective: To investigate the effects of an isolate Myofascial Release protocol (MFR) on pain, disability and fear- avoidance beliefs in patients with chronic low back pain (CLBP). Summary of background data: MFR is a form of manual medicine widely used by physiotherapists in the management of different musculoskeletal pathologies. Up to this moment, no previous studies have reported the effects of an isolated MFR treatment in patients with CLBP. Methods: Fifty four participants, with nonspecific CLBP, were randomized to MFR group (n = 27) receiving four sessions of myofascial treatment, each lasting 40 minutes, and to control group (n = 27) receiving a sham MFR. Variables studied were pain measured by means Short Form McGill Pain questionnaire (SF-MPQ) and visual analogue scale (VAS), disability measured with Roland Morris questionnaire and Fear-Avoidance Beliefs measured with FAB questionnaire (FABQ). Results: Subjects receiving MFR displayed significant improvements in pain (SF-MPQ) (mean difference -7.8; 95% CI: -14.5 to -1.1, P = 0.023) and sensory SF-MPQ subscale (mean difference -6.1; 95% CI: -10.8 to -1.5, P = 0.011) compared to the sham group, but no differences were found in VAS between groups. Disability and the FABQ score also displayed a significant decrease in the MFR group (P < 0.05) as compared to sham MFR. Conclusion: Myofascial Release Therapy produced a significant improvement in both pain and disability. However, as the minimal clinically important differences in pain and disability are included in the 95% IC, we can not know if this improvement is clinically relevant. Level of evidence: 2.
Article
Background: There is a controversy regarding whether core stability exercise (CSE) is more effective than general exercise (GE) for chronic LBP. To compare different exercises regarding their effect on improving back strength and stability, performance of abdominal muscles is a useful index. Ultrasound imaging for measuring muscle thickness could be used to assess muscle performance. Objective: The aim of this study was to compare CSE and GE in chronic LBP using ultrasound imaging for measurement of thickness of the deep stabilizing and main global trunk muscles in non-specific chronic LBP. Methods: Each program included 16 training sessions three times a week. Using ultrasound imaging, four transabdominal muscle thickness were measured before and after the intervention. Disability and pain were measured as secondary outcomes. Results: After the intervention on participants (n = 43), a significant increase in muscle thickness (hypertrophy) was seen only in right and left rectus abdominis in the GE group, but significant difference to the CSE group was only on the right side. Disability and pain reduced within the groups without a significant difference in the change between them. Conclusions: The present results provided evidence that only GE increased right and left rectus muscle thickness. The only significant difference between CSE and GE groups was the right rectus thickness. As rectus is a global muscle, the effect of GE on strength improvement (one side stronger than the other) may have a negative effect on motor control of lumbopelvic muscles and possibly increase the risk of back pain occurring or becoming worse, though this was not observed in the present study.
Article
Background: Pilates programs are widely used as a form of regular exercise in a broad range of populations investigating their effectiveness for chronic low back pain (CLBP) treatment. Objective: The aim of this study was to compare the effects of a Pilates program and a trunk strengthening exercise program on functional disability and health-related quality of life (HRQOL) in women with nonspecific CLBP. Methods: A total of 101 volunteer women with CLBP provided data with a 3-month follow-up. They were randomized to either a Pilates (n= 37), trunk strengthening exercise (n= 36) or a control group (n= 28), exercising for a period of 8 weeks, three times a week. Data were collected on HRQOL using the Short-Form 36 Health Survey (SF-36v2), and functional disability using the Roland Morris Disability Questionnaire prior to program initiation, mid-intervention, immediately after program termination, and three months post-intervention. Results: The Pilates participants reported greater improvements on self-reported functional disability and HRQOL compared with participants in the trunk strengthening exercise and control groups (p < 0.05). The effects were retained for a period of three months after program termination for the Pilates group and to a lesser extent for the trunk strengthening exercise group. Conclusions: An 8-week Pilates program improved HRQOL and reduced functional disability more than either a trunk strengthening exercise program or controls among women with CLBP.
Article
Purpose: Recent evidence suggested the significance of integrity of the tension balance of the muscle-fascia corset system in spinal stability, particularly the posterior musculofascial junction which is adjacent to dorsal located paraspinal muscles joining each other at lateral raphe (LR). The purpose of this study was to compare the contraction of the transversus abdominis (TrA) at both anterior and posterior musculofascial muscle-fascia junctions in patients with low back pain (LBP) and asymptomatic participants before and immediately after a sustained manual pressure to LR. Methods: The present observational cohort study used a single-instance, test-retest design. The outcome variables included the resting thickness (Tr), the thickness during contraction (Tc), change in thickness (ΔT), sliding of musculofascial junction (ΔX), muscle length at rest (L) and displacement pattern (ΔD) of the TrA using ultrasonography. Vertical tolerable pressure at the LR was applied manual for 1 min. Tr, Tc, ΔT, and ΔX were analyzed by three-way ANOVA (musculofascial junction sites*group* pre-post manual release). ΔL and ΔD were analyzed by two-way ANOVA (group* pre-post manual release). Results: Participants with LBP revealed less Tc, ΔT and ΔX at both sites (p < 0.005). After myofascial release, LBP group demonstrated a positive ΔD of the musculofascial junctions at both end (p < 0.001). Nevertheless, both groups increased the ΔT and ΔX at both sites (p < 0.001 and 0.001, respectively). Conclusion: The result indicated immediately effect of sustained manual pressure on musculofascial junction of TrA and supported the concept that the possible imbalanced tension of the myofascia corset of TrA in patients with LBP.