Variations in pain, disability, and psychosocial functioning among non-specific chronic low back pain patients with and without anxiety

Systematic review with meta-analysis and meta-regression. We systematically reviewed and delineated the existing evidence on sustainability effects of motor control exercises on pain intensity and disability in chronic low back pain patients when compared with an inactive or passive control group or with other exercises. Secondary aims were to reveal whether moderating factors like the time after intervention completion, the study quality, and the training characteristics affect the potential sustainability effects. Relevant scientific databases (Medline, Web of Knowledge, Cochrane) were screened. Eligibility criteria for selecting studies: All RCTs und CTs on chronic (≥ 12/13 weeks) nonspecific low back pain, written in English or German and adopting a longitudinal core-specific/stabilizing sensorimotor control exercise intervention with at least one pain intensity and disability outcome assessment at a follow-up (sustainability) timepoint of ≥ 4 weeks after exercise intervention completion. From the 3,415 studies that were initially retrieved, 10 (2 CTs & 8 RCTs) on N = 1081 patients were included in the review and analyses. Low to moderate quality evidence shows a sustainable positive effect of motor control exercise on pain (SMD = -.46, Z = 2.9, p < .001) and disability (SMD = -.44, Z = 2.5, p < .001) in low back pain patients when compared to any control. The subgroups' effects are less conclusive and no clear direction of the sustainability effect at short versus mid versus long-term, of the type of the comparator, or of the dose of the training is given. Low quality studies overestimated the effect of motor control exercises.

Study designSystematic review with meta-analysis and meta-regression.Background and objectivesWe systematically reviewed and delineated the existing evidence on sustainability effects of motor control exercises on pain intensity and disability in chronic low back pain patients when compared with an inactive or passive control group or with other exercises. Secondary aims were to reveal whether moderating factors like the time after intervention completion, the study quality, and the training characteristics affect the potential sustainability effects.MethodsRelevant scientific databases (Medline, Web of Knowledge, Cochrane) were screened. Eligibility criteria for selecting studies: All RCTs und CTs on chronic (≥ 12/13 weeks) nonspecific low back pain, written in English or German and adopting a longitudinal core-specific/stabilizing sensorimotor control exercise intervention with at least one pain intensity and disability outcome assessment at a follow-up (sustainability) timepoint of ≥ 4 weeks after exercise intervention completion.Results and conclusionsFrom the 3,415 studies that were initially retrieved, 10 (2 CTs & 8 RCTs) on N = 1081 patients were included in the review and analyses. Low to moderate quality evidence shows a sustainable positive effect of motor control exercise on pain (SMD = -.46, Z = 2.9, p < .001) and disability (SMD = -.44, Z = 2.5, p < .001) in low back pain patients when compared to any control. The subgroups’ effects are less conclusive and no clear direction of the sustainability effect at short versus mid versus long-term, of the type of the comparator, or of the dose of the training is given. Low quality studies overestimated the effect of motor control exercises.

Tactile thresholds are preserved yet complex sensory function is impaired over the lumbar spine of chronic non-specific low back pain patients: a preliminary investigation

Motor control stabilization exercise (MCSE) is evident for the management of chronic non-specific low back pain (LBP). The optimal dose for the maximal treatment success-response relationship is, thus, still unknown. PURPOSE: To systematically review the evidence for a dose-response relationship of MCSE on pain and disability in chronic non-specific LBP patients. METHODS: A systematic review with meta-regression was conducted. We searched in relevant scientific databases (Pubmed (Medline), Web of Knowledge, Cochrane). The eligibility criteria for the studies were: RCTs and CTs on chronic (≥ 12 weeks) non-specific LBP patients, written either in English or German and adopting a longitudinal MCSE intervention with at least one pain intensity and/or disability outcome assessment. Meta-regressions (dependent variable = effect sizes (Cohens d) of the interventions (once for pain and once for disability), independent variable = training characteristics (duration, frequency, time per session)) were conducted to reveal the optimal dose required for MCSE therapy success. RESULTS: From the 3,415 studies initially selected, 46 studies on n = 2,661 LBP patients were included in the analysis. N = 1,220 patients received MCSE; the training duration was 6.4 ± 2.3 weeks and the training frequency was 3.4 ± 2.0 sessions per week with a mean training time per session of 44.2 ± 17.7 min. The meta-regressions’ mean effect size was d = 1.7 for pain and 2.1, for disability, respectively. Total R2 was 0.34 and 0.38. Moderate quality evidence (R2 = 0.136) revealed that a training duration of 20 to 30 minutes elicited the largest effect (both in pain and disability, logarithmic association). Low quality evidence (R2 = 0.202) revealed that training 3 to 5 times per week led to the largest effect of MCSE in chronic non-specific LBP patients (inverted U-shaped association). Training duration showed no systematic variance explanation on the effect sizes. CONCLUSIONS: In non-specific chronic LBP patients, MCSE with a training frequency of 3 to 5 times per week (Grade C recommendation) and a training time per session of 20 to 30 minutes (Grade A recommendation) elicited the largest effect on pain and disability. Future work may focus on the definition of a minimum dosage for therapy success.

Nonspecific chronic low back pain is a multifactorial biopsychosocial health problem where accurate assessments of pain, function and movement are vital. There are few reliable and valid assessment tools evaluating movement quality, hence the aim was to investigate nonspecific chronic low back pain patients' movement patterns with the Standardised Mensendieck Test. Twenty patients (mean age=41, SD=9.02) with nonspecific chronic low back pain were examined with the Standardised Mensendieck Test whilst being videotaped and compared with 20 healthy controls. A physiotherapist, blinded to participant's group belonging, scored Standardised Mensendieck Test videos according to the standardised manual. Associations between movement quality, fear of movement and re(injury) i.e. kinesiophobia and pain intensity were also investigated. Patients scored significantly poorer than the controls in all 5 Standardised Mensendieck Test domains (p<0.001). The biggest difference was observed with regard to movement pattern domain. In women we also found a difference in the respiration pattern domain. The Standardised Mensendieck Test was able to detect significant differences in quality of movement between patients and healthy controls. These results indicate that the Standardised Mensendieck Test may be a valuable examination tool in assessment and treatment of nonspecific chronic low back pain patients. Further, longitudinal studies should investigate whether poor movement and respiration patterns are important factors in nonspecific chronic low back pain, e.g. as predictors and/or mediators of therapeutic effects.

BackgroundThe inflammatory profiles of patients with acute and chronic nonspecific low back pain (LBP) patients are distinct. Spinal manipulative therapy (SMT) has been shown to modulate the production of nociceptive chemokines differently in these patient cohorts. The present study further investigates the effect(s) of SMT on other inflammatory mediators in the same LBP patient cohorts.MethodsAcute (n = 22) and chronic (n = 25) LBP patients with minimum pain scores of 3 on a 10-point numeric scale, and asymptomatic controls (n = 24) were recruited according to stringent exclusion criteria. Blood samples were obtained at baseline and after 2 weeks during which patients received 6 SMTs in the lumbar or lumbosacral region. The in vitro production of tumor necrosis factor (TNFα), interleukin-1 β (IL-1β), IL-6, IL-2, interferon ɣ (IFNɣ), IL-1 receptor antagonist (IL-1RA), TNF soluble receptor type 2 (sTNFR2) and IL-10 was determined by specific immunoassays. Parametric as well as non-parametric statistics (PAST 3.18 beta software) was used to determine significance of differences between and within study groups prior and post-SMT. Effect size (ES) estimates were obtained using Cohen’s d.ResultsCompared with asymptomatic controls, SMT-related change scores were significant (P = 0.03–0.01) in reducing the production levels of TNFα in both patient cohorts and those of IL-6, IFNɣ and sTNFR2 (P = 0.001–0.02) in patients with chronic LBP. Above-moderate to large ES (d > 0.6–1.4) was observed for these mediators. Compared with respective baselines, a significant post-SMT reduction (P = 0.01) of IL-6 production was detected only in patients with chronic LBP while a significant increase of IL-2 production (P = 0.001 vs. control, and P = 0.004 vs. chronic LBP group) and a large ES (d = 0.87) were observed in patients with acute LBP. Pain and disability scores declined significantly (P < 0.001) in all LBP patients, and were positively correlated (P = 0.03) with IFNɣ and IL-2 levels in the acute LBP cohort.ConclusionThe short course of SMT treatments of non-specific LBP patients resulted in significant albeit limited and diverse alterations in the production of several of the mediators investigated in this study. This exploratory study highlights the potential of SMT to modulate the production of inflammatory components in acute and chronic non-specific LBP patients and suggests a need for further, randomized controlled clinical trials in this area.Trial registrationThis study was prospectively registered April 2012 with Clinical Trials.gov (#NCT01766141).https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0003ZIL&selectaction=Edit&uid=U0001V74&ts=2&cx=-axvqtg

A 2-group experimental design. To investigate differences in postural control strategies of pelvis and trunk movement between nonspecific chronic low back pain (CLBP) patients and healthy control subjects using 3-dimensional motion analysis. Increased postural sway assessed by center of pressure displacements have been documented in patients with low back pain (LBP). The 3-dimensional movement strategies used by patients with LBP to keep their balance are not well documented. Nineteen CLBP patients and 20 control subjects were included based on detailed clinical criteria. Every subject was submitted to a postural control test in an unstable sitting position. A 3-dimensional motion analysis system, equipped with 7 infrared M1 cameras, was used to track 9 markers attached to the pelvis and trunk to estimate their angular displacement in the 3 cardinal planes. The total angular deviation in all 3 directions of pelvis and trunk was higher in the CLBP group compared with the control group. In 4 of the 6 calculated differences, a significant higher deviation was found in the CLBP group (significant P-values between 0.013 and 0.047). Subjects of both groups mostly used rotation compared with lateral flexion and flexion/extension displacements of pelvis and trunk to adjust balance disturbance. The CLBP group showed a high correlation (Pearson: 0.912-0.981) between movement of pelvis and trunk, compared with the control group. A higher postural sway and high correlation between pelvis and trunk displacements was found in the LBP group compared with healthy controls.

Statistical Classification Model for nonspecific chronic low back pain (NS-CLBP) patients and controls based on parameters of motor control. Develop a Statistical Classification Model to discriminate between 2 subgroups of NS-CLBP (Flexion Pattern [FP] and Active Extension Pattern [AEP]) and a control group using biomechanical variables quantifying parameters of motor control. It has been well documented that many CLBP patients have motor control impairments of their lumbar spine. O'Sullivan proposed a mechanism-based classification system for NS-CLBP with motor control impairments based on a comprehensive subjective and physical examination to establish the relationship between pain provocation and spinal motor control. For the FP and AEP s, 2 groups defined by O'Sullivan and under investigation is this study, the motor control impairment is considered to be the mechanism maintaining their CLBP. No previous studies have used a Statistical Model with measurements of motor control impairment to subclassify NS-CLBP patients. Thirty-three NS-CLBP patients (20 FP and 13 AEP) and 34 asymptomatic subjects had synchronized lumbosacral kinematics and trunk muscle activation recorded during commonly reported aggravating postures and movements. Biomechanical variables were quantified and a Statistical Classification Model was developed. The Statistical Model used 5 kinematic and 2 electromyography variables. The model correctly classified 96.4% of cases. Selected biomechanical variables were predictors for subgroup membership and were able to discriminate the 3 subgroups. This study adds further support toward the validation of the proposed classification system.

The aim of this cross-sectional study was to compare data on the level of aerobic capacity and body composition of nonspecific chronic low back pain (CLBP) patients with normative data matched for sex, age and level of sporting activity. The study population consisted of 101 outpatients with nonspecific CLBP who had entered a rehabilitation programme. Results were as follows: the mean (standard deviation) aerobic capacity (VO2max) of CLBP patients was significantly (P<0.001) lower 7.3 (5.6) ml/kg lean body mass/min as compared with the normative data. The mean (standard deviation) body fat percentage of the patients was significantly (P<0.001) higher 3.9 % (5.9) as compared with the normative data. These results provide evidence of a reduced level of aerobic capacity and an increased body fat percentage in nonspecific CLBP patients compared with healthy participants.

The flexion-relaxation phenomenon (FRP) is frequently absent among non-specific chronic low back pain (NSCLBP) patients. However, it is unknown whether this absence is intrinsic to their pathology or merely a consequence of reduced trunk flexion. Immersive virtual reality (IVR) can create a patient avatar whose range of motion can be modulated to differ from the real movement. The present study enrolled 15 NSCLBP patients and 15 asymptomatic participants with similar characteristics to disentangle the relationship between range of motion and the FRP in NSCLBP using IVR. Trunk kinematics and lumbar muscle electromyography were assessed. The IVR environment was combined with a motion capture system to create avatars that moved like each participant. The IVR display showed a closed room and a mirror reflecting the subject’s avatar with a target line to be reached by trunk flexion. The avatar’s trunk movements were modulated from reality, leading the participants to flex their trunk more than their voluntary maximum trunk flexion. Under IVR conditions, NSCLBP patients significantly increased their trunk flexion angle, which was coupled with a significant improvement in the FRP. The absence of the FRP among the NSCLBP population appeared to be primarily related to reduced trunk flexion.

Non-specific chronic low back pain (NSCLBP) patients present with reduced back extensor muscle endurance which could be explained by the higher fatigability of their lumbar muscles. However, studies investigating lumbar muscle fatigability have shown contradictory findings. Furthermore, none investigated potential asymmetry in lumbar muscle fatigability, despite neuromuscular asymmetry being reported as a risk factor for NSCLBP. The present study's primary purpose was to determine whether NSCLBP patients presented with higher lumbar muscle fatigability and fatigability asymmetry than asymptomatic participants. Thirty NSCLBP patients and 23 asymptomatic participants performed the Sorensen test. The median frequencies from the electromyographs of the right and left erector spinae longissimus (ESL) and lumbar multifidus (LMF) were measured during the test. A linear regression was performed on the median frequencies on each muscle. Slope and initial median frequency were extracted to characterize fatigability. Asymmetry was quantified by the absolute differences between right-side and left-side muscle pairs. NSCLBP patients presented significantly poorer back extensor muscle endurance than asymptomatic participants. No differences were found between NSCLBP patients and asymptomatic participants in terms of fatigability or fatigability asymmetry for either the ESL or LMF. The initial median frequency in both muscles was significantly lower among NSCLBP patients. The present study showed that NSCLBP patients did not present higher fatigability or higher fatigability asymmetry in lumbar muscles than asymptomatic participants. The heterogeneity of the NSCLBP population, due to the absence of any specific etiology, may explain these findings. These slides can be retrieved under Electronic Supplementary Material.

The literature shows that low back pain causes a reduced lumbar range of movement, affecting patients’ proprioception and motor control. Nevertheless, studies have found that proprioception and motor control of the spine and posture are vague and individually expressed even in healthy young adults. This study aimed to investigate the standing posture and its modifications induced by an instinctive self-correction manoeuvre in subacute and chronic nonspecific low back pain (NSLBP) patients to clarify how NSLBP relates to body upright posture, proprioception, and motor control and how these are modified in patients compared to healthy young adults (121 healthy young adults: 57 females and 64 males). A cohort of 83 NSLBP patients (43 females, 40 males) were recruited in a cross-sectional observational study. Patients’ entire body posture, including 3D spine shape reconstruction, was measured using a non-ionising 3D optoelectronic stereophotogrammetric approach. Thirteen quantitative biomechanical parameters describing the nature of body posture were computed. The statistical analysis was performed using multivariate methods. NSLBP patients did not present an altered proprioception and motor control ability compared to healthy young adults. Furthermore, as for healthy subjects, NSLBP patients could not focus and control their posture globally. Proprioception and motor control in natural erect standing are vague for most people regardless of gender and concurrent nonspecific low back pain. Self-correction manoeuvres improving body posture and spine shape must be learned with specific postural training focusing on the lumbar spine.

The flexion relaxation phenomenon (FRP) is characterized by the reduction of paraspinal muscle activity at maximum trunk flexion. FRP is reported to be altered (persistence of spinal muscle activity) in more than half of nonspecific chronic low back pain (NSCLBP) patients. Little is known about how the multi-segmental spine affects FRP. The aim of this observational study was to investigate the relationship between FRP and kinematic parameters of the multi-segmental spine in NSCLBP patients. Forty NSCLBP patients and thirty-five asymptomatic participants performed a standing maximal trunk flexion task. Surface electromyography was recorded along the erector spinae longissimus. The kinematics of the spine were assessed using a 3D motion analysis system. The investigated spinal segments were upper thoracic, lower thoracic, thoracolumbar, upper lumbar, lower lumbar, and lumbopelvic. Upper lumbar ROM, anterior sagittal inclination of the upper lumbar relative to the lower lumbar in the upright position, and ROM of the upper lumbar relative to the lower lumbar during full trunk flexion were significantly correlated with the flexion relaxation ratio (Rho 0.42 to 0.58, p < 0.006). The relative position and movement of the upper lumbar segment seem to play an important role in the presence or absence of FRP in NSCLBP patients.

Objective -The primary objective of the study is to find out the effects of adding whole-body vibration therapy to conventional physiotherapy among chronic non-specific low back pain patients. Methodology:20 subjects with chronic non-specific low back pain patients were selected as samples. This study design is an experimental study and the study type is comparative. The duration of this study is 12 weeks within which whole body vibration therapy and conventional physiotherapy are given to the patients of group A and group B. subjects with chronic non-specific low back pain [ LBP], age group around 30 to 50, both males and females are included in this study. GROUP -A -Ten weeks of vibration therapy was provided to selected samples. All the subjects underwent baseline analysis and post-test analysis after ten weeks of intervention using the 3 selected outcome measures, namely the Roland Morris scale for pain, Oswestry disability index, and Visual analog scale. GROUP-B- was treated with conventional physiotherapy. Result: On comparing the between group analysis of the Roland-Morris scale, Oswestry disability index, and Visual analog scale. It has been found that there is no significant difference between group A and group.On comparing the within-group analysis, it has been found that there was a significant difference in the Roland-Morris scale of group A and group B of pre-test and post-test with the p-value 0.005. In Oswestry Disability index of group-A and group B for pre-test and post-test with ap-value of 0.005. In VAS of group A for pre-test and post-test with the p-value of 0.005 and group B with the p-value of 0.004. Conclusion: The study concluded that whole-body vibration therapy is more effective than conventional physiotherapy in treating with chronic non-specific low back pain

A cross-sectional comparative study between healthy controls and two subgroups of nonspecific chronic low back pain (LBP) patients. To determine differences in trunk muscle activation during usual unsupported sitting. Patients with LBP commonly report exacerbation of pain on sitting. Little evidence exists to confirm that subgroups of patients with nonspecific chronic LBP patients use different motor patterns in sitting than pain-free controls. A total of 34 pain-free and 33 nonspecific chronic LBP subjects were recruited. Two blinded clinicians classified nonspecific chronic LBP patients into two subgroups (active extension pattern and flexion pattern). Surface electromyography (sEMG) was recorded from five trunk muscles during subjects' unsupported "usual" and "slumped" sitting. No differences in trunk muscle activity were observed between healthy controls and nonspecific chronic LBP groups for usual sitting. When the classification system was applied, differences were identified. Compared with no-LBP controls, the active extension pattern group presented with higher levels of cocontraction of superficial fibers of lumbar multifidus (12%), iliocostalis lumborum pars thoracis (36%) and transverse fibers of internal oblique (43%). while the flexion pattern group showed a trend toward lower activation patterns (lumbar multifidus, -7%; iliocostalis lumborum pars thoracis, -6%, and transverse fibers of internal oblique, -5%). The flexion relaxation ratio of the back muscles was lower for nonspecific chronic LBP (superficial lumbar multifidus: t = 4.5; P < 0.001 and iliocostalis lumborum pars thoracis:t = 2.7; P < 0.001), suggesting a lack of flexion relaxation for the nonspecific chronic LBP. Subclassifying nonspecific chronic LBP patients revealed clear differences in sEMG activity during sitting between pain-free subjects and subgroups of nonspecific chronic LBP patients.