Cheng Kin-wing. / "May 1999." / Thesis (Ph.D.)--Chinese University of Hong Kong, 1999. / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web. / Abstracts in English and Chinese.

PhD / Abstract Low back pain is a significant public health problem in many countries of the world being one of the major causes of work absence and disability. Although the outlook for evidence-based management of low back pain has greatly improved over the past decades, many questions remain. Questions related to treatment options, underlying mechanisms of treatment effects and optimal assessment of low back pain have yet to be fully addressed by researchers. The broad aim of this thesis therefore was to contribute to a better understanding of the contemporary management of low back pain by performing studies in these key research areas. Most clinical practice guidelines recommend exercise as an effective treatment option for chronic low back pain. However the evidence for this recommendation comes from trials that are not placebo-controlled and so this may potentially provide biased estimates of the effects of exercise. Therefore a randomised controlled trial testing the effect of motor control exercise versus placebo in patients with chronic low back pain was conducted. Chapters 2 and 3 describe the trial protocol and the report of the trial respectively. A total of 154 patients with chronic low back pain were randomised to receive a motor control exercise program, or placebo (i.e. detuned short-wave therapy and detuned ultrasound therapy). Primary outcomes were pain, function, and the patient’s global impression of recovery measured at 2 months. The exercise intervention improved function and patient’s global impression of recovery, but not pain, at 2 months. The mean effect of exercise on function was 1.1 points (95%CI, 0.3 to 1.8), the mean effect on global impression of recovery was 1.5 points (95%CI, 0.4 to 2.5) and the mean effect on pain was 0.9 points (95%CI, - 0.01 to 1.8), all measured on 11 point scales. Secondary outcomes also favoured motor control exercise. This is the first study ever to demonstrate that motor control exercise is better than placebo for patients with chronic low back pain. Most of the treatment effects were maintained at 6 and 12 months follow-up. These results suggest that this intervention should be considered for patients with chronic low back pain in order to improve disability, function, and global impression of recovery, and to improve pain intensity in the long term, but not in the short term. Rehabilitative ultrasound imaging (RUSI) has been increasingly used by physiotherapists in order to identify impairments in motor control as well as to monitor progress of patients with low back pain. As with any other clinical measure it is important to know how reproducible the RUSI measures are, and although there are some reproducibility studies in the literature, no systematic review on this topic has been conducted. Therefore a systematic review was performed with the objective of assessing the reproducibility studies of RUSI for abdominal wall muscles (Chapter 4). Eligible studies were indentified via searches in CINAHL, EMBASE and MEDLINE with citation tracking via the Web of Science Index. A total of 21 studies were included. Due to heterogeneity of the studies’ designs, pooling the data for a meta-analysis was not possible. RUSI measures of thickness of abdominal wall muscles were found to be reliable. Few studies analysed the reliability for the measurement of thickness changes (reflecting the muscle activity) finding good to poor results. Evidence for the reproducibility of the difference in thickness changes over time (necessary to evaluate improvements in muscle activity with treatment) was not available. A limitation of the existing literature is that studies typically had suboptimal designs and analysis. The current evidence for the reproducibility of RUSI for measuring abdominal muscle activity is mainly based upon studies with suboptimal designs that included mostly healthy subjects, making generalisability to clinical settings uncertain. Some questions about the reproducibility of RUSI measures of abdominal wall muscles are still unanswered; this is mainly due to design issues, such as inadequate statistics, inadequate sampling and lack of control of sources of bias (e.g. blinding and absence of controlling for ordering effects). In addition the clinically important questions about the reproducibility of thickness changes (reflecting the muscle activity) and differences in thickness changes over time (reflecting the improvement or deterioration of muscle activity) have not been adequately investigated. Therefore a reproducibility study that aimed to answer these questions was performed (Chapter 5). Thirty-five patients seeking care for chronic low back pain participated in this study. RUSI measures were taken at baseline and eight weeks post-baseline. Replicate measures of thickness, thickness changes and differences in thickness changes over time were analysed. The reproducibility of static images (thickness) was excellent (ICC2,1 = 0.97, 95%CI = 0.96-0.97, Standard Error of the Measurement (SEM) = 0.04cm, Smallest Detectable Change (SDC) = 0.11cm), the reproducibility of thickness changes was moderate (ICC2,1 = 0.72, 95%CI 0.65-0.76 SEM = 15%, SDC 41%), while the reproducibility of differences in thickness changes over time was poor. Improvements in the test protocol should be undertaken in order to enhance the reproducibility of RUSI measures, especially for differences in thickness chang over time. Self-report outcome measures (questionnaires) are widely used by health care providers for measuring patient’s health status or treatment outcomes. Most of the questionnaires related to low back pain were developed in English and therefore their usefulness in non-English speaking countries is considerably limited. Cross-cultural adaptation and clinimetric testing are possibly the most efficient methods for solving this problem. Although there are many publications on the topic, a simple guide on how to perform a cross-cultural adaptation and clinimetric testing was not available. Therefore a “clinician-friendly” narrative review for Brazilian physical therapists (Chapter 6) was written. This review aimed firstly to explain the concepts and the relevance of cross-cultural adaptation and clinimetrics testing, secondly to summarise the current guidelines on the topic, thirdly to provide advice on how to choose a relevant questionnaire and finally how to evaluate the quality of an adapted questionnaire. Some examples of cross-cultural adaptations and clinimetrics testing of relevant low back pain questionnaires in the Brazilian-Portuguese language were also provided. Although the number of international versions of low back questionnaires is growing, to date it is unclear which questionnaires have been cross-culturally adapted and into which specific language. To answer these questions a systematic review was conducted in order to describe the available cross-cultural adaptations of low back pain self-report outcome measures and the clinimetric testing that has occurred for each adaptation (Chapter 7). Searches were performed in MEDLINE, EMBASE, CINALH and LILACS; these searches were supplemented with information from experts in the field of low back pain from 27 different countries to ensure that the results were comprehensive. Sixty-one adaptations were identified. While there are a large number of low back pain questionnaires available, very few have been adapted into other languages, particularly commonly spoken languages such as Mandarin, Hindi and Portuguese. The quality and comprehensiveness of clinimetric testing varied considerably, with the evaluation of reliability and construct validity most common. Further cross-cultural adaptation and clinimetric studies are clearly needed and special consideration must be given to study designs for clinimetric testing. The final aim of this thesis was to cross-culturally adapt self-report instruments relevant to the management of low back pain in Brazil. This was achieved by two independent studies. The first study (Chapter 8) aimed to cross-culturally adapt the Functional Rating Index (FRI) into Brazilian-Portuguese and to test the clinimetric properties of the FRI and also of an existing Brazilian-Portuguese version of the Roland Morris Disability Questionnaire (RMDQ) which was not fully evaluated in the original study. Both instruments were tested for internal consistency, reliability, construct validity, ceiling and floor effects and internal responsiveness in 140 chronic low back patients presenting for physiotherapy treatment in Brazil. Both instruments were considered reliable and valid for the measurement of disability in Brazilian-Portuguese speakers with low back pain, no ceiling or floor effects were detected, but the internal responsiveness of both instruments was considered small. The second study (Chapter 9) aimed to cross-culturally adapt the Patient-Specific Functional Scale (PSFS) and to perform a head-to-head comparison of the clinimetric properties of the PSFS, RMDQ and FRI. All instruments were tested for internal consistency, reliability, construct validity, ceiling and floor effects, internal and external responsiveness in 99 acute low back patients presenting for physiotherapy treatment in Brazil. In order to fully test the construct validity and external responsiveness, it was necessary to cross-culturally adapt the Pain Numerical Rating Scale and the Global Perceived Effect Scale. The results of this study demonstrate that the Brazilian-Portuguese versions of the RMDQ, FRI and PSFS have similar clinimetric properties to each other and to the original English versions; however the PSFS was the most responsive instrument. The results from the studies in Chapters 8 and 9 will benefit the understanding of low back pain by enabling international comparisons between studies conducted in Brazil and English speaking countries. In addition it will encourage researchers to include Brazilian- Portuguese speakers in their future clinical trials. Overall, the studies included in this thesis have provided an important contribution to the contemporary management of low back pain. Firstly the use of motor control exercise could be considered for patients with chronic low back pain as it produces improvements in global impression of recovery, function, disability and pain. Secondly RUSI measures of abdominal wall muscles in patients with low back pain were considered reproducible for the measurement of muscle activity, but not as an outcome measure to detect improvement/deterioration of muscle activity over the course of treatment. Thirdly just a few high-quality cross-cultural adaptations and clinimetrics testing for self-report outcome measures relevant to the management of low back pain are available, and clearly more studies in this area are needed. Finally the Brazilian-Portuguese versions of the Functional Rating Index, the Roland Morris Disability Questionnaire and the Patient-Specific Functional Scale have acceptable clinimetric properties and could be used in clinical practice as well as in research studies in Brazil.

Background: Low back pain (LBP) and low back related disorders are highly prevalent and associated with a considerable burden of pain, disability and work loss. People with a variety of low back-related complaints comprise a large proportion of referrals made to orthopedic surgeons and many of these patients are not considered to be surgical candidates or have not maximized their non-surgical options for managing their low back-related complaints. Objectives: We sought to evaluate the impact of a triage assessment program delivered by physiotherapists using a variety of approaches. Informed by a biopsychosocial model, the objectives of this dissertation were: 1) To determine the short term impact of a physiotherapy triage assessment for people with low back-related disorders on participant self-reported pain, function and quality of life and patient and referring practitioner satisfaction. 2) To determine which demographic, clinical, psychosocial and environmental factors are predictive of improved self-reported pain, function, quality of life and participant and referring practitioner satisfaction. 3) To determine the diagnostic and treatment recommendation concordance between physiotherapists and orthopaedic surgeons, using a newly developed clinical classification tool, for people presenting to a spinal triage assessment service with low back complaints. Methods: Two approaches were used to achieve the aforementioned objectives: a prospective observational study (n=115) to address the first two objectives and a sub-group reliability study (n=45) to address the third objective. Results: There was a mean overall significant improvement in the SF-36 Physical Component Summary at the 4-6 week post-test time point and relatively high satisfaction reported by participants and referring care providers. Qualitative analysis of comments revealed a variety of positive, negative and other contextual factors that may impact outcomes. A variety of different sociodemographic, psychological, clinical and other variables were associated with success or improvement in each respective outcome. There may be a potential mechanism of reassurance that occurs during the spinal triage assessment process as those with higher psychological distress were more likely to improve on certain outcomes. There was high diagnostic concordance between physiotherapists and an orthopaedic surgeon; however, there were more differences in management recommendations between the surgeon and a solo physiotherapist versus physiotherapists working in a collaborative team. Conclusions: A spinal triage assessment program delivered by physiotherapists has the potential to positively impact a variety of patient-related short term outcomes including satisfaction. Further study is needed to examine longer-term outcomes and which biopsychosocial factors may impact these outcomes.

Purpose: Biomechanical differences between people with low back pain (LBP) and healthy controls have been shown previously. LBP has been associated with standing postures in occupational settings. A transient pain-generating model allows for comparisons between pain developers (PD) and non-pain developers (NPD). The first objective was to utilize a multifactorial approach to characterize differences between PD and NPD individuals. The second objective was to investigate the impact of exercise on LBP during standing. Methods: Forty-three participants without any history of LBP volunteered for this study. Participants performed pre- and post-standing functional movements and 2-hours of standing. Continuous electromyography (EMG) data were collected from 16 trunk and hip muscles, kinematic and kinetic data were used to construct an 8-segment rigid link model. Vertebral joint rotation stiffness (VJRS) measures were calculated. Participants completed visual analog scales (VAS) rating LBP every 15 minutes during the 2-hr standing. Participants were classified as PD or NPD based on greater than 10 mm increase in VAS. Participants were assigned to exercise (EX) or control (CON) groups. All participants returned for a second data collection following 4-weeks. Results: Forty percent of participants developed LBP during standing. The PD group had elevated muscle co-activation prior to reports of pain (p < 0.05). Following standing, there was a decrease in VJRS about the lateral bend axis during unilateral stance. PDEX had decreased VAS scores during the second data collection (p = 0.007) compared with PDCON. Male PDEX had decreased gluteus medius co-activation during standing (p < 0.05). Between-day repeatability for the CON groups was excellent with intraclass correlation coefficients > 0.80 for the majority of the outcome measures. Conclusions: There were clear differences between PD/NPD groups in muscle activation patterns, prior to subjective reports of LBP, supporting the hypothesis that some of the differences observed between these groups may be predisposing rather than adaptive. An exercise intervention resulted in positive changes in the PD group, both in subjective pain scores as well as muscle activation profiles. Elevated muscle co-activation in the first 15-30 minutes of standing may indicate that an individual is at increased risk for LBP during standing.

Purpose: Biomechanical differences between people with low back pain (LBP) and healthy controls have been shown previously. LBP has been associated with standing postures in occupational settings. A transient pain-generating model allows for comparisons between pain developers (PD) and non-pain developers (NPD). The first objective was to utilize a multifactorial approach to characterize differences between PD and NPD individuals. The second objective was to investigate the impact of exercise on LBP during standing. Methods: Forty-three participants without any history of LBP volunteered for this study. Participants performed pre- and post-standing functional movements and 2-hours of standing. Continuous electromyography (EMG) data were collected from 16 trunk and hip muscles, kinematic and kinetic data were used to construct an 8-segment rigid link model. Vertebral joint rotation stiffness (VJRS) measures were calculated. Participants completed visual analog scales (VAS) rating LBP every 15 minutes during the 2-hr standing. Participants were classified as PD or NPD based on greater than 10 mm increase in VAS. Participants were assigned to exercise (EX) or control (CON) groups. All participants returned for a second data collection following 4-weeks. Results: Forty percent of participants developed LBP during standing. The PD group had elevated muscle co-activation prior to reports of pain (p < 0.05). Following standing, there was a decrease in VJRS about the lateral bend axis during unilateral stance. PDEX had decreased VAS scores during the second data collection (p = 0.007) compared with PDCON. Male PDEX had decreased gluteus medius co-activation during standing (p < 0.05). Between-day repeatability for the CON groups was excellent with intraclass correlation coefficients > 0.80 for the majority of the outcome measures. Conclusions: There were clear differences between PD/NPD groups in muscle activation patterns, prior to subjective reports of LBP, supporting the hypothesis that some of the differences observed between these groups may be predisposing rather than adaptive. An exercise intervention resulted in positive changes in the PD group, both in subjective pain scores as well as muscle activation profiles. Elevated muscle co-activation in the first 15-30 minutes of standing may indicate that an individual is at increased risk for LBP during standing.

The problem of low back pain is visibly increasing. About 80% of the population suffers from low back pain. Recently, the factors that affect lumbar stability have been an area of extensive research. The purpose of this study is to assess the effects of lumbar stabilization exercises program for young women (19-20 years) with low back pain. The following objectives were put forward: to assess stability of lumbar spine of young women before applying exercises program and after 10 weeks of muscular strengthening exercises around the lumbar spine; to evaluate changes in the core muscles before and after specific stabilization exercises and pain assessment. The study included a group of 37 young women (19-20 years), who felt low back pain at least once in their life. All participants were randomly allocated to either training group, which consisted of 20 young women or control group, which consisted of 17 participants. The subjects in the training group attended two supervised 1 hour exercise sessions per week for 10 weeks. A program of special physical exercises to improve core musculature was created for them. The exercise training program required training of deep muscles. In order to retrain the deep muscles, specific and testing with the STABILIZER was required. The control subjects continued their usual physical activities during the week. Both groups were assessed similarly two times: before training began and after it ended.mekis.

Chronic low back pain (CLBP) is a challenging problem in Nova Scotia and is a leading cause of disability and a contributor to high health related costs to the system. The primary objective of this thesis is to develop and test a methodology for the creation of an electronic standardized assessment tool for chronic conditions such as CLBP using a triangulation method. The methodology involves evidence-based, expert and explicit clinical knowledge in the development of the tool. The outcome of this research is the development of a methodology model for the generation of electronic standardized assessment form for CLBP with 30 predictive factors. Experts evaluated the form for its use and usefulness, usability, and standardized terminologies. Intra-Class Correlation (ICC) and Cronbach’s alpha were used to measure inter-rater reliabilities among experts. The results were in the fair and moderate levels of agreement due to the limitation in sample size and the variation of disciplines among participants.

Purpose: The overall aim of this thesis is to contribute new knowledge by examining psychosocial factors and return-to-work profiles of occupational low back pain patients in a rehabilitation clinic. Outcome measures for injured workers with subacute low back pain included: change in measures, program utilization, pain profiles and return-to-work. Methods: A total of 147 patients who met the eligibility criteria and consented, participated in a clinic-based, individualized, exercise-based treatment that included patient education and reassurance. A before-and-after design was used, with data collection on admission to and discharge from the program. Results: Pre-to-post analyses revealed that statistically significant improvements had occurred. However, subgroup analyses revealed differences in responses to treatment among the subgroups. Specifically, two sets of cluster analyses were conducted; each yielded two distinct subgroups of patients, one set with different lengths of time in the program, and another showing two pain intensity profiles. Furthermore, return-to-work rates varied between the groups although the overall return-to-work rate appeared high. Conclusion: Significant improvement was achieved following participation in the return-to-work rehabilitation program. However, participants with subacute nonspecific low back pain do not form a homogenous group in terms of their clinical presentation and responses to rehabilitation. Therefore, special attention might be warranted for subgroups within the sample, whom are at an increased risk for prolonged disability. / Thesis (Ph.D, Kinesiology & Health Studies) -- Queen's University, 2007-09-28 15:40:39.13

No description available.

Dissertation submitted in partial compliance with the requirements for the Masters Degree in Technology: Chiropractic, Durban University of Technology, 2010. / Background: Low back pain (LBP) is the most prevalent musculoskeletal condition experienced by human beings and the most common cause of disability in developed nations. Psychosocial factors, involving aspects of social and psychological behaviour, have previously been documented as potential risk factors in the development of adult LBP. However, more research is required to fully understand the role of psychosocial risk factors on the prevalence of LBP amongst adolescents. Objective: To determine the prevalence of LBP and to identify selected psychosocial risk factors associated with LBP amongst Grade 12 learners in the Greater Durban area. Methods: A population-based study was conducted amongst a stratified random sample of 20 public secondary schools in all three educational districts in the Greater Durban area. Data was collected by means of a structured questionnaire administered to the sample population consisting of Grade 12 learners. Using an exploratory research design, the individuals reported on demographics as well as prevalence, severity, frequency and chronicity of LBP. In addition, data was obtained regarding various psychosocial risk factors including depression, exam stress and anxiety, socio-economic status, family history of LBP, smoking, alcohol and drug abuse amongst the respondents. Results: The prevalence of LBP was 57.42% with a median frequency of 8 times a month. About a third (33.9%) of the respondents experienced difficulty bending whilst 35% reported that their LBP spread down to the legs below their knees. The daily activity most affected by LBP was having a good night‟s sleep (50.6%), followed closely by playing sports (47.4%) and concentrating in class (46.6%). The majority of the respondents that suffered from LBP had taken pain relief medication (47.1%) whilst only 21% of the respondents had missed school because of LBP. With regards to the psychosocial risk factors under investigation, three of the risk factors did not show any association to LBP. They included socio-economic status, smoking and recreational drug use. In contrast, five psychosocial risk factors showed an 6 association to LBP. They included alcohol abuse, family history, exam stress, anxiety and depression. Finally, after adjusting for all other risk factors for adolescent LBP, depression and high exam stress showed the strongest correlation with the occurrence of LBP amongst Grade 12 learners in the Greater Durban area. Conclusion: LBP amongst adolescents is a common problem that increases with age, representing a risk for LBP in adulthood. The researcher is of the opinion, that this illustrates the need for further investigations with more profound studies on the risk factors so that more light can be shed on how to manage this ever-growing problem.