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.

Thesis (M.S.)--University of Wisconsin-Madison, 1992. / Typescript. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 77-96).

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Includes bibliographical references and index.

Back pain is a very common musculoskeletal impairment in most Americans. Average annual occurrence of back pain is reported around 30% of the population and is the most common cause of activity limitation in people younger than 45 years old. Eighty percent of the back pain presents in the lumbar spine. Although this ailment is very prevalent in the American population, there is a lack of empirical evidence supporting the common clinical diagnosis and intervention back pain strategies. The frequency of back pain and the lack of treatment methods were the motivation for this investigation. It is important to better understand spine dynamics during ambulatory tasks of daily activities to identify possible biomechanical mechanisms underlying back pain. Current biomechanical quantification methods for spine dynamics are either too invasive or not detailed enough to fully comprehend detailed spinal movement. Therefore, a non-invasive but detailed procedure to calculate spine dynamics was developed and tested. In this study, multi-segmented spine dynamics (kinematics and kinetics) were calculated during four activities of daily living (level walking (W), obstacle crossing (OC), stair ascent (SA) and stair descent (SD)). Our findings suggested an in-vivo multi-segmented spine surface marker set is able to detect different and repeatable motion patterns during walking among various spinal segments. The sacrum to lower lumbar (SLL) joint had the largest range of motion (ROM) when compared to the other more superior joints (lower lumbar to upper lumbar and upper lumbar to lower thoracic). Furthermore, SA task demonstrated more flexion ROM than both W and SD tasks. In addition to task influence, joints at different spine levels also demonstrated different ROMs, where SLL had a greater ROM than upper lumbar to lower thoracic (ULLT) in the transverse plane. Age was found to not significantly affect the segmental spinal ROM or peak angles. The vertical segmental joint reaction forces were different between tasks, where SD yielded larger vertical reaction forces than W. Overall, findings from this dissertation work were able to show that a multi-segment spine marker system could be an effective tool in determining different spinal dynamics during various activities of daily living. This dissertation includes unpublished co-authored material.

Made available in DSpace on 2014-06-11T19:22:48Z (GMT). No. of bitstreams: 0 Previous issue date: 2011-06-07Bitstream added on 2014-06-13T19:28:12Z : No. of bitstreams: 1 nascimento_prc_me_prud.pdf: 2117913 bytes, checksum: 76ca018a3d60c5ded0fc7231909206b0 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / A lombalgia é uma afecção de alta incidência que gera grandes custos ao sistema de saúde. Indivíduos que experimentam um quadro álgico agudo na região lombar geralmente têm um bom prognóstico com recessão dos sintomas em algumas semanas, porém, uma parte das manifestações torna-se crônica e em sua grande maioria não apresentam uma causa, sendo assim denominada, lombalgia crônica não específica (LCNE). Entretanto, alguns relatos mostraram que fatores psicossociais estão fortemente ligados na manutenção ou regressão dos sintomas. Como alguns pacientes apresentam resposta positiva ao tratamento e outros não manifestam melhora, nos é permitido pensar que há outros fatores condicionantes da manifestação que precisam ser levantados. Através deste estudo buscamos averiguar a existência de uma associação entre a formação de um vínculo positivo entre paciente e terapeuta avaliada através do inventário de aliança terapêutica (IAT) e o recrutamento adequado dos músculos abdominais profundos. Participaram deste estudo 13 indivíduos com LCNE, estes sujeitos foram envolvidos em um programa de tratamento englobando exercícios de controle motor com oito semanas de duração. Ao final do estudo as variáveis de interesse foram analisadas revelando a existência de uma tendência na melhora do recrutamento do músculo transverso abdominal (TrA) quando há o estabelecimento de... / The low back pain is a high incidence condition which has enormous economic costs to the health system. Subjects who experience an acute painful episode in the lumbar region generally have a good prognosis with recession of symptoms in a few weeks, but some of these events become chronics and mostly do not have a cause, being so named, non-specific chronic low back pain (NS-CLBP). However, some reports have showed that psychosocial factors are strongly connected with the maintenance or regression of the symptoms. As some patient present positive response to treatment and others not show get better we can think that there are others factors conditioning of the manifestation which need to be raised. In this study we sought to determine the existence of an association between a formation of the positive bond between patient and therapist assessed by the working alliance inventory (WAI) with adequate recruitment of the deep abdominal muscles. Thirteen individual with NS-CLP participated of this study, these subjects were involved in a treatment program that included motor control exercise with 8 weeks of duration. After the study, the variables of interest were analyzed revealing the existence of trend for improve recruitment of the transversus abdominis muscle (TrA) when there is development... (Complete abstract click electronic access below)

Orientador: Rúben de Faria Negrão Filho / Banca: Fabio Micolis de Azevedo / Banca: Leonardo Oliveira Pena Costa / Banca: Maria Rita Masselli / Resumo: A lombalgia é uma afecção de alta incidência que gera grandes custos ao sistema de saúde. Indivíduos que experimentam um quadro álgico agudo na região lombar geralmente têm um bom prognóstico com recessão dos sintomas em algumas semanas, porém, uma parte das manifestações torna-se crônica e em sua grande maioria não apresentam uma causa, sendo assim denominada, lombalgia crônica não específica (LCNE). Entretanto, alguns relatos mostraram que fatores psicossociais estão fortemente ligados na manutenção ou regressão dos sintomas. Como alguns pacientes apresentam resposta positiva ao tratamento e outros não manifestam melhora, nos é permitido pensar que há outros fatores condicionantes da manifestação que precisam ser levantados. Através deste estudo buscamos averiguar a existência de uma associação entre a formação de um vínculo positivo entre paciente e terapeuta avaliada através do inventário de aliança terapêutica (IAT) e o recrutamento adequado dos músculos abdominais profundos. Participaram deste estudo 13 indivíduos com LCNE, estes sujeitos foram envolvidos em um programa de tratamento englobando exercícios de controle motor com oito semanas de duração. Ao final do estudo as variáveis de interesse foram analisadas revelando a existência de uma tendência na melhora do recrutamento do músculo transverso abdominal (TrA) quando há o estabelecimento de... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The low back pain is a high incidence condition which has enormous economic costs to the health system. Subjects who experience an acute painful episode in the lumbar region generally have a good prognosis with recession of symptoms in a few weeks, but some of these events become chronics and mostly do not have a cause, being so named, non-specific chronic low back pain (NS-CLBP). However, some reports have showed that psychosocial factors are strongly connected with the maintenance or regression of the symptoms. As some patient present positive response to treatment and others not show get better we can think that there are others factors conditioning of the manifestation which need to be raised. In this study we sought to determine the existence of an association between a formation of the positive bond between patient and therapist assessed by the working alliance inventory (WAI) with adequate recruitment of the deep abdominal muscles. Thirteen individual with NS-CLP participated of this study, these subjects were involved in a treatment program that included motor control exercise with 8 weeks of duration. After the study, the variables of interest were analyzed revealing the existence of trend for improve recruitment of the transversus abdominis muscle (TrA) when there is development... (Complete abstract click electronic access below) / Mestre

Motion and motor patterns of low back pain (LBP) sufferers have been demonstrated as different compared to those without LBP. The mechanism behind such movement alterations is not well known but is believed to be related to pain. Current biomechanical measurement of lumbar curvature and kinematics has limitations for routine clinical use. The aims of this research were to (1) investigate new motion analysis technology for dynamic lumbar curvature (fibre-optic sensors) and higher order kinematic assessment (inertial sensors) within a clinical environment; (2) determine the effect of pain relief on lumbar curvature, kinematics and muscle function in acute low back pain (ALBP) and chronic low back pain (CLBP) sufferers. Dynamic lumbar curvature was found to be reliably measureable in the clinic. Additional analysis demonstrated that regional curvature, as well as sequencing of curvature change measurement was possible. ALBP sufferers display less peak curvature during flexion and lifting compared to CLBP sufferers and both groups demonstrated the greatest curvature change in the second quartile for flexion and lifting and first for extension. Partial pain relief did not increase curvature in either group, and neither group was more likely to respond to pain relief by increasing curvature or altering sequencing. Higher order kinematics could be reliably and readily indentified in the clinic using inertial sensors. Movement-velocity plots were employed to describe the movement trajectory and irregularity. Multivariate analysis of variance revealed that neither partial pain relief (pre vs post) nor chronicity (acute vs chronic) had any effect on lumbar kinematics. Individuals appeared to exhibit different electromyography profiles. Those individuals with little deviation in muscle activation commonly displayed lower kinematic values. Partial pain relief did not alter the pattern of EMG profile, muscle onset timing or peak amplitude. These results suggest that clinicians should not expect automatic alterations in motion and motor patterns following interventions which target and achieve partial pain relief.

Faculty of Health Sciences School of Therapectic Sciences 0213128j 0117899331 / The Pilates exercise method applies many of the principles of lumbar stabilisation that have been found to be effective in the treatment of chronic low back pain. Pilates has recently found its way into the physiotherapy setting, where it is being integrated into the rehabilitation of patients with low back pain. This study consisted of a randomised control trial using an intervention group that underwent a twelve-week Pilates programme, and control group that continued with standardised physiotherapy treatment as necessary. Baseline, three-week, and twelve-week scores for a Visual Analogue Scale for pain and the Roland Morris Disability Questionnaire were recorded and compared. The Pilates group showed significantly greater improvements in pain and functional disability mean scores when compared to the control group (p=0.059 and p=0.026 respectively). It therefore appears that Pilates can be recommended as an effective treatment modality for the reduction of pain and the improvement of functional disability for chronic low back pain sufferers.

Yes / Background/Aims: This research explored the reasons why patients with low back pain chose not to return to physiotherapy following an assessment. Methods: Qualitative, semi-structured interviews were conducted using five participants with low back pain. Data were analysed to produce codes, categories and themes. Findings: Data analysis produced expectations, communication and satisfaction as key themes. Findings suggest that expectations may and may not be linked to previous physiotherapy experience, with no clear link between expectations and satisfaction. Communication including sufficient time, listening skills, empathy, and caring qualities were highly regarded. Satisfaction levels were rated highly, despite not returning to physiotherapy. Participants reported pain resolution and personal choice as reasons for not returning. Conclusions: Findings support previous research suggesting expectations are multifaceted and individualised and not always linked to previous experience. Findings suggest the physiotherapist's excellent communication skills ensured an overall positive patient experience, maintaining high satisfaction levels.