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<p>Neurodynamics refers to the mechanical and physiological components of</p> <p>the nervous system and the interconnections between them (Shacklock, 1995).</p> <p>This is a phase 1 pilot trial investigating the immediate effect of a neurodynamic</p> <p>treatment as compared to a sham treatment in eight participants with low back</p> <p>pain. Primary outcome measures included: H-reflex latency and nerve</p> <p>conduction velocity. Secondary outcome measures included: the sitting slump</p> <p>test and visual analog scale for pain following a neurodynamic treatment</p> <p>compared to a sham treatment on eight participants with low back pain. T-tests</p> <p>were used to analyze any differences between the groups at baseline and post-</p> <p>intervention. No statistically significant differences were observed between the</p> <p>groups at baseline. Statistically significant differences were noted post-</p> <p>intervention between the treatment groups for H-reflex latency (t(5)=4.323,</p> <p>p=0.008) and the unaffected leg sitting slump test (t(5)=3.402, p=0.019). The H-</p> <p>reflex latency increased for the group following the neurodynamic treatment and</p> <p>decreased following the sham treatment. This was not expected and is of</p> <p>interest due to the possible mechanisms that may be underlying these</p> <p>phenomena. Despite the small sample size used in this study, differences were</p> <p>observed and displayed trends that were unanticipated. These between-group</p> <p>differences are of interest but require further investigation using a larger sample</p> <p>population. Sample size calculations for future studies based on the primary</p> <p>outcome measures yielded a sample of 2008 participants. This accounted for</p> <p>both a 20% difference between the two groups and a 20% dropout rate. Future</p> <p>studies need to investigate the most beneficial length of time, type and dosage of</p> <p>neurodynamic treatments, as well as, the most appropriate times to assess the</p> <p>outcome measures. Comparison to controls would be beneficial in subsequent</p> <p>studies.</p> / Master of Science Rehabilitation Science (MSc)

Low back pain is a common medical problem around the world afflicting 80% of the population some time in their life. Low back injury can result from a loss of torso stability causing excessive strain in soft tissue. This investigation seeks to apply existing methods to new applications and to develop new methods to assess torso stability. First, the time series averaged finite time Lyapunov exponent is calculated from data obtained during seated stability experiments. The Lyapunov exponent is found to increase with increasing task difficulty. Second, a new metric for evaluating torso stability is introduced, the threshold of stability. This parameter is defined as the maximum task difficulty in which dynamic stability can be maintained for the test duration. The threshold of stability effectively differentiates torso stability at two levels of visual feedback. Third, the state space distribution of the finite time Lyapunov exponent (FTLE) field is evaluated for deterministic and stochastic systems. Two new methods are developed to generate the FTLE field from time series data. Using these methods, Lagrangian coherent structures (LCS) are found for an inverted pendulum, the Acrobot, and planar wobble chair models. The LCS are ridges in the FTLE field that separate two inherently different types of motion when applied to rigid-body dynamic systems. As a result, LCS can be used to identify the boundaries of the basin of stability. Finally, these new methods are used to find the basin of stability from time series data collected from torso stability experiments. The LCS and basins of stability provide a richer understanding into the system dynamics when compared to existing methods. By gaining a better understanding of torso stability, it is hoped this knowledge can be used to prevent low back injury and pain in the future. These new methods may also be useful in evaluating other biodynamic systems such as standing postural sway, knee stability, or hip stability as well as time series applications outside the area of biomechanics. / Ph. D.

A significant driver of pain in low back pain (LBP) is alteration to endogenous pain modulation (EPM). EPM can be measured using quantitative sensory tests (QST), which provides important information on nociceptive pathways. Exercise therapy is recommended as the first line of care for LBP; however, there is limited information on the mechanisms of action that lead to symptom improvements. The first manuscript was a scoping review that summarized protocols used to assess EPM using QST such as pain pressure threshold (PPT), temporal summation (TS), conditioned pain modulation (CPM) or exercise-induced hypoalgesia (EIH) in LBP. Scientific databases were searched for articles that used QST or EIH protocols in LBP. In total, 193 studies were included in this review: 172 used PPT, 54 used TS and 53 used CPM and 5 investigated EIH. There was high variability in the type of equipment, timing, trials, and testing location with many studies not reporting this information. The results demonstrate a need for standardized protocols and reporting guidelines as well as further research to aid in selecting the most appropriate QST parameters for different clinical presentations. The second manuscript was a pilot study that assessed the feasibility of a protocol investigating if changes in EPM occur after exercise therapy. Participants were recruited through a larger trial (WELBack) and were randomized to receive one of two exercise therapies. Participants attended two testing sessions (before and after an 8-week treatment) consisting of PPT, TS, CPM and EIH. Thirty-six participants were recruited and completed baseline assessments. In total, 32 (88.9%) participants completed the follow-up assessment. The results demonstrated that the protocol was feasible. Improvements to patient reported outcomes were seen, but not to all EPM measures. Future work should consider changes to the CPM protocol, and a fully powered study to investigate EPM changes after exercise therapy. / Thesis / Master of Health Sciences (MSc) / Low back pain (LBP) may occur because of changes in our nervous system, rather than a physical injury. However, there is no previous research on if exercise can improve these changes. The purpose of this thesis was to develop and test a protocol to assess how the body processes pain, and if this can change after exercise. We summarized past research on how four tests to assess pain processing have been performed. The results showed many differences in how these tests were performed and reported. More consistency and guidelines are needed to improve how these tests are conducted. Next, we conducted a study aimed to assess the feasibility of a protocol to see if changes occur in how the body processes pain after an exercise therapy program. The results of this study showed the protocol was feasible, and trends in improvement on some but not all measures.

Yes / The project was designed as a retrospective service evaluation using audit to assess the identification and documentation of red flags in initial assessment of patients with low back pain. Firstly, the documentation of 11 predetermined red flags was assessed. Secondly, the documentation of relevant additional information was assessed and finally, compliance with local policy to highlight positive red flag findings in the designated area on the paperwork was examined. The documentation for the majority of red flags was high, however, clear gaps were identified. Additionally, there was no evidence of further clinical consideration of positive red flags during the diagnostic process. Possible factors influencing red flag documentation are discussed and suggestions are provided to improve recording and response to clinical indicators of malignancy.

The prevalence of low back pain (LBP) is higher in pregnant women compared to women of the same age in a general population. Pregnancy-related LBP persists 6 years after pregnancy in 16% of women. Consequently, pregnancy represents a specific risk for LBP and persistent LBP. Pregnancy-related LBP is usually studied as a single entity, however, only one subgroup of LBP, i.e. pelvic girdle pain (PGP), seems to be associated with pregnancy. Accordingly, possible differences in subgroups of patients with LBP are unknown. The aims of this thesis were the following: 1) to describe the prevalence of clinically classified subgroups of women with LBP in a cohort (no LBP, lumbar pain, PGP, and combined pain (PGP and lumbar pain)) during pregnancy and postpartum, and 2) to determine if there was a disparity in the course, health-related quality of life (HRQL), pain intensity, disability, depressive symptoms, or muscle function in subgroups of the cohort, and 3) to identify predictors for having persistent pregnancy-related PGP postpartum. Consecutively-enrolled pregnant women were classified into LBP subgroups by mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history, and pain drawings. All women answered questionnaires (background data, EQ-5D). Women with LBP completed the Oswestry Disability Index and pain measures. The Edinburgh Postnatal Depression Scale was used to evaluate depressive symptoms at 3 months postpartum (cut-off ≥10). Trunk muscle endurance, hip muscle strength, and gait speed were investigated. Multiple logistic regression was used to identify predictors from self-reports and clinical examination. At the 12-18 gestational week evaluation, 118/308 (38%) women had no LBP, 33 (11%) had lumbar pain, 101 (33%) had PGP, and 56 (18%) had combined pain. Three months postpartum, 183/272 (67%) women had no LBP, 29 (11%) had lumbar pain, 46 (17%) had PGP, and 14 (5%) had combined pain. Pregnant women with combined pain were most affected in terms of HRQL, pain intensity, and disability. Depressive symptoms were three times more prevalent in women with LBP (27/87, 31%) than in women without LBP (17/180, 9%). Women with PGP and/or combined pain had lower values for trunk muscle endurance, hip extensor strength and gait speed compared to women without LBP. Postpartum, 16-20% of the women had persistent combined pain or PGP, whereas 1/29 had lumbar pain. Predictors for persistent PGP or combined pain were work dissatisfaction, older age, combined pain in early pregnancy, and low endurance of the back flexors. In conclusion, women with combined pain were identified to be a target group since they had the lowest recovery rate and since the classification of combined pain was found to be a predictor for persistent PGP or combined pain postpartum. The hypothesis of an association between muscle dysfunction and PGP was strengthened. Based on the finding of high comorbidity of postpartum depressive symptoms and LBP, it seems important to screen for and consider treatment strategies for both symptoms.

Diss. (sammanfattning) Linköping : Linköpings universitet, 2005. / Härtill 4 uppsatser.

Chronic pain sufferers are frequently misunderstood and stigmatised. The aim of this investigation was to provide a description of the lifewor1d of people with chronic low back pain, using the phenomenological method. Themes which emerged were that the persistent nature of chronic pain makes it particularly difficult to endure, arousing a profound fear of the future. It causes a disruption in the relationship between the person and the body, in which the person is forced to function within the constraints of pain. Sufferers are unable to fulfil social roles as expected and are forced to revise their goals and activities. The distress of their experience is mediated by the ability to make sense of their condition, finding meaning in the pain itself. The study highlights the value of the phenomenological method in health psychology. Recommendations are made which may be of benefit to people with chronic pain and their families. / Psychology / M. Sc. (Psychology)

Objective : Low back pain (LBP), and in particular sacroiliac joint syndrome, is a significant health concern for both patient and their chiropractor with regards to quality of life and work related musculoskeletal disorders. Therefore, chiropractors often utilise mechanical aids to reduce the impact on the chiropractor’s health. It is, however, important to establish whether these mechanical aids are indeed clinically effective, therefore, this study evaluated the Activator Adjusting Instrument (AAI) against an AAI placebo to determine whether this adjusting instrument is an effective aid for both the chiropractor and the patient. Method : This randomised, placebo controlled clinical trial consisted of 40 patients (20 per group), screened by stringent inclusion criteria assessed through a telephonic and clinical assessment screen. Post receipt of informed consent from the patients, measurements (NRS, Revised Oswestry Disability Questionnaire, algometer) were taken at baseline, prior to consultation three and at the follow consultation. This procedure occurred with four interventions over a two week period. Results: The AAI group showed clinical significance for all clinical measures as compared to the AAI placebo group which attained clinical significance only for the Revised Oswestry Disability Questionnaire. By comparison there was only a statistically significant difference between the groups in terms of the algometer readings (p= 0.037). Conclusion : Therefore, it is evident that the AAI seems to have clinical benefit beyond a placebo. However this is not reflected in the statistical analysis. It is, therefore, suggested that this study be repeated with a larger sample size in order to verify the effect on the statistical analysis outcomes.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2014. / Flexion distraction chiropractic technique (FDCT) is a commonly used manual therapy technique which is purported to address various clinical pain syndromes. However, it lacks the credibility of appropriate evidence-based guidelines. An analysis of the literature would be able to inform the development of guidelines. Objectives: The aim of this systematic review was to determine the evidence to support the use of FDCT in clinical practice. Data sources: A systematic review of PubMed and Summons was conducted, using the following search terms: chiropractic, flexion distraction, protocol and / or technique. Study selection: All electronic or paper, English articles, which possessed the required key indexing terms and represented randomised and non-randomised controlled study designs were included. Data extraction: Blinded review of the articles was conducted by three independent reviewers utilising the PEDro (for randomised controlled trials) and NOS for (non-randomised controlled trials). This allowed the methodological rigour of the article to be ranked. This ranking was compared to a critical appraisal of the article in order to achieve an overall decision with regards to the contribution of the article to the level of evidence for FDCT. Data synthesis: 18 review outcomes were aggregated around four clinical categories; two articles each on neck pain, chronic pelvic pain, and physiological outcomes and the remaining twelve on low back pain. There was agreement that the evidence for pelvic pain and physiological function was limited to no evidence and limited respectively. Conflicting evidence existed for neck and low back pain (single and multimodal treatment) with limited and moderate evidence respectively. Conclusion: FDCT is clinically advocated for many conditions. The evidence provided in this review indicates that practitioners should be guarded in their use of FDCT, as the evidence to its widespread use is limited to only those conditions noted in this review. Therefore, further high quality and rigorous studies are required to develop appropriate treatment guidelines for use by practitioners to adequately provide evidence based care in clinical practice.