Physical modalities in musculoskeletal disorders: evidence-based?

Učinkovitost različitih fizikalnih modaliteta koji se primjenjuju u liječenju i rehabilitaciji mišićnokoštanih poremećaja je još uvijek dvojbena. Unatoč poznatim fiziološkim učincima kliničkih podataka o učinkovitosti mnogih tehnika koje se rabe u okviru elektroterapije nema ili su nedostatni. Zbog toga za specifične intervencije često ne možemo dati kliničke preporuke. Zbog tih razočaravajućih rezultata temeljenih na dokazima istraživanja iz područja elektroterapije belgijska vlada je odlučila ne nadoknađivati većinu terapija iz ovoga područja. Vrlo je malo intervencija za mišićnokoštane poremećaje s dobrim odnosnom rizika i dobrobiti za koje je dokazana jasna učinkovitost u randomiziranim kliničkim istraživanjima. Većina studija o niskofrekventnim, srednjefrekvennim i visokofrekventnim strujama pokazala je nedostatak kliničkih znanstvenih dokaza, što je u suprotnosti s njihovom čestom uporabom u cijeloj Europi. Primjena ovih terapija zahtijeva daljnju evaluaciju. Problem većine studija je nedostatak praktične uniformnosti. Dvostruko slijepe studije nisu uvijek moguće, a niti dijagnoza nije uvijek sasvim jasna. Stoga postoji potreba za objektivnijim kliničkim strategijama. Također treba relativizirati neke od rezultata, jer kada nema jasnih dokaza za specifično liječenje, to ne znači da ono ne djeluje.A variety of physical modalities are applied in the treatment and rehabilitation of musculoskeletal disorders, but the efficacy of these passive interventions is still controversial. Despite the well-known physiological effects, there are either no clinical data or there is insufficient clinical information on the effectiveness of many techniques used in electrotherapy. As a consequence, we are often unable to make clinical recommendation regarding specific interventions. Because of these often disappointing results based on evidence-based research in electrotherapy, the Belgian government has decided not to reimburse a large number of treatments in this sector. Interventions that have been demonstrated effective through clear evidence in randomised clinical trials and with a good risk-benefit ratio are rather limited as far as musculoskeletal disorders are concerned. Most studies on low-frequency, medium-frequency (including interferential current) and high-frequency currents show the lack of clinical scientific evidence, which is in contrast with the frequent use of electrotherapy all over Europe. The application of these therapies should be further evaluated. The problem in most studies is the lack of practical uniformity (parameters, frequency, duration, etc.). Double-blind studies are not always possible and the diagnosis is not always very clear. Therefore, there is a need for more objective clinical strategies. We should also relativise some of the results because when there is no clear evidence for a specific treatment, it does not mean that this therapy does not work

Posterior muscle chain activity during various extension exercises: An observational study

Background: Back extension exercises are often used in the rehabilitation of low back pain. However, at present it is not clear how the posterior muscles are recruited during different types of extension exercises. Therefore, the present study will evaluate the myoelectric activity of thoracic, lumbar and hip extensor muscles during different extension exercises in healthy persons. Based on these physiological observations we will make recommendations regarding the use of extensions exercises in clinical practice. Methods. Fourteen healthy subjects performed four standardized extension exercises (dynamic trunk extension, dynamic-static trunk extension, dynamic leg extension, dynamic-static leg extension) in randomized order at an intensity of 60% of 1-RM (one repetition maximum). Surface EMG signals of Latissimus dorsi (LD), Longissimus thoracis pars thoracic (LTT) and lumborum (LTL), Iliocostalis lumborum pars thoracic (ILT) and lumborum (ILL), lumbar Multifidus (LM) and Gluteus Maximus (GM) were measured during the various exercises. Subsequently, EMG root mean square values were calculated and compared between trunk and leg extension exercises, as well as between a dynamic and dynamic-static performance using mixed model analysis. During the dynamic exercises a 2 second concentric contraction was followed by a 2 second eccentric contraction, whereas in the dynamic-static performance, a 5 second isometric interval was added in between the concentric and eccentric contraction phase. Results: In general, the muscles of the posterior chain were recruited on a higher level during trunk extension (mean ± SD, 56.6 ± 30.8%MVC) compared to leg extension (47.4 ± 30.3%MVC) (p ≤ 0.001). No significant differences were found in mean muscle activity between dynamic and dynamic-static performances (p = 0.053). The thoracic muscles (LTT and ILT) were recruited more during trunk extension (64.9 ± 27.1%MVC) than during leg extension (54.2 ± 22.1%MVC) (p = 0.045) without significant differences in activity between both muscles (p = 0.138). There was no significant differences in thoracic muscle usage between the dynamic or dynamic-static performance of the extension exercises (p = 0.574).Lumbar muscle activity (LTT, ILL, LM) was higher during trunk extension (70.6 ± 22.2%MVC) compared to leg extension (61.7 ± 27.0%MVC) (p = 0.047). No differences in myoelectric activity between the lumbar muscles could be demonstrated during the extension exercises (p = 0.574). During each exercise the LD (19.2 ± 13.9%MVC) and GM (28.2 ± 14.6%MVC) were recruited significantly less than the thoracic and lumbar muscles. Conclusion: The recruitment of the posterior muscle chain during different types of extension exercises was influenced by the moving body part, but not by the type of contraction. All muscle groups were activated at a higher degree during trunk extension compared to leg extension. Based on the recruitment level of the different muscles, all exercises can be used to improve the endurance capacity of thoracic muscles, however for improvement of lumbar muscle endurance leg extension exercises seem to be more appropriate. To train the endurance capacity of the LD and GM extension exercises are not appropriate

Computed tomographic analysis of the quality of trunk muscles in asymptomatic and symptomatic lumbar discectomy patients

Background: No consensus exists on how rehabilitation programs for lumbar discectomy patients with persistent complaints after surgery should be composed. A better understanding of normal and abnormal postoperative trunk muscle condition might help direct the treatment goals. Methods: A three-dimensional CT scan of the lumbar spine was obtained in 18 symptomatic and 18 asymptomatic patients who had undergone a lumbar discectomy 42 months to 83 months (median 63 months) previously. The psoas muscle (PS), the paraspinal muscle mass (PA) and the multifidus muscle (MF) were outlined at the L3, L4 and L5 level. Of these muscles, fat free Cross Sectional Area (CSA) and fat CSA were determined. CSA of the lumbar erector spinae (LES = longissimus thoracis + iliocostalis lumborum) was calculated by subtracting MF CSA from PA CSA. Mean muscle CSA of the left and right sides was calculated at each level. To normalize the data for interpersonal comparison, the mean CSA was divided by the CSA of the L3 vertebral body (mCSA = normalized fat-free muscle CSA; fCSA = normalized fat CSA). Differences in CSA between the pain group and the pain free group were examined using a General Linear Model (GLM). Three levels were examined to investigate the possible role of the level of operation. Results: In lumbar discectomy patients with pain, the mCSA of the MF was significantly smaller than in pain-free subjects (p = 0.009) independently of the level. The mCSA of the LES was significantly smaller in pain patients, but only on the L3 slice (p = 0.018). No significant difference in mCSA of the PS was found between pain patients and pain-free patients (p = 0.462). The fCSA of the MF (p = 0.186) and of the LES (p = 0.256) were not significantly different between both populations. However, the fCSA of the PS was significantly larger in pain patients than in pain-free patients. (p = 0.012). The level of operation was never a significant factor. Conclusions: CT comparison of MF, LES and PS muscle condition between lumbar discectomy patients without pain and patients with protracted postoperative pain showed a smaller fat-free muscle CSA of the MF at all levels examined, a smaller fat-free muscle CSA of the LES at the L3 level, and more fat in the PS in patients with pain. The level of operation was not found to be of importance. The present results suggest a general lumbar muscle dysfunction in the pain group, in particular of the deep stabilizing muscle system

An evaluator-blinded randomized controlled trial evaluating therapy effects and prognostic factors for a general and an individually defined physical therapy program in ambulant children with bilateral spastic cerebral palsy

Background: Cerebral palsy (CP) is characterized by a heterogeneous nature with a variety of problems. Therefore, individualized physical therapy might be more appropriate to address the needs for these children. Aim: The first aim was to compare the effectiveness of an individually-defined therapy program (IT) and a general therapy program (GT) on gait and gross motor function in children with CP. The second aim was to evaluate interaction-effects, time-effects, treatment with botulinum toxin A, age, gross Motor Function Classification Scale (GMFCS), treatment frequency and quality as factors influencing outcome. Design: An evaluator-blinded, randomized controlled trial. Setting: Outpatient rehabilitation unit. Population: Forty ambulant children with spastic bilateral CP (mean age 6 years 1 month). Methods: All children were randomly assigned to receive either IT or GT over a 10 week period. Nineteen of these children were enrolled into a second and/or third program, resulting in 60 interventions. Primary outcome was assessed with the Goal Attainment Scale (GAS) for gross motor function goals and z-scores for goals based on specific 3D gait parameters. Secondary outcome included the Gross Motor Function Measure-88 (GMFM-88) scores, time and distance gait parameters, Gait Profile Score, Movement Analysis Profiles and time needed to complete Timed-Up-and Go and Five-Times-Sit-To-Stand tests. Results: There were higher, but non-significant GAS and z-score changes following the IT program compared to the GT program (GAS: 46.2 for the IT versus 42.2 for the GT group, P=0.332, ES 0.15; z-score: 0.135 for the IT compared to 0.072 for the GT group, P=0.669, ES 0.05). Significant time-effects could be found on the GAS (P<0.001) and the GMFM-88 total score (P<0.001). Age was identified as a predictor for GAS and GMFM-88 improvement (P=0.023 and P=0.044). Conclusion: No significant differences could be registered between the effects of the IT and the GT. The favorable outcome after the IT program was only a trend and needs to be confirmed on larger groups and with programs of longer duration. Clinical Rehabilitation Impact: Both programs had a positive impact on the children's motor functioning. It is useful to involve older children more actively in the process of goal setting