The association between dry needling-induced twitch response and change in pain and muscle function in patients with low back pain: a quasi-experimental study

Objective To investigate the relationship between dry needling-induced twitch response and change in pain, disability, nociceptive sensitivity, and lumbar multifidus muscle function, in patients with low back pain (LBP). Design Quasi-experimental study. Setting Department of Defense Academic Institution. Participants Sixty-six patients with mechanical LBP (38 men, 28 women, age: 41.3 [9.2] years). Interventions Dry needling treatment to the lumbar multifidus muscles between L3 and L5 bilaterally. Main outcome measures Examination procedures included numeric pain rating, the Modified Oswestry Disability Index, pressure algometry, and real-time ultrasound imaging assessment of lumbar multifidus muscle function before and after dry needling treatment. Pain pressure threshold (PPT) was used to measure nocioceptive sensitivity. The percent change in muscle thickness from rest to contraction was calculated to represent muscle function. Participants were dichotomized and compared based on whether or not they experienced at least one twitch response on the most painful side and spinal level during dry needling. Results Participants experiencing local twitch response during dry needling exhibited greater immediate improvement in lumbar multifidus muscle function than participants who did not experience a twitch (thickness change with twitch: 12.4 [6]%, thickness change without twitch: 5.7 [11]%, mean difference adjusted for baseline value, 95%CI: 4.4 [1 to 8]%). However, this difference was not present after 1-week, and there were no between-groups differences in disability, pain intensity, or nociceptive sensitivity. Conclusions The twitch response during dry needling might be clinically relevant, but should not be considered necessary for successful treatment

Conservative management of back pain: A literature update

Most adults suffer from low back pain (LBP) at some time in their lifetime. The resulting medical costs and workrelated productivity losses make LBP one of the most expensive ailments to our society today.1 In the military, LBP is one of the largest detriments to Soldier health and mission readiness. Back disorders are among the most common causes of hospitalization, ambulatory medical visits, and restricted duty days in the U.S. Armed Forces.2 The high cost, along with the lack of consistency of medical treatment for LBP, has resulted in the creation and implementation of clinical practice guidelines (CPG) for the management and treatment of LBP around the world

How manipulation works and what it means for clinicians

Invited lectur

Netter's orthopaedic clinical examination: An evidenced based approach

Netter's Orthopaedic Clinical Examination: An Evidence-Based Approach, by Joshua Cleland and Shane Koppenhaver, helps you apply best practices to get the most clinically significant information from each physical examination. Classic Netter artwork and anatomy/biomechanics tables provide a handy anatomy and pathophysiology overview, while an evidence-based approach helps you focus on the examination techniques, tests, and measures that have been proven to yield the most meaningful diagnostic findings

Rehabilitative ultrasound imaging

Neuromuscular deficits have been linked with chronic musculoskeletal conditions. The use of ultrasound imaging (USI) to aid rehabilitation of neuromusculoskeletal disorders has been called rehabilitative ultrasound imaging (RUSI) and defined as 'a procedure used by physical therapists to evaluate muscle and related soft tissue morphology and function during exercise and physical tasks. RUSI is used to assist in the application of therapeutic interventions, providing feedback to the patient and physical therapist (Teyhen 2006). Brightness mode (b-mode) USI is the most common form used by physical therapists and will be the focus of this summary

The Fear Avoidance Model predicts short-term pain and disability following lumbar disc surgery

Objective To examine the prognostic value of the Fear Avoidance Model (FAM) variables when predicting pain intensity and disability 10-weeks postoperative following lumbar disc surgery. Methods We recruited patients scheduled for first-time, single level lumbar disc surgery. The following aspects of the FAM were assessed at preoperative baseline and after 10 postoperative weeks: numeric pain rating scale (0–10) for leg and back pain intensity separately, Pain Catastrophizing Scale (PCS), Fear Avoidance Beliefs Questionnaire (FABQ), Beck Depression Inventory (BDI), Oswestry Disability Questionnaire (ODI), and the International Physical Activity Questionnaire (IPAQ). Multivariate regression models were used to examine the best combination of baseline FAM variables to predict the 10-week leg pain, back pain, and disability. All multivariate models were adjusted for age and sex. Results 60 patients (30 females, mean [SD] age = 40.4 [9.5]) were enrolled. All FAM measures correlated with disability at baseline. Adding FAM variables to each of the stepwise multiple linear regression model explained a significant amount of the variance in disability (Adj. R2 = .38, p < .001), leg pain intensity (Adj. R2 = .25, p = .001), and back pain intensity Adj. R2 = .32, p < .001 at 10-weeks). After adjusting for age and gender, BDI and FABQ-work subscale were the only significant predictors added to each of the prediction models for the 10-week clinical outcome (leg pain, back pain, and ODI). Conclusion BDI and FABQ-work subscale variables are associated with baseline pain intensity and disability and predict short-term pain and disability following lumbar disc surgery. Measuring these variables in patients being considered for lumbar disc surgery may improve patient outcome

Subgrouping patients with low back pain: A treatment-based approach to classification

Context: Low back pain (LBP) is a prevalent condition imposing a large socioeconomic burden. Despite intensive research aimed at the efficacy of various therapies for patients with LBP, most evidence has failed to identify a superior treatment approach. One proposed solution to this dilemma is to identify subgroups of patients with LBP and match them with targeted therapies. Among the subgrouping approaches, the system of treatment-based classification (TBC) is promoted as a means of increasing the effectiveness of conservative interventions for patients with LBP.Evidence acquisition: MEDLINE and PubMed databases were searched from 1985 through 2010, along with the references of selected articles.Results: TBC uses a standardized approach to categorize patients into 1 of 4 subgroups: spinal manipulation, stabilization exercise, end-range loading exercise, and traction. Although the TBC subgroups are in various stages of development, recent research lends support to the effectiveness of this approach.Conclusions: While additional research is required to better elucidate this method, the TBC approach enhances clinical decision making, as evidenced by the improved clinical outcomes experienced by patients with LBP

The evaluation of lumbar multifidus muscle function via palpation: Reliability and validity of a new clinical test

Background context The lumbar multifidus muscle provides an important contribution to lumbar spine stability, and the restoration of lumbar multifidus function is a frequent goal of rehabilitation. Currently, there are no reliable and valid physical examination procedures available to assess lumbar multifidus function among patients with low back pain. Purpose To examine the inter-rater reliability and concurrent validity of the multifidus lift test (MLT) to identify lumbar multifidus dysfunction among patients with low back pain. Study design/setting A cross-sectional analysis of reliability and concurrent validity performed in a university outpatient research facility. Patient sample Thirty-two persons aged 18 to 60 years with current low back pain and a minimum modified Oswestry disability score of 20%. Study participants were excluded if they reported a history of lumbar spine surgery, lumbar radiculopathy, medical red flags, osteoporosis, or had recently been treated with spinal manipulation or trunk stabilization exercises. Outcome measures Concurrent measures of lumbar multifidus muscle function at the L4–L5 and L5–S1 levels were obtained with the MLT (index test) and real-time ultrasound imaging (reference standard). Methods The inter-rater reliability of the MLT was examined by measuring the level of agreement between two blinded examiners. Concurrent validity of the MLT was investigated by comparing clinicians' judgments with real-time ultrasound imaging measures of lumbar multifidus function. Results Inter-rater reliability of the MLT was substantial to excellent (κ=0.75 to 0.81, p≤.01) and free from errors of bias and prevalence. When performed at L4–L5 or L5–S1, the MLT demonstrated evidence of concurrent validity through its relationship with the reference standard results at L4–L5 (rbis=0.59–0.73, p≤.01). The MLT generally failed to demonstrate a relationship with the reference standard results from the L5–S1 level. Conclusions Our results provide preliminary evidence supporting the reliability and validity of the MLT to assess lumbar multifidus function at the L4–L5 spinal level. Additional research examining the measurement properties and utility of this test should be undertaken before confident implementation with patients

Subgrouping patients with low back pain: An updated treatment-based approach to classification

Platform presentatio

Investigation of abdominal muscle thickness changes after spinal manipulation in patients who meet a clinical prediction rule for lumbar stabilization

STUDY DESIGN: Prospective case series. OBJECTIVES: To investigate changes in abdominal muscle thickness with ultrasound imaging, after spinal manipulative therapy (SMT), in a subgroup of patients with low back pain (LBP) who meet a proposed clinical prediction rule for lumbar stabilization exercise (LSE). BACKGROUND: The characteristics of a subgroup of patients with LBP who respond clinically to LSE has been proposed. Although the pathoanatomical characteristics of this subgroup have not been determined, clinicians often assume that this type of LBP is related, in part, to neuromuscular deficits of the lateral abdominal muscles. Recent evidence suggests that SMT may facilitate abdominal muscle activity and, therefore, enhance exercises targeting these deficits. METHODS: Nineteen patients (mean ag