Exercise prescription variables predict reductions in pain intensity in adults with chronic low back pain: secondary analysis of a randomised controlled trial.

Objectives: The relationship between exercise training variables and clinical outcomes in low back pain (LBP) is unclear. The current study aimed to explore the relationship between exercise training parameters and pain intensity in individuals with chronic LBP. Methods: This study is a secondary analysis of a previously reported randomised controlled trial comparing the effects of general strength and conditioning to motor control exercises and manual therapy. This secondary analysis includes adults with chronic LBP (n=20) randomised to the general strength and conditioning programme only. Primary outcomes of this analysis were exercise training parameters (time under tension, rating of perceived exertion (RPE), session duration, session-RPE and training frequency) and pain intensity (0-100 mm visual analogue acale) measured every 2 weeks from baseline to 6 months follow-up. Linear mixed models with random effects (participants) and allowance for heterogeneity of variance (study date) were used to determine the association between pain intensity and training parameters over time. Results: Mean (95% CI) pain intensity decreased over time from baseline to 6 months follow-up by 10.7 (2.8 to 18.7) points (p=0.008). Over the 6-month intervention, lower pain intensity was associated with higher RPE (ß (95% CI) -27.168 (-44.265 to -10.071), p=0.002), greater time under tension (-0.029 (-0.056 to -0.001), p=0.040) and shorter session duration (1.938 (0.011 to 3.865), p=0.049). Conclusion: During 6 months of general strength and conditioning, lower pain intensity was associated with higher participant-reported training intensity, greater volume and shorter session duration. To ensure positive outcomes to exercise training, these variables should be monitored on a short-term basis. Trial registration number: ACTRN12615001270505.

A pilot randomised trial comparing individualised physiotherapy versus shockwave therapy for proximal hamstring tendinopathy: a protocol.

PURPOSE: Proximal hamstring tendinopathy (PHT) presents as localised lower buttock pain with tasks such as squatting and sitting. It is a condition that occurs at all ages and levels of sporting participation and can cause disability with sport, work, and activities of daily living. This paper details a pilot trial protocol for investigating the effectiveness of individualised physiotherapy compared to extracorporeal shockwave therapy (ESWT) on pain and strength in people with PHT. METHODS: The study is an assessor-blinded, pilot randomised controlled trial (RCT). One hundred participants with PHT will be recruited from the local community and sporting clubs. Participants will be randomised to receive six sessions of either individualised physiotherapy or ESWT, with both groups also receiving standardised education and advice. Primary outcomes will be global rating of change on a 7-point Likert scale, and the Victorian Institute of Sport-Hamstring (VISA-H) scale, measured at 0, 4, 12, 26 and 52 weeks. Secondary outcomes will include sitting tolerance, the modified Physical Activity Level Scale, eccentric hamstring strength, modified Tampa scale for kinesiophobia, the Örebro Musculoskeletal Pain Screening Questionnaire Short Form (ÖMPSQ-SF), Numerical Pain Rating Scale (NPRS) for average and worst pain, participant adherence, the Pain Catastrophizing scale, satisfaction scores, and quality of life. Data will be analysed on an intention to treat basis, with between-group effects estimated using linear mixed models for continuous data and Mann Whitney U tests for ordinal data. CONCLUSIONS: This pilot RCT will compare individualised physiotherapy versus ESWT for PHT. The trial will determine feasibility and estimated treatment effects to inform a definitive trial in the future. TRIAL REGISTRATION: The trial has been prospectively registered with the Australia & New Zealand Clinical Trials Registry (ACTRN12621000846820), registered 1 July 2021, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373085.

The Interaction Between Psychosocial Factors and Exercise-Induced Hypoalgesia in Pain-Free Nurses.

Purpose: This cross-sectional study aimed to investigate whether psychosocial factors were predictive for exercise-induced hypoalgesia (EIH) in pain-free adults. Methods: A sample of 38 pain-free nurses with a mean (SD) age of 26 (6) years were included in this study. Participants completed psychosocial questionnaires prior to physical tests. Pressure pain threshold (PPT) was assessed bilaterally at the calves (local), lower back (semi-local) and forearm (remote) before and immediately after a maximal graded cycling exercise test. Separate linear mixed effects models were used to determine change in PPT before and after cycling exercise (EIH). Multiple linear regression for all psychosocial variables and best subset regression was used to identify predictors of EIH at all locations. Results: The relative mean increase in PPT at the forearm, lumbar, calf, and globally (all sites pooled) was 6.0% (p<0.001), 10.1% (p<0.001), 13.9% (p<0.001), and 10.2% (p=0.013), respectively. Separate best subset multiple linear regression models at the forearm (predictors; Multidimensional Scale of Perceived Social Support (MSPSS) total), lumbar (predictors; MSPSS total, Pain Catastrophizing Scale (PCS) total, Depression Anxiety Stress Scale (DASS) depression), calf (predictors; MSPSS friends, PCS total), and global (predictors; MSPSS friends, PCS total) accounted for 7.5% (p=0.053), 13% (p=0.052), 24% (p=0.003), and 17% (p=0.015) of the variance, respectively. Conclusion: These findings confirm that cycling exercise produced EIH in young nurses and provided preliminary evidence to support the interaction between perceived social support, pain catastrophizing and EIH. Further investigation is required to better understand psychological and social factors that mediate EIH on a larger sample of adults at high risk of developing chronic musculoskeletal pain.

Features and methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a Delphi expert consensus study.

ABSTRACT: Classification of musculoskeletal pain based on underlying pain mechanisms (nociceptive, neuropathic, and nociplastic pain) is challenging. In the absence of a gold standard, verification of features that could aid in discrimination between these mechanisms in clinical practice and research depends on expert consensus. This Delphi expert consensus study aimed to: (1) identify features and assessment findings that are unique to a pain mechanism category or shared between no more than 2 categories and (2) develop a ranked list of candidate features that could potentially discriminate between pain mechanisms. A group of international experts were recruited based on their expertise in the field of pain. The Delphi process involved 2 rounds: round 1 assessed expert opinion on features that are unique to a pain mechanism category or shared between 2 (based on a 40% agreement threshold); and round 2 reviewed features that failed to reach consensus, evaluated additional features, and considered wording changes. Forty-nine international experts representing a wide range of disciplines participated. Consensus was reached for 196 of 292 features presented to the panel (clinical examination-134 features, quantitative sensory testing-34, imaging and diagnostic testing-14, and pain-type questionnaires-14). From the 196 features, consensus was reached for 76 features as unique to nociceptive (17), neuropathic (37), or nociplastic (22) pain mechanisms and 120 features as shared between pairs of pain mechanism categories (78 for neuropathic and nociplastic pain). This consensus study generated a list of potential candidate features that are likely to aid in discrimination between types of musculoskeletal pain.

Understanding how individualised physiotherapy or advice altered different elements of disability for people with low back pain using network analysis.

PURPOSE: The Oswestry Disability Index (ODI) is a common aggregate measure of disability for people with Low Back Pain (LBP). Scores on individual items and the relationship between items of the ODI may help understand the complexity of low back disorders and their response to treatment. In this study, we present a network analysis to explore how individualised physiotherapy or advice might influence individual items of the ODI, and the relationship between those items, at different time points for people with LBP. METHODS: Data from a randomised controlled trial (n = 300) comparing individualised physiotherapy versus advice for low back pain were used. A network analysis was performed at baseline, 5, 10, 26 and 52 weeks, with the 10 items of the Oswestry Disability Index modelled as continuous variables and treatment group (Individualised Physiotherapy or Advice) modelled as a dichotomous variable. A Mixed Graphical Model was used to estimate associations between variables in the network, while centrality indices (Strength, Closeness and Betweenness) were calculated to determine the importance of each variable. RESULTS: Individualised Physiotherapy was directly related to lower Sleep and Pain scores at all follow-up time points relative to advice, as well as a lower Standing score at 10-weeks, and higher Lifting and Travelling scores at 5-weeks. The strongest associations in the network were between Sitting and Travelling at weeks 5 and 26, between Walking and Standing at week 10, and between Sitting and Standing scores at week 52. ODI items with the highest centrality measures were consistently found to be Pain, Work and Social Life. CONCLUSION: This study represents the first to understand how individualised physiotherapy or advice differentially altered disability in people with LBP. Individualised Physiotherapy directly reduced Pain and Sleep more effectively than advice, which in turn may have facilitated improvements in other disability items. Through their high centrality measures, Pain may be considered as a candidate therapeutic target for optimising LBP management, while Work and Socialising may need to be addressed via intermediary improvements in lifting, standing, walking, travelling or sleep. Slower (5-week follow-up) improvements in Lifting and Travelling as an intended element of the Individualised Physiotherapy approach did not negatively impact any longer-term outcomes. TRIALS REGISTRATION: ACTRN12609000834257.

Protection motivation theory screening tool for predicting chronic low back pain rehabilitation adherence: analysis of a randomised controlled trial.

OBJECTIVE: To explore a protection motivation theory screening tool for predicting rehabilitation adherence. DESIGN: Analysis of a randomised controlled trial. SETTING: An exercise physiology and physiotherapist clinic. PARTICIPANTS: Patients with chronic low back pain (n=40). INTERVENTIONS: General strength and conditioning (GSC) compared with motor control and manual therapy. Primary and secondary outcome measures: predicting patient adherence to supervised sessions and dropout using the Sports Injury Rehabilitation Beliefs Scale, seven-item barriers checklist and Positive and Negative Affect Schedule and Sports Injury Rehabilitation Adherence Scale. RESULTS: Average attendance was 77% (motor control and manual therapy) and 60% (GSC) with eight dropouts. No Sports Injury Rehabilitation Adherence Scale values other than 5 across all three components were recorded. Treatment efficacy (p=0.019), self-efficacy (p=0.001), rehabilitation value (p=0.028) and injury severity (p=0.002) positively correlated with susceptibility (the extent of vulnerability to having health problems from not taking action). Rehabilitation value positively correlated with self-efficacy (p=0.005). Injury severity positively correlated with rehabilitation value (p=0.011). The final model for number of cancellations included rehabilitation value only and accounted for approximately 12% of variance (p=0.033). CONCLUSIONS: Perceived value of rehabilitation should be considered by clinicians in the rehabilitation setting to improve treatment adherence in patients with chronic low back pain. TRIAL REGISTRATION NUMBER: ACTRN12615001270505.

Exercise may impact on lumbar vertebrae marrow adipose tissue: Randomised controlled trial.

BACKGROUND: Animal and human cross-sectional data suggest that bone marrow adipose tissue (MAT) may respond to mechanical loads and exercise. We conducted the first randomised controlled trial of exercise on MAT modulations in humans. METHODS: Forty patients with chronic non-specific low back pain (NSCLBP) were enrolled in a six-month single-blinded randomised controlled trial (ACTRN12615001270505). Twenty patients loaded their spines via progressive upright aerobic and resistance exercises targeting major muscle groups (Exercise). Twenty patients performed non-weightbearing motor control training and manual therapy (Control). Testing occurred at baseline, 3-months (3mo) and 6-months (6mo). Lumbar vertebral fat fraction (VFF) was measured using magnetic resonance imaging axial mDixon sequences. RESULTS: When compared to baseline (percent change), lumbar vertebral fat fraction (VFF; measured using magnetic resonance imaging axial mDixon sequences) was lower in Exercise at 3mo at L2 (-3.7[6.8]%, p = 0.033) and L4 (-2.6[4.1]%, p = 0.015), but not in Control. There were no between-group effects. The effects of Exercise on VFF were sex-specific, with VFF lower in men at L2, L3, L4 at 3mo and at L1, L2, L3 and L4 at 6mo (p all ≤ 0.05), but not in women. Leg and trunk lean mass were increased at 3mo in Exercise. Changes in VFF correlated significantly with changes in total fat (ρ = 0.40) and lean (ρ = -0.41) masses, but not with lumbar BMD (ρ = -0.10) or visceral adipose tissue volume (ρ = 0.23). CONCLUSIONS: This trial provided first prospective evidence in humans that a moderate exercise intervention may modulate lumbar VFF as a surrogate measure of MAT at 3mo, yet not 6mo. The effect of exercise on MAT may be more prominent in males than females.

Network meta-analysis for comparative effectiveness of treatments for chronic low back pain disorders: systematic review protocol.

INTRODUCTION: Chronic low back pain disorders (CLBDs) present a substantial societal burden; however, optimal treatment remains debated. To date, pairwise and network meta-analyses have evaluated individual treatment modes, yet a comparison of a wide range of common treatments is required to evaluate their relative effectiveness. Using network meta-analysis, we aim to evaluate the effectiveness of treatments (acupuncture, education or advice, electrophysical agents, exercise, manual therapies/manipulation, massage, the McKenzie method, pharmacotherapy, psychological therapies, surgery, epidural injections, percutaneous treatments, traction, physical therapy, multidisciplinary pain management, placebo, 'usual care' and/or no treatment) on pain intensity, disability and/or mental health in patients with CLBDs. METHODS AND ANALYSIS: Six electronic databases and reference lists of 285 prior systematic reviews were searched. Eligible studies will be randomised controlled/clinical trials (including cross-over and cluster designs) that examine individual treatments or treatment combinations in adult patients with CLBDs. Studies must be published in English, German or Chinese as a full-journal publication in a peer-reviewed journal. A narrative approach will be used to synthesise and report qualitative and quantitative data, and, where feasible, network meta-analyses will be performed. Reporting of the review will be informed by Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidance, including the network meta-analysis extension (PRISMA-NMA). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for network meta-analysis will be implemented for assessing the quality of the findings. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review of the published data. Findings will be disseminated via peer-reviewed publication. PROSPERO REGISTRATION NUMBER: PROSPERO registration number CRD42020182039.

How does individualised physiotherapy work for people with low back pain? A Bayesian Network analysis using randomised controlled trial data.

PURPOSE: Individualised physiotherapy is an effective treatment for low back pain. We sought to determine how this treatment works by using randomised controlled trial data to develop a Bayesian Network model. METHODS: 300 randomised controlled trial participants (153 male, 147 female, mean age 44.1) with low back pain (of duration 6-26 weeks) received either individualised physiotherapy or advice. Variables with potential to explain how individualised physiotherapy works were included in a multivariate Bayesian Network model. Modelling incorporated the intervention period (0-10 weeks after study commencement-"early" changes) and the follow-up period (10-52 weeks after study commencement-"late" changes). Sequences of variables in the Bayesian Network showed the most common direct and indirect recovery pathways followed by participants with low back pain receiving individualised physiotherapy versus advice. RESULTS: Individualised physiotherapy directly reduced early disability in people with low back pain. Individualised physiotherapy exerted indirect effects on pain intensity, recovery expectations, sleep, fear, anxiety, and depression via its ability to facilitate early improvement in disability. Early improvement in disability, led to an early reduction in depression both directly and via more complex pathways involving fear, recovery expectations, anxiety, and pain intensity. Individualised physiotherapy had its greatest influence on early change variables (during the intervention period). CONCLUSION: Individualised physiotherapy for low back pain appears to work predominately by facilitating an early reduction in disability, which in turn leads to improvements in other biopsychosocial outcomes. The current study cannot rule out that unmeasured mechanisms (such as tissue healing or reduced inflammation) may mediate the relationship between individualised physiotherapy treatment and improvement in disability. Further data-driven analyses involving a broad range of plausible biopsychosocial variables are recommended to fully understand how treatments work for people with low back pain. TRIALS REGISTRATION: ACTRN12609000834257.

Randomised, cross-over trial on the effect of isotonic and isometric exercise on pain and strength in proximal hamstring tendinopathy: trial protocol.

BACKGROUND: Proximal hamstring tendinopathy (PHT) is a condition that occurs at all ages and levels of sporting participation. Presenting as localised lower buttock pain with tasks such as squatting and sitting, it can cause disability with sport, work and other activities of daily living. Recent research has investigated the effect of isometric exercise on pain and strength with a range of tendinopathies but there are no published studies on PHT. This protocol paper details a study investigating the effectiveness of isometric compared with isotonic exercise on pain and strength in people with PHT. METHODS/DESIGN: The study is a prospective, cross-over randomised controlled trial (RCT). Twenty participants with PHT, recruited from the local community and sporting clubs will be recruited for the study. Participants will receive one session of isotonic hamstring strength exercises and one session of isometric hamstring exercise, with random allocation to the order of intervention.Primary outcomes will be hamstring strength measured with a dynamometer and pain with a functional task, assessed immediately following and 45 min after intervention. A secondary outcome will be pain with sitting assessed 24 hours after intervention.The effect of isotonic versus isometric exercise on hamstring pain and strength will be determined using a repeated measures linear mixed model. Further analyses will determine the proportion of patients with clinically important pain and strength improvements, using relative risks, χ2 testing and number needed to treat. DISCUSSION: This RCT protocol will investigate the effect of isometric compared with isotonic exercise for PHT.

Effects of specific muscle activation for low back pain on activity limitation, pain, work participation, or recurrence: A systematic review.

BACKGROUND: Specific muscle activation (SMA) is a commonly used treatment for people with low back pain (LBP) however there is variability in systematic reviews to date on effectiveness. This may be because of the use of eligibility criteria incongruent with original descriptions of the SMA approach. PURPOSE: The purpose of this study was to determine the effectiveness of SMA on improving activity limitation, pain, work participation or recurrence for people with LBP. STUDY DESIGN: Systematic review METHODS: Computer databases were searched for randomised controlled trials (RCTs) published in English up to September 6, 2019. Eligibility criteria were chosen to ensure all clinically relevant RCTs were included and trials of poorly defined or executed SMA excluded. Outcomes for activity limitation, pain, work participation or recurrence were extracted. RESULTS: Twenty-eight RCTs were included in this review with 18 being considered high quality. GRADE quality assessment revealed low to high quality evidence that SMA was more effective than exercise, conservative medical management, multi-modal physiotherapy, placebo, advice and minimal intervention. CONCLUSIONS: This systematic review is the first to evaluate the effectiveness of SMA in accordance with the original clinical descriptions. We found significant evidence supporting the effectiveness of SMA for the treatment of LBP. Where significant results were demonstrated, the between-group differences were in many comparisons clinically important based on contemporary definitions and an effect size of 0.5 or more. Practitioners should consider SMA as a treatment component in their patients with LBP.

Clinical features as predictors of histologically confirmed inflammation in patients with lumbar disc herniation with associated radiculopathy.

BACKGROUND: An understanding of the clinical features of inflammation in low back pain with or without leg symptoms may allow targeted evaluations of anti-inflammatory treatment in randomised-controlled-trials and clinical practice. PURPOSE: This study evaluated the diagnostic accuracy of clinical features to predict the presence/absence of histologically confirmed inflammation in herniated disc specimens removed at surgery in patients with lumbar disc herniation and associated radiculopathy (DHR). STUDY DESIGN: Cohort Study. METHODS: Disc material from patients with DHR undergoing lumbar discectomy was sampled and underwent histological/immunohistochemistry analyses. Control discs were sampled from patients undergoing surgical correction for scoliosis. Baseline assessment comprising sociodemographic factors, subjective examination, physical examination and psychosocial screening was conducted and a range of potential clinical predictors of inflammation developed based on the existing literature. Multi-variate analysis was undertaken to determine diagnostic accuracy. RESULTS: Forty patients with DHR and three control patients were recruited. None of the control discs had evidence of inflammation compared to 28% of patients with DHR. Predictors of the presence of histologically confirmed inflammation included back pain < 5/10, symptoms worse the next day after injury, lumbar flexion range between 0 and 30° and a positive clinical inflammation score (at least 3 of: constant symptoms, morning pain/stiffness greater than 60-min, short walking not easing symptoms and significant night symptoms). The model achieved a sensitivity of 90.9%, a specificity of 92.9%, and a predictive accuracy of 92.3%. CONCLUSION: In a sample of patients with lumbar DHR a combination of clinical features predicted the presence or absence of histologically confirmed inflammation. CLINICAL RELEVANCE: These clinical features may enable targeted anti-inflammatory treatment in future RCTs and in clinical practice.

Randomized Trial of General Strength and Conditioning Versus Motor Control and Manual Therapy for Chronic Low Back Pain on Physical and Self-Report Outcomes.

Exercise and spinal manipulative therapy are commonly used for the treatment of chronic low back pain (CLBP) in Australia. Reduction in pain intensity is a common outcome; however, it is only one measure of intervention efficacy in clinical practice. Therefore, we evaluated the effectiveness of two common clinical interventions on physical and self-report measures in CLBP. Participants were randomized to a 6­month intervention of general strength and conditioning (GSC; n = 20; up to 52 sessions) or motor control exercise plus manual therapy (MCMT; n =20; up to 12 sessions). Pain intensity was measured at baseline and fortnightly throughout the intervention. Trunk extension and flexion endurance, leg muscle strength and endurance, paraspinal muscle volume, cardio­respiratory fitness and self-report measures of kinesiophobia, disability and quality of life were assessed at baseline and 3- and 6-month follow-up. Pain intensity differed favoring MCMT between-groups at week 14 and 16 of treatment (both, p = 0.003), but not at 6-month follow­up. Both GSC (mean change (95%CI): -10.7 (-18.7, -2.8) mm; p = 0.008) and MCMT (-19.2 (-28.1, -10.3) mm; p < 0.001) had within-group reductions in pain intensity at six months, but did not achieve clinically meaningful thresholds (20mm) within- or between­group. At 6-month follow-up, GSC increased trunk extension (mean difference (95% CI): 81.8 (34.8, 128.8) s; p = 0.004) and flexion endurance (51.5 (20.5, 82.6) s; p = 0.004), as well as leg muscle strength (24.7 (3.4, 46.0) kg; p = 0.001) and endurance (9.1 (1.7, 16.4) reps; p = 0.015) compared to MCMT. GSC reduced disability (-5.7 (­11.2, -0.2) pts; p = 0.041) and kinesiophobia (-6.6 (-9.9, -3.2) pts; p < 0.001) compared to MCMT at 6­month follow-up. Multifidus volume increased within-group for GSC (p = 0.003), but not MCMT or between-groups. No other between-group changes were observed at six months. Overall, GSC improved trunk endurance, leg muscle strength and endurance, self-report disability and kinesiophobia compared to MCMT at six months. These results show that GSC may provide a more diverse range of treatment effects compared to MCMT.

A multivariate prognostic model for pain and activity limitation in people undergoing lumbar discectomy.

Purpose: The purpose of this study was to identify a multivariate predictive model for 6-month outcomes on overall pain, leg pain and activity limitation in patients undergoing lumbar discectomy. Identification of predictors of outcome for lumbar discectomy has the potential to assist identifying treatment targets, clinical decision making and disease understanding.Materials and methods: Prospective cohort design. Ninety-seven patients deemed by study surgeons to be suitable for lumbar discectomy completed a comprehensive clinical and radiological baseline assessment. At 6-months post surgery outcome measures of overall and leg pain (visual analogue scale) as well as activity limitation (Oswestry Disability Index) were completed. Univariate and multivariate analyses were conducted to determine the best multivariate predictive model of outcome.Results: In the multivariate model, presence of a compensation claim, longer duration of injury and presence of below knee pain and/or parasthesia were negative prognostic indicators for at least two of the outcomes. Peripheralization in response to mechanical loading strategies was a positive prognostic indicator for overall pain and leg pain. A range of other prognostic indicators for one outcome were also identified. The prognostic model explained up to 32% of the variance in outcome.Conclusions: An 11-factor prognostic model was identified from a range of clinically and radiologically assessed variables in accordance with a biopsychosocial model. The multivariate model has potential implications for researchers and practitioners in the field. Further high quality research is required to externally validate the prognostic model, evaluate effect of the identified prognostic factors on treatment effectiveness and explore potential mechanisms of effect.

Exercise for the intervertebral disc: a 6-month randomised controlled trial in chronic low back pain.

BACKGROUND CONTEXT: Muscle, bone and tendon respond anabolically to mechanical forces. Whether the intervertebral disc (IVD) can benefit from exercise is unclear. PURPOSE: To examine whether exercise can beneficially affect IVD characteristics. STUDY DESIGN/SETTING: This is a single-blinded 6-month randomised controlled trial (ACTRN12615001270505) in an exercise and physiotherapy clinic. PATIENT SAMPLE: Forty patients with chronic non-specific low back pain (NSCLBP) are included in this study. OUTCOME MEASURES: The primary outcome was lumbar IVD T2 time (MRI). Secondary outcomes included IVD diffusion coefficient and IVD expansion with short-duration lying. METHODS: Twenty patients progressively loaded their lumbar IVDs (exercise) via an exercise programme involving progressive upright aerobic and resistance exercises targeting the trunk and major muscle groups and were compared to twenty patients who performed motor control training and manual therapy (control). Testing occurred at baseline, 3 months and 6 months. RESULTS: Seventeen exercise and fifteen control patients completed the interventions. There were no group-by-time differences in T2 time of the entire IVD (exercise 94.1 ± 10.0 ms vs. control 96.5 ± 9.3 ms, p = 0.549). Exercise patients had shorter T2 time in the posterior annulus at 6 months (82.7 ± 6.8 ms vs. 85.1 ± 8.0 ms, p = 0.028). Exercise patients showed higher L5/S1 apparent diffusion coefficients and decreased IVD height at 3 months (both p ≤ 0.050). After adjustments for multiple comparisons, differences lost statistical significance. Per-protocol and intent-to-treat analyses yielded similar findings. CONCLUSIONS: This trial found that 6 months of exercise did not benefit the IVD of people with NSCLBP. Based on this index study, future studies could investigate the effect of exercise on IVD in different populations, with different types, durations and/or intensities of exercise, and using different IVD markers. These slides can be retrieved under Electronic Supplementary Material.

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain.

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

General strength and conditioning versus motor control with manual therapy for improving depressive symptoms in chronic low back pain: A randomised feasibility trial.

OBJECTIVES: Exercise can be used as a treatment for depressive symptoms in the general population. However, little is known as to whether exercise has mental health benefits for adults experiencing chronic low back pain (CLBP). The aim of this study was to examine the feasibility of two intervention protocols commonly used in clinical practice for treating chronic low back pain, but with differing exercise dose, on depressive symptoms. METHODS: Forty men and women (mean age = 35) experiencing chronic persistent (>3 months), non-specific low back pain were recruited into a randomised clinical trial during 2015-2016. Participants were randomised to receive motor control (low-dose exercise) and manual therapy (n = 20), or general strength and conditioning training (moderate-dose exercise) (n = 20). Depressive symptoms were assessed fortnightly throughout a 6-month follow-up period using the Centre for Epidemiologic Studies Depression Scale (CES-D 10). Linear mixed models were used to examine within-group and between-group changes in depressive symptoms. RESULTS: Mean CES-D 10 score at baseline was 9.17 (SD = 4.32). There was evidence of a small decrease in average depressive symptoms over time (ß -0.19 per fortnight, 95% CI = -0.34, -0.02). However, there was no evidence that change over time was dependent on treatment group. CONCLUSIONS: Reduction in depressive symptoms amongst adults with CLBP occurred with both treatment methods (motor control [low-dose exercise] and manual therapy; or general strength and conditioning [moderate-dose exercise]). Further interventions including a true control group are needed to draw conclusions as to the effectiveness of each of these treatment methods on depressive symptoms amongst adults with CLBP. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12615001270505. Registered on 20 November 2015.

Individualised manual therapy plus guideline-based advice vs advice alone for people with clinical features of lumbar zygapophyseal joint pain: a randomised controlled trial.

OBJECTIVES: To determine whether individualised manual therapy plus guideline-based advice results in superior outcomes to advice alone in participants with clinical features potentially indicative of lumbar zygapophyseal joint pain. DESIGN: Multi centre parallel group randomised controlled trial. SETTING: 14 physiotherapy clinics in Melbourne, Australia. PARTICIPANTS: Sixty-four participants with clinical features potentially indicative of lumbar zygapophyseal joint pain. INTERVENTIONS: 10-weeks of physiotherapy comprising individualised manual therapy based on pathoanatomical, psychosocial and neurophysiological barriers to recovery plus guideline-based advice (10 sessions) or advice alone (two sessions). MAIN OUTCOME MEASURES: Primary outcomes were activity limitation (Oswestry Disability Index), and separate 0 to 10 numerical rating scales for leg pain and back pain. Measures were taken at baseline and 5, 10, 26 and 52-week. RESULTS: Between-group differences for back pain favoured individualised manual therapy over advice for back pain at 5 (1.0; 95% CI 0.6 to 2.0), 10 (1.5; 95% CI 0.5 to 2.4) and 26-weeks (1.4; 95% CI 0.4 to 2.3) as well as for activity limitation at 26 (8.3; 95% CI 2.6 to 14.2) and 52-weeks (8.2; 95% CI 2.3 to 14.2). There were no significant between-group differences for leg pain. Secondary outcomes and responder analyses also favoured individualised manual therapy at almost all time-points. CONCLUSIONS: In participants with clinical features potentially indicative of lumbar zygapophyseal joint pain, individualised manual therapy led to greater reduction in back pain at 5, 10 and 26-week follow-up as well as activity limitation at 26 and 52-weeks. Between-group differences were likely to be clinically important. TRIAL REGISTRATION: ACTRN12609000334202.