Physical therapy for acute and sub-acute low back pain: A systematic review and expert consensus.

OBJECTIVE: To review the effectiveness of different physical therapies for acute and sub-acute low back pain supported by evidence, and create clinical recommendations and expert consensus for physiotherapists on clinical prescriptions. DATA SOURCES: A systematic search was conducted in PubMed and the Cochrane Library for studies published within the previous 15 years. REVIEW METHODS: Systematic review and meta-analysis, randomized controlled trials assessing patients with acute and sub-acute low back pain were included. Two reviewers independently screened relevant studies using the same inclusion criteria. The Physiotherapy Evidence Database and the Assessment of Multiple Systematic Reviews tool were used to grade the quality assessment of randomized controlled trials and systematic reviews, respectively. The final recommendation grades were based on the consensus discussion results of the Delphi of 22 international experts. RESULTS: Twenty-one systematic reviews and 21 randomized controlled trials were included. Spinal manipulative therapy and low-level laser therapy are recommended for acute low back pain. Core stability exercise/motor control, spinal manipulative therapy, and massage can be used to treat sub-acute low back pain. CONCLUSIONS: The consensus statements provided medical staff with appliable recommendations of physical therapy for acute and sub-acute low back pain. This consensus statement will require regular updates after 5-10 years.

The effects of biofeedback training for efficient activation of infraspinatus on proprioception and EMG activity during shoulder external rotation.

The purpose of this study investigated which biofeedback (BF) training enables efficient activation of the infraspinatus muscle that affect joint position sense (JPS) and force sense (FS) of the shoulder joint. Twenty healthy males participated and performed three external rotation (ER) exercises under three randomly assigned training conditions: 1) non-biofeedback (NBF), 2) BF and 3) force biofeedback (FBF). Each exercise was performed at intervals of one week between training conditions. After performed the ER exercise under each training condition, the relative error (RE) was calculated at shoulder ER 45° and 80°, and then shoulder ER force were measured to determine the JPS error and FS error, respectively. Muscle activity of infraspinatus and posterior deltoid were measured and compared between training conditions. The RE of shoulder ER 45° and 80° were significantly lower under the FBF conditions than other training conditions (P < 0.05). The RE of shoulder ER force were also significantly lower under the FBF conditions compared to those under the other training conditions (P < 0.05). The activity of the infraspinatus muscle was significantly higher under the FBF conditions during all three ER exercises than other training conditions (p < 0.05). We suggest that BF trainings can be useful to improve the proprioception of shoulder joint as well as activation of infraspinatus muscle while performing the ER exercises.

Effect of Pelvic Floor Muscle Training Using Pressure Biofeedback on Pelvic Floor Muscle Contraction and Trunk Muscle Activity in Sitting in Healthy Women.

Pelvic floor muscle training (PFMT) has been recommended as the first choice as one of the effective methods for preventing and improving urinary incontinence (UI). We aimed to determine whether pressure biofeedback unit training (PBUT) improves short term and retention performance of pelvic floor muscle contraction. The muscle activities of the external oblique (EO), transversus/internal oblique (TrA/IO), multifidus (MF) and the bladder base displacement were measured in the verbal feedback group (n = 10) and PBU group (n = 10) three times (baseline, post-training, and at the 1-week follow-up). Surface electromyographic activity was recorded from the EO, TrA/IO, and MF muscles. The bladder base displacement was measured using ultrasound. The results were analyzed using two way mixed ANOVA. The bladder base displacement may have elevated more in the PBU group than in the verbal feedback group due to decreased TrA/IO activity. These findings indicate that PBUT is a better method than verbal feedback training.

Effects of the abdominal drawing-in maneuver on hamstring rotational activity and pelvic stability in females.

BACKGROUND: The medial hamstring (MH) and lateral hamstring (LH) can be selectively trained through tibial internal and external rotation during prone knee flexion. However, no study has identified how a combined tibial rotation and lumbo-pelvic stability strategy influences MH and LH muscle activities. OBJECTIVE: To investigate the combined effects of tibial rotation and the abdominal drawing-in maneuver (ADIM) on MH and LH muscle activities as well as pelvic rotation during prone knee flexion. METHODS: Fifteen female volunteers performed prone knee flexion with tibial internal and external rotation, with and without the ADIM. Under each condition, MH and LH muscle activities were measured by surface electromyography (EMG), and the pelvic rotation angle by a smartphone inclinometer application. RESULTS: The results showed increased MH (without the ADIM: p< 0.001, effect size (d) = 2.05; with the ADIM: p< 0.001, d= 1.71) and LH (without the ADIM: p< 0.001, d= 1.64; with the ADIM: p= 0.001, d= 1.58) muscle activities under internal and external tibial rotation, respectively. However, addition of the ADIM led to increased MH (internal tibial rotation: p= 0.001, d= 0.67; external tibial rotation: p= 0.019, d= 0.45) and LH (internal tibial rotation: p= 0.003, d= 0.79; external tibial rotation: p< 0.001, d= 1.05) muscle activities combined with reduced pelvic rotation (internal tibial rotation: p< 0.001, d= 3.45; external tibial rotation: p< 0.001, d= 3.01) during prone knee flexion. CONCLUSIONS: These findings suggest that the ADIM could be useful for reducing compensatory pelvic rotation and enhancing selective muscle activation in the MH and LH, according to the direction of tibial rotation, during prone knee flexion.

The Effects of Abdominal Hollowing and Bracing Maneuvers on Trunk Muscle Activity and Pelvic Rotation Angle during Leg Pull Front Pilates Exercise.

Pilates methods use mats for trunk muscles stabilization exercises, and leg pull front (LPF) is one of the traditional Pilates mat exercises. Abdominal hollowing (AH) and Abdominal bracing (AB) maneuvers are recommended to stabilize the trunk muscles and prevent unwanted pelvic movement during motion. This study aimed to explore the effects of AH and AB on electromyography (EMG) activity of the trunk muscles and angle of pelvic rotation during LPF. A total of 20 healthy volunteers participated in the study. AH, AB, and without any condition (WC) were randomly performed during LPF exercise. Each was repeated three times for 5 s. The trunk muscle activities were measured using EMG and rotation of pelvis was measured using a Smart KEMA device. The activities of the transversus abdominis/obliquus internus abdominis (TrA/IO) and right obliquus externus abdominis (EO) muscles were highest in LPF-AH compared to the other conditions. Multifidus (MF) activity was significantly greater in LPF-AH and LPF-AB compared to that of without any condition. The pelvic rotation angle was significantly smaller in LPF-AB. Therefore, AH maneuver during LPF for trunk muscle stabilization exercises is suitable for selective activation of the TrA/IO, and AB maneuver during LPF is recommended for the prevention of unwanted pelvic rotation.

Effects of Intended Scapular Posterior Tilt Motion on Trapezius Muscle Electromyography Activity.

The intended scapular motion is a strategy to strengthen the lower trapezius (LT). However, few studies have explored the effects of the intended scapular posterior tilt motion on selective LT activation. Thus, the present study investigated the effect of the intended scapular posterior tilt on the electromyography (EMG) activity of trapezius muscles during prone shoulder horizontal abduction (PSHA). Eighteen asymptomatic men performed three types of PSHA: (1) preferred PSHA, (2) PSHA with the intended scapular posterior tilt, and (3) PSHA with the intended scapular posterior tilt and trunk extension. EMG activity of the upper trapezius (UT), middle trapezius (MT), and LT were measured during PSHAs. Scapular posterior tilt angle, with and without the intended scapular posterior tilt, were measured using inclinometer. The results indicated that LT muscle activity increased when scapular posterior tilt was applied with and without trunk extension (14-16%), compared to the preferred condition, during PSHA (p < 0.05). However, the addition of trunk extension to PSHA with the intended scapular posterior tilt increased the UT muscle activity (28%) and the UT/LT (29%) and UT/MT (31%) ratios (p < 0.05). The scapular posterior tilt angle was higher (15%) when applying the intended scapular posterior tilt (p = 0.020). These findings suggest that the intended scapular posterior tilt may be a useful strategy for selective LT muscle activation.

Effects of Visual Biofeedback on Symmetrical Movements During Bridge Exercise With Sling.

CONTEXT: Asymmetrical movements of trunk and lower-extremity are common during the bridge exercise on the unstable condition. However, no studies have investigated whether visual biofeedback of pressing pressure on the unstable surface changes muscle activation patterns of trunk and hip extensors and pelvic rotation during the bridge exercise. OBJECTIVE: To investigate how visual biofeedback of pressing pressure influences symmetrical activity of lumbar and hip extensor and pelvic rotation. DESIGN: Cross-sectional study. SETTING: Laboratory. PARTICIPANTS: Twenty healthy males participated in this study. INTERVENTIONS: The participants performed 2 versions of the bridge exercise: the standard bridge exercise and the bridge exercise with visual biofeedback using amount of pressing pressure on the sling. MAIN OUTCOME MEASURES: Surface electromyography was used to measure the symmetry (ie, the difference between dominant and nondominant sides) of muscle activation in the bilateral erector spinae, gluteus maximus, and hamstring muscles, and motion sensors were used to assess pelvic rotation. Symmetry of pressing pressure was measured using a tension meter. RESULTS: The differences between the dominant and nondominant pressing pressures and differences between the electromyography activity of the dominant and nondominant erector spinae, gluteus maximus, and hamstring were significantly smaller during the bridge exercise with visual biofeedback than during the standard bridge exercise (P < .05). In addition, there was significantly less pelvic rotation during the bridge exercise with visual biofeedback than during the standard bridge exercise (P < .05). CONCLUSIONS: The present findings suggest that visual biofeedback strategy may be a useful method for enhancing the symmetrical activation of the erector spinae, gluteus maximus, and hamstring and for reducing pelvic rotation during the bridge exercise on the unstable surface.

The application of the Neurac technique vs. manual therapy in patients during the acute phase of subacromial impingement syndrome: A randomized single-blinded controlled trial.

BACKGROUD: Although the effect of exercise in patients during the subacute and/or chronic subacromial impingement syndrome has been reported, only a few studies have examined the effect of pain free exercise in the acute phase of this disorder. OBJECTIVE: To compare the effect of training using the Neurac technique which combines body segments suspension and vibration vs. manual therapy, on various relevant outcome parameters in patients with acute subacromial impingement syndrome (PASIS). METHOD: Twenty-six patients underwent a 4 week intervention program. Using random assignment, half of the patients were treated using the Neurac device while the other half was treated using manual therapy. The outcome parameters consisted of shoulder pain, shoulder function, range of motion (ROM) and the isokinetic strength of the external and internal rotators at 60 and 180∘/s. RESULTS: Following either modes of interventions, the pain, function, and ROM improved significantly compared to pre-intervention levels in both groups. Time-by-group interaction was observed for the rotational strength which increased significantly and exclusively in the Neurac group. CONCLUSIONS: Given its positive effect on shoulder pain, function, ROM and the isokinetic strength of the external and internal rotators, we recommend the application of the Neurac technique in PASIS.

Scapula muscle exercises using the Neurac technique for a patient after radical dissection surgery: a case report.

Background: After radical neck dissection, spinal accessory nerve damage can result in scapular muscle weakness, which causes shoulder pain, dysfunction, and a limited range of motion (ROM); scapular muscle strengthening exercises are used to reduce these symptoms. This report focuses on the importance of trapezius and serratus anterior strength exercises to reduce symptoms after radical neck dissection. Case Description: The patient was a 30-year-old female who had received radical neck dissection 3 years previously. She complained of shoulder pain, dysfunction, and limited ROM during shoulder elevation. Outcome: She was successfully treated by increasing trapezius and serratus anterior strength and improving pain, function, and range of motion by applying the Neurac technique for 12 weeks. Further controlled studies are required to identify the generalizability of these findings.

Effects of self-stretching with mobilization on shoulder range of motion in individuals with glenohumeral internal rotation deficits: a randomized controlled trial.

BACKGROUND: The combined effects of cross-body stretching and dorsal glide mobilization have not been examined previously, although both stretching and mobilization maneuvers are effective for improving shoulder range of motion (ROM). Thus, the aim of this study was to demonstrate the effects of stretching with mobilization (SWM) on glenohumeral (GH) internal rotation (IR) and horizontal adduction (HA) ROM. METHODS: Forty individuals with GH IR deficits were randomized to perform simultaneous combined cross-body stretching and dorsal glide mobilization (SWM group, comprising 10 male and 10 female patients) or cross-body stretching alone (stretching group, comprising 10 male and 10 female patients). GH IR ROM, HA ROM, and shoulder mobility were assessed before and immediately following interventions. Group and time differences were analyzed using 2-way repeated-measures analysis of variance. RESULTS: Greater changes in GH IR ROM (6°, P < .001), HA ROM (10°, P < .001), and shoulder mobility (-2 cm, P = .018) were observed in the SWM group than in the stretching group, although significant increases were observed in GH IR ROM (SWM group, P < .001; stretching group, P < .001), HA ROM (SWM group, P < .001; stretching group, P = .042), and shoulder mobility (SWM group, P < .001; stretching group, P < .001) after both interventions. CONCLUSION: This study shows that SWM could be a useful exercise for shoulder ROM recovery in individuals with GH IR deficits.

Effects of real-time visual biofeedback of pelvic movement on electromyographic activity of hip muscles and lateral pelvic tilt during unilateral weight-bearing and side-lying hip abduction exercises.

Although neutral pelvic alignment is important for hip abduction exercises, studies exploring objectively monitored pelvic alignment on the gluteus medius (Gmed) muscle activity during hip abduction exercises, especially under weight-bearing (WB) conditions, are limited. Therefore, we examined the effects of real-time visual biofeedback (RVBF) of pelvic movement on electromyographic (EMG) activity of hip muscles and lateral pelvic tilt during unilateral WB and side-lying hip abductions. Fifteen male participants performed unilateral WB and side-lying hip abduction exercises with and without RVBF. Under the RVBF condition, participants monitored pelvic movements in real time during hip abduction exercises. EMG activity of Gmed and quadratus lumborum (QL) as well as lateral pelvic tilt angle were recorded during each hip abduction exercise. Gmed EMG activity increased, while lateral pelvic tilt decreased during both hip abduction exercises with RVBF (p < 0.05). Additionally, the changes in Gmed activity, the Gmed/QL activity ratio, and the lateral pelvic tilt angle under RVBF were greater during unilateral WB hip abduction than during side-lying hip abduction (p < 0.05). These results suggest that RVBF of pelvic movement could be useful to strengthen Gmed and prevent compensatory lateral pelvic movement during hip abduction exercises, especially in the unilateral WB position.

Effects of non-paretic arm movements during bridge exercises on trunk muscle activity in stroke patients.

[Purpose] The purpose of this study was to determine the effects of non-paretic arm movement during the bridge exercise on trunk muscle activity in stroke patients. [Participants and Methods] In total, 18 stroke patients were recruited. Surface EMG electrodes were attached over the trunk muscles (rectus abdominis, RA; internal oblique, IO; erector spinae, ES), and three kinds of bridge exercises were performed: 1) 'standard' bridge, 2) bridge with unilateral isometric arm flexion, and 3) bridge with unilateral isometric arm horizontal abduction. [Results] According to the activity of the trunk muscles measured during bridge exercises, only the IO and ES showed significantly greater muscle activity during bridges with isometric arm horizontal abduction and flexion than during the standard bridge. Additionally, comparison of the paretic and non-paretic sides showed that muscle activity was higher on the paretic side. [Conclusion] This study showed that, as an exercise to heighten the activity of the trunk muscles in stroke patients, bridge exercises with accompanying non-paretic arm flexion and horizontal abduction were more effective clinically than a standard bridge.

Effect of the scapula-setting exercise on acromio-humeral distance and scapula muscle activity in patients with subacromial impingement syndrome.

OBJECTIVES: The aim of present study was to investigate the effect of the scapula setting exercise on acromio-humeral distance (AHD) and the activity of scapula muscles in patients with subacromial impingement syndrome (SIS). STUDY DESIGN: Cross sectional study. SETTING: Pusan National University Yangsan Hospital in South Korea. PARTICIPANTS: Twenty-eight patients with SIS. MAIN OUTCOME MEASURES: We measured AHD by ultrasound and muscle activation of the serratus anterior (SA), upper trapezius (UT), middle trapezius (MT), and lower trapezius (LT) by surface electromyography and compared outcome measures between patients with and without the SSE. The SSE involved maintaining the scapula in upward rotation with posterior tilting in the resting position, and passive shoulder elevation at 60° in the scapula plane. RESULTS: The AHD (rest and 60°: P < 0.001), as well as muscle activity of SA (rest: P = 0.001, 60°: P = 0.004), MT (rest: P < 0.001, 60°: P = 0.001), and LT (rest: P = 0.001, 60°: P < 0.001), was significantly increased by SSE with the arm at rest and with passive 60° shoulder elevation. CONCLUSIONS: These findings suggest that the SSE could be used to increase the AHD and activity of the serratus anterior, middle trapezius, and lower trapezius muscles in patients with SIS. CLINICAL TRIALS: Gov identifier: KCT0002687.

Effects of 3 Infraspinatus Muscle Strengthening Exercises on Isokinetic Peak Torque and Muscle Activity.

CONTEXT: The infraspinatus muscle plays a particularly important role in producing primary external rotation (ER) torque and dynamic stability of the shoulder joint. Previous studies have reported that prone external rotation with horizontal abduction (PER), side-lying wiper exercise (SWE), and standing external rotation (STER) were effective exercises for strengthening the infraspinatus. However, we do not have enough knowledge about changes in muscle strength and dynamic muscle activity in each exercise under dynamic conditions. OBJECTIVE: To compare the ER muscle strength, muscle activity among exercise methods and between muscle contraction types during 3 different exercises. DESIGN: Repeated measures design in which ER muscle strength and muscle activities data were collected from subjects under 3 exercise conditions. SETTING: Outpatient clinic. PARTICIPANTS: A total of 15 healthy men with no shoulder, neck, or upper-extremity pain were participated. INTERVENTION: The subjects performed 3 different exercises randomly in concentric and eccentric using a Biodex dynamometer at an angular velocity of 60°/s. MAIN OUTCOME MEASURES: The ER peak torque (PT) data was collected and surface electromyography was used to measure the activity of the infraspinatus and posterior deltoid muscles and infraspinatus to posterior deltoid muscle activity ratio. RESULTS: There was significant main effect for muscle contraction type in ER PT (P < .05). The concentric PT was greater during PER (P < .05) and SWE (P < .05) compared with eccentric. The main effect for exercise was found in ER PT and muscle activity (P < .05). The ER PT and infraspinatus muscle activity were the largest increased during PER whereas the lowest during STER in both concentric and eccentric (P < .05). CONCLUSION: The results of this study suggest that PER is an exercise for strengthening the infraspinatus muscle effectively.

Comparison of Shoulder Protraction Strength and Electromyography Activity of Serratus Anterior and Pectoralis Major in Subjects With or Without a Winged Scapula.

CONTEXT: A winged scapula (WS) is associated with faulty posture caused by weakness of the serratus anterior (SA), which mainly acts as a scapular stabilizer muscle. It is important to accurately assess and train the SA muscle with a focus on scapula stabilizers during musculoskeletal rehabilitation of individuals with a WS. OBJECTIVE: The authors examined muscle activity in the SA and pectoralis major (PM), upper trapezius (UT), and anterior deltoid (AD) as well as shoulder protraction strength during isometric shoulder protraction in individuals with and without a WS. DESIGN: Cross-sectional study. SETTING: A clinical biomechanics laboratory. PARTICIPANTS: In total, 27 males with no shoulder, neck, or upper-extremity pain participated. MAIN OUTCOME MEASURES: Isometric shoulder protraction strength was collected and surface electromyography used to measure the activity of the SA, PM, UT, and AD muscles and selective SA activity ratio to other shoulder muscles. RESULTS: Electromyography activity of the SA muscle and shoulder protraction strength were significantly lower in individuals with a WS compared with the non-WS group (P < .05). In contrast, PM muscle activity and the PM-to-SA, UT-to-SA, and AD-to-SA ratios were significantly greater in individuals with a WS than in individuals without winging (P < .05). CONCLUSIONS: Isometric shoulder protraction for measuring SA strength in individuals with a WS should focus on isolated muscle activity of the SA, and SA strengthening exercises are important for individuals with a WS.

Electromyographic activity of the serratus anterior and pectoralis major during isometric scapular protraction at different resistance intensities in subjects with and without a winged scapula.

BACKGROUND: During maximal isometric protraction, it is important to determine the optimal resistance intensity in subjects with a winged scapula, for inducing isolated activity of the serratus anterior against the pectoralis major, which is activated as a synergistic muscle. The aim of the present study was to determine electromyographic activities of the serratus anterior and pectoralis major muscles during isometric shoulder protraction at different levels in subjects with and without a winged scapula. METHODS: Thirty male subjects performed isometric shoulder protraction in a sitting position at different resistance intensity levels (100%, 80%, and 60% of maximal protraction strength). Surface electromyographic data of the serratus anterior and pectoralis major muscles were gathered simultaneously using fixed instrumentation to measure isometric shoulder protraction. FINDINGS: Muscle activity of the serratus anterior in subjects without a winged scapula was significantly greater than that of subjects with a winged scapula across all three conditions, whereas muscle activity of the pectoralis major was lower in subjects without a winged scapula. In addition, winged scapula muscle activity corresponding to maximal protraction was significantly greater than that in the submaximal condition. INTERPRETATION: In a clinical setting, submaximal resistance can be more optimal than maximal effort during isometric shoulder protraction in individuals with a winged scapula.

Effects of deep breathing on internal oblique and multifidus muscle activity in three sitting postures.

[Purpose] This study was to investigate differences in the level of activity of the external oblique (EO), internal oblique (IO), and multifidus (MF) muscles with deep breathing in three sitting postures. [Subjects and Methods] Sixteen healthy women were recruited. The muscle activity (EO, IO, MF) of all subjects was measured in three sitting postures (slumped, thoracic upright, and lumbo-pelvic upright sitting postures) using surface electromyography. The activity of the same muscles was then remeasured in the three sitting postures during deep breathing. [Results] Deep breathing significantly increased activity in the EO, IO, and MF compared with normal breathing. Comparing postures, the activity of the MF and IO muscles was highest in the lumbo-pelvic upright sitting posture. [Conclusion] An lumbo-pelvic upright sitting posture with deep breathing could increase IO and MF muscle activity, thus improving lumbo-pelvic region stability.

Effects of visual cue and cognitive motor tasks on standing postural control following a chronic stroke.

[Purpose] The objective of the study was to examine the effects of visual cue and cognitive motor tasks on quiet standing posture center of pressure (COP) and the weight loads to the paretic and non-paretic legs in chronic stroke patients. [Subjects and Methods] Twenty chronic stroke patients were included in the study. COP total distance, sway velocity, and the weight loads to the paretic and non-paretic legs of the participants were measured while they performed a visual cue task, cognitive motor task, and dual task. The parameters were compared using a repeated three-way analysis of variance. [Results] When the visual cue was provided, the COP total distance and sway velocity were significantly reduced compared with when no visual cue was given. When the cognitive motor task was performed, the COP total distance and sway velocity decreased significantly compared to when the task was not performed. [Conclusion] These findings suggest that visual cue and cognitive motor tasks could be used as parts of a rehabilitative training program to improve the control of standing in chronic stroke patients. In addition, visual cues can be used as an intervention to train the paretic leg of stroke patients.

Relationship between hamstring length and gluteus maximus strength with and without normalization.

[Purpose] This study assessed the relationship between hamstring length and gluteus maximus (GM) strength with and without normalization by body weight and height. [Subjects and Methods] In total, 34 healthy male subjects volunteered for this study. To measure GM strength, subjects performed maximal hip joint extension with the knee joints flexed to 90° in the prone position. GM strength was normalized for body weight and height. [Results] GM strength with normalization was positively correlated with hamstring length, whereas GM strength without normalization was negatively correlated with hamstring length. [Conclusion] The normalization of GM strength by body weight and height has the potential to lead to more appropriate conclusions and interpretations about its correlation with hamstring length. Hamstring length may be related to GM strength.