Physiotherapy informed by Acceptance and Commitment Therapy for chronic low back pain: A mixed-methods treatment fidelity evaluation.

OBJECTIVES: A randomized controlled trial of a new type of Physiotherapy informed by Acceptance and Commitment Therapy (PACT), found that it improved functioning in people with chronic low back pain compared to usual physiotherapy care. Fidelity evaluation is necessary to understand trial processes and outcomes. This study evaluated PACT treatment fidelity including delivery, receipt, and enactment. DESIGN: A mixed-methods study nested within a randomized controlled trial was conducted. METHODS: A total of 72 (20% of total) PACT treatment audio files were independently assessed by two raters, according to a novel framework developed to measure PACT treatment content adherence, therapeutic alliance, ACT competence, and treatment enactment. Interview transcripts from 19 trial participants randomized to PACT were analysed thematically for evidence of treatment receipt and enactment. RESULTS: PACT physiotherapists delivered treatment as intended with high content adherence and satisfactory therapeutic alliance, but ACT competence was low. Qualitative findings indicated participant receipt of 11/17 and enactment of 3/17 components; 89% (n = 17) and 47% (n = 9) of participants reported treatment receipt and enactment of at least one component, respectively. CONCLUSIONS: This mixed-methods study of PACT treatment demonstrated high fidelity reflecting treatment content delivery and receipt, and therapeutic alliance. There was some evidence of treatment enactment in participants with chronic low back pain. Low ACT competence could be addressed through additional support and adaptations to therapeutic processes for delivery by physiotherapists.

An exploration of experiences and beliefs about low back pain with Arab Muslim patients.

PURPOSE: Pain has psychological, social, physical and spiritual dimensions and therefore this experience is influenced by culture. The aim of this study was to explore the experiences and beliefs of Arab Muslim patients with low back pain (LBP) in Bahrain. METHODS: We recruited Arab Muslim patients attending physiotherapy with LBP ≥3 months, and ≥18 years of age. Socio-demographic information and a Visual Analogue Scale (VAS) score for pain intensity were collected. Focus groups were conducted between 2013-2014, using pre-determined semi-structured interview questions. Qualitative content analysis was applied with single counting and inclusion of negative instances. RESULTS: 18 participants attended three focus groups (14 females and 4 males) with a mean VAS(SD) = 5.28(±1.97). Five themes were identified; (1) loss of independence, (2)change in identity causes distress, (3) beliefs and attitudes towards low back pain, (4)trying to cope with LBP, and (5)experiences within the healthcare system. CONCLUSIONS: Religious and cultural beliefs influenced pain-related beliefs, fear-avoidance beliefs and catastrophizing. We recommend addressing cultural gender roles and using "active" forms of religious coping to inform treatment. Participants' experiences within and experiences of the healthcare system were similar to Western cultures. This encourages the application of Western findings into practice to facilitate the management of these patients.IMPLICATIONS FOR REHABILITATIONA qualitative exploration was undertaken to explore the experiences of Muslim and/or Arab patients with LBP.Our findings show that females have prioritised family needs over their own, primarily due to perceived gender roles.Contrary to previous findings labelling religious coping as a passive strategy, our findings suggest that religious coping strategies can be both positive and active strategies; such as participation in religious occasions and frequenting mosques.We support recommendations from Western literature to manage LBP; such as prioritising patient education and joint decision-making.

Experiences of training and delivery of Physical therapy informed by Acceptance and Commitment Therapy (PACT): a longitudinal qualitative study.

OBJECTIVES: Physiotherapy informed by Acceptance and Commitment Therapy (PACT) is a novel intervention that is related to improved disability and functioning in people with chronic lowback pain. This study explored physiotherapists experiences over time of the PACT training programme and intervention delivery. DESIGN: A longitudinal qualitative study using semi-structured, in-depth, individual interviews at three time points was conducted. METHODS: A phenomenological approach underpinned the methods. Interviews followed topic-guides developed a priori. Transcribed interviews were coded inductively to generate themes. Data were member checked by participants and validated by two researchers. PARTICIPANTS: Eight clinical physiotherapists from three secondary care centres in the United Kingdom (n = 5 female; age, 24 to 44 years; duration of practice, 3 to 14 years) were included. RESULTS: Five themes emerged from the data. Experiential learning techniques were challenging but valued because they bridged theoretical principles and concepts with practice. Ongoing individual and group supervision was beneficial, but required tailoring and tapering. PACT delivery extended physiotherapy skills and practice, including techniques that acknowledged and addressed patient treatment expectations. With experience, participants desired greater flexibility and autonomy to tailor PACT delivery. CONCLUSIONS: PACT training and delivery were acceptable to physiotherapists. Existing skills were developed and additional, applicable approaches were provided that addressed psychosocial and behavioural aspects of chronic low back pain.

Immediate effects of cervical mobilisations on neck muscle activity during active neck movements in patients with non-specific neck pain. A double blind placebo controlled trial.

BACKGROUND: Cervical mobilisations are used to treat people with neck pain but their mechanisms of action are unclear. One theorised reason for induced analgesia is effect on neck muscle activity. OBJECTIVES: To assess the effects of cervical mobilisations on muscle activity during active neck movements and whether changes in muscle activity are associated with changes in symptoms. DESIGN: Double-blind randomised placebo controlled trial. SETTING: Primary care. PARTICIPANTS: 40 patients (aged 19 to 80 years, 24 female) with non-specific neck pain. INTERVENTIONS: One session of cervical mobilisations or motionless manual contact (placebo). MAIN OUTCOME MEASURES: sternocleidomastoid (SCM), scalene (SCA), upper trapezius (UT) and erector spinae (ES) surface electromyography (SEMG) during active neck flexion, extension, side flexion and rotation was measured immediately before and after the intervention. Patients were classified as responders according to change in symptoms assessed using the Global Rating of Change Scale (GROC). RESULTS: Compared with placebo, patients receiving mobilisation showed an increase in contralateral UT and ES SEMG during rotation and contralateral and ipsilateral SCM, SCA and UT during side flexion (P<0.05), however changes were mostly associated with an increase in range and speed of movement. The only association with GROC was increased (5%) SEMG in the contralateral SCM during side flexion in the mobilisation group (P=0.013). CONCLUSION: Cervical mobilisations caused increased neck SEMG, mostly due to increased movement range and speed. Change in muscle activity is unlikely to be a major mechanism of action of cervical mobilisations in symptomatic improvement with physiological neck movements. (ClinicalTrials.gov record number: 2016/066). CLINICAL TRIALS REGISTRY: ClinicalTrials.gov record number: 2016/066.

Physical Therapy Informed by Acceptance and Commitment Therapy (PACT) Versus Usual Care Physical Therapy for Adults With Chronic Low Back Pain: A Randomized Controlled Trial.

Chronic low back pain (CLBP) is a major cause of global disability and improving management is essential. Acceptance and commitment therapy (ACT) is a promising treatment for chronic pain but has not been modified for physical therapy. This randomized controlled trial (RCT) compared physical therapy informed by ACT (PACT) against standard care physical therapy for patients with CLBP. Patients with CLBP (duration ≥12 weeks, mean 3 years) were recruited from physical therapy clinics in 4 UK public hospitals. The Roland-Morris Disability Questionnaire (RMDQ) at 3 months' post-randomization was the primary outcome. Two hundred forty-eight participants (59% female, mean age = 48) were recruited and 219 (88.3%) completed measures at 3 and/or 12 months' follow-up. At 3 months, PACT participants reported better outcomes for disability (RMDQ mean difference = 1.07, p = .037, 95% CI = -2.08 to -.07, d = .2), Patient Specific Functioning (p = .008), SF12 physical health (p = .032), and treatment credibility (p < .001). At 12 months' follow-up, there were no significant differences between groups. PACT was acceptable to patients and clinicians and feasible to deliver. Physical therapists incorporated psychological principles successfully and treatment was delivered with high (≥80%) fidelity. Our results may inform the management of CLBP, with potential benefits for patients, health care providers, and society. PERSPECTIVE: Psychologically informed physical therapy has great potential but there are challenges in implementation. The training and support included in the PACT trial enabled the intervention to be delivered as planned. This successfully reduced disability in the short but not long term. Findings could inform physical therapists' treatment of CLBP.

Association between sympathoexcitatory changes and symptomatic improvement following cervical mobilisations in participants with neck pain. A double blind placebo controlled trial.

BACKGROUND: sympathoexcitation observed with passive cervical mobilisations may imply activation of an endogenous pain inhibition system resulting in hypoalgesia. However, research is mostly in asymptomatic participants and there is very limited evidence of a relationship between sympathoexcitation and symptomatic improvement in people with clinical pain. OBJECTIVE: to investigate the effects of cervical mobilisations on the sympathetic nervous system in participants with neck pain, and to explore the relationship between symptomatic improvement and sympathoexcitation. DESIGN: double-blind randomised controlled trial. METHOD: 40 participants with neck pain (aged 20-69 years, 25 female) were randomly allocated to either cervical mobilisations or motionless placebo. Skin conductance was measured before, during, and after intervention. After interventions were completed, their credibility was assessed. Participants were classified as responders or non-responders according to global symptom change. RESULTS: participants receiving mobilisations were more likely to be classified as responders (odds ratio: 4.33, p = 0.03) and demonstrated greater change in most outcome measures of sympathoexcitation from baseline to during the intervention but not from during to after the intervention. There was no association between sympathoexcitation and symptomatic improvement. Mobilisations and placebo were equally credible. CONCLUSIONS: These findings suggest sympathoexcitatory changes may be caused by an orienting response unrelated to the activation of an endogenous pain inhibition system Alternatively, the observed lack of an association may be explained by the existence of various mechanisms for pain relief. This study used single outcome measures of sympathoexcitation and symptomatic improvement and other measures may reveal different things. CLINICALTRIALS. GOV NUMBER: M10/2016/095.

Immediate effects of cervical mobilisations on global perceived effect, movement associated pain and neck kinematics in patients with non-specific neck pain. A double blind placebo randomised controlled trial.

BACKGROUND: Neck pain is prevalent, costly and disabling. Cervical mobilisations are frequently used to treat it but their effectiveness has been questioned by several systematic reviews. Evidence suggests that better outcomes are achieved with mobilisations when they are applied to specific patient subgroups. A criteria for patients suitable for neck mobilisations has been proposed, but the effectiveness on this patient subgroup has not been tested. OBJECTIVE: To assess the effectiveness of cervical mobilisations applied to a subgroup of patients with neck pain who fulfil specific criteria. DESIGN: Randomised controlled trial. METHOD: 40 patients with neck pain attending a Physiotherapy clinic were recruited and randomised to a single session of either cervical mobilisations or motionless manual contact placebo. The immediate effects on global perceived effect, range of movement (ROM), movement velocity and movement associated pain were assessed. RESULTS: mobilisation participants reported significantly better global perceived effect (p˂0.001) and improvements in movement associated pain (p = 0.041). Mobilisations produced a significant increase in ROM in side flexion (p = 0.006) and rotation (p = 0.044) when compared with placebo, but only in patients with pre-intervention ROM restriction. 29-47% of all movement associated pains were resolved following mobilisations and 11-27% following placebo. Patients in both groups showed a significant (p < 0.05) increase in movement velocity, but only in those who had a velocity restriction pre-intervention. CONCLUSIONS: Cervical mobilisations are effective in improving movement-associated pain, increasing ROM and velocity, and patient perceived improvement when applied to patients with neck pain that fulfil a criteria. Their use should be advocated.

Reliability of a Method to Measure Neck Surface Electromyography, Kinematics, and Pain Occurrence in Participants With Neck Pain.

OBJECTIVE: To investigate the reliability of a novel method to measure neck surface electromyography (SEMG), kinematics, and pain during active movements in participants with neck pain. METHODS: This test-retest study evaluated 23 participants with chronic neck pain. Each was measured twice within a single session. Three-dimensional kinematics and SEMG were recorded in 10° increments during forward and side flexion, extension, and rotation of the neck. Neck position during pain occurrence was also measured. RESULTS: Intraclass correlation coefficients were >0.80 for 96% and 100% of SEMG and kinematic data, respectively. The percentage of standard error of the measurement (SEM) values were <25% for 91% of all SEMG measures; most were <15%, and some were <10%. For ranges of motion in the primary plane, percentage of SEM values were all <6% (SEM 1°-3°). Intraclass correlation coefficients for neck position during pain occurrence were all >0.60, except for right rotation (0.48) (SEM values 2°-8°). Pain occurred approximately 59% to 75% into the total range of motion and persisted to its end. CONCLUSIONS: This methodology showed good reliability. It may be suitable for neck pain subclassification to evaluate the effects of treatment on pain, kinematics, and muscle activity during functional neck movements. The point of pain occurrence suggests increasing mechanical load on tissues may be one of the causative factors for movement-associated neck pain.

Differences in neck surface electromyography, kinematics and pain occurrence during physiological neck movements between neck pain and asymptomatic participants. A cross-sectional study.

BACKGROUND: Neck pain has been associated with altered muscle activity and impaired kinematics. Patients frequently report pain during physiological neck movements. Previously, the average muscle activity during these movements has been measured. However, muscle activity is modulated by the position in the range of movement, hence the study of neck muscle activity in discrete sections of the range of movement is warranted. Evidence is conflicting regarding range of movement restriction in neck pain. No study has assessed the point in the range of movement at which pain occurs. This study aimed to investigate neck kinematics, muscle activity and pain during physiological neck movements in participants with and without neck pain. METHODS: Neck kinematics and surface electromyography were recorded continuously and analysed in 10° increments during forward and side flexion, extension and rotation of the neck in 20 neck pain and 20 asymptomatic participants. Point of pain occurrence in the range of movement was recorded. FINDINGS: Neck pain participants demonstrated significantly lower activity of scalene during flexion and extension, and a non-significant higher activity in sternocleidomastoids during rotation. No differences in neck kinematics were observed. 65% of neck pain participants reported pain during at least one neck movement. Pain was reported in the last ≈20-40% of the range of movement. INTERPRETATION: Exercises used in current practice to minimise scalene activity may not be appropriate for all neck pain patients. Restricted range of movement is not a consistent feature of neck pain. Movement associated neck pain is present at the end of range of movement, which has implications for the study of neck pain and rehabilitation.

Comparison of standing postural control and gait parameters in people with and without chronic low back pain: a cross-sectional case-control study.

OBJECTIVE: Differences in postural control and gait have been identified between people with and without chronic low back pain (CLBP); however, many previous studies present data from small samples, or have used methodologies with questionable reliability. This study, employing robust methodology, hypothesised that there would be a difference in postural control, and spatiotemporal parameters of gait in people with CLBP compared with asymptomatic individuals. METHODS: This cross-sectional case-control study age-matched and gender-matched 16 CLBP and 16 asymptomatic participants. Participants were assessed barefoot (1) standing, over three 40 s trials, under four posture challenging conditions (2) during gait. Primary outcome was postural stability (assessed by root mean squared error of centre of pressure (CoP) displacement (CoPRMSEAP) and mean CoP velocity (CoPVELAP), both in the anteroposterior direction); gait outcomes were hip range of movement and peak moments, walking speed, cadence and stride length, assessed using force plates and a motion analysis system. RESULTS: There were no differences between groups in CoPRMSEAP (P=0.26), or CoPVELAP (P=0.60) for any standing condition. During gait, no differences were observed between groups for spatiotemporal parameters, maximum, minimum and total ranges of hip movement, or peak hip flexor or extensor moments in the sagittal plane. CONCLUSIONS: In contrast to previous research, this study suggests that people with mild to moderate CLBP present with similar standing postural control, and parameters of gait to asymptomatic individuals. Treatments directed at influencing postural stability (eg, standing on a wobble board) or specific parameters of gait may be an unnecessary addition to a treatment programme.

Translation, cross-cultural adaptation and psychometric properties of the Back Beliefs Questionnaire in Modern Standard Arabic.

Purpose To translate and cross-culturally adapt the Back Beliefs Questionnaire (BBQ) into modern standard Arabic and examine its validity, acceptability and reliability in Arabic-speaking patients with low back pain (LBP). Method The BBQ was forward, back-translated and reviewed by an expert committee. Seventeen bilingual patients completed Arabic and English BBQs. LBP patients (n = 199) completed the Arabic BBQ. Sixty-four repeated it a week later, and 151 completed the Arabic Fear-avoidance Beliefs Questionnaire (FABQ). Results The expert committee followed advice from the developers to maintain Arabic equivalence of "back trouble(s)". Patients found the questionnaire comprehensible and acceptable. Agreement between the English and Arabic versions of the BBQ was acceptable, ICC = 0.65 (0.25-0.86). Most item-by-item agreement ranged from fair to moderate (K = 0.12-0.54). Mean (SD) of BBQ, FABQ total, work and physical activity subscales were 25.31(6.13), 44.76(19.49), 21.17(10.10) and 13.95(6.65). The BBQ correlated with the FABQ at r = -0.33, work subscale r = -0.29 and physical activity r = -0.30 (all p < 0.01). Cronbach's α = 0.73 indicated high internal consistency. Test-retest reliability was high, ICC = 0.80 (0.68-0.87). Item-by-item agreement ranged from fair to acceptable (K = 0.31-0.66). Conclusions The Arabic BBQ has good comprehensibility and acceptability, acceptable agreement with the English BBQ, high internal consistency and test-retest reliability. We recommend its use with Arabic-speaking LBP patient to determine their beliefs and attitudes about their back pain, as they have been shown to be important predictors of persistent LBP disability. Implications for Rehabilitation There are limited valid and reliable outcome measures for back pain in Arabic. The Back Beliefs Questionnaire (BBQ) is a tool that measures attitudes and beliefs about back pain. We recommend the use of our valid and reliable, translated and cross-culturally adapted tool with Arabic-speaking patients. The tool can measure attitudes and beliefs concerning the future consequences of LBP, with regards to recovery and return to work in this sample. Findings will improve back pain management options aimed at reducing back pain disability though challenging and modifying beliefs in the Middle East or with migrant populations in the West.

Do rocker-sole shoes influence postural stability in chronic low back pain? A randomised trial.

BACKGROUND: People with chronic low back pain (CLBP) demonstrate greater postural instability compared with asymptomatic individuals. Rocker-sole shoes are inherently unstable and may serve as an effective balance training device. This study hypothesised that wearing rocker-sole shoes would result in long-term improvement in barefoot postural stability in people with CLBP. METHODS: 20 participants with CLBP were randomised to wear rocker-sole or flat-sole shoes for a minimum of 2 hours each day. Participants were assessed barefoot and shod, over three 40 s trials, under 4 posture challenging standing conditions. The primary outcome was postural stability assessed by root mean squared error of centre of pressure (CoP) displacement (CoPRMSE AP) and mean CoP velocity (CoPVELAP), both in the anteroposterior direction, using force plates. Participants' were assessed without knowledge of group allocation at baseline, 6 weeks and 6 months (main outcome point). Analyses were by intention-to-treat. RESULTS: At 6 months, data from 11 of 13 (84.6%) of the rocker-sole and 5 of 7 (71.4%) of the flat-sole group were available for analysis. At baseline, there was a mean increase in CoPRMSE AP (6.41 (2.97) mm, p<0.01) and CoPVELAP (4.10 (2.97) mm, p<0.01) in the rocker-sole group when shod compared with barefoot; there was no difference in the flat-sole group. There were no within-group or between-group differences in change in CoP parameters at any time point compared with baseline (1) for any barefoot standing condition (2) when assessed shod eyes-open on firm ground. CONCLUSIONS: Although wearing rocker-sole shoes results in greater postural instability than flat-sole shoes, long-term use of rocker-sole shoes did not appear to influence postural stability in people with CLBP.

Physiotherapy informed by Acceptance and Commitment Therapy (PACT): protocol for a randomised controlled trial of PACT versus usual physiotherapy care for adults with chronic low back pain.

INTRODUCTION: Chronic low back pain (CLBP) is a common condition and source of significant suffering, disability and healthcare costs. Current physiotherapy treatment is moderately effective. Combining theory-based psychological methods with physiotherapy could improve outcomes for people with CLBP. The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of Physiotherapy informed by Acceptance and Commitment Therapy (PACT) on functioning in patients with CLBP. METHODS AND ANALYSIS: The PACT trial is a two-armed, parallel-group, multicentre RCT to assess the efficacy of PACT in comparison with usual physiotherapy care (UC). 240 patients referred to physiotherapy with CLBP will be recruited from three National Health Service (NHS) hospitals trusts. Inclusion criteria are: age ≥18 years, CLBP ≥12-week duration, scoring ≥3 points on the Roland-Morris Disability Questionnaire (RMDQ) and adequate understanding of spoken and written English to participate. Patients will be randomised to PACT or UC (120 per arm stratified by centre) by an independent randomisation service and followed up at 3 and 12 months post randomisation. The sample size of 240 will provide adequate power to detect a standardised mean difference of 0.40 in the primary outcome (RMDQ; 5% significance, 80% power) assuming attrition of 20%. Analysis will be by intention to treat conducted by the trial statistician, blind to treatment group, following a prespecified analysis plan. Estimates of treatment effect at the follow-up assessments will use an intention-to-treat framework, implemented using a linear mixed-effects model. ETHICS AND DISSEMINATION: This trial has full ethical approval (14/SC/0277). It will be disseminated via peer-reviewed publications and conference presentations. The results will enable clinicians, patients and health service managers to make informed decisions regarding the efficacy of PACT for patients with CLBP. TRIAL REGISTRATION NUMBER: ISRCTN95392287; Pre-results.

Mechanism of Action of Spinal Mobilizations: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To review the evidence regarding the mechanism of action of mobilizations. SUMMARY OF BACKGROUND DATA: Spinal mobilizations-low velocity passive oscillatory movements-reduce spinal pain in some patient subgroups. Identifying patients likely to respond remains a challenge since mobilizations' mechanism(s) of action are unclear. METHODS: Medline, Web of Science, Cinahl, Embase, and Scopus databases were searched for relevant studies. Reference lists of included studies were hand searched. Studies were included if the intervention was passive spinal mobilizations, participants were symptomatic, and outcomes evaluated possible mechanisms of action. Methodological quality was independently assessed by two assessors using a modified Cochrane Back Review Group tool. RESULTS: Twenty-four studies were included in the review. Four were classified high risk, 14 moderate risk, and four low risk of bias. Commonest methodological limitations were lack of participant blinding, adequate randomization and allocation concealment, and sample size calculation. Evidence suggests that spinal mobilizations cause neurophysiological effects resulting in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation, and improved muscle function. Mobilizations have no effect on temperature pain threshold. Three of four studies reported reduction in spinal stiffness, heterogeneous in location and timing. There is limited evidence (one study in each case) to suggest that mobilizations produce increased nociceptive flexion reflex threshold, improved posture, decreased concentration of substance P in saliva, and improved sway index measured in cervical extension. Evidence does not support an effect on segmental vertebral movement. Two studies investigated correlations between hypoalgesia and mechanism: one found a correlation with sympathoexcitatory changes, whereas the other found no correlation with change in stiffness. CONCLUSION: These findings suggest involvement of an endogenous pain inhibition system mediated by the central nervous system, although this is yet to be investigated directly. There is limited evidence regarding other possible mechanisms. LEVEL OF EVIDENCE: 3.

Cross-cultural translation, adaptation, and psychometric testing of the Roland-Morris disability questionnaire into modern standard Arabic.

STUDY DESIGN: Cross-cultural translation, adaptation, and psychometric testing. OBJECTIVE: To cross-culturally translate and adapt the Roland-Morris Disability Questionnaire (RMDQ) into Modern Standard Arabic and examine its validity with Arabic-speaking patients with low back pain (LBP). SUMMARY OF BACKGROUND DATA: The English RMDQ is valid, reliable, and commonly used to assess LBP disability in clinical practice and research. There is no valid and reliable version of the RMDQ in Modern Standard Arabic. METHODS: The RMDQ was forward translated and back translated. An expert committee of musculoskeletal physiotherapists reviewed the translation. Eight patients with LBP evaluated item-by-item comprehensibility. Ten patients piloted the RMDQ for overall comprehensibility and acceptability. Seventeen bilingual patients tested the agreement of the Arabic and English RMDQs. Two-hundred one patients completed the RMDQ and the visual analogue scale. Sixty-four patients were followed-up for test-retest reliability. RESULTS: Translation of most items was uncontroversial. The expert committee found the Arabic RMDQ clinically and culturally appropriate. They reviewed item 11, addressing bending and kneeling, because this has a clinical significance and cultural/religious implication regarding prayer positions. All patients reported that it was easy to understand and complete. The Arabic RMDQ had high overall agreement with the English RMDQ for the global score (intraclass correlation coefficient [ICC] = 0.925; 0.811-0.972). Kappa statistics showed good item-by-item agreement (none ≤0.30). Mean (SD) RMDQ and visual analog scale scores of 201 patients were 10.53 (4.80) and 5.11 (2.28), respectively. The RMDQ had a low correlation against pain intensity (r = 0.259; P < 0.01). A Cronbach α of 0.729 showed high internal consistency. Test-retest reliability of the Arabic RMDQ was good (ICC = 0.900; 95% confidence interval, 0.753-0.951). Kappa statistics were high for 18 items and fair for 6. CONCLUSION: The Arabic version of the RMDQ has good comprehensibility and acceptability, high internal consistency and reliability, low correlation against pain intensity, and good agreement with the English RMDQ. We recommend its use with Arabic-speaking patients with LBP. LEVEL OF EVIDENCE: 3.

Effectiveness of rocker sole shoes in the management of chronic low back pain: a randomized clinical trial.

STUDY DESIGN: Multicenter, assessor-blind, randomized, clinical trial. OBJECTIVE: To compare the effectiveness of rocker sole footwear to traditional flat sole footwear as part of the management for people with low back pain (LBP). SUMMARY OF BACKGROUND DATA: During the past decade, persistent advertising has claimed that footwear constructed with a rocker sole will reduce LBP. However, there is no robust evidence to support these claims. METHODS: One hundred fifteen people with chronic LBP were randomized to wear rocker sole shoes or flat sole shoes for a minimum of 2 hours each day while standing and walking. Primary outcome was the Roland Morris Disability Questionnaire (RMDQ). In addition, participants attended an exercise and education program once a week for 4 weeks and wore their assigned shoes during these sessions. Participants were assessed without their knowledge of group allocation prerandomization, and at 6 weeks, 6 months, and 1 year (main outcome point). Analysis was by intention-to-treat method. RESULTS: At 12 months, data from 44 of 58 (77.2%) of the rocker sole group and 49 of 57 (84.5%) of the flat sole group were available for analysis. In the rocker sole group, mean reduction in RMDQ was -3.1 (95% CI [confidence interval], -4.5 to -1.6), and in the flat sole group, it was -4.4 (95% CI, -5.8 to -3.1) (a greater negative value represents a greater reduction in disability). At 6 months, more people wearing flat shoes compared with those wearing rocker shoes demonstrated a minimal clinically important improvement in disability (53.2% and 31.1%, respectively; P = 0.03). Between-group differences were not significant for RMDQ or any secondary outcomes (e.g., pain) at any time. People reporting pain when standing and walking at baseline (n = 59) reported a greater reduction in RMDQ at 12 months in the flat sole group (-4.4 [95% CI, -6.0 to -2.8], n = 29) than the rocker sole group (-2.0 [95% CI, -3.6 to -0.4], n = 30) (P < 0.05). CONCLUSION: Rocker sole shoes seem to be no more beneficial than flat sole shoes in affecting disability and pain outcomes in people with chronic LBP. Flat shoes are more beneficial for LBP aggravated by standing or walking. LEVEL OF EVIDENCE: N/A.

Effect of pilates mat exercises and conventional exercise programmes on transversus abdominis and obliquus internus abdominis activity: pilot randomised trial.

Pilates training is said to increase Transversus abdominis (TrA) and Obliquus internus (OI) activation during exercise and functional activities. 34 Pain-free health club members with no Pilates experience, mean (SD) age 30(7) years, were randomised to Pilates mat exercises or strength training. Participants exercised unsupervised twice-weekly for eight weeks. TrA and OI thickness (a proxy for muscle activity at the low-medium efforts of our exercises) were measured with ultrasound pre- and post-training during Pilates exercises 'Imprint' (an abdominal drawing-in manoeuvre) and 'Hundreds A' (lying supine, arms slightly raised, hips and knees flexed to 90°) and 'Hundreds B' (as A, with neck flexion) and functional postures sitting and standing. Pilates participants had increased TrA thickness in Hundreds A [all values mean (SD) mm]: 3.7(1.3) pre-intervention, 4.7(1.1) post-intervention (P = 0.007); and decreased OI muscle thickness during Imprint: 11.7(2.8) pre-intervention, 10.8(3.5) post-intervention (P = 0.008). Strength training participants had greater OI thickness during Imprint (P = 0.014), Hundreds A (P = 0.018) and Hundreds B (P = 0.004) than Pilates participants post-intervention. There were no changes in muscle thickness at rest or during functional postures. Pilates training appears to increase TrA activity but only when performing Pilates exercises. Further research is required into Pilates in clinical populations and how to increase deep abdominal activation during functional activities.

Transversus abdominis and obliquus internus activity during pilates exercises: measurement with ultrasound scanning.

OBJECTIVE: To assess activity of transversus abdominis (TrA) and obliquus internus abdominis (OI) muscles during classical Pilates exercises performed correctly and incorrectly, and with or without equipment. DESIGN: Repeated-measures descriptive study. SETTING: Pilates studio. PARTICIPANTS: A volunteer sample of women (n=18) and men (n=8), mean age +/- SD (43+/-14y), with more than 6 months classical Pilates training and no back pain or other condition likely to influence abdominal muscle activity. INTERVENTIONS: Participants performed Pilates imprint, hundreds A and B, roll-up, and leg-circle exercises on a mat. The hundreds exercise was also performed on a reformer (sliding platform). Mat imprint and hundreds exercises were instructed to be performed correctly (with abdominal drawing-in) or incorrectly (without drawing-in). MAIN OUTCOME MEASURE: Thickness of TrA and OI middle fibers measured with ultrasound imaging. RESULTS: TrA thickness increased during the mat imprint, hundreds A, hundreds B, leg-circle, and roll-up exercises (all P=.001) compared with resting. OI thickness increased during the mat imprint, hundreds A, hundreds B, leg-circle (all P=.001), and roll-up exercises (P=.002) compared with resting. TrA thickness during reformer hundreds B was greater than during mat hundreds B (P=.011); OI thicknesses were not different for this comparison. During incorrect imprint, neither TrA or OI thicknesses were different to resting. TrA and OI muscle thicknesses were moderately correlated (R=.410; P=.001). CONCLUSIONS: This study provides the first evidence that a selection of classic Pilates exercises activates TrA and OI. Use of the reformer exercise machine can result in greater TrA activation in some exercises. TrA and OI did not function independently during these exercises. Research into the training effects of Pilates or in patient populations can be undertaken using ultrasonography in submaximal exercises.