Disability reduction following a lumbar stabilization exercise program for low back pain: large vs. small improvement subgroup analyses of physical and psychological variables.

BACKGROUND: Little is known about why patients with low back pain (LBP) respond differently to treatment, and more specifically, to a lumbar stabilization exercise program. As a first step toward answering this question, the present study evaluates how subgroups of patients who demonstrate large and small clinical improvements differ in terms of physical and psychological changes during treatment. METHODS: Participants (n = 110) performed the exercise program (clinical sessions and home exercises) over eight weeks, with 100 retained at six-month follow-up. Physical measures (lumbar segmental instability, motor control impairments, range of motion, trunk muscle endurance and physical performance tests) were collected twice (baseline, end of treatment), while psychological measures (fear-avoidance beliefs, pain catastrophizing, psychological distress, illness perceptions, outcome expectations) were collected at four time points (baseline, mid-treatment, end of treatment, follow-up). The participants were divided into three subgroups (large, moderate and small clinical improvements) based on the change of perceived disability scores. ANOVA for repeated measure compared well-contrasted subgroups (large vs. small improvement) at different times to test for SUBGROUP × TIME interactions. RESULTS: Statistically significant interactions were observed for several physical and psychological measures. In all these interactions, the large- and small-improvement subgroups were equivalent at baseline, but the large-improvement subgroup showed more improvements over time compared to the small-improvement subgroup. For psychological measures only (fear-avoidance beliefs, pain catastrophizing, illness perceptions), between-group differences reached moderate to strong effect sizes, at the end of treatment and follow-up. CONCLUSIONS: The large-improvement subgroup showed more improvement than the small-improvement subgroup with regard to physical factors typically targeted by this specific exercise program as well as for psychological factors that are known to influence clinical outcomes.

The relationship between clinical examination measures and ultrasound measures of fascia thickness surrounding trunk muscles or lumbar multifidus fatty infiltrations: An exploratory study.

Patients with chronic low back pain (CLBP) exhibit remodelling of the lumbar soft tissues such as muscle fatty infiltrations (MFI) and fibrosis of the lumbar multifidus (LuM) muscles, thickness changes of the thoracolumbar fascia (TLF) and perimuscular connective tissues (PMCT) surrounding the abdominal lateral wall muscles. Rehabilitative ultrasound imaging (RUSI) parameters such as thickness and echogenicity are sensitive to this remodelling. This experimental laboratory study aimed to explore whether these RUSI parameters (LuM echogenicity and fascia thicknesses), hereafter called dependent variables (DV) were linked to independent variables (IV) such as (1) other RUSI parameters (trunk muscle thickness and activation) and (2) physical and psychological measures. RUSI measures, as well as a clinical examination comprising physical tests and psychological questionnaires, were collected from 70 participants with LBP. The following RUSI dependent variables (RUSI-DV), measures of passive tissues were performed bilaterally: (1) LuM echogenicity (MFI/fibrosis) at three vertebral levels (L3/L4, L4/L5 and L5/S1); (2) TLF posterior layer thickness, and (3) PMCT thickness of the fasciae between subcutaneous tissue thickness (STT) and external oblique (PMCTSTT/EO ), between external and internal oblique (PMCTEO/IO ), between IO and transversus abdominis (PMCTIO/TrA ) and between TrA and intra-abdominal content (PMCTTrA/IA ). RUSI measures of trunk muscle's function (thickness and activation), also called measures of active muscle tissues, were considered as independent variables (RUSI-IV), along with physical tests related to lumbar stability (n = 6), motor control deficits (n = 7), trunk muscle endurance (n = 4), physical performance (n = 4), lumbar posture (n = 2), and range of motion (ROM) tests (n = 6). Psychosocial measures included pain catastrophizing, fear-avoidance beliefs, psychological distress, illness perceptions and concepts related to adherence to a home-based exercise programme (physical activity level, self-efficacy, social support, outcome expectations). Six multivariate regression models (forward stepwise selection) were generated, using RUSI-DV measures as dependent variables and RUSI-IV/physical/psychosocial measures as independent variables (predictors). The six multivariate models included three to five predictors, explaining 63% of total LuM echogenicity variance, between 41% and 46% of trunk superficial fasciae variance (TLF, PMCTSTT/EO ) and between 28% and 37% of deeper abdominal wall fasciae variance (PMCTEO/IO , PMCTIO/TrA and PMCTTrA/IA ). These variables were from RUSI-IV (LuM thickness at rest, activation of IO and TrA), body composition (percent fat) and clinical physical examination (lumbar and pelvis flexion ROM, aberrant movements, passive and active straight-leg raise, loaded-reach test) from the biological domain, as well as from the lifestyle (physical activity level during sports), psychological (psychological distress-cognitive subscale, fear-avoidance beliefs during physical activities, self-efficacy to exercise) and social (family support to exercise) domains. Biological, psychological, social and lifestyle factors each accounted for substantial variance in RUSI-passive parameters. These findings are in keeping with a conceptual link between tissue remodelling and factors such as local and systemic inflammation. Possible explanations are discussed, in keeping with the hypothesis-generating nature of this study (exploratory). However, to impact clinical practice, further research is needed to determine if the most plausible predictors of trunk fasciae thickness and LuM fatty infiltrations have an effect on these parameters.

Global Survey of Demand-Side Factors and Incentives that Influence Advanced Trauma Life Support (ATLS) Promulgation.

BACKGROUND: We aimed to identify and describe demand-side factors that have been used to support ATLS global promulgation, as well as current gaps in demand-side incentives. METHODS: We performed a cross-sectional survey about demand-side factors that influence the uptake and promulgation of ATLS and other trauma-related CME courses. The survey was sent to each of the four global ATLS region chiefs and 80 ATLS country directors. Responses were described and qualitative data were analyzed using a content analysis framework. RESULTS: Representatives from 30 countries and each region chief responded to the survey (40% response rate). Twenty of 30 country directors (66%) reported that there were some form of ATLS verification requirements. ATLS completion, not current verification, was often the benchmark. Individual healthcare systems were the most common agency to require ATLS verification (37% of countries) followed by medical/surgical accreditation boards (33%), governments (23%), training programs (27%), and professional societies (17%). Multiple credentialing frameworks were reported including making ATLS verification a requirement for: emergency unit or trauma center designation (40%), contract renewal or promotion (37%); professional licensing (37%); training program graduation (37%); and increases in remuneration (3%). Unique demand-side incentives were reported including expansion of ATLS to non-physician cadre credentialing and use of subsidies. CONCLUSION: ATLS region chiefs and country directors reported a variety of demand-side incentives that may facilitate the promulgation of ATLS. Actionable steps include: (i) shift incentivization from ATLS course completion to maintenance of verification; (ii) develop an incentive toolkit of best practices to support implementation; and (iii) engage leadership stakeholders to use demand-side incentives to improve the training and capabilities of the providers they oversee to care for the injured.

Structural remodeling of the lumbar multifidus, thoracolumbar fascia and lateral abdominal wall perimuscular connective tissues: A search for its potential determinants.

Recently remodeling of lumbar soft tissues has received increased research attention. However, the major determinants that influence remodeling need to be elucidated in order to understand the impact of different rehabilitation modalities on tissue remodeling. The main aim of this study was to explore the between-subject variance of different measures of lumbar soft tissues quantified with rehabilitative ultrasound imaging (RUSI). RUSI measures (n = 8) were collected from 30 subjects without and 34 patients with LBP: (1) lumbar multifidus (LM) echogenicity (fatty infiltration/fibrosis) at three vertebral levels (L3/L4, L4/L5 and L5/S1) (n = 3); (2) posterior layer thickness of the thoracolumbar fascia (n = 1); and (3) thickness of the fasciae surrounding the external oblique (EO), internal oblique (IO), and transversus abdominis (TrA) (n = 4). Forward stepwise multivariate regression modeling was conducted with these RUSI measures as dependent variables, using the following independent variables as potential determinants: age, sex, the presence of LBP, body size/composition characteristics (height, weight, trunk length, subcutaneous tissue thickness over the abdominal, and LM muscles), trunk muscle function (or activation) as determined with the percent thickness change of LM, EO, IO, and TrA muscles during a standardized effort (RUSI measures), and physical activity level during sport and leisure activities as estimated with a self-report questionnaire. Two or three statistically significant predictors (or determinants) were selected in the regression model of each RUSI measure (n = 8 models), accounting for 26-64% of their total variance. The subcutaneous tissue thickness on the back accounted for 15-30% variance of LM echogenicity measures and thoracolumbar fascia thickness while the subcutaneous tissue thickness over the abdominals accounted for up to 42% variance of the fascia separating the subcutaneous adipose tissues and the EO muscle. The thickness of IO at rest accounted for 13-21% variance of all investigated abdominal fasciae except the fascia separating the subcutaneous adipose tissue and EO. Pain status accounted for 13-18% variance of the anterior and posterior fasciae of the TrA. Age accounted for 11-14% variance of LM echogenicity at all investigated vertebral levels while sex accounted for 15-21% variance of LM echogenicity at L3/L4 and fascia separating subcutaneous adipose tissue and EO muscle. The function (or activation) of EO and LM at L3/L4 accounted for 8-11% variance of the thoracolumbar fascia and fascia separating TrA and intra-abdominal content (TrA posterior fascia), respectively. Finally, the physical activity level during sport activities accounted for 7% variance of the fascia separating the subcutaneous adipose tissues and the EO muscle. These findings suggest that determinants other than body size characteristics may impact the remodeling of lumbar soft tissues, more importantly the subcutaneous adipose tissue deposits (thickness RUSI measures), which are associated with ectopic fat deposition in the LM and in the fasciae that are more closely positioned to the surface. While age, sex, and pain status explain some variability, modifiable factors such as physical activity level as well as trunk muscle thickness and function were involved. Overall, these results suggest that rehabilitation can potentially impact tissue remodeling, particularly in terms of intramuscular and perimuscular adipose tissues.

A Novel Immune Modulator for Patients With Necrotizing Soft Tissue Infections (NSTI): Results of a Multicenter, Phase 3 Randomized Controlled Trial of Reltecimod (AB 103).

BACKGROUND AND OBJECTIVE: Reltecimod, a CD 28 T-lymphocyte receptor mimetic, inhibits T-cell stimulation by an array of bacterial pathogens. A previous phase 2 trial demonstrated improved resolution of organ dysfunction after NSTI. We hypothesized that early administration of reltecimod would improve outcome in severe NSTI. METHODS: Randomized, double-blind, placebo-controlled trial of single dose reltecimod (0.5 mg/kg) administered within 6 hours of NSTI diagnosis at 65 of 93 study sites. Inclusion: surgical confirmation of NSTI and organ dysfunction [modified Sequential Organ Failure Assessment Score (mSOFA) score ≥3]. Primary analysis was modified Intent-to-Treat (mITT), responder analysis using a previously validated composite endpoint, necrotizing infection clinical composite endpoint, defined as: alive at day 28, ≤3 debridements, no amputation beyond first operation, and day 14 mSOFA ≤1 with ≥3 point reduction (organ dysfunction resolution). A prespecified, per protocol (PP) analysis excluded 17 patients with major protocol violations before unblinding. RESULTS: Two hundred ninety patients were enrolled, mITT (Reltecimod 142, Placebo 148): mean age 55 ±â€Š15 years, 60% male, 42.4% diabetic, 28.6% perineal infection, screening mSOFA mean 5.5 ±â€Š2.4. Twenty-eight-day mortality was 15% in both groups. mITT necrotizing infection clinical composite endpoint success was 48.6% reltecimod versus 39.9% placebo, P = 0.135 and PP was 54.3% reltecimod versus 40.3% placebo, P = 0.021. Resolution of organ dysfunction was 65.1% reltecimod versus 52.6% placebo, P = 0.041, mITT and 70.9% versus 53.4%, P = 0.005, PP. CONCLUSION: Early administration of reltecimod in severe NSTI resulted in a significant improvement in the primary composite endpoint in the PP population but not in the mITT population. Reltecimod was associated with improved resolution of organ dysfunction and hospital discharge status.

Ultrasound Elastographic Measurement of Sciatic Nerve Displacement and Shear Strain During Active and Passive Knee Extension.

There is current need for objective measures of sciatic nerve mobility in patients with sciatic-type pain. The objective of the study was to assess the feasibility and reliability of ultrasound elastography to quantify sciatic nerve displacement and shear strain at the sciatic nerve-hamstring muscle interface during active and passive knee extension-flexion exercises performed while sitting in healthy people. Ultrasound elastography showed excellent intrarater within-session reliability for assessing sciatic nerve displacement and sciatic nerve-hamstring muscle interface shear strain during active knee extension-flexion exercises. These findings will inform similar future work conducted in patients with sciatic-type pain.

Validation of an Inertial Sensor System for Physical Therapists to Quantify Movement Coordination During Functional Tasks.

Physical therapists evaluate patients' movement patterns during functional tasks; yet, their ability to interpret these observations consistently and accurately is unclear. Physical therapists would benefit from a clinic-friendly method for accurately quantifying movement patterns during functional tasks. Inertial sensors, which are inexpensive, portable sensors capable of monitoring multiple body segments simultaneously, are a relatively new rehabilitation technology. We sought to validate an inertial sensor system by comparing lower limb and lumbar spine kinematic data collected simultaneously with a commercial inertial sensor system and a motion camera system while 10 subjects performed functional tasks. Mean and peak segment angular displacement data were calculated and compared between systems. Mean angular displacement root mean square error between the systems across all tasks and segments was <5°. Mean differences in peak displacements were generally acceptable (<5°) for the femur, tibia, and pelvis segments for all tasks; however, the inertial system overestimated lumbar flexion compared to the motion camera system. These data suggest that the inertial system is capable of measuring angular displacements within 5° of a system widely accepted for its accuracy. Standardization of sensor placement, better attachment methods, and improvement of inertial sensor algorithms will further increase the accuracy of the system.

The effects of an 8-week stabilization exercise program on lumbar movement sense in patients with low back pain.

BACKGROUND: Lumbar stabilization exercises have gained popularity and credibility in patients with non-acute low back pain. Previous research provides more support to strength/resistance and coordination/stabilisation programs. Some authors also suggest adding strength/resistance training following motor control exercises. However, the effect of such a lumbar stabilization program on lumbar proprioception has never been tested so far. The present study investigated the effects of an 8-week stabilization exercise program on lumbar proprioception in patients with low back pain (LBP) and assessed the 8-week test-retest reliability of lumbar proprioception in control subjects. METHODS: Lumbar proprioception was measured before and after an 8-week lumbar stabilization exercise program for patients with LBP. Control subjects participated in the same protocol but received no treatment. RESULTS: The lumbar proprioception measure showed moderate reliability. Patients with LBP and control subjects demonstrated no differences in lumbar proprioception at baseline. Participants from both groups showed better proprioception following the 8-week interval, demonstrating the presence of learning between testing days. CONCLUSIONS: The improvement of lumbar proprioception seen in both groups was ascribed to motor learning of the test itself. The effect of lumbar stabilization exercises on lumbar proprioception remains unknown because the LBP group did not show lumbar proprioception impairments.

Detection of postural sway abnormalities by wireless inertial sensors in minimally disabled patients with multiple sclerosis: a case-control study.

BACKGROUND: Common clinical neurological exams can be insensitive to balance and mobility impairment at the early stages of multiple sclerosis (MS) and may not correspond with patient reports. Instrumented measurement of standing postural sway with inertial motion sensors may provide sensitive measures of balance impairment and better correspond with patient reports. METHODS: While wearing wireless inertial sensors, 20 subjects with MS - Expanded Disability Status Scale of less than 3.0 and a Timed 25 Foot Walk of 5 sec or less - and 20 age- and sex-matched control subjects stood with eyes open and eyes closed on a foam surface. Forty-six outcome measures of postural sway were derived. A stepwise logistic regression model determined which measures of instrumented sway provide independent predictors of group status. Subjects with MS also completed the Activities-Specific Balance Confidence (ABC) scale and the 12-Item MS Walking Scale (MSWS-12) as measures of subject-reported balance and mobility impairment. RESULTS: The regression model identified medio-lateral sway path length and medio-lateral range of sway acceleration amplitude, each in the eyes-open condition, as the only two significant independent predictors to differentiate subjects with MS from those without MS (model chi-squared = 34.55, p < 0.0001): accuracy = 87.5 %, positive likelihood ratio = 6 (2.09-17.21), negative likelihood ratio = 0.12 (0.03-0.44). Range of sway acceleration amplitude significantly correlated with both ABC (Spearman's r = -0.567, p = 0.009) and MSWS-12 scores (Spearman's r = -0.590, p = 0.006). CONCLUSIONS: Postural sway abnormalities in subjects with MS who are minimally disabled were detected using wireless inertial sensors and may signify a superior sensitivity to identify balance impairment prior to developing clinically evident disability or impaired gait speed. Further study is needed to confirm the clinical significance and predictive value of these objectively identified balance impairments.

Reaching back to enhance the future: the American Association for the Surgery of Trauma Diversity, Equity and Inclusion Pipeline Program.

Objectives: There are significant disparities in the surgical workforce in comparison with medical student demographics. Pipeline programs have shown to be effective in addressing gaps. The American Association for the Surgery of Trauma Diversity, Equity and Inclusion Committee designed a longitudinal pipeline program with high school student mentees and surgeon mentors providing an in-person hands-on workshop. Methods: The mentee demographics and socioeconomic status at the time of application were determined using overall percentages and the Area Deprivation Index (ADI). Program application essays were qualitatively analyzed for common themes. The pre-workshop and post-workshop and 6-month follow-up surveys were analyzed for mentee experience and areas for improvement. Results: Mentees selected were 30% male (N=3 of 10), 70% female (N=7 of 10), 50% black or African American (N=5 of 10) and 30% Hispanic or Latinx (N=3 of 10). The majority of mentees were in the most disadvantaged groups in their state by the ADI (N=8 of 9, 89%). Many of the application essays highlighted a personal loss as driving the interest in a health career with several of those losses based on 'gun violence'. There was under-representation in medicine racial/ethnic or gender concordance for 80% (N=8 of 10) of the mentee-mentor pairings. In the pre-workshop survey, even those students with high-grade point averages and strong academic achievement in science courses indicated low confidence in their ability to succeed. Most students (N=7 of 10, 70%) reported a strong positive connection with their mentor in the post-workshop survey. There was a reduction in self-identified modifiable barriers to success for 83% (N=5 of 6) of the mentees. One-third of students who responded to the 6-month survey indicated that they had issues with maintaining contact with their mentors after the workshop. Conclusion: The pipeline program was able to reach the target demographic and increase interest in surgery. Positive mentee/mentor relationships were formed. There are improvements to be made in longitudinal components of the program to ensure lasting results. Level of evidence: III.

Maximizing wound coverage in full-thickness skin defects: A randomized-controlled trial of autologous skin cell suspension and widely meshed autograft versus standard autografting.

BACKGROUND: Traumatic insults, infection, and surgical procedures can leave skin defects that are not amenable to primary closure. Split-thickness skin grafting (STSG) is frequently used to achieve closure of these wounds. Although effective, STSG can be associated with donor site morbidity, compounding the burden of illness in patients undergoing soft tissue reconstruction procedures. With an expansion ratio of 1:80, autologous skin cell suspension (ASCS) has been demonstrated to significantly decrease donor skin requirements compared with traditional STSG in burn injuries. We hypothesized that the clinical performance of ASCS would be similar for soft tissue reconstruction of nonburn wounds. METHODS: A multicenter, within-patient, evaluator-blinded, randomized-controlled trial was conducted of 65 patients with acute, nonthermal, full-thickness skin defects requiring autografting. For each patient, two treatment areas were randomly assigned to concurrently receive a predefined standard-of-care meshed STSG (control) or ASCS + more widely meshed STSG (ASCS+STSG). Coprimary endpoints were noninferiority of ASCS+STSG for complete treatment area closure by Week 8, and superiority for relative reduction in donor skin area. RESULTS: At 8 weeks, complete closure was observed for 58% of control areas compared with 65% of ASCS+STSG areas (p = 0.005), establishing noninferiority of ASCS+STSG. On average, 27.4% less donor skin was required with ASCS+ STSG, establishing superiority over control (p < 0.001). Clinical healing (≥95% reepithelialization) was achieved in 87% and 85% of Control and ASCS+STSG areas, respectively, at 8 weeks. The treatment approaches had similar long-term scarring outcomes and safety profiles, with no unanticipated events and no serious ASCS device-related events. CONCLUSION: ASCS+STSG represents a clinically effective and safe solution to reduce the amount of skin required to achieve definitive closure of full-thickness defects without compromising healing, scarring, or safety outcomes. This can lead to reduced donor site morbidity and potentially decreased cost associated with patient care.Clincaltrials.gov identifier: NCT04091672. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level I.

The Advanced Trauma Operative Management course--a two student to one faculty model.

BACKGROUND: The internationally recognized Advanced Trauma Operative Management (ATOM) course uses a 1:1 student-to-faculty teaching model. This study examines a two student to one faculty ATOM teaching model. MATERIALS AND METHODS: We randomly assigned 16 residents to four experienced ATOM faculty members. Half started with the one-student model and the other half with the two-student model and then switched using the same faculty. Students and faculty completed forms on the educational value of the two models (1 = very poor; 2 = poor; 3 = average; 4 = good; and 5 = excellent) and identified educational preferences and recommendations. RESULTS: We assigned educational values for the 13 procedures as follows: All faculty rated the one-student model as excellent; six members rated the two-student model as excellent, and seven as good. Students rated 50%-75% as excellent and 12%-44% as good for the two-student model, and 56%-81% as excellent and 12%-44% as good for the one-student model. Given resource constraints, all faculty and 88% of students preferred the two-student model. With no resource constraints, 75% of students and 50% of faculty chose the two-student model. All faculty and students rated both models "acceptable." Overall, 81% of students and 50% of faculty rated the two-student model better. All faculty members recommended that the models be optional; 94% of students recommended that they be either optional (50%) or a two-student model (44%). Performing or assisting on each procedure twice was considered an advantage of the two-student model. CONCLUSIONS: The two-student teaching model was acceptable and generally preferred in this study. With appropriately trained faculty and students, the two-student model is feasible and should result in less animal usage and possibly wider promulgation.

Advanced Surgical Skills for Exposure in Trauma (ASSET): the first 25 courses.

BACKGROUND: The Advanced Surgical Skills for Exposure in Trauma (ASSET) course was developed to address limited experience of residents and practicing surgeons (PS) in rapid exposure of major blood vessels for trauma. This one day, case based, scenario driven, fresh cadaver dissection course emphasizes rapid surgical exposure of the vasculature of the neck, chest, abdomen, pelvis and extremities with additional focus on fasciotomies and pelvic packing. Contained herein are the results of the first 25 courses. METHODS: Data collected from 25 ASSET courses conducted between September 2010 and February 2012 included self-reported comfort level (5 point Likert scale) with each of 25 specific skills before and upon completion of the course, and evaluation of the course content. Statistical analysis was accomplished using the Student t-test with α set at P < 0.05. RESULTS: Ninety-one surgical trainees and 123 PS were taught at 11 ASSET sites. Self-assessed comfort levels for all 25 queried skills and exposures improved significantly over baseline with P values ranging from 1.6 × 10(-7) to 3.9 × 10(-41). Participants gained new knowledge (4.83 on 5 point scale); learned new techniques (4.83), felt better prepared to expose traumatically injured vessels (4.88), and would recommend the course to a colleague (4.92). CONCLUSIONS: The ASSET course was well received and significantly improved self-reported confidence in the exposures needed to care for trauma in both surgical trainees and PS. Ongoing experience with this course will enable more comprehensive psychometric analysis and further validation of this curriculum.

Lumbar multifidus muscle thickness does not predict patients with low back pain who improve with trunk stabilization exercises.

OBJECTIVE: To understand lumbar multifidus (LM) muscle activation as a clinical feature to predict patients with low back pain (LBP) who are likely to benefit from stabilization (STB) exercises. DESIGN: Prospective, cohort study. SETTING: Outpatient physical therapy clinics. PARTICIPANTS: Persons with LBP were recruited for this study. Subjects (N=25) were classified as either eligible to receive STB exercises or ineligible on the basis of current clinical prediction rules. INTERVENTIONS: Six weeks of STB treatment. MAIN OUTCOME MEASURES: Before and after treatment, subjects underwent rehabilitative ultrasound imaging to quantify LM-muscle activation and completed disability and pain questionnaires. Analyses were performed to examine the (1) relation between LM-muscle activation and current clinical features used to predict patients with LBP likely to benefit from STB exercises, (2) LM-muscle activation between the STB-eligible and STB-ineligible groups before and after STB treatment, and (3) relation between LM-muscle activation before STB treatment and (a) disability and (b) pain outcomes after treatment for both groups. RESULTS: No relation was found between LM-muscle activation and the number of clinical features. Before STB treatment, LM-muscle activation between the STB-eligible and STB-ineligible groups did not differ. After STB treatment, LM-muscle activation differed between the groups; however, this interaction was because the LM-muscle activation for the STB-eligible group decreased after treatment while that for the STB-ineligible group increased after treatment. Finally, only the STB-eligible group had a significant reduction in disability following treatment; however, no relation was found between LM-muscle activation before treatment and (a) disability or (b) pain outcomes after treatment in the STB-eligible group. CONCLUSIONS: LM-muscle activation does not appear to be a clinical feature that predicts patients with LBP likely to benefit from STB exercises.

Physical activity for patients with chronic low back pain: What are physical therapists prescribing?

BACKGROUND: Despite the extensive evidence supporting physical activity (PA) for managing chronic low back pain (CLBP), little is known about PA prescription by physical therapists treating patients with CLBP. OBJECTIVE: 1) Explore how PA prescriptions provided by outpatient physical therapists treating patients with CLBP align with PA guidelines. 2) Examine the barriers and facilitators of PA prescription among physical therapists working with patients with CLBP. METHODS: We conducted a qualitative study with outpatient physical therapists who treat CLBP. Semi-structured interviews provided an understanding of physical therapist experience with PA prescription among patients with CLBP. The interviews were transcribed, coded, and analyzed thematically. RESULTS: The 18 participants had an average of 13.4 (6.4) years of clinical experience in outpatient physical therapy. Thematic analysis revealed: 1) Physical therapists' articulate knowledge of PA guidelines and importance of physical activity; 2) Patient factors take priority over the PA guidelines for people with CLBP; and 3) The importance of building and maintaining a strong patient-therapist relationship influences physical therapist prescription of PA for patients with CLBP. CONCLUSION: When providing PA recommendations for patients with CLBP, general movement recommendations are emphasized in place of explicit PA prescriptions. Our findings highlight factors for consideration when prescribing movement and PA for patients with CLBP.

Individuals with non-specific low back pain in an active episode demonstrate temporally altered torque responses and direction-specific enhanced muscle activity following unexpected balance perturbations.

Individuals with a history of non-specific low back pain (LBP) while in a quiescent pain period demonstrate altered automatic postural responses (APRs) characterized by reduced trunk torque contributions and increased co-activation of trunk musculature. However, it is unknown whether these changes preceded or resulted from pain. To further delineate the relationship between cyclic pain recurrence and APRs, we quantified postural responses following multi-directional support surface translations, in individuals with non-specific LBP, following an active pain episode. Sixteen subjects with and 16 without LBP stood on two force plates that were translated unexpectedly in 12 directions. Net joint torques of the ankles, knees (sagittal only), hips, and trunk, in the frontal and sagittal planes, were quantified and the activation of 12 muscles of the lower limb unilaterally and the dorsal and ventral trunk, bilaterally, were recorded using surface electromyography (EMG). Peaks and latencies to peak joint torques, rates of torque development (slopes), and integrated EMGs characterizing baseline and active muscle contributions were analyzed for group by perturbation direction (torques) and group by perturbation by epoch interaction (EMG) effects. In general, the LBP cohort demonstrated APRs that were of similar torque magnitude and rate but peaked earlier compared to individuals without LBP. Individuals with LBP also demonstrated increased muscle activity following perturbation directions in which the muscle was acting as a prime mover and reduced muscle activity in opposing directions, proximally and distally, with some proximal asymmetries. These altered postural responses may reflect increased muscle spindle sensitivity. Given that these motor alterations are demonstrated proximally and distally, they likely reflect the influence of central nervous system processing in this cohort.

Is There a Place for Hyperbaric Oxygen Therapy?

Hyperbaric oxygen therapy (HBOT) involves treating patients by providing 100% oxygen through inhalation while inside a treatment pressurized chamber. The oxygen acts as a drug and the hyperbaric chamber as the dosing device. The effect of hyperbaric hyperoxia is dose dependent and, therefore, treatment depth and duration are important when considering its use. HBOT can either be the primary method of treatment or used adjunctively to medications or surgical techniques. The underpinning physiology is to bring oxygen-rich plasma to hypoxic tissue, preventing reperfusion injury, strengthening immune responsiveness, and encouraging new collagen deposition as well as endothelial cell formation.

Have Students Used Techniques to Stop the Bleed?

INTRODUCTION: The Stop the Bleed course was initiated in response to the Hartford Consensus and over 1 million people have been taught basic bleeding control techniques. Our study sought to determine the extent to which this training has been utilized. METHODS: Surveys were sent by email to students that had taken the Stop the Bleed course through our institution in 2017 or 2018. Data were collected utilizing the REDCap system and statistical calculations were performed. RESULTS: 2505 surveys were sent with 445 (18%) responses. The mean age of respondents was 48 years of age, 343 (77%) were female, and 230 (52%) were in the medical field. There were 17 respondents (3.8%) that stated they had utilized the techniques taught in the course; 16 out of 17 put pressure on a wound, 7 packed a wound, and 6 used a tourniquet. Patients had been injured by a variety of mechanisms including gunshot wound, stabbing, accidental laceration, and motor vehicle collision. Patients had good outcomes with 3 out of 17 surviving to emergency medical services arrival without known final outcome and the remaining 14 were known to do well. CONCLUSION: The Stop the Bleed course is important to enable bystanders to provide hemorrhage control. Our study shows that the techniques have been utilized with 17 treated patients having a good outcome and while a utilization rate of 3.8% may appear low, it is similar to the utilization rate of cardiopulmonary resuscitation instruction of 2%.

Derivation of clinical prediction rules for identifying patients with non-acute low back pain who respond best to a lumbar stabilization exercise program at post-treatment and six-month follow-up.

Low back pain (LBP) remains one of the most common and incapacitating health conditions worldwide. Clinical guidelines recommend exercise programs after the acute phase, but clinical effects are modest when assessed at a population level. Research needs to determine who is likely to benefit from specific exercise interventions, based on clinical presentation. This study aimed to derive clinical prediction rules (CPRs) for treatment success, using a lumbar stabilization exercise program (LSEP), at the end of treatment and at six-month follow-up. The eight-week LSEP, including clinical sessions and home exercises, was completed by 110 participants with non-acute LBP, with 100 retained at the six-month follow-up. Physical (lumbar segmental instability, motor control impairments, posture and range of motion, trunk muscle endurance and physical performance tests) and psychological (related to fear-avoidance and home-exercise adherence) measures were collected at a baseline clinical exam. Multivariate logistic regression models were used to predict clinical success, as defined by ≥50% decrease in the Oswestry Disability Index. CPRs were derived for success at program completion (T8) and six-month follow-up (T34), negotiating between predictive ability and clinical usability. The chosen CPRs contained four (T8) and three (T34) clinical tests, all theoretically related to spinal instability, making these CPRs specific to the treatment provided (LSEP). The chosen CPRs provided a positive likelihood ratio of 17.9 (T8) and 8.2 (T34), when two or more tests were positive. When applying these CPRs, the probability of treatment success rose from 49% to 96% at T8 and from 53% to 92% at T34. These results support the further development of these CPRs by proceeding to the validation stage.