Performance-integrated self-report measurement of physical ability.

BACKGROUND CONTEXT: The technology of self-report measures has advanced rapidly over the past few years. Recently, this technology was used to develop a performance-integrated self-report measure for use with patients with musculoskeletal impairments that may lead to work disability. Psychometric studies of the new measure in patient populations have been successful. A validation study of the measure with adults in good general health is necessary. PURPOSE: The purpose of this study was to assess the concurrent validity of a new performance-integrated self-report measure, the multidimensional task ability profile (MTAP). STUDY DESIGN/SETTING: A prospective validation study was conducted in which a self-report measure was administered online, and a physical performance test was administered at various clinics in North America. PATIENT SAMPLE: One hundred ninety-six (34% male) adult volunteers in good general health participated in this study. OUTCOME MEASURES: Self-report measure-MTAP. Physiologic measure-EPIC Lift Capacity test. METHODS: The MTAP was administered online within 1 week of formal testing of lift capacity using a standardized lift capacity test, the EPIC Lift Capacity test. MTAP scores were compared with performance on the EPIC Lift Capacity test. Stepwise regression analysis was used to identify the strength of the relationship between the two measures and the relative explanation of lift capacity variance by the MTAP score, along with gender and age. RESULTS: The combination of MTAP score, gender, and age demonstrated a regression coefficient of R=0.82, which accounts for 67.3% of the variance in lift capacity. CONCLUSIONS: The MTAP displayed good concurrent validity compared with actual physical performance as assessed by the EPIC Lift Capacity test. Modern performance-integrated self-report measures, such as the MTAP, have the potential to provide information about functional capacity that is sufficiently useful to confirm status and help guide treatment algorithms.

Evidence-informed management of chronic low back pain with lumbar extensor strengthening exercises.

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of to The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this supplement were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

A method to provide a more efficient and reliable measure of self-report physical work capacity for patients with spinal pain.

Self-report measures of functional ability are commonly used in occupational rehabilitation to measure the current status of an individual and his or her progress in response to intervention. Most of these measures have been developed using classical test theory that does not provide calibration of the items. Methods of test development that originated in the field of Education have been applied recently to healthcare measures, providing item calibration and allowing proportional evaluation of total scores. The purpose of this article is to demonstrate the application of these methods in the revision of an existing self-report measure. The potential value of these methods to improve established measures is demonstrated.

Continuous low-level heat wrap therapy for the prevention and early phase treatment of delayed-onset muscle soreness of the low back: a randomized controlled trial.

OBJECTIVE: To evaluate the effects of continuous low-level heat wrap therapy for the prevention and early phase treatment (ie, 0-48 h postexercise) of delayed-onset muscle soreness (DOMS) of the low back. DESIGN: Two prospective randomized controlled trials. SETTING: Outpatient medical facility. PARTICIPANTS: Sixty-seven subjects asymptomatic of back pain and in good general health (mean age, 23.5+/-6.6 y). INTERVENTIONS: Participants performed vigorous eccentric exercise to experimentally induce low back DOMS. Participants were assigned to 1 of 2 substudies (prevention and treatment) and randomized to 1 of 2 treatment groups within each substudy: prevention study (heat wrap, n=17; control [nontarget muscle stretch], n=18) and treatment study (heat wrap, n=16; cold pack, n=16). Interventions were administered 4 hours before and 4 hours after exercise in the prevention study and between hours 18 to 42 postexercise in the treatment study. MAIN OUTCOME MEASURES: To coincide with the expected occurrence of peak symptoms related to exercise-induced low back DOMS, hour 24 postexercise was considered primary. Pain intensity (prevention) and pain relief (treatment) were primary measures, and self-reported physical function and disability were secondary measures. RESULTS: In the prevention study, at hour 24 postexercise, pain intensity, disability, and deficits in self-reported physical function in subjects with the heat wrap were reduced by 47% (P<.001), 52.3% (P=.029), and 45% (P=.013), respectively, compared with the control group. At hour 24 in the treatment study, postexercise, pain relief with the heat wrap was 138% greater (P=.026) than with the cold pack; there were no differences between the groups in changes in self-reported physical function and disability. CONCLUSIONS: In this small study, continuous low-level heat wrap therapy was of significant benefit in the prevention and early phase treatment of low back DOMS.

Effects of pelvic stabilization on lumbar muscle activity during dynamic exercise.

Many commonly utilized low-back exercise devices offer mechanisms to stabilize the pelvis and to isolate the lumbar spine, but the value of these mechanisms remains unclear. The purpose of this study was to examine the effect of pelvic stabilization on the activity of the lumbar and hip extensor muscles during dynamic back extension exercise. Fifteen volunteers in good general health performed dynamic extension exercise in a seated upright position on a lumbar extension machine with and without pelvic stabilization. During exercise, surface electromyographic activity of the lumbar multifidus and biceps femoris was recorded. The activity of the multifidus was 51% greater during the stabilized condition, whereas there was no difference in the activity of the biceps femoris between conditions. This study demonstrates that pelvic stabilization enhances lumbar muscle recruitment during dynamic exercise on machines. Exercise specialists can use these data when designing exercise programs to develop low back strength.

Treating acute low back pain with continuous low-level heat wrap therapy and/or exercise: a randomized controlled trial.

BACKGROUND CONTEXT: Restorative exercise and palliative modalities are frequently used together for the treatment of acute low back pain. However, little is known about the effects of combining these treatments. PURPOSE: To evaluate the efficacy of combining continuous low-level heat wrap therapy with directional preference-based exercise on the functional ability of patients with acute low back pain. STUDY DESIGN/SETTING: A randomized controlled trial was conducted at three outpatient medical facilities. PATIENT SAMPLE: One hundred individuals (age 31.2+/-10.6 years) with low back pain of less than 3 months duration. OUTCOME MEASURES: The primary outcome measure was functional ability assessed by the Multidimensional Task Ability Profile questionnaire. Secondary outcomes were disability assessed by the Roland-Morris Disability Questionnaire and pain relief assessed by a 6-point verbal rating scale. METHODS: Participants were randomized to one of four groups: Heat wrap therapy alone (heat wrap, n=25); directional preference-based exercise alone (exercise, n=25); combination of heat wrap therapy and exercise (heat+exercise, n=24); or control (booklet, n=26). Treatment was administered for five consecutive days and included four visits to the study center over 1 week. RESULTS: At 2 days after the conclusion of treatment (Day 7), functional improvement for heat+exercise was 84%, 95%, and 175% greater than heat wrap, exercise, and booklet, respectively (p<.05). Seventy-two percent of the subjects in the heat+exercise group demonstrated a return to pre-injury function compared with 20%, 20%, and 19% for heat wrap, exercise, and booklet, respectively (p<.05). Disability reduction for heat+exercise was 93%, 139%, and 400% greater than heat wrap, exercise, and booklet, respectively (p<.05). Pain relief for heat+exercise was 70% and 143% greater than exercise and booklet, respectively (p<.05). CONCLUSIONS: Combining continuous low-level heat wrap therapy with directional preference-based exercise during the treatment of acute low back pain significantly improves functional outcomes compared with either intervention alone or control. Either intervention alone tends to be more effective than control.

Reliability and validity of a new computer-administered pictorial activity and task sort.

Development of a new pictorial activity and task sort and examination of its reliability and validity is described. The Multidimensional Task Ability Profile (MTAP) is the latest in a series of measures that use a combination of drawings and task descriptions in a self-report format to assess functional capacity. The MTAP is found to be reliable on a test-retest and split-half basis. The concurrent validity of the MTAP was examined in performance testing of lift capacity. Results demonstrate that the MTAP has good concurrent validity.

Pseudarthrosis after lumbar spine fusion: nonoperative salvage with pulsed electromagnetic fields.

We studied 100 patients in whom symptomatic pseudarthrosis had been established at more than 9 months after lumbar spine fusion. All patients were treated with a pulsed electromagnetic field device worn consistently 2 hours a day for at least 90 days. Solid fusion was achieved in 67% of patients. Effectiveness was not statistically significantly different for patients with risk factors such as smoking, use of allograft, absence of fixation, or multilevel fusions. Treatment was equally effective for posterolateral fusions (66%) as with interbody fusions (69%). For patients with symptomatic pseudarthrosis after lumbar spine fusion, pulsed electromagnetic field stimulation is an effective nonoperative salvage approach to achieving fusion.

Biochemical injection treatment for discogenic low back pain: a pilot study.

BACKGROUND CONTEXT: Biochemical treatment options including attempts at intervertebral disc restoration are desirable for the physiologic treatment of degenerative disc disease. PURPOSE: This was a pilot study to test the potential effectiveness of intradiscal injection therapy using agents known to induce proteoglycan synthesis in the treatment of intervertebral disc disease. STUDY DESIGN: Prospective, within subject, experimental design was applied in the study. PATIENT SAMPLE: Thirty patients, average age 46.5 years, with chronic intractable low back pain of 8.5 years average duration, took part in the study. All patients had lumbar discography with reproduction of pain. OUTCOME MEASURES: Pretreatment Roland-Morris disability scores and visual analogue scores were compared with 1-year follow-up posttest values of these scores. METHODS: Lumbar intervertebral discs were injected with a solution of glucosamine and chondroitin sulfate combined with hypertonic dextrose and dimethlysulfoxide (DMSO). Assessment of pain and disability was completed before treatment and an average of 12 months after the last treatment. RESULTS: Posttreatment Roland-Morris scores for the entire group of 30 patients of 6.4+/-.994 were significantly (p<.001) lower than pretreatment scores of 12.0+/-.92 (mean+/-SE). The posttreatment visual analogue scores of 3.00+/-.44 were also significantly less than the pretreatment of 6.11+/-.33 (mean+/-SE). Although the results were statistically significant for the 30 patients as a whole, 17 of the 30 patients (57%) improved markedly with an average of 72% improvement in disability scores and 76% in visual analogue scores. The other 13 patients (43%) had little or no improvement. Patients who did poorly included those with failed spinal surgery, spinal stenosis and long-term disability. There were no complications or serious side effects, although postinjection pain was moderate to severe for 48 to 72 hours and required epidural steroids in five cases. CONCLUSIONS: The results of this pilot study suggest that intradiscal injection therapy with glucosamine, chondroitin sulfate, hypertonic dextrose and DMSO warrants further evaluation with randomized controlled trials.

The role of measured resistance exercises in adolescent scoliosis.

Twenty adolescent patients (18 girls and 2 boys) with scoliosis ranging from 15 degrees-41 degrees in their major curve were treated with a progressive resistive training program for torso rotation. All patients demonstrated an asymmetry of rotation strength measured on specialized equipment, and surface electrode electromyograms showed inhibition of lumbar paraspinal muscles. Sixteen of 20 patients demonstrated curve reduction, and no patient showed an increase in curve.

Electromyographic activity of the trunk extensor muscles: effect of varying hip position and lumbar posture during Roman chair exercise.

OBJECTIVE: To evaluate the effect of hip position and lumbar posture on the surface electromyographic activity of the trunk extensors during Roman chair exercise. DESIGN: Descriptive, repeated measures. SETTING: University-based musculoskeletal research laboratory. PARTICIPANTS: Twelve healthy volunteers (7 men, 5 women; age range, 18-35y) without a history of low back pain were recruited from a university setting. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Surface electromyographic activity was recorded from the lumbar extensor, gluteal, and hamstring musculature during dynamic Roman chair exercise. For each muscle group, electromyographic activity (mV/rep) was compared among exercises with internal hip rotation and external hip rotation and among exercises by using a typical lumbar posture (nonbiphasic) and a posture that accentuated lumbar lordosis (biphasic). RESULTS: For the lumbar extensors, electromyographic activity during exercise was 18% greater with internal hip rotation than external hip rotation (P< or =.05) and was 25% greater with a biphasic posture than with a nonbiphasic posture (P< or =.05). For the gluteals and hamstrings, there was no difference in electromyographic activity between internal and external hip rotation or between biphasic and nonbiphasic postures (P >.05). CONCLUSION: The level of recruitment of the lumbar extensors can be modified during Roman chair exercise by altering hip position and lumbar posture. Clinicians can use these data to develop progressive exercise protocols for the lumbar extensors with a variety of resistance levels without the need for complex equipment.

Back extension endurance and strength: the effect of variable-angle roman chair exercise training.

STUDY DESIGN: A pre- and postintervention randomized, controlled trial was conducted. OBJECTIVE: To evaluate the effect of progressive resistance exercise training using a variable-angle Roman chair on the development of lumbar extensor endurance and strength. SUMMARY OF BACKGROUND DATA: Progressive resistance exercise for the lumbar extensors has been used successfully for low back pain rehabilitation, but the limitations of currently available back exercise devices have negatively affected its use. METHODS: For this study, 36 healthy volunteers were randomized into one of two groups: a variable-angle Roman chair exercise group (n = 18) that performed one set of 15 to 25 repetitions of dynamic progressive resistance back extension exercise on a variable-angle Roman chair three times per week for 8 weeks or a control group (n = 18) that did not perform resistance exercise. Before training and after 4 and 8 weeks of training, static back extension endurance (seconds) and isometric lumbar extension strength (Newton.meters) were recorded. RESULTS: The variable-angle Roman chair exercise group displayed a 42% increase in static back extension endurance at the 4-week and 8-week tests relative to the pretraining measure (P < 0.05). The control group did not increase back endurance time at either the 4-week or 8-week tests (P > 0.05). Neither the variable-angle Roman chair exercise group nor the control group displayed an increase in lumbar extension strength at the 4-week or 8-week tests (P > 0.05). CONCLUSIONS: Dynamic progressive resistance exercise training on a variable-angle Roman chair is capable of developing back extension endurance. Future research is needed to determine the clinical applicability of variable-angle Roman chair exercise training for patients with low back pain patients.

The contribution of aerobic fitness and back strength to lift capacity.

STUDY DESIGN: This study used a concurrent validation design with 45 healthy female participants. OBJECTIVE: To measure the relative contributions of aerobic capacity and back strength to lift capacity. SUMMARY OF BACKGROUND DATA: This was the first concurrent study of the relations among spine strength, aerobic capacity, and lift capacity. Previous research had demonstrated moderate to strong relations between spine strength and lift capacity and between aerobic capacity and lift capacity. METHODS: Multiple regression techniques were used on reliable and valid measures of each construct to study the individual and joint contributions of spine strength and aerobic capacity to lift capacity. RESULTS: Both spine strength and aerobic capacity make significant independent contributions to lift capacity, accounting for 11% and 27% of the variance, respectively. Taken together, the predictive power of these variables on lift capacity accounts for 43% of the variance. CONCLUSIONS: Lift capacity is dependent on both back strength and aerobic capacity. It may be inappropriate to use lift capacity as an indicator for the severity of spine impairment in a disability determination system without taking into account the individual's aerobic capacity. Treatment intended to improve the lift capacity of persons with spine impairment should anticipate that improvement in both back strength and aerobic capacity will improve lift capacity.

A prospective short-term study of chronic low back pain patients utilizing novel objective functional measurement.

The present study utilized recently developed diagnostic tests that permit recognition of functional deficits in spine mobility, trunk strength, endurance, coordination, and dynamic lifting capacity. Changes in these tests were compared to changes in psychological functioning (e.g., self-report of pain) as well as to outcome criteria such as return-to-work and resolution of litigation. The study utilized these tests repeatedly during a new treatment approach to feed back objective information of the patient's functional capacity, not amenable to simple visual inspection, to both the patient and the surgeon. The program itself integrated a low back physical rehabilitation program with a multimodal pain management program and was guided by repeated functional capacity measurements. A total of 66 patients were evaluated. Results demonstrated significant improvement in physical function in these patients, which was also accompanied by changes in self-report of pain complaints. Moreover, an 82% return-to-work rate was achieved in this sample which was initially 92% unemployed. These results indicate that the physician dealing with chronic low back dysfunction can employ objective measures of functional capacity as an alternative to the sole reliance on pain patient self-report or structured tests, such as radiographic imaging, which merely document a universal, progressive degenerative process.

A comprehensive treatment approach to chronic low back pain.

A comprehensive treatment program for chronic disability related to back disease has been presented. This program has used not only more traditional methods of medical care for the structural disabilities of chronic mechanical back disorders, but has used principles of active patient participation in the improvement process. The patients are educated in the manifestations of pain behavior in the phase II treatment program emphasis on pain sources is downgraded to allow positive reinforcement for healthy behavior to develop. By use of an organized team approach, a significant number of patients can be processed; and an overall reduction in use of alternative medical resources has occurred.