Does poor sleep quality lead to increased low back pain the following day?

OBJECTIVES: This study explored the relationship between sleep quality and next-day pain intensity for people with low back pain and investigated whether there was any evidence that this relationship was causal. METHODS: We conducted a secondary analysis of an observational study that investigated sleep quality in people with low back pain. People with low back pain were recruited from primary care and the community. Sleep quality was measured with subjective (self-report) and objective (polysomnography (PSG)) measures. PSG analysis classifies sleep into stages, of which slow-wave sleep (SWS) is thought to have a key role in maintaining or increasing pain intensity. We drew directed acyclic graphs to identify possible confounders of the relationship between both measures of sleep quality, and pain intensity. We constructed two linear regression models to explore the effect of subjective and objective sleep quality on next-day pain intensity before and after confounder adjustment. RESULTS: Thirty-nine participants were included in the study. For participants with low back pain, self-reported better quality sleep ß=-0.38 (95% CI -0.63 to -0.13), or spending a greater proportion of time in SWS ß=-0.12 (95% CI -0.22 to -0.02) was associated with lower next day pain intensity. After confounder adjustment, the effect reduced and was no longer significant for either self-reported ß=-0.18 (95% CI -0.46 to 0.10), or SWS ß=-0.08 (95% CI -0.18 to 0.03). CONCLUSIONS: Sleep quality, whether measured by self-report or proportion of time in SWS, was associated with next day pain intensity for people with low back pain. However, this relationship is likely to be confounded and therefore not likely to be causal.

Efficacy of core stability training on upper extremity performance in collegiate athletes.

OBJECTIVE: To determine the efficacy of a five-week core stability training program for collegiate athletes on upper extremity performance measures. METHODS: Seventy healthy collegiate athletes (age 21.6±1.7years; height 175±4.63 cm; body mass 65.31±5.63 kg) were randomly allocated to experimental (n=35) and control group (n=35). The experimental group has undergone a five-week core stabilisation protocol (three days /week) and regular training, whereas the control group maintained their regular training. The upper quarter Y balance test (UQ-YBT) and Functional throwing performance index (FTPI) were assessed pre and post-training. RESULTS: The results of mixed ANOVA show that there was a significant interaction between time and group variables on YBT (p<0.001, ηp2 =0.759) and FTPI (p<0.001, ηp2 =0.411) after five weeks of core stability training. Statistically, significant improvement was shown in YBT (mean change=15.2, p<0.001) and FTPI (mean change=14.4, p<0.001) in the experimental group; however, there was no significant change observed in both outcomes in the control groups. CONCLUSION: After five weeks of core stabilisation training program, the measures of UQ-YBT and FTPI were improved, thus advocating the use of a core stabilisation training program among collegiate athletes to enhance their upper extremity performance.

The effect of isokinetic hip muscle strength on normal medial longitudinal arch feet and pes planus.

Pes planus is a common foot and ankle physiologic deformity. The normal medial longitudinal arch is depressed or flattened due to a lack of strength in associated muscles, ligaments, and tendons. This study aimed to investigate how isokinetic hip muscular strength affected normal medial longitudinal arch feet and pea planus. Forty adult subjects participated in this study: 20 with pea planus and 20 with normal medial longitudinal arched feet. Both groups were similar in age (p=.074), weight (p=.324), height (p=.211), and BMI (p=.541). The navicular drop test determined the differences in navicular height. An isokinetic dynamometer was used to determine hip muscular strength (peak torque and total work) during hip flexion, extension, abduction, and adduction at speeds of 90°/s and 180°/s. A Kruskal-Wallis test was computed to determine the comparison between the normal medial longitudinal arch and pea planus. Subjects with normal medial longitudinal arch had more muscle strength than pes planus. Hip muscle strength did not show any significant difference between both groups. The abductor and adductor group muscles' total work were higher in subjects with pes planus. This study showed that normal medial longitudinal arched foot subjects have higher muscle strength than pes planus. However, the hip abductors were significantly lower in pes planus after measuring the total work, suggesting that individuals with pes planus are easily fatigued, possibly due to the overuse of the muscles that compensate for any changes in lower limb alignment.

Musculoskeletal Pain in Undergraduate Students Is Significantly Associated with Psychological Distress and Poor Sleep Quality.

Musculoskeletal pain (MSKP), psychological distress, and poor sleep quality are common among undergraduate university students. Yet, few studies have assessed the association between MSKP and psychological distress and poor sleep quality. This cross-sectional study was conducted to determine this association among undergraduate students at a major public university in Saudi Arabia. MSKP was assessed using the Nordic Musculoskeletal Questionnaire, psychological distress using the Depression, Anxiety and Stress (DASS-21) questionnaire, and sleep quality using the Pittsburgh Sleep Quality Index. A total of 339 undergraduate students from various specialties provided complete responses and were included. The most common site of MSKP in the past 12 months and the past 7 days were neck pain (54.6% and 41.9%, respectively) and low back pain (49.4% and 48.2%, respectively). There was no difference in the prevalence of MSKP across colleges. The reported MSKP in the past 12 months and 7 days were significantly associated with the students' level of anxiety and stress as well as sleep quality (p < 0.05 for all), while depression was only significantly associated with MSKP in the past 7 days.

Beliefs, Attitudes, and Behaviors of Saudi Physiotherapists Toward Evidence-Based Practice: A Multicenter, Cross-Sectional Study.

Background: Evidence-based practice (EBP) has gained significant importance in clinical practice worldwide, including physiotherapy, but there are limited studies that have assessed the knowledge, attitude, and behaviors of Saudi physiotherapists toward EBP. Objective: To determine the beliefs, attitudes, knowledge, and experience of Saudi physiotherapists in public hospitals of the Eastern Province of Saudi Arabia toward EBP as well as identify barriers that limit the integration of EBP in clinical practice. Materials and Methods: This cross-sectional design included all Saudi physiotherapists working in four major tertiary hospitals in the Eastern Province of Saudi Arabia. The Evidence-Based Practice Questionnaire was used to elicit responses. The association between attitudes, awareness, and knowledge scores and the demographic data such as age group, years of experience, and level of education was assessed. Results: The questionnaire was distributed to a total of 171 physiotherapists, of which 118 (69%) responded. About 90% of the participants agreed or strongly agreed that EBP is necessary for clinical practice. However, about 25%, 19%, and 18% of the participants reported that EBP does not consider clinical limitations, support physiotherapy intervention, or consider patients' physiotherapy preferences, respectively. The most common barrier in the implementation of EBP in daily clinical practice was insufficient time (>50%), followed by self-efficacy in retrieving evidence from the literature and translating research findings into clinical practice. Years of experience, age, and gender were significant factors associated with physiotherapists' beliefs and attitudes toward implementing EBP. Conclusions: Although EBP was favored, several barriers exist that hinder its adoption by physiotherapists. Institutional support and research skill development may help accelerate EBP adoption levels and should be considered by policymakers.

Cross-Cultural Adaptation and Clinimetric Testing of Functional Rating Index (FRI) Outcome Measure into the Arabic Language.

Background: The Functional Rating Index (FRI) is a self-report scale widely used to determine the level of disability in low back pain (LBP) populations. Objectives: This study was aimed at conducting the cross-cultural adaptation of the FRI-Arabic version (FRI-Ar) and testing the clinometric properties of FRI-Ar. Methods: The cross-cultural adaptation process was used to develop the FRI-Ar. This study included acute and subacute LBP patients. Each patient was asked to complete the questionnaires at three time points: baseline, 24-hour follow-up, and two-week follow-up. The questionnaires used were FRI-Ar, Roland-Morris Disability Questionnaire (RMDQ), Oswestry Disability Index (ODI), Numerical Pain Rating Scale (NPRS), Global Perceived Effect Scale (GPE), and Patient-Specific Functional Scale (PSFS). Statistical analysis was carried out to measure the instrument's reliability, validity, and responsiveness. Results: The FRI was cross-culturally adapted to the Arabic language, and the adapted version was validated. Two hundred patients completed the questionnaires at the baseline; however, 120 patients completed the questionnaires at 24-hour and two-week follow-up. Cronbach's alpha, interclass correlation coefficient (ICC2,1), standard error of measurement (SEM), and minimal detectable change (MDC95%) for the FRI-Ar were observed as 0.85, 0.85, 1.17 (2.9%), and 3.24, respectively. The FRI-Ar showed a moderate positive correlation only with the RMDQ, ODI, and NPRS (p < 0.05). Also, it showed the responsiveness with a small effect size (ES = 0.29) and standardized response mean (SRM = 0.44). Conclusion: The FRI-Ar was developed, and it showed good reliability and validity. However, it revealed the responsiveness with the small change. It can evaluate both pain and functional limitations in acute and subacute LBP patients. Before using it in the Arabic population with acute and subacute LBP, it is recommended to conduct further research to test internal and external responsiveness using an external criterion with a more extended follow-up period and suitable interventions.

Determining the knee joint laxity between the pronated foot and normal arched foot in adult participants.

AIM OF THE STUDY: Foot pronation is often associated with increased internal rotation of the lower limb, predisposing the knee joint to greater stress. However, the impact of the pronated foot on knee joint laxity has not been well understood. The study aims to find out the effect of the pronated foot on knee joint laxity. METHODS: Forty adult participants were recruited for the study: 20 with asymptomatic pronated foot and 20 control subjects with the normal arched foot. Foot assessments were performed by navicular drop test and rearfoot angle measurements. Knee joint laxity was measured by a KT 1000 arthrometer of the dominant leg. An independent t-test was performed to detect the differences between both groups. RESULTS: Both groups were similar in age, BMI and physical activity level. The findings showed no significant differences between the pronated foot and control group in the knee joint laxity (P = 0.645). CONCLUSIONS: There were no significant differences in anterior knee displacement between the pronated foot and normal arch foot. The study showed that pronated foot might not be responsible for ACL injuries during the age of twenties and cofounding factors. Further research is needed to investigate older subjects with the pronated foot.

Patellar Tendinopathy-Does Injection Therapy Have a Role? A Systematic Review of Randomised Control Trials.

Injection treatment is one of the most widely used methods for the conservative management of patellar tendinopathy. The objective of this systematic review was to synthesise data from randomised control trails on the effectiveness of various injections used in the management of patellar tendinopathy. An electronic search was conducted in the Web of Science, Scopus, PubMed, and SPORTDiscus databases. To be included in the current systematic review, the study had to be an RCT conducted on human participants that investigated the effect of at least one injection treatment on the management of patellar tendinopathy. Selected studies were required to report either patient-reported outcomes or biological and clinical markers of the tendon healing. The methodological quality of the studies was appraised using the revised Cochrane risk of bias tool for RCTs (RoB 2.0). Nine RCTs on seven types of injections were included in this review, with an overall positive outcome. Pain intensity was measured in all the studies. The VISA P score was the most used outcome measure (n = 8). A wide variety of interventions were compared with injection therapy, including eccentric training, extracorporeal shockwave, and arthroscopy. It can be concluded that the injection treatments can produce promising results in the management of patellar tendinopathy. However, because of the limited number of studies and the disparities in the study populations and protocols, it is not possible to make a firm conclusion on the efficacy of these injection methods, and these results should be inferred with care.

Comparison of 3D Hip Joint Kinematics in People with Asymptomatic Pronation of the Foot and Non-Pronation Controls.

BACKGROUND: The impact of asymptomatic pronation on proximal joints during motion has not been well understood, and research on it remains limited. Therefore, the current study determines the effect of asymptomatic pronation of the foot on hip joint kinematics during gait. METHODS: Forty participants were recruited for the study (20 with asymptomatic pronated feet and 20 with non-pronated feet). Foot assessment was conducted by navicular drop and rear-foot angle tests. Hip joint kinematics were measured via MVN Xsens system 3D-motion capture from sagittal, frontal and transverse planes during gait. An independent t-test was used to identify differences in kinematic variables. RESULTS: Both groups were similar in characteristics, and there were no significant differences between the groups in age (P = 0.674) and BMI (P = 0.459). However, there was a significant difference in arch height (P = 0.001) and rear-foot angle (P = 0.001). Our findings showed there were insignificant differences between the asymptomatic pronated foot and non-pronated foot control groups in hip joint kinematics of sagittal (P = 0.618), frontal (P = 0.276), and transverse (P = 0.337) planes during a full gait cycle. CONCLUSION: Patients with asymptomatic pronation of the foot and non-pronation of the foot showed similar movement patterns of hip kinematics in all three planes. The findings of the present study highlight the need for clinicians to consider foot alignment when examining patients with asymptomatic pronation of the foot and non-pronation of the foot.

Efficacy of Pulsed Low-Frequency Magnetic Field Therapy on Patients with Chronic Low Back Pain: A Randomized Double-Blind Placebo-Controlled Trial.

STUDY DESIGN: A randomized double-blind placebo-controlled trial. PURPOSE: To investigate the efficacy of pulsed electromagnetic field (PEMF) therapy combined with therapeutic exercises in the treatment of chronic low back pain (CLBP). OVERVIEW OF LITERATURE: Low back pain (LBP) is the most common musculoskeletal pain disorder. Most available interventions for CLBP have modestly beneficial outcomes. Despite the potential effect of PEMF therapy on LBP, there have been few studies regarding its effectiveness. METHODS: Forty-two patients (22 males, 20 females), were randomized into either the treatment group (PEMF and therapeutic exercises) or placebo group (sham PEMF and exercises). Primary outcome measures were pain intensity on the 10-point Numeric PainRating Scale and disability measured by the Roland-Morris Disability Questionnaire. The patients were assessed at baseline, during the treatment period (weeks 3, 6, and 9), and after treatment (week 13). RESULTS: The treatment group experienced a more rapid improvement in both pain and disability compared with the placebo group. The analysis showed a significant improvement in the pain intensity and disability scores in the treatment group at week 3 (p<0.05), whereas an improvement in the placebo group was detected at week 6. The significant improvement in both groups was sustained for weeks 6, 9, and 13. There was no difference between the groups in scores of pain intensity and disability at weeks 6 and 13. CONCLUSIONS: PEMF therapy improved pain and disability in patients with CLBP. However, it does not seem to be superior to other treatment options.

Effects of pulsed low-frequency magnetic field therapy on pain intensity in patients with musculoskeletal chronic low back pain: study protocol for a randomised double-blind placebo-controlled trial.

INTRODUCTION: The aim of the present study is to investigate the effectiveness of pulsed low-frequency magnetic field (PLFMF) on the management of chronic low back pain (CLBP). METHODS AND ANALYSIS: A randomised double-blinded controlled clinical trial will be conducted, involving 200 patients with CLBP. Participants will be randomised in a 1:1 ratio to receive either active PLFMF (experimental arm) or sham treatment (control arm) using a permuted-block design which will be stratified according to three subtypes of musculoskeletal CLBP (nociceptive, peripheral neuropathic or central sanitisation). The intervention consists of three sessions/week for 6 weeks. The primary outcome is the percentage change in Numerical Rating Scale (NRS) pain at week 24 after treatment completion with respect to the baseline. Secondary outcomes include percentage NRS pain during treatment and early after treatment completion, short form 36 quality of life, Roland and Morris Disability Questionnaire; Depression Anxiety Stress Scale 21, Patient Specific Functional Scale, Global perceived effect of condition change, Pittsburgh Sleep Quality Index and Modified Fatigue Impact Scale. Measures will be taken at baseline, 3 and 6 weeks during the intervention and 6, 12 and 24 weeks after completing the intervention. Adverse events between arms will be evaluated. Data will be analysed on an intention-to-treat basis. ETHICS AND DISSEMINATION: The study is funded by Imam Abdulrahman Bin Faisal University (IAU). It has been approved by the institutional review board of IAU (IRB- 2017-03-129). The study will be conducted at King Fahd Hospital of the University and will be monitored by the Hospital monitoring office for research and research ethics. The trial is scheduled to begin in September 2018. Results obtained will be presented in international conferences and will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12618000921280, prospectively.

Poor sleep quality is strongly associated with subsequent pain intensity in patients with acute low back pain.

OBJECTIVE: Recent research suggests that sleep quality and pain intensity are intimately linked. Although sleep problems are common in patients with low back pain, the effect of sleep quality on the levels of pain intensity is currently unknown. The aim of this study was to investigate the effect of sleep quality on subsequent pain intensity in patients with recent-onset low back pain. METHODS: Data on 1,246 patients with acute low back pain were included in the analysis. Sleep quality was assessed using the sleep quality item of the Pittsburgh Sleep Quality Index, scored on a 0-3-point scale, where 0 = very good sleep quality and 3 = very bad sleep quality. Pain intensity was assessed on a numerical rating scale (range 0-10). A generalized estimating equation (GEE) analysis modeled with an exchangeable correlation structure was used to examine the relationship between sleep quality and pain intensity. The model further controlled for symptoms of depression and prognostic factors for low back pain. RESULTS: The GEE analysis demonstrated a large effect of poor sleep on subsequent pain intensity, such that for every 1-point decrease in sleep quality (based on a 0-3-point scale), pain intensity (based on a 0-10-point scale) increased by 2.08 points (95% confidence interval 1.99-2.16). This effect was independent of depression and common prognostic factors for low back pain. CONCLUSION: Sleep quality is strongly related to subsequent pain intensity in patients with acute low back pain. Future research is needed to determine whether targeting sleep improvement contributes to pain reduction.

Assessing sleep disturbance in low back pain: the validity of portable instruments.

Although portable instruments have been used in the assessment of sleep disturbance for patients with low back pain (LBP), the accuracy of the instruments in detecting sleep/wake episodes for this population is unknown. This study investigated the criterion validity of two portable instruments (Armband and Actiwatch) for assessing sleep disturbance in patients with LBP. 50 patients with LBP performed simultaneous overnight sleep recordings in a university sleep laboratory. All 50 participants were assessed by Polysomnography (PSG) and the Armband and a subgroup of 33 participants wore an Actiwatch. Criterion validity was determined by calculating epoch-by-epoch agreement, sensitivity, specificity and prevalence and bias- adjusted kappa (PABAK) for sleep versus wake between each instrument and PSG. The relationship between PSG and the two instruments was assessed using intraclass correlation coefficients (ICC 2, 1). The study participants showed symptoms of sub-threshold insomnia (mean ISI = 13.2, 95% CI = 6.36) and poor sleep quality (mean PSQI = 9.20, 95% CI = 4.27). Observed agreement with PSG was 85% and 88% for the Armband and Actiwatch. Sensitivity was 0.90 for both instruments and specificity was 0.54 and 0.67 and PABAK of 0.69 and 0.77 for the Armband and Actiwatch respectively. The ICC (95%CI) was 0.76 (0.61 to 0.86) and 0.80 (0.46 to 0.92) for total sleep time, 0.52 (0.29 to 0.70) and 0.55 (0.14 to 0.77) for sleep efficiency, 0.64 (0.45 to 0.78) and 0.52 (0.23 to 0.73) for wake after sleep onset and 0.13 (-0.15 to 0.39) and 0.33 (-0.05 to 0.63) for sleep onset latency, for the Armband and Actiwatch, respectively. The findings showed that both instruments have varied criterion validity across the sleep parameters from excellent validity for measures of total sleep time, good validity for measures of sleep efficiency and wake after onset to poor validity for sleep onset latency.

The bidirectional relationship between pain intensity and sleep disturbance/quality in patients with low back pain.

OBJECTIVES: This study investigated the bidirectional relationship between the intensity of low back pain (LBP) and sleep disturbance. Further, the study aimed to determine whether any relationship is dependent on pain duration, symptoms of depression and anxiety, and the method of sleep assessment (subjective vs. objective). MATERIALS AND METHODS: Eighty patients with LBP completed a sleep diary. A subgroup of 50 patients additionally wore an electronic device (Armband) to measure sleep for 7 consecutive days. Pain intensity was assessed twice daily using a sleep diary. Depression and anxiety symptoms were assessed at baseline using the Depression Anxiety Stress Scale questionnaire. Generalized estimating equations (GEE) with an exchangeable correlation structure were used to examine the relationship between day-time pain intensity and sleep. RESULTS: The GEE analysis showed that a night of poor sleep quality, difficulty falling sleep (assessed by the sleep diary), waking after sleep onset, and low sleep efficiency (assessed by the sleep diary and Armband) were followed by a day with higher pain intensity. Further, a day with higher pain intensity was associated with a decrease in the subsequent night's sleep quality, an increase in sleep latency (assessed by the sleep diary), waking after sleep onset (assessed by both measures), and low sleep efficiency (assessed by the Armband). DISCUSSION: The findings demonstrate that there is a bidirectional relationship between sleep and pain intensity in patients with LBP. The relationship is independent of pain duration and baseline symptoms of depression and anxiety and somewhat dependent on the method of sleep measurement (sleep diary or Armband). Future research is needed to determine whether targeting sleep improvement in patients with LBP contributes to pain reduction.

Detecting insomnia in patients with low back pain: accuracy of four self-report sleep measures.

BACKGROUND: Although insomnia is common in patients with low back pain (LBP), it is unknown whether commonly used self-report sleep measures are sufficiently accurate to screen for insomnia in the LBP population. This study investigated the discriminatory properties of the Pittsburgh Sleep Quality Index (Pittsburgh questionnaire), Insomnia Severity Index (Insomnia index), Epworth Sleepiness Scale (Epworth scale) and the sleep item of the Roland and Morris Disability Questionnaire (Roland item) to detect insomnia in patients with LBP by comparing their accuracy to detect insomnia to a sleep diary. The study also aimed to determine the clinical optimal cut-off scores of the questionnaires to detect insomnia in the LBP population. METHODS: Seventy nine patients with LBP completed the four self-reported questionnaires and a sleep diary for 7 consecutive nights. The accuracy of the questionnaires was evaluated using Receiver Operator Characteristic (ROC) curves with the Area Under the Curve (AUC) used to examine each test's accuracy to discriminate participants with insomnia from those without insomnia. RESULTS: The Pittsburgh questionnaire and Insomnia index had moderate accuracy to detect insomnia (AUC = 0.79, 95% CI = 0.68 to 0.87 and AUC = 0.78, 95% CI = 0.67 to 0.86 respectively), whereas the Epworth scale and the Roland item were not found to be accurate discriminators (AUC = 0.53, 95% CI = 0. 41 to 0.64 and AUC = 0.64, 95% CI = 0.53 to 0.75 respectively). The cut-off score of > 6 for the Pittsburgh questionnaire and the cut-off point of > 14 for the Insomnia index provided optimal sensitivity and specificity for the detection of insomnia. CONCLUSIONS: The Pittsburgh questionnaire and Insomnia index had similar ability to screen for insomnia in patients with low back pain.

Prevalence of sleep disturbance in patients with low back pain.

Low back pain (LBP) is a common health condition that is often associated with disability, psychological distress and work loss. Worldwide, billions of dollars are expended each year trying to manage LBP, often with limited success. Recently, some researchers have reported that LBP patients also report sleep disturbance as a result of their LBP. However, as most of this evidence was obtained from highly selected groups of patients or from studies with small samples, high quality data on prevalence of sleep disturbance for patients with LBP are lacking. It is also unclear whether sleep disturbance is more likely to be reported by patients with recent-onset LBP than by patients with persistent LBP. Finally, it is not known whether high pain intensity, the most relevant condition-specific variable, is associated with higher rates of reported sleep disturbance. The present study aimed to determine the prevalence of reported sleep disturbance in patients with LBP. In addition, we aimed to determine whether sleep disturbance was associated with the duration of back pain symptoms and whether pain intensity was associated with reported sleep disturbance. Data from 1,941 patients obtained from 13 studies conducted by the authors or their colleagues between 2001 and 2009 were used to determine the prevalence of sleep disturbance. Logistic regression analyses explored associations between sleep disturbance, the duration of low back symptoms and pain intensity. The estimated prevalence of sleep disturbance was 58.7% (95% CI 56.4-60.7%). Sleep disturbance was found to be dependent on pain intensity, where each increase by one point on a ten-point visual analogue scale (VAS) was associated with a 10% increase in the likelihood of reporting sleep disturbance. Our findings indicate that sleep disturbance is common in patients with LBP. In addition, we found that the intensity of back pain was only weakly associated with sleep disturbance, suggesting that other factors contribute to sleep problems for LBP patients.