The comparative effectiveness of a multimodal program versus exercise alone for the secondary prevention of chronic low back pain and disability.

OBJECTIVE: The objective of this study was to examine whether a multimodal, secondary prevention program (MP) is superior to a general physical exercise program (EP) in influencing the process leading to chronic low back pain (LBP) in nurses with a history of back pain. DESIGN: The study was conducted as a randomized controlled parallel-group trial. SETTING: The interventions were performed in a single center at the Department of Physical and Rehabilitation Medicine at the University of Munich in Germany. PARTICIPANTS: A total of 235 nurses from 14 nearby hospitals and nursing homes who experienced at least one episode of back pain during the previous 2 years were invited into the study. Of these, 183 nurses were enrolled and 169 (83 in the MP and 86 in the EP) qualified for the intent-to-treat analysis. INTERVENTIONS: The EP consisted of 11 group sessions, each lasting 1 hour. After introductory sessions, subsequent sessions included general physical strengthening and stretching exercises as well as instructions for a home-training program. The MP consisted of 17 group sessions of 1.75 hours and one individual session of 45 minutes. In addition to the full EP, the MP included 5 psychological units, 7 segmental stabilization exercises units, and 8 ergonomic and workplace-specific units. MAIN OUTCOME MEASUREMENTS: The primary study end-point variable was pain interference, and the secondary study end-point variables were pain intensity and functioning as measured with the West Haven-Yale Multidimensional Pain Inventory and the Short Form-36, respectively. These study end-point variables were defined a priori. RESULTS: There was no statistically significant difference between the 2 groups. Small-to-moderate effects were observed in both intervention programs across all study end-point variables. For pain interference, the effect size at 12 months after intervention was 0.58 in the MP and 0.47 in the EP. CONCLUSIONS: A multimodal program is not superior to a general exercise program in influencing the process leading to chronic LBP in a population of nurses with a history of pain. The most likely explanation is a common psychological mechanism leading to improved pain interference that is irrespective of the program used. Considering the lower resources of the general exercise program, the expense for a multimodal program is not justified for the secondary prevention of LBP and disability.

Reliability of a test measuring transversus abdominis muscle recruitment with a pressure biofeedback unit.

BACKGROUND: There are indications that segmental stabilising exercises (SSEs) are effective in the treatment of low back pain. The evaluation of successful training in SSE performance in patients requires a reliable outcome measure. The PRONE test gives an indication of the activity of the transversus abdominis muscle. Performed in prone lying using a pressure biofeedback unit, it has been used as an aid to training and to assess the subject's ability to perform SSEs correctly. OBJECTIVES: To evaluate inter-observer and test-retest reliability of the PRONE test. DESIGN: Repeated measures by three observers on 2 days. SETTING: Department of Physical Medicine and Rehabilitation, Ludwig-Maximilian University, Munich, Germany. PARTICIPANTS: Forty nurses (39 females and one male), aged between 24 and 62 years, with at least one episode of low back pain. MAIN OUTCOME MEASURES: During the test, movement of the abdominal wall was monitored by measuring a change in pressure during muscle contraction termed 'abdominal hollowing'. Defined observation and palpation criteria were verified by the observers to ensure correct execution of the test. METHODS: Participants were tested on two separate days. On the first day, Observer A performed two similar test sets, each with four exercises. On the second test day, Observers B and C conducted one test set each. RESULTS: This study found an intra-class correlation coefficient (ICC) of 0.47 [95% confidence interval (CI) 0.20 to 0.67] for inter-observer reliability, and an ICC of 0.81 (95% CI 0.67 to 0.90) for test-retest reliability. Kappa values and the limits of agreement were also calculated with similar results. CONCLUSIONS: For this subject group, the PRONE test had relatively low inter-observer reliability but, as may be expected, higher test-retest reliability. It is suggested that by providing visual feedback, the PRONE test may enhance patients' insight into their deep abdominal muscle recruitment and thereby increase their motivation to exercise.

Change factors explaining reductions of "interference" in a multidisciplinary and an exercise prevention program for low back pain.

OBJECTIVES: To identify relevant changes in process variables that are associated with outcome following an exercise and a multidisciplinary secondary prevention program for low back pain. METHODS: Data from a randomized controlled clinical trial to examine the effectiveness of an exercise and a multidisciplinary prevention program were analyzed using multiple regression analyses. The specific goal was to examine the amount of variance in changes in "interference" postintervention that could be explained by prechanges to postchanges in physical and psychologic parameters, and to determine if there are interactions between physical/psychologic parameters and the program type. RESULTS: One hundred sixty-two (89%) participants were included in the regression analyses. Reductions of interference at postmeasurement were explained best by reductions of pain intensity and catastrophizing in the multidisciplinary and the exercise prevention program. No significant interaction between the changes in process variables and the program type was found. The final model could explain 68.7% of variance. CONCLUSIONS: Owing to methodologic limitations, strong conclusions cannot be drawn from this study. The findings suggest that treatment success in exercise and multidisciplinary interventions might be influenced by the same change factors, namely changes in pain and psychologic factors. The results raise the question of whether the mechanism through which exercise works, is improve in physical variables, or rather a change in psychologic attributes, in that people correct their irrational cognitions by making experiences that differ from their expectations. If these findings can be confirmed in longitudinal studies with more measurement points, they would have implications for treatment refinement.

Segmental stabilizing exercises and low back pain. What is the evidence? A systematic review of randomized controlled trials.

STUDY DESIGN: A systematic review of randomized controlled trials. OBJECTIVES: To evaluate the effectiveness of segmental stabilizing exercises for acute, subacute and chronic low back pain with regard to pain, recurrence of pain, disability and return to work. METHODS: MEDLINE, EMBASE, CINAHL, Cochrane Controlled Trials Register, PEDro and article reference lists were searched from 1988 onward. Randomized controlled trials with segmental stabilizing exercises for adult low back pain patients were included. Four comparisons were foreseen: (1) effectiveness of segmental stabilizing exercises versus treatment by general practitioner (GP); (2) effectiveness of segmental stabilizing exercises versus other physiotherapy treatment; (3) effectiveness of segmental stabilizing exercises combined with other physiotherapy treatment versus treatment by GP and (4) effectiveness of segmental stabilizing exercises combined with other physiotherapy treatment versus other physiotherapy treatment. RESULTS: Seven trials were included. For acute low back pain, segmental stabilizing exercises are equally effective in reducing short-term disability and pain and more effective in reducing long-term recurrence of low back pain than treatment by GP. For chronic low back pain, segmental stabilizing exercises are, in the short and long-term, more effective than GP treatment and may be as effective as other physiotherapy treatments in reducing disability and pain. There is limited evidence that segmental stabilizing exercises additional to other physiotherapy treatment are equally effective for pain and more effective concerning disability than other physiotherapy treatments alone. There is no evidence concerning subacute low back pain. CONCLUSION: For low back pain, segmental stabilizing exercises are more effective than treatment by GP but they are not more effective than other physiotherapy interventions.