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Introduction: Neuromuscular electrostimulation (NMES) represents a therapeutic approach for addressing chronic low back pain (CLBP); however, the influence of NMES dose on muscle activity remains subject to debate.

Objective: To compare the impact of two distinct NMES protocols employing Aussie current, characterized by varying dosages emphasizing time cycle alterations, on electromyographic activity within the multifidus muscles in individuals afflicted with CLBP.

Methods: A randomized clinical trial encompassed 18 volunteers diagnosed with mechanical CLBP. These volunteers were randomly assigned to two NMES intervention groups with dissimilar dosages: 15 repetitions ($E$${}_{15}$) and 30 repetitions ($E$${}_{30}$ ). In both interventions, the current amplitude was tailored to individual perception and documented at the culmination of each session. Over the course of four weeks, two sessions took place per week. Electromyographic activity of the multifidus muscles was evaluated using surface electromyography before and after the intervention. The assessment focuses on both time-domain analysis using Root Mean Square (RMS) and frequency-domain analysis involving mean activation frequency (FREQ).

Results: There are no interactions between the time and intervention, but there is the time effect on RMS, indicating that post-intervention muscle activity exceeded pre-intervention values in both groups. FREQ values did not exhibit statistically significant discrepancies.

Conclusions: This study showed that NMES using the Aussie current is effective in increasing muscle activity in individuals with CLBP, and the results were not influenced by the different cycle times with equal volumes.

Purpose: Low back pain is a common issue among older adults, often attributed to weakened trunk muscles. Understanding the relationship between muscle mass and abdominal pressure can offer valuable insights for managing low back pain. This study aimed to explore the correlation of external abdominal pressure using a novel device with abdominal muscle mass and low back pain.

Methods: Elderly individuals over the age of sixty-five were recruited. External abdominal pressure was measured using RECORE, while muscle mass and thickness were assessed via impedance measurement and ultrasound. The presence of low back pain was also investigated.

Results: Correlation analysis showed a weak correlation between abdominal pressure and trunk muscle mass, as well as a weak correlation with the thickness of deep muscles, transversus abdominis ($r$ = 0.37) and internal oblique ($r$ = 0.33). Logistic analysis demonstrated a significant association between abdominal pressure and the presence of low back pain.

Conclusion: Our findings suggest that abdominal pressure is weakly linked to abdominal muscle size, particularly the deep muscles, and that measuring external abdominal pressure can provide insights into abdominal muscle function and low back pain in older adults.

Background: Chronic Low Back Pain (CLBP) has been the leading cause of disability globally for at least three decades. Totally, 10% to 20% of people who experience acute lower back pain episodes often develop CLBP. In CLBP, there is an altered sensorimotor pathway which impairs body the balance. There are lacunae in studies prescribing balance exercise to CLBP individuals. This study aims to determine the effects of balance exercises on pain intensity, back physical performance, trunk extensor muscle endurance, and disability in CLBP individuals.

Methods: A qualified therapist unaware of the study assessed all outcome measures (Visual Analogue scale– VAS, Oswestry Disability Index — ODI, Back Performance Scale — BPS, Biering Sorenson test — BST) at baseline, end of 4th week, and 8th week. All participants underwent balance exercise intervention for 30 min/day, 3 days a week, for 8 weeks. Repeated measures ANOVA was performed at $p$ < 0.05.

Results: Out of 65 screened participants, 40 (24 females, 16 males) fulfilled the study criteria and performed the balance exercise. The BPS score for back physical performance, VAS score for patient-reported pain intensity, BST value for trunk extensor muscle endurance, and ODI score for low back disability domains significantly improved after the balance exercise intervention at the end of 4th week and 8th week ($p$ < 0.05).

Conclusions: Balance exercise effectively improves back physical performance, reducing pain and back-related impairments. Further, the controlled trial is warranted to add the level of evidence.

Background: Musculoskeletal disorders (MSDs) are major health problems that cause disability and, as a result, have a significant impact on the quality of life of individuals and also impose very high economic costs on countries School teachers are a professional group with a high prevalence of musculoskeletal disorders, especially in the lumbar, neck, and shoulder regions. Therefore, this study was conducted with the aim of determining the prevalence and risk factors associated with neck/shoulder pain and low back pain among school teachers.

Methods: A cross-sectional study was conducted in Eslamabad-e Gharb City, located in western Iran, between May and June 2023. The study included 361 teachers selected from primary, secondary, and high schools in the city. Data collection was performed using two questionnaires designed to assess demographic characteristics, lifestyle factors, occupational characteristics, and social-psychological exposures related to neck/shoulder and low back pain. The face validity of the questionnaires was evaluated by eight teachers. Data analysis was conducted using SPSS24 software, utilizing a binary logistic regression model.

Results: A significant 63.4% of participants reported experiencing pain in the neck, shoulder, and lower back. Factors significantly associated with neck pain include: bachelor’s degree (OR = 4.23, 95% CI = 1.28–13.98), larger household size (OR = 1.96, 95% CI = 1.11–3.46), teaching in co-ed schools (OR = 0.11, 95% CI = 0.01–0.81), not maintaining a forward-bent neck posture for long periods (OR = 0.30, 95% CI = 0.20–0.80), and job satisfaction (OR = 0.15, 95% CI = 0.10-0.88). Factors significantly associated with shoulder pain include: bachelor’s degree (OR = 4.22, 95% CI = 1.31–13.60), sleep duration of $\ge$9 h (OR = 2.73, 95% CI = 1.06–6.99), employment in a private school (OR = 2.12, 95% CI = 1.05–4.28), and lack of support from colleagues (OR = 2.47, 95% CI = 1.04–5.85). Factors significantly associated with low back pain include: number of working $\ge$10 h per week (OR = 1.08, 95% CI = 1.01–1.60), avoiding prolonged forward bending of the neck (OR = 0.84, 95% CI = 0.52–0.99), inappropriate desk and chair (OR = 1.92, 95% CI = 1.09–3.74), and job satisfaction (OR = 0.49, 95% CI = 0.16–0.92).

Conclusion: The findings stress the essential role of ergonomic practices, supportive work environments, and job satisfaction in reducing musculoskeletal disorders among teachers. Prioritizing ergonomic practices and fostering supportive work environments can significantly reduce musculoskeletal pain among teachers.

Lower back pain is one of the most prevalent health issues, affecting more than 80% of adults worldwide. Thermotherapy including heat wrap and dry sauna has long been utilized for pain relief and relaxation. Far-infrared graphene-based thermography is a heat therapy method where the graphene emits far-infrared rays that can penetrate human skin. However, its effects remain largely unstudied compared to conventional thermotherapy. This study investigates the impact of far-infrared graphene-based thermotherapy on healthy individuals and individuals associated with nonspecific low back pain. Over four sessions, 24 subjects undergo 30 min treatments, with measurements including body heat profiles, blood oxygen levels, joint angles, pain scales, and Oswestry scores. Results indicate increased body heat and blood oxygen levels post-treatment, alongside significant reductions in pain scores. However, changes in joint angles were not statistically significant, suggesting no immediate impact on locomotion. In conclusion, far-infrared graphene-based thermotherapy shows promise for pain relief and improved blood oxygenation, however, it has not been proven to improve locomotion.

Gua Sha is a traditional East Asian healing technique where the body surface is "press-stroked" with a smooth-edged instrument to raise therapeutic petechiae that last 2–5 days. The technique is traditionally used in the treatment of both acute and chronic neck and back pain. This study aimed to measure the effects of Gua Sha therapy on the pain ratings and pressure pain thresholds of patients with chronic neck pain (CNP) and chronic low back pain (CLBP). A total of 40 patients with either CNP or CLBP (mean age 49.23 ± 10.96 years) were randomized to either a treatment group (TG) or a waiting list control group (WLC). At baseline assessment (T1), all patients rated their pain on a 10 cm visual analog scale (VAS). Patients' pressure pain thresholds (PPT) at a site of maximal pain (pain-maximum) and an adjacent (pain-adjacent) site were also established. The treatment group then received a single Gua Sha treatment. Post-intervention measurements were taken for both groups at T2, seven days after baseline assessment (T1), using the same VAS and PPT measurements in precisely the same locations as at T1. Final analysis were conducted with 21 patients with CNP and 18 patients with CLBP. The study groups were equally distributed with regard to randomization. Patients in both the CNP and the CLBP treatment groups reported pain reduction (p < 0.05) and improved health status from their one Gua Sha treatment, as compared to the waiting list group. Pain sensitivity improved in the TG in CNP, but not in CLBP patients, possibly due to higher pressure sensitivity in the neck area. No adverse events were reported. These results suggest that Gua Sha may be an effective treatment for patients with chronic neck and low back pain. Further study of Gua Sha is warranted.

Acupuncture has been used as a therapeutic intervention for the treatment of numerous diseases and symptoms for thousands of years, and low back pain has been studied and treated the most in acupuncture clinics. Traditional theory strongly suggests that the selection of acupoints will influence their clinical effects and combinations (e.g., the clinical effects of a particular acupoint or combination on reducing pain), but this idea was not considered in earlier systematic reviews and meta-analyses. We performed a systematic review, meta-analysis, and network analysis to evaluate the magnitude of the effects of acupoints used to treat low back pain in randomized controlled clinical trials. We found that acupuncture significantly reduced pain in patients with low back pain compared with the control group. The most frequently prescribed acupoints were BL23, GV3, BL20, BL40, and BL25, whereas the acupoints with the highest average effect size scores were BL20, GV3, GB30, GB34, and BL25. Further, the combinations of BL23-BL40, BL23-B25, and BL23-BL60 were the most frequently prescribed, while BL23-GV3, BL40-GV4, and BL23-BL25 showed the largest average effect size. By calculating clinical outcomes based on average effect sizes, we found that the most popular acupoints might not always be associated with the best results. Although a more thorough investigation is necessary to determine the clinical effects of each acupoint and combination on patients, we suggest that our approach may offer a fresh perspective that will be useful for future research.

Recommendations on the use of acupuncture in managing low back pain (LBP) vary across different guidelines. The methodological quality of existing systematic reviews and meta-analyses on this topic also demonstrates considerable diversity, potentially leading to biased conclusions. Therefore, we comprehensively searched PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Chinese National Knowledge Infrastructure (CNKI) databases and conducted an umbrella review. Scrutiny was performed to ascertain whether primary studies within the systematic reviews and meta-analyses adhered to our inclusion criteria, followed by a meticulous reanalysis of pertinent data. Participant numbers, heterogeneity, publication bias, and excessive significance were taken into account when assessing the credibility of the evidence. For robustness, sensitivity analysis was performed using the leave-one-out method. The results of the umbrella review yielded highly suggestive evidence in favor of the immediate and short-term analgesic effects of acupuncture, with suggestive evidence supporting intermediate-term analgesic effects. However, the effectiveness of acupuncture on disability improvement has demonstrated weak to suggestive evidence. Evidence supporting the enhancement of quality of life by acupuncture is limited. The leave-one-out analysis corroborated the robustness of the meta-analysis, further confirming the credibility of the findings. This umbrella review indicated that the most significant advantage of acupuncture for LBP is its capacity to reduce pain.

Current mathematical material laws work quite accurately with conventional engineering materials because they are linear and isotropic. These laws are much less effective, however, at representing living tissues. Biomechanical engineers therefore often face the problems of modelling material non-linearities, particularly with the soft tissues, muscles and tendons of the human body. The non-linear and often anisotropic structure of these materials makes any mathematical representation very difficult. In particular, the lack of a good general mathematical model of the intervertebral disc has hampered the study of spinal mechanics, as the disc annulus is a nonlinear fibrous tissue with highly directional properties. Previous studies have concentrated on the overall behavior of discs and this has been largely explained but knowledge is still very limited on the effect of the individual disc components. This means that current mathematical models are poor when it comes to describing a prolapsed disc, where there has been failure of at least one of the components. This finite element study described here focuses on the disc annulus properties and their effect on disc behavior. The novelty of this study lies in the material formulation of the annulus fibrosus, which changes its Young's modulus according to a non-linear curve.

The conventional lumbar traction techniques which has been in use to manage low back pain, has ordinarily utilized multiple sessions of horizontal traction during a treatment. However, this mode of proceeding proved unable to give discreet therapeutical benefits.^30,43 Would the therapeutic outcome become improved by modifying the established proceeding? We have tried the Abbreviated Measured Vertical Traction (Abbr.M.V.T.) technique in the treatment of resistant low back pain. The referred technique utilizes a single session of strong stretch, which is applied once only upon a patient suspended from a frame. In this paper we report the interesting issue of this application on five back pain patients with different diagnoses.

Lumbar spine function may be clinically assessed by subjective physician findings or by a more sophisticated mean such as 3-D dynamometric system. This system was developed to differentiate objectively between physiologic and non-physiological behavior of LBP patients. The same system is used, concurrently, to categorize the physiologic tests according to functional limitation. The four major parameters used for assessing spinal disability are: range of motion, maximal isometric torque, maximal velocity and maximal torque in the secondary axis. Six other independent parameters were used in order to assess non-cooperative or non-physiologic behavior. For the study, 108 non-symptomatic subjects and 595 LBP patients were tested. All patients had a physical examination before being tested on the dynamometric device (the IsoStation B-200). One hundred and ten patients were classified as non-physiological and 91 were classified in the gray zone.

The results support the use of 3-D dynamometry to objectively classify the patient's performance reliability. The measured parameters are objective and reliable indicators of the patient's physical condition and credibility that should influence both the patient's assessment and treatment.

This is a prospective multi-center cohort study to evaluate the acceptability and effectiveness of a new device the OrthoTrac™ which aims at unloading the spine in an upright posture. Three hundred and thirteen patients (313) were enrolled and 201 completed an eight-week trial. Outcomes were determined using a Visual Analog Scale and SF-36. Both scales improved significantly over the eight-week period.

We conclude that this novel treatment benefit patients with back pain. Subgroups need to be identified and randomized controlled trials performed on these groups.

Purpose: The study compared the efficacy of hydrotherapy and land-based exercises in the management of chronic low back pain (CLBP). Methods: Twelve patients diagnosed with CLBP were randomly assigned into either hydrotherapy or land-based exercise groups. Similar exercises were prescribed for both groups throughout the 6-week program. The treatment outcome measures were Visual Analog Scale (VAS), Modified Schober Flexion Technique (MSFT) and Modified Schober Extension Technique (MSET). Participants were assessed at baseline and after six weeks by an independent assessor. Paired t-test was used to compare within group scores whilst between-group comparison of post-treatment outcomes was analyzed using unpaired t-test. Alpha level was set at p < 0.05. Results: The mean (standard deviation) duration of symptoms for land-based and hydrotherapy groups were 48.5 (37.39) months and 66.0 (48.45) months, respectively. There were significant differences (p < 0.05) between the pre-treatment and post-treatment VAS, MSFT and MSET for the hydrotherapy groups. Whilst the VAS and MSET scores were significantly different (p < 0.05) from baseline scores in land group, the MSET failed to show any significant difference. Comparison of both groups showed hydrotherapy group scoring significantly higher (p < 0.05) only on MSFT than land group. Conclusion: The two exercise media were relevant in the management of CLBP, though hydrotherapy seems to be better for spinal flexibility, thus serving as a better alternative in clinical practice.

Purpose: The present study was undertaken to find out the relationship among outcome variables as well as association between dependent variables with physical characteristics in low back pain (LBP) patients. Correlations between outcome variables [pain, back pressure changes (BPC), abdominal pressure changes (APC), walking, stairs climbing, stand ups, quality of life (QOL) and sexual frequency] of all LBP subjects before and after treatment were assessed. Regression analysis was used to estimate baseline BPC and APC of LBP subjects from their baseline demographic characteristics (age, height, waist circumference, systolic blood pressure, and pulse rate) and severity of pain. Methods: A total of 141 nonspecific chronic LBP patients were recruited. After baseline recording, all subjects were given trunk stabilization training for 20 regular days. After training, the follow-up was done at a gap of each 15 days up to 6 months (180 days). At the last follow-up session (180th day), the outcome variables were recorded again. Findings: The present study found an inverse relation between pain and muscle functions (BPC: r = -0.36; p < 0.01 and APC: r = -0.26; p < 0.01). This study also showed that BPC was more inversely related with the pain than APC. Conclusions: This study concludes that physical strength (BPC and APC) of LBP subjects is more closely associated with the pain than the functional ability (walking, stairs climbing and stand ups). This study also estimated (baseline or before treatment) BPC and APC in LBP subjects from their physical characteristics and pain severity.

Purpose: This study reports percent of bodyweight represented by school bags carried by students in Nigeria. Method: 381 secondary school students were randomly selected in this cross-sectional study. Informed consent and assents were obtained. Weights, heights and backpack weights (BPWT) were measured by blinded researchers. Data was analyzed using descriptive statistics, independent t-test, Chi square and odds ratio, at 0.05 α-level. Results: The mean age, height weight and BMI of participants were 14.01±2.17 years, 1.56±0.11 m, 46.19±9.65 kg, 18.89±3.12 kg/m², respectively. Average total weight of bags carried by participants was 4.48 kg, relative BPWT was 10.16%, and 65% carried bags on their back. There was no significant association between BPWT and back pain (X² = 0.106. p = 0.744). The relative risks [odds ratio (OR) and 95% confidence interval (CI)] of developing back pain among those that carry normal BPWT compared with those who carry above normal BPWT to school was (OR 0.805; CI 0.478–1.355), (OR 0.733; CI 0.295–1.817) and (OR 0.883; CI 0.454–1.718) for total, junior and senior secondary schools participants, respectively. Conclusion: Percent of body weights represented by the weights of bags carried by students in a Nigerian school fell between the recommended 10–15%. A 10% relative weight is recommended for secondary school students in Nigeria.

Purpose: This study aims to determine the relation among the commonly used different tests of evaluating core stability performance. Establishing this relationship is important as different authors have used different types of tests for evaluating core stabilization in their study yet relation among these tests and the individual importance of each of these tests is not clearly established so far. Methods: Among 40 recreationally active subjects the core stability performance was evaluated using variety of different tests reported in the previous literatures. Results: Results show that there was no significant correlation among the performance scores on different test of core stability. Conclusions: The assessment of the core stability performance must be in concordance with the need of the individual and of the study. Also, different tasks or sports selectively require different components of the core stability. In order to evaluate more than one component of the core stability performance, the different combinations of the tests must be used. If one wishes to test all the components of the core stabilization, then no single test is sufficient and a battery of test must be used to assess different components separately.

Purpose: The device for intervertebral assisted motion (DIAM™) is an interspinous (ISP) implant used to augment surgical decompression of lumbar degenerative conditions: Lumbar spinal stenosis [LSS; foraminal (FS) or central canal (CS)], herniated and degenerated disc disease, facet joint pain syndrome (FJPS) and minor degenerative spondylolisthesis (DS). Limited evidence guides its use in defined clinical indications, while few studies demonstrate effect according to clinically meaningful change (MCID). This prospective longitudinal study examined the efficacy of DIAM-augmented decompression surgery in the broad application of a single-center clinical reality. Methods: Eighty-one consecutive cases [37F, 44M; 52 years (SD 13)] were examined for two years after DIAM-augmented decompression surgery. Patient-reported pain [back and leg; visual analogue scale (VAS)], function [Oswestry disability index (ODI)], and satisfaction (Likert scale) were serially examined and referenced to contemporary MCID thresholds. Subjects were classified into anatomical and diagnostic categories and analyzed according to subgroups to better inform clinical pathways. Serial change was assessed with Scheffe post-hoc test; change scores with unpaired t-tests and descriptive statistics (p < 0.05). Results: Subjects reported 20.4% (SD 29.5; p < 0.0001) mean improvement in back pain, 20.3% (SD 30.6; p < 0.0001) in leg pain, and 15.1% (SD 20.8; p < 0.0001) in function at two years postoperatively. Greatest improvement was seen at six weeks for back pain (by 30.5%; p < 0.0001) and leg pain (by 29.4%; p < 0.0001) and three months for function (by 18.7%; p < 0.0001). Leg pain deteriorated between six weeks and 18 months (p < 0.05). There were more responders at one compared to two years after surgery. FS cases showed superior improvement compared to DS subjects (p < 0.05). Cases receiving multiple adjunctive surgical decompressions in addition to their DIAM had superior improvement than those receiving a single procedure (p < 0.05). Conclusions: Clinical improvement in back pain, leg pain and function were achieved to two years in a single-center cohort of 81 cases with lumbar degenerative disease who received DIAM-augmented decompression surgery. Subsets of the sample had a superior sustained response including foraminal/lateral recess stenosis patients and cases treated with > 1 adjunctive decompression techniques. The need for assessing homogeneous cohorts in future studies is emphasized.

Purpose: To assess and compare the effect of aquatic and conventional physical therapy, two well-known non-operative therapeutic options in patients with lumbar spinal stenosis (LSS). Methods: 50 patients with low back pain and the diagnosis of LSS were recruited in this prospective parallel randomized controlled trial. Patients in group one were enrolled in aquatic therapy program and those in group two attended physical therapy sessions through application of physical modalities and receiving a home-based exercise program. Pain and walking ability were measured in each group before therapy, immediately after therapy and three months later. Results: Patients in both groups improved regarding pain either assessed immediately after therapy (repeated measure test, p < 0.001) or three months later (Wilcoxon test, p < 0.001 for group one and p = 0.005 for group two). Functioning improved in both groups (repeated measure test, p < 0.001) but this advantage did not remain significant after three months follow up in group two (repeated measure test, p = 0.002 in group one and p = 0.181 in group two). Patients in group one had significantly more favorable outcome than group two regarding functioning (independent samples t-test, p = 0.02) and pain (Mann–Whitney test, p = 0.001); however, this superiority didn't sustain in long term follow up. Conclusion: Aquatic therapy can provide greater short term improvement in pain and functioning than conventional physical therapy in patients with LSS especially those with limited capability for exercise on land.

The erector spinae muscle is categorized as the intermediate layer of the intrinsic back muscles. Textbooks often describe the iliocostalis thoracis as originating superior to the iliocostalis lumborum. Six cadavers were dissected to reveal the iliocostalis thoracis origin and insertion points which show that the iliocostalis thoracis has fascicular attachments to the common erector spinae tendon. After reviewing nine common anatomy textbooks, 66.7% did not describe the iliocostalis thoracis as having fascicular extension into the common erector spinae tendon in both the text and illustrations. Interestingly, 22.2% of these textbooks had text that explained the attachments differently than the illustrations showed. While all cadaver specimens are inherently different, this finding shows that textbooks should reflect the fact that the iliocostalis thoracis originates from the common erector spinae tendon. This outcome could influence the healthcare a patient receives for antalgic compensatory posture associated with low back pain.

Purpose: The rate of spondylolysis in adolescent athletes ranges from 11–47%. Due to the long recovery process associated with a spondylolysis and the fact that bony union only occurs in 25–37% of patients necessitates that risk factors for this condition are identified so that prevention techniques can be developed. Research has shown that those with spondylolysis have different sagittal alignment than normal populations. The purpose of this study was to compare hip flexibility and sagittal plane alignment of subjects with NSLBP and SLBP. Methods: A total of 61 subjects between the ages of 12–21 with back pain for at least 2 weeks were enrolled. All subjects had radiographs and advanced imaging to evaluate for spondylolysis. A Thomas test and 90-90 test were used to assess hip flexor and hamstring flexibility, respectively. Pelvic incidence, sacral slope, pelvic tilt, and lumbar lordosis were measured on a standing lateral radiograph. Results: After adjusting for age, gender, and sport, those with SLBP had greater pelvic incidence ($p>0.01$), sacral slope ($p>0.01$) and tighter hamstrings ($p=0.02$) Conclusions: Athletes with SLBP have tighter hamstrings and increased sacral slope and pelvic incidence when compared with athletes with NSLBP.