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Background: Practice guidelines recommend various types of exercise for chronic back pain but there have been few head-to-head comparisons of these interventions. General exercise seems to be an effective option for management of chronic low back pain (LBP) but very little is known about the management of a sub-acute LBP within sub-groups. Recent research has developed clinical tests to identify a subgroup of patients with chronic non-specific LBP who have movement control dysfunction (MD)., Method/design: We are conducting a randomized controlled trial (RCT) to compare the effects of general exercise and specific movement control exercise (SMCE) on disability and function in patients with MD within recurrent sub-acute LBP. The main outcome measure is the Roland Morris Disability Questionnaire., Discussion: European clinical guideline for management of chronic LBP recommends that more research is required to develop tools to improve the classification and identification of specific clinical sub-groups of chronic LBP patients. Good quality RCTs are then needed to determine the effectiveness of specific interventions aimed at these specific target groups. This RCT aims to test the hypothesis whether patients within a sub-group of MD benefit more through a specific individually tailored movement control exercise program than through general exercises.

The aim was to study if postoperative rehabilitation improves functional outcome in lumbar spinal stenosis (LSS). Surgically treated LSS patients (n = 102) were randomized to rehabilitation-group (A) and "standard postoperative treatment"--group (B). Intervention for A-group started 3 months postoperatively, consisting of once a week outpatient visits for 12 weeks (1.5 h per visit; 1-6 patients per one physiotherapist). Physiotherapist guided stretching and strengthening exercises. A-group performed individually estimated exercises at those visits with guiding and at home up to 24-month postoperative follow-up. Physiotherapeutic guidance (12 times) was repeated after 12 months, in order to update exercises and motivate patients to keep training. For B-group, the "standard treatment" thus included normal postoperative treatment, or no treatment/self-management. Outcome measures were measured at the start and the end of the first physiotherapeutic intervention (3 and 6 months postoperatively), and at 12- and 24-month postoperative follow-ups. Oswestry Disability Index (ODI, 0-100%) was the main outcome measure. The other outcome measures were back- and leg pain separately (NRS-11); satisfaction (7-point scale) and treadmill test (0-1,000 m; not at 6 month). The intervention consisting of 12 + 12 physiotherapeutic sessions with further home exercises did not influence the course ODI in the 24-month postoperative follow-up (p = 0.95 for ODI; "as-rehabilitated" analysis). No influence on any other outcome measures was observed. After LSS surgery, routinely performed outpatient rehabilitation did not improve functional outcome compared to standard treatment. In addition, it had no impact on the back and leg pain, satisfaction and walking ability.

Objective: To analyse the effects of gait therapy for patients after acute stroke in a randomized controlled trial., Methods: Fifty-six patients with a mean of 8 days post-stroke participated in: (i) gait trainer exercise; (ii) walking training over ground; or (iii) conventional treatment. Patients in the gait trainer exercise and walking groups practiced gait for 15 sessions over 3 weeks and received additional physiotherapy. Functional Ambulatory Category and several secondary outcome measures assessing gait and mobility were administered before and after rehabilitation and at 6-month follow-up. Patients also evaluated their own effort., Results: Walking ability improved more with intensive walk training compared with conventional treatment; median Functional Ambulatory Category was zero in all patients at the start of the study, but it was 3 in both walk-training groups and 0.5 in the conventional treatment group at the end of the therapy. Median Functional Ambulatory Category was 4 in both walk-training groups and 2.5 in conventional treatment group at 6-month follow-up. Mean accomplished walking distance was not different between the gait trainer exercise and over ground walking groups. Borg scale indicated more effort in over ground walking. Secondary outcomes also indicated improvements., Conclusion: Exercise therapy with walking training improved gait function irrespective of the method used, but the time and effort required to achieve the results favour the gait trainer exercise. Early intensive gait training resulted in better walking ability than did conventional treatment.

We assessed the effects and strenuousness of intensive gait-oriented inpatient rehabilitation initiated very early after stroke. Therapy content and interrater reliability of the assessments were also analyzed. Of 22 patients, 19 (average 8.0 d poststroke) completed the study. Before rehabilitation, 13 patients were unable to walk or needed two assistants to walk and 6 patients needed one assistant. Patients spent a daily maximum of 1 h therapy time to obtain 20 min of walking. Additional physiotherapy was also provided during the 3 wk therapy period. Seven structured motor tests were recorded before and after rehabilitation and at 6 months postrehabilitation, and perceived exertion was followed during physiotherapy. After rehabilitation, 16 patients could walk unassisted and 3 needed one assistant to walk. Mean +/- standard deviation exercise walking distance was 10,784 +/- 4,446 m and exercise was ranked as slightly strenuous. After 3 wk, the patients' 10 m walking time, ankle spasticity, lower-limb muscle force, and motor scale scores improved (p < 0.05). The early intensive rehabilitation was well tolerated and only three patients dropped out. Improved motor abilities were seen in all stroke patients.

Background: To compare the effectiveness of pelvic floor training (PFT) with the aid of a home biofeedback device to PFT alone for urodynamic stress urinary incontinence (SUI) in women after a 1-year follow-up., Methods: A randomized study comparing two conservative interventions was conducted in an outpatient clinic of a university hospital. Thirty-five consecutive women were randomized to either the PFT with home biofeedback group or the PFT alone group. The intensive training period lasted 12 weeks. After 1 year, 33 women could be evaluated according to the protocol. At the 1-year visit pelvic floor muscle activity was measured and the need for surgical intervention was evaluated. Logistic multivariate analysis was used to predict response to the PFT., Results: In the home biofeedback training group 11/16 (68.8%) avoided surgery vs. 10/19 (52.6%) in the PFT alone group. The difference was not statistically significant. In the nonoperated home biofeedback group the increase in pelvic floor muscle activity (p = 0.005 in supine, p = 0.005 in standing) and the decrease in leakage index (p = 0.05) was significant after 12 weeks and pelvic floor activity remained constant. By contrast, in the nonoperated PFT group the increase in pelvic floor muscle activity after 12 weeks predicted a good result for conservative treatment., Conclusions: This randomized controlled trial suggests that the home biofeedback method in PFT has a good success rate of 68.8%. The change achieved in leakage index after 12 weeks of training predicted an effective outcome for conservative treatment.

Objectives: To assess the activities of paraspinal and abdominal muscles during therapeutic exercises for the treatment of patients with nonspecific chronic low back pain (CLBP), and to study the effects of active physical rehabilitation on these activities., Design: A cross-sectional study comparing muscle activities during 18 stabilization exercises, and a prospective follow-up of patients with CLBP during rehabilitation., Setting: Rehabilitation clinic in university hospital in Finland., Participants: Nine volunteers (5 men, 4 women) aged 27 to 58 years., Intervention: Three months of active outpatient rehabilitation (4 to 6 times in a rehabilitation clinic, supplemented with self-motivated exercise at home) supervised by a physiotherapist., Main Outcome Measures: Surface electromyography was recorded bilaterally from L5 level paraspinal, rectus abdominis, and obliquus externus abdominis muscles. The recorded signal was averaged and normalized to the maximal electromyographic amplitude obtained during the maximal voluntary contraction. The measurements were taken before and after the exercise treatment period., Results: CLBP patients showed variable trunk muscle activity patterns during the different therapeutic exercises, similar to those that we reported earlier in healthy subjects. The maximal trunk isometric extension (pre, 147.3+/-75.9Nm; post, 170.1+/-72.3Nm) and flexion (pre, 72.0+/-37.9Nm; post, 93.5+/-42.5Nm) torques did not show a significant changes during the exercise period. However, trunk rotation-flexion torque (pre, 52.9+/-26.5Nm; post, 82.4+/-65.8Nm) increased significantly (35.8%) after the exercise period (P<.05). The corresponding maximal electromyographic amplitudes of back and abdominal muscles remained unchanged. Disability, as assessed by visual analog scale and Oswestry Disability Index, did not change., Conclusions: The CLBP patients performed therapeutic exercises with similar abdominal and back extensor muscle activities in the same way as the healthy subjects in our earlier studies. In this study, active physical rehabilitation had no effect on the abdominal and back muscle activities or on pain and functional disability indices.

Objective: To investigate the effects of strength training on neuromuscular functions in elderly females with fibromyalgia (FM)., Methods: Thirteen females with fibromyalgia [group FMt; mean age (s.d.) 60.2 (2.5) years] and 11 healthy controls [group HCt; 64.2 (2.7) yr] carried out supervised strength training twice a week for 21 weeks. Thirteen FM patients [group FMc; 59.1 (3.5) yr] served as non-training controls. Maximal isometric force and electromyographic (EMG) activity of the right quadriceps femoris in knee extension and flexion actions, maximal 10-m walking speed, and 10-step stair-climbing time were measured. Tender points were assessed by palpation, subjectively perceived symptoms with a visual analogue scale, and the self-reported physical function capacity by Health Assessment Questionnaire (HAQ)., Results: The mean (s.d.) increases in maximal extension force during the training period in groups FMt and in HCt were 32 (33)% (P < 0.001) and 24 (12)% (P < 0.001) respectively and those of flexion were 13 (20)% (P < 0.05) and 24 (17)% (P < 0.01). Explosive force of the extensors increased in both FMt and in HCt. The integrated EMGs of the vastus lateralis and medialis muscles increased in both FMt and HCt. Muscle forces and EMGs in group FMc remained at the basal level. Walking speed, stair-climbing time and the HAQ index improved in group FMt. The changes in the number of tender points and in perceived symptoms were in favour of the training group FMt., Conclusions: The data support the hypothesis that elderly female FM patients have normal neuromuscular function. Supervised strength training also suits elderly FM patients, has positive effects on perceived symptoms and improves functional capacity without complications.

Context: Active physical training is commonly recommended for patients with chronic neck pain; however, its efficacy has not been demonstrated in randomized studies., Objective: To evaluate the efficacy of intensive isometric neck strength training and lighter endurance training of neck muscles on pain and disability in women with chronic, nonspecific neck pain., Design: Examiner-blinded randomized controlled trial conducted between February 2000 and March 2002., Setting: Participants were recruited from occupational health care systems in southern and eastern Finland., Patients: A total of 180 female office workers between the ages of 25 and 53 years with chronic, nonspecific neck pain., Interventions: Patients were randomly assigned to either 2 training groups or to a control group, with 60 patients in each group. The endurance training group performed dynamic neck exercises, which included lifting the head up from the supine and prone positions. The strength training group performed high-intensity isometric neck strengthening and stabilization exercises with an elastic band. Both training groups performed dynamic exercises for the shoulders and upper extremities with dumbbells. All groups were advised to do aerobic and stretching exercises regularly 3 times a week., Main Outcome Measures: Neck pain and disability were assessed by a visual analog scale, the neck and shoulder pain and disability index, and the Vernon neck disability index. Intermediate outcome measures included mood assessed by a short depression inventory and by maximal isometric neck strength and range of motion measures., Results: At the 12-month follow-up visit, both neck pain and disability had decreased in both training groups compared with the control group (P<.001). Maximal isometric neck strength had improved flexion by 110%, rotation by 76%, and extension by 69% in the strength training group. The respective improvements in the endurance training group were 28%, 29%, and 16% and in the control group were 10%, 10%, and 7%. Range of motion had also improved statistically significantly in both training groups compared with the control group in rotation, but only the strength training group had statistically significant improvements in lateral flexion and in flexion and extension., Conclusions: Both strength and endurance training for 12 months were effective methods for decreasing pain and disability in women with chronic, nonspecific neck pain. Stretching and fitness training are commonly advised for patients with chronic neck pain, but stretching and aerobic exercising alone proved to be a much less effective form of training than strength training.

Objective: To assess the activities of the paraspinal and abdominal muscles during manually assisted therapeutic exercises (MATEs) and nonassisted therapeutic exercises (NATEs) that are used in the initial phases of the progressive exercise programs designed for the treatment of low back pain., Design: Thirteen healthy subjects volunteered in the study. Surface electromyography (EMG) was recorded. The recorded EMG signal was averaged and normalized to the maximal EMG amplitude obtained during the maximal voluntary contraction (%EMGmax)., Results: In general, the %EMGmax values were higher during NATEs than during MATEs. Sitting seemed to activate lumbar L5 level paraspinal muscles to the same extent as MATEs., Conclusion: MATEs require only minimal trunk muscle activities, and thus, they may not be sufficiently intense to improve the trunk muscle performance. NATEs require high trunk muscle activities that are adequate for improving the trunk muscle performance, but they may cause high compressive loading of the lumbar spine, and if unchecked, this can aggravate low back pain.

Objectives: To assess the paraspinal and abdominal muscle activities during different therapeutic exercises and to study how load increment produced by varying limb movements and trunk positions could affect these muscle activities., Design: A cross-sectional study comparing muscle activities between men and women., Setting: Rehabilitation clinic in university hospital., Participants: Twenty-four healthy volunteers (14 women, 10 men) aged 21 to 39 years., Interventions: Subjects performed 16 different therapeutic exercises commonly used to treat low back pain., Main Outcome Measures: Surface electromyography was recorded from the paraspinal (T9, L5) and abdominal (rectus abdominis, obliquus externus) muscles during these exercises. Average electromyographic amplitudes obtained during the exercises were normalized to the amplitude in maximal voluntary contraction (% MVC) to produce interindividually comparable muscle activity assessments., Results: Mean average normalized electromyographic amplitudes (% MVC) of the exercises were below 50% MVC. At L5 level, the multifidus muscle activities were significantly higher (p <.05) in women than in men, whereas no significant difference was found at T9 level. Similarly, rectus abdominis and obliquus externus activities were significantly higher (p <.001, p <.05) in women than in men. Load increment in hands or unbalanced trunk and limb movements produced higher paraspinal and abdominal muscle activities (p <.05)., Conclusions: Simple therapeutic exercises are effective in activating both abdominal and paraspinal muscles. By changing limb and trunk positions or unbalancing trunk movements, it is possible to increase trunk muscle activities. Women were better able to activate their stabilizing trunk muscles than men; but it is also possible that men, having a much higher degree of strength on maximal contraction, only need to activate a smaller amount of that maximum to perform a similar activity.

Background: Therapeutic exercises are widely used in the treatment of low back problems. Clinical knowledge about targeting the load in these exercises, however, is insufficient. This study assessed the L2 and L5 level paraspinal and gluteus maximus muscle activities in different therapeutic exercises. Intramuscular and surface electromyography (EMG) measurements were obtained to study whether surface EMG measurements can be used in the assessment of multifidus muscle function., Methods: Eleven healthy subjects (5 men, 6 women) 21 to 38 years of age volunteered for the study. The subjects performed 18 different therapeutic exercises. During the exercises paraspinal EMG was recorded using fine wire and surface electrodes. The normalized peak and average muscle EMG activities (percentage of amplitude in maximal voluntary contraction [MVC]) during each task were determined., Results: The correlations between the average intramuscular and surface activities of the normalized EMG (% of MVC) at the L2 and L5 levels were .928 and .950, respectively. The peak and average EMG amplitudes of the exercises were below 50% and 25% of MVC, respectively. At the L5 level, the multifidus peak and average EMG amplitudes (% MVC) were higher in women than in men, whereas no significant difference was found at the L2 level. In women, the normalized multifidus EMG amplitude was higher at the L5 level than at the L2 level, whereas no significant difference was found in men. In both sexes, the normalized EMG amplitude was higher in the multifidus than in the longissimus muscle., Conclusion: Surface EMG measurements may be used in the assessment of multifidus muscle function. Simple therapeutic exercises are effective in activating the lumbar paraspinal muscles.

Study Design: A randomized study comparing the results of active rehabilitation and passive control treatment in patients with chronic low back pain with follow-up at 6 months and 1 year., Objectives: To study the efficacy of active rehabilitation on pain, self-experienced disability, and lumbar fatigability., Summary of Background Data: Exercises in an outpatient setting are widely used for the treatment of chronic low back pain. The efficacy of the active rehabilitation approach has been documented in randomized control studies, but these studies have seldom been focused on lumbar fatigability, which is now recognized as a frequent problem among patients with chronic low back pain., Methods: Fifty-nine middle-aged patients (37 men and 22 women) with nonspecific chronic low back pain were randomly assigned to 12 weeks' active rehabilitation or to a passive control treatment (massage, thermal therapy). Pain and disability index, low back pain intensity (visual analog scale, 100 mm), and the objectively assessed lumbar muscle fatigability (spectral electromyogram, mean power frequency slope [MPFSLOPE]) in a new 90-second submaximal isoinertial back endurance test were recorded before and after the interventions and at 6-month and 1-year follow-up visits., Results: Results of repeated measures multivariate analysis of variance indicated that back pain intensity (visual analog scale) and functional disability (pain and disability index score) decreased, and lumbar endurance (MPFSLOPE) improved significantly more (P < 0.05) in the active rehabilitation group than in the passive control treatment group, when measured at a 1-year follow-up examination. The group difference in visual analog scale and pain and disability index changes became even more significant at the end of 1 year. The change in lumbar endurance was significantly greater in the active rehabilitation group than in the passive control treatment group at the 6-month follow-up, but not at the 1-year follow-up., Conclusions: The active progressive treatment program was more successful in reducing pain and self-experienced disability and also in improving lumbar endurance than was the passive control treatment. However, the group difference in lumbar endurance tended to diminish at the 1-year follow-up.

This first IAMMM report concerns the evidence for efficacy in the lumbar region only for those interventions which are common in manual/musculoskeletal medicine. [ABSTRACT FROM AUTHOR]