Julie A. Hides, Warren R. Stanton, Shaun McMahon, Kevin Sims, Carolyn A. Richardson

STUDY DESIGN: A single blinded, pre-post treatment assessment. OBJECTIVES: (1) To investigate, using ultrasound imaging, the cross-sectional area (CSA) of the lumbar multifidus muscle at 4 vertebral levels (L2, L3, L4, L5) in elite cricketers with and without low back pain (LBP) and (2) to document the effect of a staged stabilization training program on multifidus muscle CSA. BACKGROUND: Despite high fitness levels and often intensive strength training programs, athletes still suffer LBP. The incidence of LBP among Australian cricketers is 8% and as high as 14% among fast bowlers. Previous researchers have found that the multifidus muscle contributes to segmental stability of the lumbopelvic region, however the CSA of this muscle has not been previously assessed in elite cricketers. METHODS AND MEASURES: CSAs of the multifidus muscles were assessed at rest on the left and right sides for 4 vertebral levels at the start and completion of a 13 week cricket training camp. Participants who reported current or previous LBP were placed in a rehabilitation group. The stabilization program involved voluntary contraction of the multifidus, transversus abdominis, and pelvic floor muscles with real-time feedback from rehabilitative ultrasound imaging (RUSI), progressed from non-weightbearing to weight-bearing positions and movement training. Pain scores (using a visual analogue scale) were also collected from those with LBP. RESULTS: The CSAs of the multifidus muscles at the L5 vertebral level increased for the 7 cricketers with LBP who received the stabilization training, compared with the 14 cricketers without LBP who did not receive rehabilitation (p=0.004). In addition, the amount of muscle asymmetry among those with LBP significantly decreased (p=0.029) and became comparable to cricketers without LBP. This effect was not evident for the L2, L3 and L4 vertebral levels. There was also a 50% decrease in the mean reported pain level among the cricketers with LBP. CONCLUSION: Multifidus muscle atrophy can exist in highly active, elite athletes with LBP. Specific retraining resulted in an improvement in multifidus muscle CSA and this was concomitant with a decrease in pain.

J Orthop Sports Phys Ther., Epub 7 December 2007, doi:10.2519/jospt.2008.2658

KEY WORDS: asymmetry, low back/lumbar spine rehabilitation, rehabilitative ultrasound imaging, therapeutic exercise, ultrasound imaging [quote=Person][/quote]
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Shaun O’Leary, Deborah Falla, †, Paul W. Hodges, Gwendolen Jull and Bill Vicenzino, ,
†Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Denmark.
Division of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia.
Received 27 September 2006; revised 18 May 2007; accepted 23 May 2007. Available online 19 July 2007.

Abstract
This study compared the effect of 2 specific cervical flexor muscle exercise protocols on immediate pain relief in the cervical spine of people with chronic neck pain. In addition, the study evaluated whether these exercise protocols elicited any systemic effects by studying sympathetic nervous system (SNS) function and pain at a location distant from the cervical spine. Participants were randomly allocated into either a cranio-cervical flexion (CCF) coordination exercise group (n = 24) or a cervical flexion (CF) endurance exercise group (n = 24). Measures of pain and SNS function were recorded immediately before and after a single session of the exercise interventions. Pain measures included visual analogue scale (VAS) ratings of neck pain at rest and during active cervical motion and pressure pain threshold (PPT) and thermal pain threshold (TPT) recordings over the cervical spine and at a remote site on the leg. Measures of SNS function consisted of blood flow, skin conductance, skin temperature, heart rate, and blood pressure. Immediately after 1 session of exercise, there was a reasonably sized increase of 21% (P < .001, d = 0.88) and 7.3% (P = .03, d = 0.47) in PPT locally at the neck for the CCF exercise and the CF exercise, respectively. There were no changes in local neck TPT with either exercise. Pressure pain threshold and TPT at the leg and SNS did not change after exercise. Only the CCF exercise demonstrated a small improvement in VAS ratings during active movement (change on 10-cm VAS: CCF, 0.42 cm (P = .04). This study shows that specific CCF therapeutic exercise is likely to provide immediate change in mechanical hyperalgesia local to the neck with translation into perceived pain relief on movement in patients with chronic neck pain.

Perspective
This study showed an immediate local mechanical hypoalgesic response to specific exercise of the cervical spine. Understanding the pain-relieving effects of exercise will assist the clinician in prescribing the most appropriate exercise protocols for patients with chronic neck pain.

Key words: Neck pain; therapeutic exercise; hypoalgesia; pain modulation

Supported by the Physiotherapy Research Foundation (No. 009/02) and the National Health and Medical Research Council (NHMRC) (ID 252771) of Australia. Deborah Falla was supported by a Fellowship awarded by the NHMRC of Australia (ID 351678) and Paul Hodges was supported by an NHMRC Principal Research Fellowship (ID 401599).
Address reprint requests to Dr. Bill Vicenzino, Division of Physiotherapy, University of Queensland, St Lucia Queensland 4072, Australia.

The Journal of Pain
Volume 8, Issue 11, November 2007, Pages 832-839
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Deborah Falla, Shaun O’Learya, Amy Fagana, Gwendolen Julla

Received 7 September 2005; received in revised form 6 February 2006; accepted 2 June 2006
Abstract

Specific strategies to optimally facilitate postural muscles to retrain postural form are advocated in the clinical management of neck pain. The purpose of this study was to compare the activation of selected cervical, thoracic and lumbar muscles during independent and facilitated postural correction in sitting in 10 subjects with chronic neck pain. Deep cervical flexor (DCF) muscle activity was recorded with custom electrodes inserted via the nose and fixed by suction to the posterior mucosa of the oropharynx. Surface electrodes were placed over the thoracic erector spinae and lumbar multifidus muscles. Root-mean-square EMG amplitude was measured for each muscle across two conditions. In the first condition, subjects were instructed to spontaneously “sit up straight” from a slumped posture without any other guidance from the therapist. In the second condition the therapist provided specific manual and verbal facilitation to assist the patient to correct to an upright pelvic position with a neutral spinal lumbo-pelvic position. Activation of the DCF and lumbar multifidus muscles (P<0.05) were significantly greater when the therapist facilitated postural correction compared to independent sitting correction. Specific postural-correction strategies result in better facilitation of key postural muscles compared to non-specific postural advice. The results of this study highlight the need for clinical skill and precision in postural training of patients with neck pain.
Keywords: Posture, Exercise, Neck pain, Electromyography

a Division of Physiotherapy, The University of Queensland, Brisbane, Australia

b Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark

Corresponding Author InformationCorresponding author. Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Engineering and Science, Aalborg University, Fredrik Bajers Vej 7D-3, DK-9200 Aalborg, Denmark. Tel.: +4596357459; fax: +4598154008.

&#9734; This research was undertaken in the Division of Physiotherapy, The University of Queensland, Australia.

PII: S1356-689X(06)00078-6

doi:10.1016/j.math.2006.06.003

© 2006 Elsevier Ltd. All rights reserved.

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Alexander Karl Brenner, Kyle B. Kiesel, Norman W. Gill, Christopher J. Buscema

STUDY DESIGN: Case report. BACKGROUND: The use of spinal manipulation as a treatment to facilitate neuromuscular control of the paraspinal musculature is not well described in the literature. The use of rehabilitative ultrasound imaging (RUSI) may offer a convenient way to investigate and document possible changes occurring in the lumbar multifidus associated with manipulation intervention. CASE DESCRIPTION: The patient was a 33-year-old male with a 21-year history of low back pain and left posterior thigh pain who presented with lumbar hypomobility and met a previously published clinical prediction rule for spinal manipulation. During examination, the patient was asked to perform a prone upper extremity lifting task to assess activation in the lumbar multifidus during an automatic task. Through palpation, the examiner noted a decreased contraction of the left multifidus between L4-S1 compared to the right. To explore this further, a decision was made to assess the multifidus with RUSI, which confirmed the activation deficit noted during palpation. A lumbar regional manipulation was performed with the intention of reducing spinal hypomobility and assessing changes in multifidus activation. Imaging of the multifidus muscles at the L4-5 and L5-S1 levels were obtained premanipulation, immediately postmanipulation, and 1 day after manipulation. OUTCOMES: An increased ability to thicken the multifidus during a prone upper extremity lifting task was noted immediately and 1 day after manipulation. Average percent change in thickness at the L4-5 and L5-S1 levels with the prone arm lift was 3.6% premanipulation, 17.2% immediately postmanipulation, and 20.6% approximately 24 hours postmanipulation. Improvements in the thickening of the multifidus muscle during the upper extremity lifting task were greater than 3 standard errors of the measurement. Other changes included immediate palpable improvement in the contraction of the multifidus during the upper extremity lifting task, along with the patient report of increased ease of lifting. DISCUSSION: In this case report we quantified the short-term influence of spinal manipulation on multifidus muscular activation using RUSI. No cause-and-effect claims can be made; however, the results provide preliminary evidence to suggest that spinal manipulation may influence multifidus muscle function. RUSI offers a convenient way to investigate and document these changes.

Conclusions:
This case report provides preliminary evidence to suggest that spinal manipulation may influence multifidus muscle function.

J Orthop Sports Phys Ther. 2007;37(10):613-619, published online 29 May 2007. doi:10.2519/jospt.2007.2470
KEY WORDS: motor control, reflexogenic, sonography

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