Featured Articles #003: Low Back Pain, Multiple Sclerosis, Shoulder Conditions and Pulmonary Arterial Hypertension
Previously featured articles #3: Sepember 23, 2021 – October 24, 2021.
Does Motor Control Exercise Restore Normal Morphology of Lumbar Multifidus Muscle in People with Low Back Pain? – A Systematic Review
Abstract
Background
Aberrant morphological changes in lumbar multifidus muscle (LMM) are prevalent among patients with low back pain (LBP). Motor control exercise (MCE) aims to improve the activation and coordination of deep trunk muscles (eg, LMM), which may restore normal LMM morphology and reduce LBP. However, its effects on LMM morphology have not been summarized.
Objective: This review aimed to summarize evidence regarding the (1) effectiveness of MCE in altering LMM morphometry and decreasing LBP; and (2) relations between post-MCE changes in LMM morphometry and LBP/LBP-related disability.
Methods
Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, EMBASE and SPORTDiscus were searched from inception to 30 September 2020 to identify relevant randomized controlled trials. Two reviewers independently screened articles, extracted data, and evaluated risk of bias and quality of evidence.
Results
Four hundred and fifty-one participants across 9 trials were included in the review. Very low-quality evidence supported that 36 sessions of MCE were better than general physiotherapy in causing minimal detectable increases in LMM cross-sectional areas of patients with chronic LBP. Very low- to low-quality evidence suggested that MCE was similar to other interventions in increasing resting LMM thickness in patients with chronic LBP. Low-quality evidence substantiated that MCE was significantly better than McKenzie exercise or analgesics in increasing contracted LMM thickness in patients with chronic LBP. Low-quality evidence corroborated that MCE was not significantly better than other exercises in treating people with acute/chronic LBP. Low-quality evidence suggested no relation between post-MCE changes in LMM morphometry and LBP/LBP-related disability.
Conclusion
There is preliminary evidence that MCE may change LMM morphology, although it may be dose dependent. Specifically, 36 or more sessions of MCE may increase LMM CSA in patients with CLBP. However, existing evidence does not support that MCE is more effective than other exercises in treating acute/chronic LBP. That said, future research is warranted to determine the effects of MCE on segmental or global morphometry (including intramuscular fatty infiltration) of LMM and clinical outcomes, as well as to quantify the causal relationships between changes in LMM morphology and LBP/LBP-related disability
EFFECT OF EXERCISE ON FATIGUE IN MULTIPLE SCLEROSIS: A NETWORK META-ANALYSIS COMPARING DIFFERENT TYPES OF EXERCISE
Abstract
Objective
A network meta-analysis (NMA) of current evidence was conducted to determine if physical exercise has a positive influence on multiple sclerosis (MS) fatigue and type of exercise with the largest effect on fatigue also according to disease severity.
Methods
Data sources: MEDLINE, EMBASE, SPORTDiscus, PEDro, Cochrane Library and Web of Science. The search strategy combined relevant terms related to: a) multiple sclerosis; b) clinical trials; c) exercise; and d) fatigue, from inception to February 2021. Study selection: Randomized controlled trials concerning the effectiveness of different types of exercise on total and physical fatigue in people with MS were included. Data extraction: The data were extracted into predesigned data extraction tables. Risk of bias was evaluated with the Cochrane Risk of Bias tool (RoB 2.0) and to evaluate the quality of the evidence, the Grading of Recommendations, Assessment, Development and Evaluation tool was used.
Data synthesis
A total of 58 studies were examined. Data were pooled using a random effects model. A ranking of seven and eight different exercise interventions for physical and total fatigue scores, respectively, was achieved. The highest effects for pairwise comparisons were for combined exercise and resistance training versus control (ranging between -0.74 and -1.24). In the NMA, combined exercise (-1.51; 95% CI: -2.01, -1.01) and resistance training (-1.15; 95% CI -1.81, -0.49) compared to the control group achieved the highest effects for physical and total fatigue, respectively.
Conclusion
Exercise should be considered an effective fatigue management strategy. Among the different exercise modalities, combined exercise is the most effective exercise modality for improving both, physical and total fatigue. Resistance training is also an effective exercise for total fatigue among people diagnosed with MS.
Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis
Abstract
Objective
To assess the effects of mobilization with movement (MWM) on pain, range of motion (ROM), and disability in the management of shoulder musculoskeletal disorders.
Methods
Six databases and Scopus, were searched for randomized control trials. The ROB 2.0 tool was used to determine risk-of-bias and GRADE used for quality of evidence. Meta-analyses were performed for the sub-category of frozen shoulder and shoulder pain with movement dysfunction to evaluate the effect of MWM in isolation or in addition to exercise therapy and/or electrotherapy when compared with other conservative interventions.
Results
Out of 25 studies, 21 were included in eight separate meta-analyses for pain, ROM, and disability in the two sub-categories. For frozen shoulder, the addition of MWM significantly improved pain (SMD −1.23, 95% CI −1.96, −0.51)), flexion ROM (MD −11.73, 95% CI −17.83, −5.64), abduction ROM (mean difference −13.14, 95% CI −19.42, −6.87), and disability (SMD −1.50, 95% CI (−2.30, −0.7). For shoulder pain with movement dysfunction, the addition of MWM significantly improved pain (SMD −1.07, 95% CI −1.87, −0.26), flexion ROM (mean difference −18.48, 95% CI- 32.43, −4.54), abduction ROM (MD −32.46, 95% CI – 69.76, 4.84), and disability (SMD −0.88, 95% CI −2.18, 0.43). The majority of studies were found to have a high risk of bias.
Conclusion
MWM is associated with improved pain, mobility, and function in patients with a range of shoulder musculoskeletal disorders and the effects clinically meaningful. However, these findings need to be interpreted with caution due to the high levels of heterogeneity and risk of bias.
Level of Evidence: Treatment, level 1a.
Optimal aerobic exercise intensity and its influence on the effectiveness of exercise therapy in patients with pulmonary arterial hypertension: a systematic review
Abstract
Background
Exercise intensity in exercise training programs is an important determinant of program efficacy, such as improvement in exercise capacity and quality of life (QOL). It is not well known whether differently applied exercise intensities are efficacious when used in exercise-based cardiac rehabilitation programs for patients with pulmonary arterial hypertension (PAH).
Methods
Three databases (PubMed, EMBASE, and CINAHL) were searched with the following inclusion criteria: comparative study of exercise interventions for patients with pulmonary arterial hypertension. Three clinical specialists (a physician, nurse, and exercise physiologist) selected the included articles using the process of systematic review. Included articles were grouped according to aerobic exercise intensity: low, moderate-to-vigorous, and vigorous. The level of evidence for each study was rated using Sackett’s levels of evidence.
Results
Of 1,452 studies reviewed, 8 were included according to the inclusion criteria (3 randomized controlled trials (RCTs), 3 prospective studies, and 2 case series). Exercise capacity for a six-minute walk distance (mean: 57.7 m) and QOL improved in the above moderate intensity group, while the low intensity group did not show improvement after intervention. For termination criteria, data obtained from the reviewed articles were not sufficient to suggest any exercise intensity recommendations for patients with pulmonary arterial hypertension.
Conclusion
The findings in this study suggest that at least moderate aerobic exercise intensity is needed to significantly improve six-minute walk distance and QOL in individuals diagnosed with World Health Organization Group 1 of pulmonary arterial hypertension. There is a need for prospective RCTs comparing different exercise intensities in this patient population.
