Randomized trial comparing the effects of one set vs two sets of resistance exercises for patients with cLBP.

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Limke JC, Eur J Phys Rehab Med. Dec;44 2008.

 

This interesting study at the New England Baptist bone and joint institute in Boston investigated the efficacy of its (2) set progressive resistance (PRE) program used to reverse deconditioning vs just (1) set. They were investigating whether completing (1) vs. (2) sets of resistance exercise during an otherwise identical spine rehab program would prove additional benefits from the additional set. There were 100 subjects with a mean age of 46. The measures included back strength and progressive iso-inertial lifting evaluation (PILE) at discharge from the program. Exercises consisted of Cybex back extension, rotary torso, pull downs, various hip and leg exercises as well as lifting crates. A (4) rep max as well as the PILE measures were the outcome measures.

Results: at discharge there was NO significant difference in strength, disability or pain measures between subjects completing (1) vs. (2) sets.

Conclusions:  These findings suggest that there is NO added benefits for completing a second set for patients with cLBP.

 

Intradiscal pressure in vivo

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Wilke HJ et al Clinical biomech 16; 2001.

 

Intradiscal pressure measurements were taken in a variety of postures and activities many replicating the earlier work of Nachemson. Prone-lying: 0.1 Mpa, Side-lying: 0.12, relaxed-standing: 0.5, flexed-standing: 1.1, flexion-sitting: 0.83. Lifting 40lbs with a rounded back: 2.3, with flexed knees: 1.7, with weight close to the body: 1.1. Interestingly pressure during the night increased from 0.1 to 0.24, a near two and a half increase which helps explain the pain & stiffness in many in the AM as well as the severe pain noted by those with active annular tears. While exercising pressure curves were similar; 0.43-0.50. The greatest change in pressure was with flexion, changing nearly linearly with flexion angle: 1.08 at 36 degrees. Extension there was a linear increase but the highest pressure only reached 0.6 at a 20 degree angle. Again a pressure-mitigation with extension is observed which further reinforces the value of positional-prone-extension during traction. Lateral bending showed symmetrical behavior, with an increase up to .60 at an angle approx. 20 degrees. Beyond those ranges pressure decreased to .38 by 30 degrees. The assumption is that muscular contraction accounts for the pressure increase in the initial bending however at a certain angle gravity creates muscular release as the passive system takes over.

Studies like this one can help us greatly in ADL and exercise prescription.

A brief discussion on lumbar lateral bending

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Most lumbar disc herniations protrude posterolateral, away from the center of the body. Once lateral the disc can lie either lateral or medial to the nerve root, the terms lateral &medial refer to the relationship between the disc and the nerve root NOT the relationship to the midline.  A lateral presentation finds the patient leaning away from the side of pain, medial leaning into the pain side.

Antalgia can help differentiate these two conditions and improve clinical treatment choice. Leaning the patient in the opposite direction increases radicular irritation in both conditions. However like extension pain at the initial motions, tolerance and improvement to repetitive motions signals a potential ‘directional preference’ and a less recalcitrant presentation in some cases. Many times patients will present with antalgia in more than one position and this needs to be taken into account as well.

Though Kemps test has been used to differentiate facet involvement its indications by some authors suggests a herniation differential in the case of antalgia as well. It is often done in the seated posture to increase IDP. Antalgia noted before these tests, resistance to lateral bending into and opposing antalgia and the resultant changes in back/leg pain must be taken into account in interpretation.

Long term outcomes of surgical and nonsurgical management of sciatica secondary to lumbar HNP: 10 year results.

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Atlas SJ et al Spine Apr 15, 2005.

 

This 10 year Maine study supports previous population studies on surgery vs. conservative treatments.

It points out that surgical patients tend to have worse baseline symptoms and poorer functional status.

At 10 years 25% of surgery patients had opted for at least one additional operation and 25% of the non-surgical group had at least one operation as well. At 10 years 69% of surgery patients reported improvement vs. 61% of non-surgical patients.  A larger proportion of surgical patients reported their back and leg symptoms were ‘much better or completely gone’(56% vs 40%) and were more satisfied with their current status (71% vs. 56%). When work and disability status were compared it was comparable between both groups.

 

Bell’s Palsy – Laser Therapy Treatments

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In 2013, Alayat et al reported on a randomized double-blind placebo-controlled trial of laser therapy for the treatment of 48 patients with Bell’s palsy. Facial exercises and massage  were given to all patients. Patients were randomized to one of three groups: high-intensity laser therapy, low-level laser therapy or exercise only. Laser treatment was given three times per week to eight points of the affected side for six weeks. At three and six weeks after treatment, outcomes were assessed using the facial disability scale (FDI) and the House-Brackmann scale (HBS). Significant improvements in recovery were seen in both laser therapy groups over exercise alone with the most improvement seen with high-intensity laser.

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