1. Investigación

Study design: Double-blind, randomized parallel sham-controlled trial with concealed allocation and intention-to treat analysis. Objective: To investigate the effects of an isolate myofascial release (MFR) protocol on pain, disability, and fear-avoidance beliefs in patients with chronic low back pain (CLBP). Summary of background data: MFR is a form of manual medicine widely used by physiotherapists in the management of different musculoskeletal pathologies. Up to this moment, no previous studies have reported the effects of an isolated MFR treatment in patients with CLBP. Methods: Fifty-four participants, with nonspecific CLBP, were randomized to MFR group (n = 27) receiving four sessions of myofascial treatment, each lasting 40 minutes, and to control group (n = 27) receiving a sham MFR. Variables studied were pain measured by means Short Form McGill Pain Questionnaire (SF-MPQ) and visual analog scale (VAS), disability measured with Roland Morris Questionnaire, and fear-avoidance beliefs measured with Fear-Avoidance Beliefs Questionnaire. Results: Subjects receiving MFR displayed significant improvements in pain (SF-MPQ) (mean difference -7.8; 95% confidence interval [CI]: -14.5 to -1.1, P = 0.023) and sensory SF-MPQ subscale (mean difference -6.1; 95% CI: -10.8 to -1.5, P = 0.011) compared to the sham group, but no differences were found in VAS between groups. Disability and the Fear-Avoidance Beliefs Questionnaire score also displayed a significant decrease in the MFR group (P < 0.05) as compared to sham MFR. Conclusion: MFR therapy produced a significant improvement in both pain and disability. Because the minimal clinically important differences in pain and disability are, however, included in the 95% CI, we cannot know whether this improvement is clinically relevant.

Background and purpose: Because of its high prevalence and association with negative health-related outcomes, frailty is considered one of the most important issues associated with human aging and its mitigation is among the essential public health goals for the 21st century. However, very few studies have focused on institutionalized older adults, despite the knowledge that frailty can be reversible when identified and treated from its earliest stages. Therefore, the objective of this study was to evaluate the effects of a supervised group-based multicomponent exercise program intervention with or without oral nutritional supplementation on functional performance in frail institutionalized older adults. Methods: This was a multicenter randomized controlled trial study with a 6-month intervention period. A total of 111 frail institutionalized older adults (75 years or older) who met at least 3 of the 5 Fried frailty criteria were randomly allocated to the control group (CG; n = 34, mean age = 87.3 ± 5.3 years), a supervised group-based multicomponent Otago Exercise Program group (OEP; n = 39, mean age = 86 ± 5.9 years), or a supervised group-based multicomponent exercise program intervention with oral nutritional supplementation (OEP+N; n = 38, mean age = 84.9 ± 6 years). Measurements included the Timed Up and Go test (TUG), Berg Balance Scale (BBS), Short Physical Performance Battery, repeated chair stand test (STS-5), handgrip strength (HGS), 10-m walking test, and 6-minute walking test, both at baseline and after the 6-month intervention period. Results and discussion: The between-group analysis by 2-way analysis of covariance showed significant improvement in the TUG [{OEP vs CG: -8.2 seconds, 95% CI [-13.3 to -2.9]; P < .001}; {OEP vs OEP+N: -7.3 seconds, 95% CI [-12.4 to -2.2]; P = .002}], BBS [{OEP vs CG; 8.2 points, 95% CI [5.2 to 11.2]; P < .001}; [{OEP+N vs CG: 4.6 points, 95% CI [1.6 to 7.6]; P < .001}; {OEP vs OEP+N: 3.5 points, 95% CI [0.6 to 6.5]; P = .011}], and HGS [{OEP vs CG: 3.4 kg, 95% CI [1.5 to 5.3]; P < .001}; {OEP+N vs CG: 3.6 kg, 95% CI [1.7 to 5.5]; P < .001}]. Additionally, the within-group analysis showed a significant improvement in the TUG (-6.9 seconds, 95% CI [-9.8 to -4.0]; P < .001) and BBS (4.3 points, 95% CI [2.6 to 5.9]; P < .001) in the OEP group. A significant decrease in the BBS and HGS was shown in the CG. Conclusions: A 6-month supervised group-based multicomponent exercise intervention improved the levels of mobility, functional balance, and HGS in frail institutionalized older adults. Further research will be required to evaluate the nutritional supplementation effects on functional performance to better determine its clinical applicability for tackling frailty.

OBJECTIVE: To evaluate the pain-relieving effect of transcutaneous electrical nerve stimulation (TENS) during office-based hysteroscopy without sedation. METHODS: We conducted a randomized, double-blind, placebo-controlled trial. Participants were randomly assigned to the active TENS, placebo TENS, or control group. The active TENS intervention consisted of a varying high-frequency (80–100 Hz), 400-microseconds, individually adjusted, high-intensity TENS application with two self-adhesive electrodes placed parallel to the spinal cord at the T10–L1 and S2–S4 levels. In the placebo group, participants were connected to the TENS unit but delivering no electrical stimulation. The primary outcome was self-reported pain intensity (0–100 mm) measured on a visual analog scale at several stages (entry, contact, biopsy, and residual). The minimum clinically relevant difference for the visual analog scale has been previously reported as 10 mm. Sample size was calculated to provide 80% power to show a 10-mm difference (α=0.0125) in the primary outcome. Secondary outcomes included duration of the procedure, vital parameters, vasovagal symptoms, and participant satisfaction index (0–10 rating scale). RESULTS: A total of 138 women (46 per group) participated in the study between January 2016 and April 2016. No differences were found between groups regarding age, weight, body mass index, parity status, menopausal status, or previous hysteroscopy status. Visual analog scale scores highlighted a decrease in pain in the active TENS group compared with the placebo group (entry: −11 mm, 95% confidence interval [CI] −17 to −5; contact: −21.9 mm, 95% CI −30 to −13.9; biopsy: −30.5 mm, 95% CI −47.1 to −13.8, P<.001). Moreover, the reduction in pain reached the minimum clinically relevant difference. Regarding satisfaction, results also revealed differences between active TENS and placebo groups (1.3, 95% CI 0.5–2.2, P=.001). CONCLUSION: Transcutaneous electrical nerve stimulation reduces pain and increases patient satisfaction during office hysteroscopy without sedation.

Objetivo: Determinar los efectos del estiramiento de la musculatura isquiotibial sobre el patrón de activación del erector spinae durante los movimientos de flexoextensión de tronco. Hipótesis: El estiramiento repetido de la musculatura isquiotibial podría acortar la duración del período del silencio mioeléctrico del erector spinae durante la flexoextensión de tronco. Metodología: Se registraron en 14 sujetos sanos la activación electromiográfica (EMG) del erector spinae y los grados de flexión de cadera durante movimientos de flexoextensión de tronco antes y después de realizar el estiramiento isquiotibial. Las variables de estudio fueron el rango máximo de movimiento de cadera, los porcentajes de flexión de cadera en el offset/onset del erector spinae y la actividad EMG media de este músculo en las fases excéntrica y concéntrica. Resultados: La prueba T mostró que no existen diferencias significativas en el momento de aparición del offset y del onset antes y después del estiramiento. Se observó un aumento significativo de la actividad EMG del erector durante la contracción concéntrica tras el estiramiento. Conclusión: El estiramiento prolongado de las estructuras isquiotibiales no produce variaciones en la duración del período del silencio mioeléctrico del erector spinae, pero sí sobre su actividad EMG media durante la extensión de tronco, con lo que podría estar alterándose la coactivación muscular necesaria para proporcionar estabilidad al raquis lumbar.

This study aimed to analyze the position of the lumbopelvic region and lumbar muscle activity in the most common breastfeeding positions. We recorded the curvatures of the lumbar spine and pelvis by means of an electrogoniometer, and the muscle activation levels of the erector spinae with electromyography, in 34 women in erect standing and breastfeeding their children in several positions. Both side lying and clutch-hold positions showed a greater degree of lumbar spine flexion compared to standing. In all sitting postures it was observed that the pelvis was placed in retroversion when compared to standing and side lying. In muscle activity, it was observed that the activation intensity of the right erector in the right side-supported side lying position was significantly lower compared to the rest of breastfeeding postures and standing. Side lying may be a better position to avoid muscle fatigue.

Transcutaneous electrical nerve stimulation (TENS) is a nonpharmacological modality widely used to manage pain; however, its effectiveness for individuals with fibromyalgia (FM) has been questioned. In previous studies and systematic reviews, variables related to dose of TENS application have not been considered. The objectives of this meta-analysis were (1) to determine the effect of TENS on pain in individuals with FM and (2) determine the dose-dependent effect of TENS dose parameters on pain relief in individuals with FM. We searched the PubMed, PEDro, Cochrane, and EMBASE databases for relevant manuscripts. Data were extracted from 11 of the 1575 studies. The quality of the studies was assessed using the PEDro scale and RoB-2 assessment. This meta-analysis was performed using a random-effects model that, when not considering the TENS dosage applied, showed that the treatment had no overall effect on pain (d+ = 0.51, P > 0.050, k = 14). However, the moderator analyses, which were performed assuming a mixed-effect model, revealed that 3 of the categorical variables were significantly associated with effect sizes: the number of sessions (P = 0.005), the frequency (P = 0.014), and the intensity (P = 0.047). The electrode placement was not significantly associated with any effect sizes. Thus, there is evidence that TENS can effectively reduce pain in individuals with FM when applied at high or at mixed frequencies, a high intensity, or in long-term interventions involving 10 or more sessions.

The countermovement jump, the V-cut test, the muscle thickness and the adjacent subcutaneous fat thickness of the gastrocnemius medialis and rectus femoris are important physiological indicators for success in basketball. The aims of this study were to evaluate between-age-category and between-gender differences in these indicators and examine the relationships between physical tests and ultrasound measurements. The measurements were recorded in a sample of 131 elite basketball players (66 males) who played in three age-categories (U14, U16, or U18). We performed two-way analysis of covariance tests and age-adjusted partial correlation analyses. U16 and U18 males showed better performance in the countermovement jump and V-cut tests and lower adjacent subcutaneous fat thickness of the gastrocnemius medialis and rectus femoris compared to the U14 males (p≤.001) and to age-category equivalent female players (p≤.001). Comparisons between the age categories in females did not show significant differences in any of the study variables. Adjacent subcutaneous fat thickness of the gastrocnemius medialis explained 22.3% of the variation for the countermovement jump result and 12.9% of the variation for the V-cut result in males (p<.01). This study is the first to show the association and predictive role of subcutaneous fat thickness measured by ultrasound in physical performance of male and female elite youth basketball players.

BACKGROUND CONTEXT: The kinematics of the lumbar region and the activation patterns of the erector spinae muscle have been associated with the genesis of low back pain, which is one of the most common complications associated with pregnancy. Despite the high prevalence of pregnancy-related low back pain, the biomechanical adaptations of the lumbar region during pregnancy remain unknown. PURPOSE: This study analyzes lumbar spine motion and the activation pattern of the lumbar erector spinae muscle in healthy pregnant women. STUDY DESIGN: A case-control study. PATIENT SAMPLE: The study involved 34 nulliparous women (control group) and 34 pregnant women in the third trimester (week 36 § 1). OUTCOME MEASURES: We recorded the parameters of angular displacement of the lumbar spine in the sagittal plane during trunk flexion-extension, and the EMG activity of the erector spinae muscles during flexion, extension, eccentric and concentric contractions, and the myolectrical silence. METHODS: The participants performed several series of trunk flexion-extension movements, which were repeated 2 months postpartum. The position of the lumbar spine was recorded using an electromagnetic motion capture system. EMG activity was recorded by a surface EMG system and expressed as a percentage of a submaximal reference contraction. RESULTS: Antepartum measurements showed a decrease (relative to control and postpartum measurements) in lumbar maximum flexion (52.5 § 10.5° vs 57.3 § 7.7° and 58.7 § 8.6°; p < .01), the percentage of lumbar flexion during forward bending (56.4 § 5.6% vs 59.4 § 6.8% and 59.7 § 5.6%; p < .01), and the time keeping maximum levels of lumbar flexion (35.7 § 6.7% vs 43.8 § 5.3% and 50.1 § 3.7%; p < .01). Higher levels of erector spinae activation were observed in pregnant women during forward bending (10.1 § 4.8% vs 6.3 § 2.4% and 6.6 § 2.7%; p < .01) and eccentric contraction (12.1 § 5.2% vs 9.4 § 3.1% and 9.1 § 2.9%; p < .01), as well as a shortened erector spinae myoelectric silence during flexion. CONCLUSIONS: Pregnant women show adaptations in their patterns of lumbar motion and erector spinae activity during trunk flexion-extension. These changes could be associated with the genesis of pregnancy-related low back pain, by means of biomechanical protection mechanisms against the increase on abdominal mass and ligamentous laxity.

Objective: To investigate the effects of an osteopathic manipulative treatment (OMT), which includes a diaphragm intervention compared to the same OMT with a sham diaphragm intervention in chronic nonspecific low back pain (NS-CLBP). Design: Parallel group randomized controlled trial. Setting: Private and institutional health centers. Participants: Participants (N=66) (18-60y) with a diagnosis of NS-CLBP lasting at least 3 months. Interventions: Participants were randomized to receive either an OMT protocol including specific diaphragm techniques (n=33) or the same OMT protocol with a sham diaphragm intervention (n=33), conducted in 5 sessions provided during 4 weeks. Main Outcome Measures: The primary outcomes were pain (evaluated with the Short-Form McGill Pain Questionnaire [SF-MPQ] and the visual analog scale [VAS]) and disability (assessed with the Roland–Morris Questionnaire [RMQ] and the Oswestry Disability Index [ODI]). Secondary outcomes were fear-avoidance beliefs, level of anxiety and depression, and pain catastrophization. All outcome measures were evaluated at baseline, at week 4, and at week 12. Results: A statistically significant reduction was observed in the experimental group compared to the sham group in all variables assessed at week 4 and at week 12 (SF-MPQ [mean difference −6.2; 95% confidence interval, −8.6 to −3.8]; VAS [mean difference −2.7; 95% confidence interval, −3.6 to −1.8]; RMQ [mean difference −3.8; 95% confidence interval, −5.4 to −2.2]; ODI [mean difference −10.6; 95% confidence interval, −14.9 to 6.3]). Moreover, improvements in pain and disability were clinically relevant. Conclusions: An OMT protocol that includes diaphragm techniques produces significant and clinically relevant improvements in pain and disability in patients with NS-CLBP compared to the same OMT protocol using sham diaphragm techniques.