Critically-Appraised Topic
Citation: Freiwald J, Hoppe MW, Beermann W, Krajewski J, Baumgart C. Effects of supplemental heat therapy in multimodal treated chronic low back pain patients on strength and flexibility. Clin Biomech (Bristol, Avon). 2018;57:107-113.
Brief Description of patient: – Patient is a 47-year-old male who is referred to physical therapy after complaints of reoccurring low back pain. Patient has problem sitting for long periods of time (1 hr) and needs to stand up to stretch or the pain will increase. Patient also presents with weakness in L hip abductors with MMT score of 2+/5 and hamstrings MMT score of 3/5. Patient’s work performance is limited by pain and wants to return to work pain free.
PICO Question: Will the supplementation of heat therapy be more beneficial than traditional strength and flexibility exercises to improve the low back pain of a 47 year old male patient?
Databases Searched and Key Words: PubMed, MEDLINE, low back pain, heat therapy, traditional strengthening exercises, physical therapy, strength and flexibility
Question Type: Therapy (Intervention)
Methods: The study is a randomized, active controlled, double blinded observational, and took place at six different physiotherapy centers with a standardized multimodal treatment concept from 01/05-06/30/14. The study was approved and accepted by the Ethic Committee of the University of Wuppertal, Germany. Patients ranged from 18-55 y/o that were qualified based on the chronic LBP diagnosis were referred for the study by physicians in outpatient clinics. Inclusion criteria includes prolonged inability to work due to low back pain and non-traumatic back pain that have lasted for over 6 months hindering ADLs (activities of daily living.) Exclusion criteria were patients suffering from back pain caused by clinically or multi-system medical diseases (e.g multiple myeloma.) 176 patients were randomly assigned in a 1:1 ratio in chronological order into the MTC group and the MTC & heat wrap group. 12 weeks of standardized multimodal with and without the heat therapy ended with a second and final examination. The 12 weeks treatment were carried out in two phases 6 weeks each. Both groups each had 90 min therapy and training per week in phase 1, and 1–2 units each with 90 min therapy and training per week in phase. Statistical analyses between the treatment for both groups were analyzed using a 2-factorial analysis of variance (ANOVA, time x group). A P value of ≤0.10 was considered as statistically significant. The reason for this value was because of expectance of the therapeutic heat application within a MTC to have only a small impact on strength and flexibility (biomechanical parameters).
Validity: Group assignment was randomized including blinding the investigator and were recruited from outpatient clinics by referring physicians. Both groups that had a diagnosis of chronic low back pain and a case of prolonged inability to work due to back pain were included in the inclusion criteria. Another criterion that was included was the use of the Owestry Low Back Pain Questionnaire Index (ODI) with ≤41% (i.e., a moderate disability). Similar baseline characteristics such as age, weight, BMI, selected back pain complaints data from medical history, back complaint duration, doctor visits, days unfit to work, sick leave and days in hospital were recorded at the pre-treatment session. Assessment of patient’s biomechanical parameters were conducted with the training stations (SCHNELL Trainingsgeräte). Measurement of flexibility, ROM in (flexion, extension, lateral flexion, rotation), strength, and torque in (flexion, extension, lateral flexion, rotation). The absolute number of treatments did not change between the two groups. Both groups conducted two phases of training with a duration of six weeks each. The heat wrap group received a heat wrap at 40 °C (mild heat) over 8 h to be worn on the lower back. The heat wraps were applied directly after the treatment and had to be worn the following night with a second device applied on the next day. Intensity and frequency of the therapy and training load for the second phase were determined according to baseline characteristics of the patients and individual response to therapy and training. The length of the study was long enough to be plausible and for the outcomes of interest to occur.
Results: In both groups, averages of ROM increased in all directions. No significant time x group interaction effects were observed (P ≥ 0.55). Both groups also saw an increased in strength (torque) average in all directions. Significant time x group interaction effects for extension (P = 0.09), right rotation (P=0.09) and left rotation (P=0.08).
Critical Appraisal: Group assignments were randomized. There was a control (MTC) and an intervention group (MTC & heat wrap) and both received the same absolute amount of treatment sessions and all have had baseline and several assessments before the treatment had started. The length of time of the study was sufficient to gain expected outcomes. Outcome measures used were valid and reliable. Both parametric and non-parametric data analyses were utilized to note the differences between groups. There were no adverse effects or potential risks reported during and after using the heat wrap therapy as was indicated in the study. The investigators were also blinded. No participants were lost and no intention-to-treat analysis were observed.
Applicability to the patient: Heat wrap therapy can be effective in patients with low back pain who fits the inclusion criteria. Flexibility improvements were not seen and strength gains are most significant in extension along with both side of trunk rotation. In addition, no risks or potential adverse effects were observed with the supplemental use of heat therapy along with strength training. For strength enhancement, the method is highly recommended and potential improvements in patient ADL (activities of daily living) were also discussed.
Clinical Bottom line: Thermotherapy may help improve trunk strength especially in extension/rotation and achieve functional outcome among patients with low back pain. Thermotherapy may be applied as part of an overall physical therapy plan of care but further evidence is needed in order to access its full therapeutic advantages.
Author of CAT (Date): Avon Bristol (August 2018)
Critically-Appraised Topic
Citation: Freiwald J, Hoppe MW, Beermann W, Krajewski J, Baumgart C. Effects of supplemental heat therapy in multimodal treated chronic low back pain patients on strength and flexibility. Clin Biomech (Bristol, Avon). 2018;57:107-113.
Brief Description of patient: – Patient is a 47-year-old male who is referred to physical therapy after complaints of reoccurring low back pain. Patient has problem sitting for long periods of time (1 hr) and needs to stand up to stretch or the pain will increase. Patient also presents with weakness in L hip abductors with MMT score of 2+/5 and hamstrings MMT score of 3/5. Patient’s work performance is limited by pain and wants to return to work pain free.
PICO Question: Will the supplementation of heat therapy be more beneficial than traditional strength and flexibility exercises to improve the low back pain of a 47 year old male patient?
Databases Searched and Key Words: PubMed, MEDLINE, low back pain, heat therapy, traditional strengthening exercises, physical therapy, strength and flexibility
Question Type: Therapy (Intervention)
Methods: The study is a randomized, active controlled, double blinded observational, and took place at six different physiotherapy centers with a standardized multimodal treatment concept from 01/05-06/30/14. The study was approved and accepted by the Ethic Committee of the University of Wuppertal, Germany. Patients ranged from 18-55 y/o that were qualified based on the chronic LBP diagnosis were referred for the study by physicians in outpatient clinics. Inclusion criteria includes prolonged inability to work due to low back pain and non-traumatic back pain that have lasted for over 6 months hindering ADLs (activities of daily living.) Exclusion criteria were patients suffering from back pain caused by clinically or multi-system medical diseases (e.g multiple myeloma.) 176 patients were randomly assigned in a 1:1 ratio in chronological order into the MTC group and the MTC & heat wrap group. 12 weeks of standardized multimodal with and without the heat therapy ended with a second and final examination. The 12 weeks treatment were carried out in two phases 6 weeks each. Both groups each had 90 min therapy and training per week in phase 1, and 1–2 units each with 90 min therapy and training per week in phase. Statistical analyses between the treatment for both groups were analyzed using a 2-factorial analysis of variance (ANOVA, time x group). A P value of ≤0.10 was considered as statistically significant. The reason for this value was because of expectance of the therapeutic heat application within a MTC to have only a small impact on strength and flexibility (biomechanical parameters).
Validity: Group assignment was randomized including blinding the investigator and were recruited from outpatient clinics by referring physicians. Both groups that had a diagnosis of chronic low back pain and a case of prolonged inability to work due to back pain were included in the inclusion criteria. Another criterion that was included was the use of the Owestry Low Back Pain Questionnaire Index (ODI) with ≤41% (i.e., a moderate disability). Similar baseline characteristics such as age, weight, BMI, selected back pain complaints data from medical history, back complaint duration, doctor visits, days unfit to work, sick leave and days in hospital were recorded at the pre-treatment session. Assessment of patient’s biomechanical parameters were conducted with the training stations (SCHNELL Trainingsgeräte). Measurement of flexibility, ROM in (flexion, extension, lateral flexion, rotation), strength, and torque in (flexion, extension, lateral flexion, rotation). The absolute number of treatments did not change between the two groups. Both groups conducted two phases of training with a duration of six weeks each. The heat wrap group received a heat wrap at 40 °C (mild heat) over 8 h to be worn on the lower back. The heat wraps were applied directly after the treatment and had to be worn the following night with a second device applied on the next day. Intensity and frequency of the therapy and training load for the second phase were determined according to baseline characteristics of the patients and individual response to therapy and training. The length of the study was long enough to be plausible and for the outcomes of interest to occur.
Results: In both groups, averages of ROM increased in all directions. No significant time x group interaction effects were observed (P ≥ 0.55). Both groups also saw an increased in strength (torque) average in all directions. Significant time x group interaction effects for extension (P = 0.09), right rotation (P=0.09) and left rotation (P=0.08).
Critical Appraisal: Group assignments were randomized. There was a control (MTC) and an intervention group (MTC & heat wrap) and both received the same absolute amount of treatment sessions and all have had baseline and several assessments before the treatment had started. The length of time of the study was sufficient to gain expected outcomes. Outcome measures used were valid and reliable. Both parametric and non-parametric data analyses were utilized to note the differences between groups. There were no adverse effects or potential risks reported during and after using the heat wrap therapy as was indicated in the study. The investigators were also blinded. No participants were lost and no intention-to-treat analysis were observed.
Applicability to the patient: Heat wrap therapy can be effective in patients with low back pain who fits the inclusion criteria. Flexibility improvements were not seen and strength gains are most significant in extension along with both side of trunk rotation. In addition, no risks or potential adverse effects were observed with the supplemental use of heat therapy along with strength training. For strength enhancement, the method is highly recommended and potential improvements in patient ADL (activities of daily living) were also discussed.
Clinical Bottom line: Thermotherapy may help improve trunk strength especially in extension/rotation and achieve functional outcome among patients with low back pain. Thermotherapy may be applied as part of an overall physical therapy plan of care but further evidence is needed in order to access its full therapeutic advantages.
Author of CAT (Date): Avon Bristol (August 2018)