Effectiveness of lumbar stabilization exercise with real-time ultrasound imaging biofeedback on lumbar multifidus muscle cross-sectional area in individuals with non-specific chronic low back pain: a study protocol for a randomized controlled trial

Background Structural impairment of the lumbar multifidus muscle, such as reduced cross-sectional area, is evident among individuals with chronic low back pain. Real-time ultrasound imaging (RUSI) biofeedback has been reported to improve preferential activation of as well as retention in the ability to activate the lumbar multifidus muscle during lumbar stabilization exercises (LSE). However, evidence of the effectiveness of this treatment approach in individuals with non-specific chronic low back pain (NCLBP) is still limited. The purpose of this study is, therefore, to determine the effectiveness of LSE with RUSI biofeedback on lumbar multifidus muscle cross-sectional area in individuals with NCLBP. Methods/Design This study is a prospective, single-center, assessor-blind, three-arm, parallel randomized controlled trial to be conducted at National Orthopedic Hospital, Kano State, Nigeria. Ninety individuals with NCLBP will be randomized in a 1:1:1: ratio to receive LSE, LSE with RUSI biofeedback, or minimal intervention. All participants will receive treatment twice weekly for 8 weeks. The primary outcome will be the lumbar multifidus muscle cross-sectional area. The secondary outcomes will include pain (Numerical Pain Rating Scale), functional disability (Roland–Morris Disability Questionnaire), and quality of life (12-Item Short-Form Health Survey). All outcomes will be assessed at baseline, 8 weeks post-intervention, and 3 months follow-up. Discussion To our knowledge, this study will be the first powered randomized controlled trial to compare the effectiveness of LSE training with and without RUSI biofeedback in individuals with NCLBP. The outcome of the study may provide evidence for the effectiveness of LSE with RUSI biofeedback on enhancing the recovery of the lumbar multifidus muscle in individuals with NCLBP. Trial registration Pan African Clinical Trials Registry (PACTR201801002980602). Registered on January 16, 2018.

Ultrasound Imaging Analysis of the Lumbar Multifidus Muscle Echo Intensity: Intra-Rater and Inter-Rater Reliability of a Novice and an Experienced Rater

Background and Objectives: Ultrasound echo intensity (EI) of the lumbar multifidus muscle (LMM) could offer valuable insights regarding muscle quality in people with low back pain (LBP). However, whether the rater’s experience noticeably influences the reliability and precision of LMM EI measurements has not been established. The aims of this study were to investigate the intra-rater and inter-rater reliability of LMM EI measurements, and to compare the reliability and SEM between a novice and an experienced rater. Materials and Methods: Twenty athletes (10 females, 10 males) with a history of LBP were included in this study. Transverse ultrasound images of LMM were taken at L5 in prone. LMM EI measurements were obtained bilaterally by tracing the maximum ROI representing the LMM cross-sectional area (CSA), avoiding the inclusion of bone or surrounding fascia. All measurements were performed by two novice raters and an experienced researcher. Each measurement was acquired by each rater three times for each side on three different images, and the average was used in the analyses. Raters were blinded to each other’s measurements and the participant’s clinical information. Intra-class correlation coefficients (ICCs) were obtained to assess the intra-rater and inter-rater reliability. Results: The intra-rater ICC values for the LMM measurements for the experienced rater were excellent (ICC all > 0.997). The inter-rater reliability ICC values showed moderate to excellent reliability (0.614 to 0.994) and agreement between the novice raters and the experienced rater, except for Novice 1 for the right LMM, which revealed lower ICCs and a wider 95% CI. Intra-rater and inter-rater reliability results were similar when separately looking at the right and left side of the muscle and participant gender. Conclusions: Our findings support the clinical use of ultrasound imaging for the assessment of LMM EI in individuals with LBP.

Study on the cross-sectional area of the multifidus muscle at the L4-L5 level on ultrasound images of Olympic-style weightlifting and judo athletes

BACKGROUND: The multifidus muscle is located near the spine and controls the erection of the spine and stabilization during movements of the spine and extremities, and assists in all other spinal movements. Differences in paraspinal muscles between sides and levels, particularly in he multifidus, have been proposed as possible indicators of low back pain or spinal pathology. OBJECTIVE: This study aims to examine the cross-sectional area of the lumbar multifidus muscle at L4-L5 vertebral levels on ultrasound images of athletes in Olympic-style weightlifting, judo athletes and sedentary individuals. METHODS: This study included asymptomatic male athletes (athletes in Olympic-style weightlifting, n= 17, age: 19.24 ± 1.88, judo athletes, n= 17, age: 19.18 ± 1.23) and sedentary individuals (n= 17, age: 19.88 ± 1.31). The cross-sectional area of lumbar multifidus muscles was assessed bilaterally at the L4-L5 segments level in prone and using ultrasound imaging. RESULTS: Lumbar multifidus muscle cross-sectional areas of athletes in Olympic-style weightlifting and judo athletes were larger than those of sedentary individuals (p< 0.004). No asymmetric development was observed in cross-sectional areas of right-left lumbar multifidus muscle at L4-L5 levels of athletes in Olympic-style weightlifting and sedentary individuals (p> 0.008). The cross-sectional areas of the right and left lumbar multifidus muscle at L5 segment of individuals in judo athletes was found to be asymmetrical (p< 0.008). CONCLUSION: Our study shows that the cross-sectional areas of athletes in Olympic-style weightlifting and judo athletes are larger than that of sedentary individuals. The difference in the cross-sectional area of the lumbar multifidus muscle of athlete and sedentary groups might be said to result from hypertrophic effect of trainings of these athletes on the cross-sectional area of the lumbar multifidus muscle.

Effects of Lumbar Stabilization Exercises with Real-Time Ultrasound Imaging Biofeedback on Lumbar Multifidus Muscle Cross-Sectional Area in Individuals with Chronic Nonspecific Low Back Pain: A Study Protocol for a Randomized Controlled Trial

Background: Impairments in the lumbar multifidus muscle such as reduced muscle thickness and fat infiltrations are evident in individuals with low back pain. Lumbar stabilization exercises (LSE) with real-time ultrasound imaging (RUSI) biofeedback has been reported to improve preferential activation of as well as retention in the ability to activate of the lumbar multifidus muscle, thus enhancing recovery. However, the effects of using this treatment approach in individuals with nonspecific chronic low back pain (NCLBP) seemed not to have widely reported. The purpose of this study is, therefore, to investigate the effects of LSE with RUSI biofeedback on lumbar multifidus muscle cross-sectional area in individuals with NCLBP patients. Method: This study is a prospective, single-center, assessor-blind three-arm, randomized controlled to be conducted at National Orthopedic Hospital, Kano State, Nigeria. Ninety-one individuals with NCLBP will be randomly assigned into one of the three treatment groups of equal sample size (n = 30); LSE group, LSE with RUSI biofeedback group, or control (minimal intervention). The participants in the LSE and LSE with RUSI biofeedback group will also receive the same intervention as the control group. All participants will receive treatment twice weekly for 8 weeks. The primary outcome will be lumbar multifidus muscles cross-sectional area while the secondary outcomes will be pain, functional disability and quality of life. All outcomes will be assessed at baseline, and at 8 weeks and 3 months post-intervention.Discussion: The outcome of the study may support the evidence for the effectiveness of LSE with RUSI biofeedback in the rehabilitation of individuals with NCLBP. It may also provide a rationale for the physiotherapists to make use of diagnostic ultrasound as a feedback mechanism in enhancing the performance and retention of LSE program as well as monitoring the patient’s recovery.Trial registration: Pan African Clinical Trials Registry, (PACTR201801002980602), Registered on 16 January 2018.