April Journal Club

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    • #8505
      Michael McMurray
      Keymaster

      For this month’s journal club, the discussion board will be more focused on the attached article. During the meeting, we will focus on the case and how the two intertwine. Attached below is an outline of the article and the article itself.

      1) Research is one of my weak points and I always seem to have a difficult time coming up with PICO questions and properly searching for them in an efficient manner. After a few failed attempts, I used a few key words and mesh terms and found the attached article…

      While answering the “how did you narrow it down” question, I felt that my reasonings were quite weak. Of course the keywords were in the title, that was one of my filters. I used the PEDro score, which is nice way to find strong articles but should I really base my selection on that? The last way I narrowed it down was the year because I wanted the article to be relevant. How do you all narrow down your results to pick your final article?

      2) What do you think about the experimental and control groups? Do the interventions seem to be adequate and functional?

      3) One of the secondary outcome measures is neuromuscular response of trunk muscles, where the clinicians utilized surface electromyography to measure activations of rectus abdominis, TrA, iliocostalis lumborum pars thoracis, and superficial fibres of LM muscles. Do you think that this outcome measure has any significance clinically?

      4) Any other general opinions on the article?

    • #8515
      awilson12
      Participant

      1) I go back and forth with trying a more specific search first or a broad search just to see the extent of information out there. I feel like now I tend towards starting with a broad search then filter from there (year, more specific search terms, etc.). When I am between a few articles a few things that I use to guide my decision are comparing which article most closely answers the specifics of my PICO question, is recent, the strength of the journal it is published in, and which seems to have stronger methodology.

      2) I think that all of the interventions are very much non-functional (could maybe argue a case for chops & lifts at least getting closer) in the CSE, PNF, and control groups. Also curious how 3×10 of trunk curls and leg extensions takes 20 minutes…

      3) I find it hard to trust surface EMG for measuring deep trunk muscle activity and also am not sure that this has much merit in terms of relationship to pain, disability, and functional improvements.

      4) The intro and discussion talked a lot about the importance of specific activation of deep musculature as being preventative and curative for low back pain and I’m not sure I can get on board with that reasoning for improvements seen in pain and disability in this study. Also the population was surprisingly narrow- mostly younger females with < 1 year duration of symptoms and low pain and disability.

    • #8516

      1) I am also admittedly poor at search strategy overall. I find I do better when starting specific and then pulling words to broaden my search. Past an abstract I go straight to the methods to figure out the sample size, study design, and blinding to see how well done the study is.

      2) They don’t seem “functional” but I think that comes with the territory of “lumbar stabilization.” I feel like these are things that most clinicians would call “core stability” and they outline a clear progression to follow. Maybe not what I would do with my patients, but a fair guide to follow in a research study.

      3) Did some digging in their sources as well as on my own. I’ve always heard in passing the surface EMG is mediocre at best, especially in the trunk, but couldn’t back it up. As far as reliability it seems it can be fairly reliable, but only in partial contractions. Things get less reliable when you utilize max trunk contractions (which they did in this study). Also somewhat interested to know what the “intra-rater reliability test for measurement of muscle activity assessed by the assessor” was.

      As far as whether or not it was worth assessing at all, clinically probably not, but I can see them looking for some sort of biologic plausibility that “I train deep core mm therefore they work better.” This doesn’t prove out though as the PNF exercises provided similar improvements (however valid they may be).

      4) Great call on the participants Anna. I didn’t see that at first. To me there’s a difference between C-LBP x1 year vs 5 years +.

      Overall, seems like one more piece of evidence that specific TrA and multifidus training doesn’t do much better than more general exercise interventions.

    • #8518
      helenrshep
      Participant

      1) I basically do what you did, though I’m not super strong with searching research either. I try to get the list down to a manageable number (by PEDRO score, year, maybe journal, etc) then read through titles and abstracts.

      2) While the exercises seem totally not functional, CSE more some than the PNF with the progression to chops, I think the frequency/time of visits (3 weekly 30 min sessions for 4 weeks) is at least similar to what we’d do in the clinic. I’m also SUPER confused by all the rest? They were having participants rest 30 seconds between REPS and then a full minute between sets, meaning they rested 5 1/2 minutes per exercise while only working for 50 seconds. Seems pretty underdosed to me.. And for the exercises that weren’t a hold they still rested between reps. I just can’t imagine dong ONE bridge then taking a 30 second break… I also agree with Anna that I think the control group did overall less exercise in general since it was only 20 min total compared to 30 min and they did fewer exercises.

      3) Great points, Taylor – thanks for looking into that! Given that in functional activities we aren’t activating those muscles in isolation, it seems pretty clinically irrelevant to me to try to look at activation of the individual muscles (which are tiny…), not even considering it’s not a very reliable technique to begin with.

      4) This is an age-old debate about the TA I think… I was under the impression it had kind of been settled that general exercise is just as good as TA specific exercise. I think we just need to load people and get them moving!

    • #8519
      Steven Lagasse
      Participant

      1) When trying to find an article, a specific PICO question is most important. Once I come to my PICO, I’ll enter that into PEDro for their rigorous ranking system. However, PEDro can be fickle, so if I’m not getting what I want I’ll try Pubmed. I have found using synonymous words, and the use of “AND” and/or “OR” quite useful. If I find an article on Pubmed, I’ll then look it up on PEDro as well to get a sense of its strength. There is no perfect system, but a strong PICO certainly sets you up for success. I’ll also read some abstracts and make sure the article speaks to what I am looking for, whether it fits my bias or not.

      2) As Taylor said, the exercise selection, overall, is nonfunctional. This comes with the territory of “stabilization.” Both treatment groups are missing patient-specific exercises. Although appropriate for the purpose of this study and generalizability, it certainly isn’t helpful in terms of returning a patient to their baseline function.

      3) Agreed with the above opinions. Hard to say that these EMG findings can be directly correlated to decreases in pain and improved function. Also, how sure can we be that the appropriate deep trunk musculature is being assessed by transcutaneous EMG? Hard to know for sure.

      4) What is interesting, is all three groups utilized some form of core stabilization. However, both experimental groups improved significantly while the control group did not. The argument here can be that the experimental groups were more specific and thus demonstrated greater improvement. Conversely, both experimental groups were not all that patient-specific. This may instead support an argument that the more involved we therapists are in the treatment sessions (i.e. manual therapy, education, touch, etc.) the better our outcomes. The way I see it, the therapist is inevitably more involved via manual and verbal cues during a manually resisted isometric exercise or PNF pattern versus having the patient independently perform a supine curl-up. Thoughts?

    • #8520
      lacarroll
      Participant

      1) I feel like I still struggle with this too. I tend to be more specific at first, then broaden out my terms if I need to, then I tend to skim abstracts until I find something that most closely fits my PICO. I also like to look at the references in some articles to see if they can help guide me towards a better/more relevant option.

      2) The exercises are pretty much not functional, but the PNF group did seem to at least progress more towards a functional movement pattern, but again, like Anna and Helen said, there are very few reps performed in a LOT of time, which doesn’t seem like an adequate workload to me.

      3) I agree with everyone else on this one. It’s hard to put much stock into a surface measurement of deep muscles that has limited reliability with no real clinical value.

      4) Like Anna said, I thought the population was pretty narrow, with a bias towards a younger demographic. It seems like this article took a step back from functional activities and higher-level exercises to investigate the worth of very basic, low level exercises which doesn’t make a lot of sense to me. As to Steve’s point, I think the outcomes may demonstrate the benefits of more active treatment strategies over passive ones, like ultrasound.

    • #8521
      pbarrettcoleman
      Participant

      1) How do you all narrow down your results to pick your final article?

      Write a solid PICO that naturally narrows down the field then play around with search words to find a reasonable enough amount of titles (50 – 100) to scan until I find a a title that really grabs my attention. That usually gets me 5 -10 solid articles where I read the abstract and then decide which one to actually read.

      2) What do you think about the experimental and control groups? Do the interventions seem to be adequate and functional?

      At first glance, all of it seems super non-specific and general. I think Steven makes good points that the delivery of care in the experiment groups is probably more hands on and more involved and might deliver more positive perceived benefits of care. Clinical reasoning also seems absent from all of it. And of course it’s not functional, but like Taylor said, almost all “lumbar stability” exercises fit in that box.

      3) Do you think that this outcome measure has any significance clinically?

      With what we know about non-specific LBP, I have a hard time using this one finding and having it move the needle in clinic. One, I have no way to measure EMG so I couldn’t use it as a goal, but I’m not sold that this is the reason that they improved.

      4) Any other general opinions on the article?

      This is kind of a throwback study that hearkens back to the local vs. global core stabilization debate and the best way to get that TA firing. From what we know now about the multifactorial cause of back pain, it seems like it lacks the breadth of possible impairments and inputs for addressing LBP — reading it felt like I was going backwards in time.

    • #8523
      Michael McMurray
      Keymaster
        ANNA

      1) Gotcha, thanks Anna. Seems like a similar strategy that I try to use.

      2) Very true, I was thinking the same thing. Even the control group of “general trunk strengthening interventions were strange, I am not sure the last time I have given a trunk curl as an exercise.

      3) I agree, I don’t trust it much either and obviously don’t utilize it in the clinic. I agree that it may be a stretch to correlate it to the outcomes directly.

      4) I agree, Anna, I think they used strong language about activation of deep musculature. They also speak about disturbances in mechanoreceptors and proprioception which may affect motor control and stability in the low back which I can get on board with a lot more than the direct correlation to pain and disability. The population was very narrow and I missed that with my first read through due to the inclusion criteria and lack of mention of population in the participant section.

        TAYLOR

      1) Interesting, I haven’t thought of doing it this way. That makes sense to make sure the study is well done before choosing it. I did this with this article but unfortunately did not delve deep enough. It looked good on the surface but there were a lot of things that fell through the cracks.

      2) I agree, I believe that a lot of “lumbar stabilization” interventions are not the most functional, especially the basic ones. I would have liked to see them use the basic interventions at first to try and “teach” the patients what to feel and then progress to utilizing that while performing more functional tasks.

      3) Awesome, thanks for that. That is really interesting, I did not know that and should have done some digging myself. Very true, I agree that clinically it isn’t worth assessing but I can see why they may have wanted to use it as a pre and post test to have some objective data for measuring their outcome.

      4) I agree, while the article seems to lean towards core strengthening and PNF compared to their general exercise group. I would argue your point.

        HELEN

      1) Gotcha, I’m glad to hear that what I did wasn’t totally off the wall. Unfortunately that strategy (especially focusing on the PEDro score and year) biased my opinion while first reading through this article.

      2) Those are all valid points and I am not sure why they had the participants resting after each rep, very confusing indeed.

      3) Very true, we don’t use those muscles in isolation during functional tasks. While it may not be great carry-over for function, I’m thinking the authors were more likely using this to help “support” their claim for activation of these muscles being a factor in reducing patient’s pain and disability. Objectively, how else can we measure for this specific impairment?

      4) Amen

        STEVEN

      1) That all makes perfect sense, thanks for sharing that. That is somewhat similar to what I did and relied to heavily on the PEDro scoring and the abstract, so we have to make sure to not let those bias our selections of articles.

      2) Very true, not functional or specific at all. I would be interested to see how the findings would have differed with more appropriate selections of interventions.

      3) Very true, I am not sure how they can state that they are isolating the muscles that they are looking for.

      4) I like your thought process here. Adding in the therapist involvement is definitely a factor not addressed in the paper.

        LAUREN

      1) Awesome, I like the idea of skimming through the references!

      2) I agree the selection of interventions and dosing was lacking

      3) Again, I agree with you and everyone on that. Clinically not relevant but for test, treat, retest it may help have some objective measures?

      4) Agreed, the article definitely stepped back in regards to treatment interventions.

        BARRETT

      1) Nice, sounds like a solid strategy.

      2) Very true, there isn’t much along the lines of clinical reasoning.

      3) I agree, very hard to use clinically. I am hoping it was more used for comparative reasons pre and post test.

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