Evidence-Based Physical Therapy (EBP) uses the best research evidence with clinical expertise and user’s preferences to produce the most appropriate and effective care. At week 43 in 2023, we had Blended Intensive program (BIP) in Finland, Kuopio Savonia University of Applied Science about EBP. This BIP program opened with welcome words of the president of The European Network of Physiotherapy in Higher Education (ENPHE) and followed with the basis of EBP and teachers who highlighted the main challenges at different Physical Therapy fields week 43 in 2023 we had Blended Intensive program (BIP) in Finland, Kuopio Savonia University of applied science. More than 40 physiotherapy students and 7 teachers from three universities (Savonia University of Applied Sciences, Finland, Universidade da Coruña, Spain, and Charles University Prague, actively participated this week and shared experiential group dynamics and social activities. Students worked together and wrote articles devoted to the following themes: Evidence Based in McKenzie, back pain, spinal cord injuries, aquatic therapy, ergonomics at work, Nordic walking, sport injuries, sport and young adults: Prevention of sport injuries and children with disabilities. In the following you can consult the works presented by the students on each topic.

Introduction

Low back pain (LBP) is a pain, tension or stiffness which appears between the costal inferior margin and the gluteal folds (Chou R. 2010). LBP is the leading cause of long-term disability worldwide with a lifetime incidence of 58-84%. Besides, 11% of men and 16% women suffer from chronic LBP (more than 12-week prevalence) and up to 90% cases are non-specific (without clear cause). 

Chronic non-specific low back pain (CNSLBP) has been studied during the years and many trials were done to try to find the most suitable treatment. Nowadays, many treatments are well-known and developed as they have proved to be effective. 

The need to establish a common path to follow in the intervention of acute and chronic low back pain made the existence of clinical guides a must. In 2021 there were developed some clinical practice guidelines linked to the international classification of functioning, disability and health from the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association by the name of “Interventions for the management of acute and chronic low back pain: Revision 2021” (George et al., 2021). 

The guidelines provided in this work included not only information about the clinical practise intervention itself but also about the evidence map of the intervention methods in which the intervention is based.

Evidence map divided the intervention process into 3 groups (A, B and C) based on the quality assessment and support of the evidence found. In those groups the user can see which treatments are more likely to be effective by classifying them if you should use, may use or can use the specific treatment for the intervention.

The treatments classified in the “Should Use” group are those with the most evidence literature supporting them, and, in that group, you can find them in 3 principal groups depending on the type of intervention.

• Exercise: general training, muscle strengthening and endurance, specific trunk activation, aerobic, aquatic, multimodal.
• Manual and other-directed therapies: thrust or nonthrust joint mobilization.
• Patient education: pain neuroscience education not as a stand-alone treatment, active treatment (yoga, stretching, Pilates, and strength training).

In our clinical experience we have observed a remarkable weakness and lack of stabilization in abdominal muscles in patients with CNSLBP. Therefore, we decided to choose the specific trunk activation treatments to increase de quality of our intervention. Our searches were focused on the activation of the abdominal muscles, more specifically on the transversus abdominis. Transversus abdominis (TrA) is a deep abdominal muscle which makes part of the lateral abdominal wall (transversus, internal oblique and external oblique). Its importance as a lumbar stabilizer and its relationship with lumbar multifidus (Hides et al. 2011) makes the TrA a real target when it comes to specific trunk activation. 

Regarding the importance of the transversus abdominis activation, the next articles were chosen to provide evidence of its implication in CNSLBP:

The relationship of transversus abdominis and lumbar multifidus clinical muscle tests in patients with chronic low back pain. This investigation by Julie Hides measured muscle size and distribution of pain by manual examination and biofeedback on 82 patients. She was able to prove that the ability to contract multifidus (important lumbar stabilizer) was related to the ability to contract TrA with the odds of a good contraction of multifidus being 4.5 times higher for patients who had a good contraction of TrA.(Hides et al 2011)

Impaired static postural control correlates to the contraction ability of trunk muscle in young adults with chronic non-specific low back pain: A cross-sectional study. Healthy individuals (n = 25) and individuals with CNSLBP (n = 30) were included. The thickness of the bilateral transversus abdominis (TrA) and lumbar multifidus (MF) was measured during rest and maximal voluntary contraction, and the change percentages (TrA%, MF%) were calculated. Regarding postural control, COP path length and sway area during the stance tasks were measured thrice in each group. The results of Wang’s study showed that compared with healthy individuals, impaired postural control during static stance with eyes open in patients with CNSLBP was likely to be related to the poor contraction ability of bilateral transversus abdominis and correlated to the normal contraction ability of right lumbar multifidus.(Wang et al 2022)

Effect of Motor Control Training on Trunk Muscle Morphometry, Pain, and Disability in People with Chronic Low Back Pain: A Systematic Review and Meta-Analysis. In this Meta-Analysis, PubMed, Web of Science, Scopus, and Cochrane Library databases were searched from study inception until January 2021. Randomized control trials evaluating both muscle morphometry and pain or disability in individuals with chronic low back pain were included. Study selection, data extraction, and quality assessment were performed by 2 reviewers independently. The results show that this systematic review and meta-analysis found that motor control exercise training increased the transverse abdominis contraction ratio (muscle activation) and improved the level of pain and disability compared to other interventions that used in people with chronic low back pain. However, motor control exercise training was not superior to other interventions in increasing the resting thickness of deep abdominal and lumbar multifidus muscles in intervention times less than 12 weeks. (Wong et al 2014)

Conclusion

After our search of EBP to support the importance of the activation of transverse abdominis in CNSLBP intervention we can reliably confirm that its implication an activation both improves the level of pain and disability compared to motor control treatments that focus on other abdominal muscles.

Discussion

Despite current clinical practice of assessment and rehabilitation of transverse abdominis in patients with CNSLBP is supported by the findings in our search, we think that future studies should investigate if a neurophysiological relationship exists between TrA and other lumbar stabilizers to improve motor control programs.

Our learning experiences

During this BIP (Blended Intensive Programme) week, we have learned to co-operate internationally. We have become familiar with Finnish, Spanish and Czech cultures and traditions. We have delved into evidence-based information through lectures, where we have developed our critical thinking in acquiring sources and verifying the strength of the evidence.  Besides, we have observed that cultural differences also became notable different point of view on the acquisition of evidence-based information in physiotherapy.

Fernández Anxo, Physiotherapy student, A Coruña University of Health Sciences, A Coruña, Spain

Helvelahti Harkko, Physiotherapy student, Savonia University of Applied Sciences, Kuopio, Finland

Montoiro Miguel, Physiotherapy student, A Coruña University of Health Sciences, A Coruña, Spain

Nurmiainen Riina, Physiotherapy student, Savonia University of Applied Sciences, Kuopio, Finland

Marja Äijö, PhD, PhD, Principal lecturer of gerontology and rehabilitation, Savonia University of Applied Sciences, Finland

Mari Tuppurainen, physiotherapy lecture, Savonia University of Applied Sciences, Kuopio, Finland

Dagmar Pavlu, Physiotherapist, Assoc. Prof. Charles University, Czech Republic

Ivana Vláčilová, Professor, Charles University, Czech Republic

Jamile Vivas Costa, PhD, MSc, PT. Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Researcher at Psychosocial intervention and functional rehabilitation group, Universidade da Coruña, Spain

Montserrat Fernández Pereira, MSc, PT.  Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Physiotherapist at Spinal Cord Injury Unit, A Coruña Hospital (CHUAC), Spain

Verónica Robles García, PhD, MSc, PT, OT. Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Researcher at the Neuroscience and motor control group, Universidade da Coruña and Biomedical Institute of A Coruña, Spain

References

George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA, et al. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. Journal of Orthopaedic & Sports Physical Therapy [Internet]. 2021 Nov;51(11):CPG1–60. Available from: https://www.jospt.org/doi/10.2519/jospt.2021.0304

Hides J, Stanton W, Dilani Mendis M, Sexton M. The relationship of transversus abdominis and lumbar multifidus clinical muscle tests in patients with chronic low back pain. Manual Therapy. 2011 Dec;16(6):573–7. Available from: https://pubmed.ncbi.nlm.nih.gov/21641268/

Wang H, Zheng J, Fan Z, Luo Z, Wu Y, Cheng X, et al. Impaired static postural control correlates to the contraction ability of trunk muscle in young adults with chronic non-specific low back pain: A cross-sectional study. Gait & Posture. 2022 Feb;92:44–50. Availiable from: https://pubmed.ncbi.nlm.nih.gov/34823100/

Wong AYL, Parent EC, Funabashi M, Kawchuk GN. Do Changes in Transversus Abdominis and
Lumbar Multifidus During Conservative Treatment Explain Changes in Clinical Outcomes
Related to Nonspecific Low Back Pain? A Systematic Review. The Journal of Pain. 2014
Apr;15(4):377.e1–35. Avaliable from: https://pubmed.ncbi.nlm.nih.gov/24184573/