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Spasticity is one of the main complications of a stroke. This double-blind, randomized controlled trial aimed to compare the result of three sessions of dry needling (DN) versus sham DN on the affected upper limbs in post-stroke survivors. We recruited 24 patients (age 57.0 ± 9.6 years; male 71%). Patients were randomly allocated to two groups: a DN group and a sham DN group. The primary outcome measures were the Modified Modified Ashworth Scale (MMAS) and the Box and Block Test (BBT). Secondary outcome measures included active and passive wrist range of motion (AROM and PROM). All assessments were measured at baseline, immediately after the last session of the intervention, and one month later. Patients in the DN group had improved upper limb spasticity and passive wrist range of motion compared to control group (P < 0.05). There were no between-group differences in other outcome measures (P > 0.05). Dry needling is a useful method for improving muscle spasticity in the upper limbs of patients with stroke.

Background Most papers examining the lateral abdominal muscles (LAMs) and low back pain (LBP) are cross-sectional, with groups of participants being divided into a control and an LBP group. We hypothesized that morphological measurements of the LAMs in adolescent soccer players may predict future LBP incidence. The aim of this study was to examine the associations between the morphology of LAMs and LBP incidence rate among adolescent soccer players. Methods Ninety-seven adolescent male soccer players with no LBP at baseline were recruited into the prospective cohort study. The thickness of the LAMs was measured at baseline by ultrasound imaging in a supine rest position. Nine cases of LBP occurred during the follow-up 6 month observation. Results An obliquus internus (OI) asymmetry was related to increasing LBP risk (odds ratio = 19.99; 95%CI: 2.4–167.9). Spearman correlation also showed a linear relationship between OI asymmetry value and duration of LBP ( R = 0.75, p = 0.02). An OI side-to-side difference greater than 1.25 mm suggests possible LBP incidence in the 6-month observation among adolescent soccer players. Conclusion The morphological changes of the OI may be related to LBP’s incidence in adolescent soccer players. The presence of OI asymmetry increases the odds of LBP by at least 2.4times. Hypertrophy of the OI on one side of the body may contribute to trunk muscle imbalance.

Study Design Psychometric study. Objective The purpose of this study is to translate, culturally adapt and evaluate the validity and reliability of the Persian (Farsi) version of GLTEQ in patients with multiple sclerosis. Methods This study had three phases, including translation of the questionnaire into Persian and making cultural adaptation, evaluation of pre-final version of questionnaire’s comprehensibility in a pilot study, and investigation of reliability and validity of the final version of the translated questionnaire. Content validity, and convergent validity (correlations among the Persian version of GLTEQ and Global physical activity questionnaire (GPAQ), and international physical activity questionnaire (IPAQ)) and after all test-retest reliability were studied. Results The subjects were 87 MS patients. The Persian version demonstrated moderate to good convergent validity; the correlation coefficient between the Persian version and GPAQ was r=0.64 (p Conclusions The Persian version of GLTEQ is a valid and reliable instrument to assess physical activity in patients with MS. This questionnaire can be a step toward standardization of physical activity measurement in patients with MS. Also, in research, it provides the possibilities to carry on a comparative study across cultures using the same outcome measure.

Knee osteoarthritis (OA) causes functional limitation in weight-bearing actlVltles including walking. To investigate the multimodal impact of acupuncture, exercise therapy, and concurrent functional electrical stimulation (FES) on knee osteoarthritis. We designed a multidisciplinary treatment package including acupuncture; home based exercise therapy, and concurrent functional electrical stimulation during treadmill walking. Outcomes measurements included the numerical rating scale (NRS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Tampa Scale of Kinesiophobia (TSK). Measurements were completed at baseline and following the treatment phase which consisted of six individual sessions. A 48-year-old male, office worker presented with a history of chronic right knee. During the previous year, he was diagnosed with knee osteoarthritis after clinical physical examination by a sports medicine physician. Following our novel training intervention, the patient reported a reduction in pain intensity from 8 to 2 on the NRS, improved in all KOOS subscale scores, and improved in the TSK scale (reduction from 15 to 11). In addition, the patient reported that he was able to return to work and undertake normal activities of daily living with reduced knee pain. This case report showed that our novel multimodal intervention including six sessions of acupuncture, exercise therapy, and treadmill walking with functional electrical stimulation (FES) had a positive impact on knee pain and function in a middle-aged male with knee osteoarthritis.

Aim The COVID-19 pandemic is a global health emergency, and therefore the prevention and treatment of this disease is an important priority of world health. In the present study, some risk factors, including unhealthy nutrition, obesity, and physical inactivity, were assessed in patients infected with SARS-CoV-2, and their effects on the severity and duration of disease were evaluated. Subject and methods The present study was a cross-sectional study. Data was collected from all patients who visited the respiratory emergency department from March 20, 2020 to April 24, 2020 in the University Hospital. The outcome measures were body mass index, diet quality that was evaluated with a 16-item food intake questionnaire, and physical activity level that was assessed by the global physical activity questionnaire. Results Two hundred and six patients’ data was analyzed. The results investigated that patients with lower levels of physical activity or lower MET.min/week were affected by a more severe form of the disease (p = 0.05 and p = 0.03, respectively). We found that patients with a healthier dietary pattern were affected by lower severity of illness (p

Many studies have investigated the prevalence of neck pain (NP) and its risk factors in the general population. However, the prevalence of NP among athletes has not yet been systematically investigated. We aimed to systematically review the prevalence of NP in athletes. A comprehensive search was conducted in September 2015 using PubMed, Ovid SP Medline, ISI, and Google Scholar. We included studies in English that reported the prevalence of NP in an athletic population during a defined period of time. We assessed the risk of bias in studies due to various definitions of NP, response rates, and reliability of the study instruments. Two reviewers independently assessed the studies’ quality and performed data extraction. Of 1,675 titles identified, eight articles were assessed for risk of bias, and six with low or moderate risk were included. NP was shown to be prevalent in athletes, with a 1-week prevalence ranging from 8% to 45%, a 1-year prevalence ranging from 38% to 73%, and a lifetime prevalence of about 48%. The prevalence of NP in athletes is high. More studies regarding the prevalence and risk factors of NP may be useful for planning educational programs and developing appropriate rehabilitation protocols and preventive guidelines. Researchers are encouraged to perform epidemiologic studies in athletes with a low risk of bias.

STUDY DESIGN Single-blinded randomized controlled trial. PURPOSE To evaluate the effects of a multi-step core stability exercise program in nurses with chronic low back pain (CLBP). OVERVIEW OF LITERATURE CLBP is a common disorder among nurses. Considering that patient-handling activities predispose nurses to CLBP, core stability exercises suggested for managing CLBP in the general population may also be helpful in nurses. However, sufficient evidence is not available on whether a multi-step core stability exercise program affects pain, disability, quality of life, and the diameter of lateral abdominal muscles in nurses with CLBP. METHODS In this single-blinded randomized controlled trial, 36 female nurses with CLBP were recruited. The sample was divided into two groups of 18 patients (intervention and control). Nurses in the intervention group performed core stability exercises for 8 weeks, based on a progressive pattern over time. Roland-Morris Disability Questionnaire (RDQ), quality of life (36-item Short Form Health Survey [SF-36]), ultrasound assessment of the diameter of lateral abdominal muscles, and Visual Analog Scale (VAS) score for pain were evaluated in the participants before and after the trial. Sixteen nurses (eight from each group) dropped out of the study, and analysis of covariance was used to compare outcomes for the remaining nurses in the intervention (10 nurses) and control (10 nurses) groups. RESULTS The results after the trial showed significant improvements in RDQ, SF-36, and VAS score in the intervention group compared with that in the control group (p

STUDY DESIGN Translation and cultural adaptation of the National Institutes of Health (NIH) Task Force's minimal dataset. OBJECTIVE The purpose of this study was to evaluate validity and reliability of the Farsi version of NIH Task Force's recommended multidimensional minimal dataset for research on chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA Considering the high treatment cost of CLBP and its increasing prevalence, NIH Pain Consortium developed research standards (including recommendations for definitions, a minimum dataset, and outcomes' report) for studies regarding CLBP. Application of these recommendations could standardize research and improve comparability of different studies in CLBP. METHODS This study has three phases: translation of dataset into Farsi and its cultural adaptation, assessment of pre-final version of dataset's comprehensibility via a pilot study, and investigation of the reliability and validity of final version of translated dataset. Subjects were 250 patients with CLBP. Test-retest reliability, content validity, and convergent validity (correlations among different dimensions of dataset and Farsi versions of Oswestry Disability Index, Roland Morris Disability Questionnaire, Fear-Avoidance Belief Questionnaire, and Beck Depression Inventory-II) were assessed. RESULTS The Farsi version demonstrated good/excellent convergent validity (the correlation coefficient between impact dimension and ODI was r = 0.75 [P

To assess the prevalence and correlates of low physical activity among Iranian population aged 15-64 years. We used the data collected in National Surveillance of Risk Factors of Non-Communicable Diseases in Iran, 2011. Physical activity was categorized in 3 levels of low, moderate, and high based on a Persian version of Global Physical Activity Questionnaire. The multistage cluster sampling design was accounted for using complex survey analysis method. The sample included 10016 individuals; 41.7% (n = 4178) were men and 58.3% (n = 5837) were women. The mean (SD) age of participants was 38.8 (14.9) years also, and 69.8% (n = 6991) of the participants were from urban areas. The prevalence of low physical activity in the whole population was estimated to be 44.8% (95% CI: 41.7, 48.1). The odds of lower physical activity in the women were 3 times greater than men (OR = 3.14; 95% CI: 2.64, 3.57); in the wealthiest people was 25% lower than the poorest people (OR = 0.75; 95% CI: 0.60, 0.94). The odds of lower physical activity in the age groups 55-64 years were 44% greater than the youngest age groups 15-24 years (OR = 1.44; 95% CI: 1.23, 1.68). The odds of lower physical activity in the obese participants were 18% greater than normal-weight people (OR = 1.18; 95% CI: 1.01, 1.38).). The odds of lower physical activity in diabetic patients were 30% greater than healthy people (OR: 1.30; 95% CI: 1.07, 1.57). The prevalence of low physical activity in Iran, 2011 was high. The correlates of low physical activity in Iran are different to those of Western populations. The main associated factors with low physical activity were female gender, urban area, low socioeconomic status, obesity, diabetes, and older age. Public health policies should target the groups at highest risk of low physical activity.

A 40-year-old retired male elite athlete with more than 20 years' experience in wrestling and bodybuilding with mild elbow pain and disability of 2 years presented to our clinic reporting an acute pain in medial aspect of the elbow. Physical examination revealed symptoms of left Golfer's elbow during target-directed movements. The results of sonography in left elbow showed low level of hypo echo irregularity and increased blood flow in color Doppler mode in the common flexor origin. The pain amplitude was moderate at rest and extremely high during kinetic and intentional movements. During last 2 years, the patient tried different types of therapy including manual therapy, Transcutaneous electrical nerve stimulation and also received a variety of injections none of which were effective for reducing pain and disability. This is the first study showed that one sessions of dry needling improved both pain and disability and helped to return to a normal life and exercise training.

Introduction Physical activity-enhancing websites have created a new accessible and cost-effective method to increase the level of physical activity. The purpose of this study was to assess the impact of an individualized internet-based physical activity program on improving physical activity level. Methods This study conducted May-Dec 2018 was a single blind parallel group randomized controlled trial. Participants were recruited by distributing advertisements on popular Persian websites. Participants meeting eligibility criteria were randomly assigned to individualized (N=91) or non-individualized internet-based physical activity (N=93) intervention groups. The designed website for the study included an interactive computer-tailored exercise program that generated progressing physical activity recommendations for individualized intervention group based on the progression process for 10 weeks and a fixed exercise program for non-individualized group. Results Drop outs in the individualized group were 15 and in the non-individualized group were 14. Following the ten-week exercise program, the individualized group's physical activity level according to GPAQ questionnaire assessments was significantly improved in the travel section (p-value Conclusions Based on the current study, an individualized internet-based physical activity intervention might be effective in improving the level of physical activity. Conducting future studies during the COVID-19 pandemic is mandated to assess the impact.

There is increasing evidence in support of multidisciplinary approaches for management of chronic neck pain. Although presence of different team members is one of the strengths of these approaches, it can limit the access to these treatments. The main objective of this study is designing and investigating the efficacy of a concise rehabilitation program. Thirty-nine patients with sub-acute and chronic non-specific neck pain underwent an 8-week rehabilitation program. Baseline and 8 weeks' follow-up data regarding neck pain (visual analog scale, neck disability index and quality of life) were compared using paired T test. After eight weeks of study, pain and disability significantly decreased: -3.8 of 10 (95% CI: -4.6 to -3.0) (p-value

Background: Chronic musculoskeletal pain (CMP) is increasing in prevalence rapidly. Over the past 2 decades low back pain has been ranked globally as the primary cause of years lived with disability. The primary objective of this study was to investigate the prevalence of chronic neck pain (CNP), chronic low back pain (CLBP), and chronic knee pain (CKP) and their related risk factors in the national Iranian population. Methods: We analyzed data obtained through a cross-sectional, population-based survey of 7889 Iranians who were aged between 30 and 70 years. Results: The prevalence of CNP, CLBP, and CKP was 15.34%, 27.18%, and 29.97%, respectively. Female sex, aging, body mass index≥25, Lur or Arab ethnicity, illiteracy, passive smoking, positive osteoporosis history, and low or high physical activity levels were risk factors for CLBP, CNP, and CKP after adjustment for potential confounders. For example, in participants with a body mass index≥30, odds ratios for CNP, CLBP, and CKP adjusted for age, sex, ethnicity, living area, education, employment status, smoking, and physical activity levels were 1.26 (95% confidence interval [CI], 1.04-1.52), 1.37 (95% CI, 1.17-1.59), and 1.64 (95% CI, 1.41-1.91), respectively. Conclusions: This is the first study investigating the prevalence of CNP, CLBP, and CKP in the national population of Iran. It shows some modifiable risk factors for CMP, and suggests that affordable planning for these risk factors can be valuable in preventing CMP globally. However, this is a cross-sectional study and future longitudinal studies in this field are necessary.

BACKGROUND: While researchers have investigated low back pain (LBP) and its association with the thickness of trunk muscles in the general population, few articles have studied this relationship in athletes. HYPOTHESIS/PURPOSE: To compare the lateral abdominal muscle thickness and other possible functional risk factors in young soccer players with and without LBP. STUDY DESIGN: Cross-sectional study METHODS: Thirty young male soccer players, with and without LBP, from the Premier League participated in this study. The thicknesses of the external oblique, internal oblique and transversus abdominis muscles were measured via musculoskeletal ultrasound imaging, bilaterally. In addition, hamstring flexibility, lumbar spine flexion range of motion, and trunk extensor muscle endurance were measured and were compared in those with and without the history of LBP. RESULTS: The mean age of the subjects was 17.4 (+/- 1.1) years. There was no statistically significant difference between groups (p > 0.05). Subjects with a history of LBP during their lifetime of sports participation (sports life), within the prior year, and within the prior month had statistically significant lower external oblique muscle thickness bilaterally (p

Background: Body composition and dietary pattern in athletes are important factors in improving performance. The athletes use a wide range of supplements, most of which are not prescribed by specialists. Objectives: The aims of the present study were the assessment of body composition and food frequency questionnaire of elite Iranian soccer players in Tehran province. The type and frequency of used supplements were assessed. Methods: The study was a cross-sectional study on 10 - 34 year-old male soccer players. Body composition was measured by body impedance analyzer. Dietary pattern was assessed by food frequency questionnaire. The type and frequency of used supplements assessed was evaluated by an open-ended questionnaire with the main supplement groups. Results: In total, 3839 soccer players from Tehran leagues participated in this study. The mean ± SD height, age, weight, and body mass index (BMI) of the participants were 170.7 ± 10.6 cm, 17.8 ± 4.2 years, 61.9 ± 12.9 kg and 21.0 ± 2.8 Kg/m2, respectively. The most frequently used in the main food groups was bread in grain group (82%, 4 - 7 times/week). Skeletal muscle mass had a significant relationship with the frequency of high protein containing foods consumption (P: 0.007) (CI: 0.004 - 0.02). Energy drinks (11.4%), antioxidant and vitamins supplements (6.4%), carbohydrate supplements (6.3%) and protein supplements (5.7%) were the more frequent supplements used. Conclusions: The present study showed that body composition of Iranian young male soccer players had some differences in relation to that in the other countries. The soccer players should be educated in the field of healthy nutrition and best food groups and supplement selection.

Background: Spasticity is one of the main complications in poststroke survivors leading to difficulties in walking and standing resulting in high levels of disability. Objective: The aim of the study was to investigate the effects of deep dry needling on lower limb dysfunction in poststroke spastic patients. Methods: A randomized clinical trial conducted in poststroke survivors who were assigned to one of 2 groups: Deep dry needling (intervention group) and sham dry needling (control group). The primary outcome measures were Modified Modified Ashworth Scale (MMAS) and functional tests (timed up and go test, 10-meter walk test). Secondary outcome measures were active ankle dorsiflexion range of motion (AROM), passive ankle dorsiflexion range of motion (PROM), single leg stance test, and Barthel index. All measurements were assessed at baseline (T0), immediately after the third session 1 week later (T1), and 1 month after the end of the intervention (T2). Results: We recruited 24 patients (71% male; mean age 57 ± 10 years; 26.4 ± 1.8 kg•m−2; time since event: 25.2 ± 12.5 months). There were significant improvements in MMAS, timed up and go test, 10-meter walk test, Barthel scale, and PROM (P .05). Conclusions: Deep dry needling decreases muscle spasticity and improves lower limb function and gait speed in poststroke survivors.

A prospective cross-sectional study.The aim of this study was to evaluate the prevalence and associated factors with low back pain (LBP) in female adolescents of high school age.The prevalence of LBP in Tehran is high, and the majority of previous studies on LBP in adolescent and its risk factors have been performed in the developed countries. Therefore, identification of risk factors and planning appropriate protocols for prevention of LBP in adolescents may substantially decrease the prevalence of LBP and its burden in developing countries in future.In a prospective cross-sectional study, demographic characteristics, including age, body mass index (BMI), weight and mode of using backpack, family history of LBP in first degree relatives, and passive smoking status of the participants along with a history of LBP were recorded. Joint hypermobility was assessed using Beighton scale. Also, anthropometric measurements, spinal flexion, and hip joint range of motion were measured for each participant.In total, 372 students participated in the study. The mean (SD) age of the participants was 15.8 (0.9) years. The lifetime, more than 3 months, and last month history of LBP was 46.2%, 11.6%, and 31.2%, respectively. Positive history of LBP in the first-degree relatives was significantly associated with LBP in the participants (P 0.01). The prevalence of passive smoking was significantly higher in the participants with last month history of LBP (P = 0.03). The prevalence of joint hypermobility was 15.9% and was significantly higher in those with the lifetime and last month history of LBP (P 0.01).LBP is a common complaint among adolescent and high school girl students. The results of this study identified the prevalence and associated factors with LBP in high school students and will help develop strategies for prevention and treatment of LBP in the adolescent population.3.

Background The prevalence of low back pain (LBP) in athletes across a variety of time frames and sports is not known. Objectives To systematically collate and appraise studies on the prevalence of LBP in athletes and stratify by point, one year and life-time prevalence. Methods A comprehensive search was conducted in February 2016. The following sources were individually searched: PubMed (1950 to present), Ovid SP Medline (1950 to present), ISI (1982 to present) and Google Scholar; Surveys were included if they aimed to report the prevalence of LBP amongst the athletes. Two reviewers independently evaluated the methodological quality of the studies. Results The literature search generated 4379 records. Title and/or abstracts were reviewed by two investigators and full-texts of 201 relevant articles were selected for further evaluation. Studies were included if they reported the prevalence of LBP in an athletic population (any level of participation in sports and any age range) and were written in English. Furthermore, to adequately assess the prevalence rate, studies had to report the number of athletes with LBP as a percentage of the total number of athletes. Studies that did not contain necessary data to calculate prevalence rate including case reports and non-original studies were excluded and 41 studies entered the bias assessment step. A bias assessment was applied to the methodology of 41 studies, and 36 with low to moderate risk for bias were included in this review. LBP in athletes was shown to have a point prevalence ranging from 10% to 67%, a one-year prevalence ranging from 17% to 94%, and a life-time prevalence ranging from 33% to 84%. The highest prevalence of LBP was found among skiers, floorball players and rowers and the lowest were found in shooters, golfers and triathletes. Conclusion Like general population, LBP is quite prevalent among athletes. There is a lack of sound data on the prevalence and mechanism of LBP in some popular sports such as volleyball, swimming and track and field. The lack of standardization of research methods and outcome measurement tools are significant problems in literature. Researchers need to use standard and internationally acceptable definitions for LBP and related functional disability. Investigators are encouraged to conduct epidemiologic studies, along with search for possible mechanism of LBP, by recruitment of large sample population of the athletes who are selected through randomization of the national population and adopt recent recommendations for a standard definition of LBP.

The addition of exercise prescription as a part of patient treatment to medical school curricula currently seems necessary due to the high rate of morbidity and mortality of non-communicable diseases (NCDs).1 Many studies have shown the importance of regular physical activity in preventing NCDs and their risk factors such as cardiovascular problems, diabetes, cancer, hypertension and obesity.2 Based on the World Health Organization (WHO)’s action plan, healthcare policies should be in line with increasing physical activity for all people.2 Physicians can play an important role in making this possible.3 Studies have shown, however, that graduate medical students are not well prepared to achieve this goal.4 5 Also, with an increase in athletes’ participation in recreational and professional sports activities, physicians can play a significant role in the management of athletes’ injuries.6 Therefore, creating an educational Sports and Exercise Medicine (SEM) curriculum for medical students is both helpful and necessary. ### Challenges ahead Considering the variety of educational courses offered at medical school and students’ compact study schedule, finding the time, relevant content and experienced faculty members who can teach the syllabus of the SEM curriculum are all challenging. Harden has proposed 10 steps for planning and developing a curriculum (Harden’s 10 questions).7 Identification of needs and establishment of learning outcomes are the primary steps. It is expected that young doctors should be able to prescribe exercise and physical activity for the promotion of health and NCD prevention, and course evaluations should be defined based on these goals. Methods of content organisation and educational strategies should then be selected. Across the various proposed learning strategies, problem-based learning, integrated methods and elective programmes make it easier to reach the aforementioned goals. Professors can apply a range of teaching methods including lectures, study groups, slides, computers and simulators. For …

Objectives To compare the thickness of lateral abdominal muscles and Cross Sectional Area (CSA) of lumbar Multifidus Spinae (LM) muscles of competitive off-road cyclists with and without Low Back Pain (LBP). We also aimed to compare the maximum isometric back strength and endurance, as well as flexibility of lower back in cyclists with LBP and in the controls. Methods The thickness of Transversus Abdominis (TrA), Internal Oblique (IO) and External Oblique (EO) along with the CSA of LM muscles of 14 professional competitive off-road cyclists with LBP and 24 controls were measured by ultrasound (US) in hook-lying position on the examination table, and mounted on the bicycle. In addition, the back strength and endurance of the subjects and the flexibility of the participants were measured. Results Data showed a significantly lower thickness of Transversus Abdominis (TrA) and CSA of LM muscles in cyclists with LBP comparing to controls in all positions. No significant result regarding the flexibility of the subjects in case group comparing with the controls was found (p= 0.674). In addition, it was found that there is no significant difference in isometric back strength of the subjects between the groups (p= 0.105). However, we found that subjects with LBP have a lower endurance in back dynamometry with 50% of their maximum isometric back strength (p= 0.016). Conclusion In this study, useful information regarding possible factors associated with low back pain in off- road cyclists was found (lower thickness of TrA and LM muscles and decreased back endurance).

To investigate the prevalence of low back pain (LBP) and its absence rate among female university student athletes in different types of sports. A cross-sectional study based on a standard self-reporting questionnaire was performed among 1335 athletes. Participants were female athletes who attended the National Sports Olympiad of Female University Students in basketball, volleyball, futsal, tennis, badminton, swimming, track and field, shooting, and karate. One thousand and fifty-nine athletes with the mean (SD) age of 23.1 (3.8) years responded to the questionnaire (response rate 79 %). The 12-month prevalence of LBP was 39.0 %; in addition, lifetime and point prevalence of LBP were 59.7 and 17.8 %, respectively. Basketball (47.9 %) and karate (44.0 %) players had reported the highest 12-month prevalence of LBP. Also, LBP prevalences in shooting (29.7 %) and badminton (42.4 %) players were not negligible. Results show that, LBP led to relatively high absence rate from training sessions (27.9 %) and matches (13.0 %). While most of the existing literatures regarding female athletes’ LBP have focused on particular sports with specific low back demands (such as skiing and rowing), many other sports have not been studied very well in this regard. Investigating LBP prevalence and related factors in other types of sports, such as combat sports, badminton and shooting, can help us better understand the prevalence of low back pain and provide us with necessary insight to take effective steps towards its prevention in athletes.

Objectives The aim of this study was to compare the effect of diet and an abdominal resistance training program to diet alone on abdominal subcutaneous fat thickness and waist circumference of overweight and obese women. Methods This randomized clinical trial included 40 overweight and obese women randomly divided into 2 groups: diet only and diet combined with 12 weeks of abdominal resistance training. Waist and hip circumferences and abdominal skin folds of the subjects were measured at the beginning and 12 weeks after the interventions. In addition, abdominal subcutaneous fat thickness of the subjects was measured using ultrasonography. Percentage body fat and lean body mass of all the subjects were also measured using a bioelectric impedance device. Results After 12 weeks of intervention, the weight of participants in both groups decreased; but the difference between the 2 groups was not significant (P = .45). Similarly, other variables including abdominal subcutaneous fat, waist circumference, hip circumference, body mass index, body fat percentage, and skin fold thickness were reduced in both groups; but there were no significant differences between the groups. Conclusions This study found that abdominal resistance training besides diet did not reduce abdominal subcutaneous fat thickness compared to diet alone in overweight or obese women.

Objectives: The aim of this study was to examine the incidence and patterns of primary exercise headache (PEH) in resistance trained male athletes. PEH is observed particularly during or after severe physical exercise and lasts up to 48 hours. While the focus of the literature has mainly been on the prevalence of PEH in the general population, few studies on athlete populations have been conducted so far. Therefore in a cohort study we examined the incidence and patterns of PEH in resistance trained athletes in an Iranian male sample. Methods: A population of 116 resistance trained athletes, between 14 to 63 years old, was recruited. PEH was identified in the athletes according to a questionnaire based on the 3rd international classification of headache disorders. The athletes were followed up for six months on a monthly basis while the incidence, pattern and risk factors of PEH were evaluated in them in a precise manner. Results: The incidence of PEH in overall participants was evaluated 4.8 in 1000 hours exercise. The prevalence of headache during the follow-ups was 19.8% in which the highest headache incidence occurred in 20-30 years old athletes. PEH mainly occurred after sports and the quality of PEH was mainly a sudden (81%) pulsating (47%) headache which was felt mostly in the occipital region (39%). The incidence of PEH had a strong statistical correlation with having a history of PEH (odds: 3.8; 95% CI: 1.02 - 14.3). Conclusions: Our study showed that incidence and prevalence of PEH in resistance trained athletes might be higher than general population. History of PEH was the main risk factor for developing PEH in resistance trained athletes.

The purpose of this study was to evaluate validity and reliability of a new proposed questionnaire for assessment of functional disability in athletes with low back pain (LBP).Validity and reliability study.Elite athletes participating in different fields of sports.Participants were 165 male and female athletes (between 12 and 50 years old) with LBP.Athlete Disability Index (ADI) Questionnaire which is developed by the authors for assessing LBP-related disability in athletes, Oswestry Disability Index (ODI), and the Roland-Morris Disability Questionnaire (RDQ).Self-reported responses were collected regarding LBP-related disability through ADI, ODI, and RDQ.The test-retest reliability was strong, and intraclass correlation value ranged between 0.74 and 0.94. The Cronbach alpha coefficient value of 0.91 (P0.001) demonstrated excellent internal consistency of the questionnaire. The correlation coefficient between ADI and ODI was r = 0.918 (P0.0001), between ADI and RDQ was r = 0.669 (P0.0001), and between ADI and visual analog scale was r = 0.626 (P0.001). According to ODI and RDQ, disability levels were mild in the large majority of subjects (91.5% and 86.0%, respectively). Alternatively, disability assessments by the ADI did not cluster at the mild level and ranged more broadly from mild to very high.The ADI is a reliable and valid instrument for assessing disability in athletes with LBP. Compared with the available LBP disability questionnaires used in the general population, ADI can more precisely stratify the disability levels of athletes due to LBP.

Introduction/Background Cycling with or without functional electrical stimulation (FES) is an effective way to rehabilitate patients with lower limb disability. The purpose of this systematic review and meta-analysis was to quantify the effectiveness of different protocols of cycling with/without FES on lower limbs after stroke. Material and method The following databases were searched: PubMed, Cochrane Central Register of Controlled Trials, Ovid Medline, EBSCO Cumulative Index of Nursing and Allied Health Literature, Ovid EMBASE, Physiotherapy Evidence Database (PEDro), and Occupational Therapy Systematic Evaluation of Effectiveness, by means of words relevant to randomized and stroke, cycling and lower limbs disability. Randomized-controlled trials from 1990 to July 2017 were included following predetermined search and selection criteria. Data extraction was performed using a predetermined data collection form. Results A total of 15 trials satisfied eligibility criteria for this review. Cycling had a positive effect on 6 meter walking test performance [30.4 s; −1.9 to 62.6 (standardized mean difference; 95% confidence interval)] compared with no or placebo intervention (control). Cycling had a positive effect on walking speed (0.10 m/s; 0.1–0.2), based on the results of 10 meter walking test, compared with control. Cycling had a positive effect on balance based on Berg score (0.25; −0.44 to 0.94) compared with control. Cycling with FES had a positive effect on balance (1.95; 1.33–2.52) compared with cycling alone. Conclusion Although cycling alone has a positive effect on walking ability, walking speed, and balance the effects are small and variable. In terms of balance, positive effects substantially smaller when compared with concurrent effect of FES with cycling with low evidence. It appears that cycling with or without functional electrical stimulation has positive effects on walking ability walking speed and balance, but further research is needed to confirm the clinical utility of these modalities for stroke patients.

Background: It has been suggested that weakness and asymmetry of core stabilizing muscles have an important role in the development of scoliosis and its complications, especially low back pain. However there is insufficient data comparing symmetry and function of these muscles in scoliotic patients with the normal population. Also there are only a few studies assessing the relationship between the degree of spinal deviation and asymmetry of core stabilizing muscles. This study evaluates the thickness, symmetry, and activation of the external oblique (EO), the internal oblique (IO) and the transversus abdominis (TrA) muscles of patients with AIS and compares these data with a group of normal adolescents. Objectives: The objective of this observational study was to know the asymmetry pattern of lateral abdominal muscles at rest and during the abdominal drawing-in maneuver (ADiM) in adolescents with idiopathic scoliosis and to compare it with a group of healthy adolescents. Methods: Twenty healthy adolescents and twenty patients with AIS, aged 10 to 18 years, were included. The thickness of lateral abdominal muscles was measured, using ultrasound, at the end of normal exhalation at rest and during the abdominal drawing-in maneuver (ADiM). Muscular activity was represented as absolute difference and percentage change in the muscle thickness during the ADiM compared with rest. Results: There was no side to side asymmetry in muscle thickness at rest and also during ADiM in two groups. Thickness of right EO [0.39 (0.09) in the AIS group compared to 0.51 (0.12) in the normal group] and left EO [0.38(0.10) in the AIS group compared to 0.50 (0.11) in the normal group] at rest was higher in the normal group (P < 0.05). The activity of right and left EO was higher in AIS group (P < 0.05). There was a positive correlation between the lumbar Cobb’s angle with the right and the right-to-left difference of TrA thickness during the ADiM (P < 0.05). In other words, the more the lumbar Cobb’s angle to the right, the thicker the right TrA relative to the left TrA during the ADiM. Conclusions: The EO muscle was thinner and had higher activity during ADiM in the AIS group. Analysis of our data showed that in the AIS group the higher the lumbar spinal curve to the right, the thicker the right TrA compared to the left TrA.

Background Low back pain (LBP) is a common complaint amongst adolescent athletes. While different studies have shown association between LBP and trunk muscle thickness in the general population, few articles have studied it in adolescent athletes. Objectives The aim of this study is to compare lateral abdominal muscle thickness and function, and cross sectional area (CSA) of lumbar multifidus (LM) in adolescent soccer players with and without LBP. Methods In total, 28 adolescent soccer players with and without LBP, from the premier league participated in this study. The thickness of external oblique, internal oblique and transversus abdominis and the CSA of the LM muscles at L4 level on both sides were measured at rest and contraction via ultrasound imaging (USI). In addition, leg length discrepancy, hamstring flexibility, active lumbar forward flexion, and isometric muscle endurance of trunk extensors were measured in both groups. (study design/setting: case control study). Results The mean (SD) age in LBP group and non-LBP group were 14.0 (1.1) and 14.1 (0.9) years, respectively. There was no significant difference in baseline characteristics of participants between groups. Findings showed no significant difference between LBP and non-LBP groups comparing all measured variables. Conclusions The data obtained support that there is not a correlation between abdominal muscle thickness and CSA of the lumbar multifidi and LBP in adolescent soccer players. These findings suggest that other factors rather than the thickness of deep trunk muscles may play a more significant role in the etiology of LBP in adolescent soccer players.

STUDY DESIGN A cross-sectional, population-based survey. OBJECTIVE The aim of this study was to estimate the prevalence, and biological and psychological correlates of low back pain (LBP) in large, populated urban areas. SUMMARY OF BACKGROUND DATA LBP is a common and costly medical problem all around the world. Currently, there are limited data available on prevalence as well as biological and psychological correlates of LBP in large urban populations in developing countries. METHODS Here, in a cross-sectional, population-based survey, we analyzed data obtained from 22,952 subjects living in Tehran. RESULTS Chronic, 1-year, and point prevalence of LBP among subjects were 12.2%, 42.1%, and 36.2%, respectively. LBP was more prevalent among older population, women, housewives, and obese people after adjustment for confounding factors using logistic regression models. In addition, persons with a general health questionnaire (GHQ-28) score ≥6 were about 2 times more likely to experience LBP in comparison with others. Both subjects with higher educational levels and those who were never married reported significantly less LBP. Furthermore, we could not find any significant correlation between smoking and physical activity level with LBP. CONCLUSION LBP is prevalent among the general population of Tehran. Our findings can help health care providers regarding logical assignment of limited resources, in order to create multidimensional prevention plans according to potentially modifiable associated factors. LEVEL OF EVIDENCE 3.

Previous studies have shown atrophy of paravertebral lumbar muscles in patients with lumbar radicular pain and have proposed rehabilitative approaches based on these findings. However, changes in cervical paravertebral muscles in patients with cervical radicular pain are still unknown.The aim of this study was to compare the cross-sectional area (CSA) of the longus colli muscle (LCM) in patients with cervical radicular pain and healthy controls via ultrasound measurement.Case-control study.Outpatients who came for treatment to the neurosurgery clinic.A total of 20 patients with more than 4 weeks of cervical radicular pain and 20 healthy matched (for body mass index, age, and gender) control subjects.Ultrasound measurements.The CSA of the LCM at the level of C5-C6 was measured by ultrasound with the subject in supine position. Also, Neck Disability Index (NDI), and visual analogue scale (VAS) scores were reported by patients. An independent-sample t test was used for investigation of differences in CSA and other variables in both groups.A total of 20 patients with cervical radicular pain with a mean age of 42.4 years (standard deviation [SD] = 7 years) and 20 healthy matched controls with mean age of 40.7 years (SD = 7 years) participated in the study. Patients with cervical radicular pain showed smaller CSA of the LCM bilaterally compared with controls (mean difference: 0.37 [SD = 0.15]; P.001). In the patient group, there were no significant differences between the CSA of the LCM in the involved and noninvolved sides. No correlations between the CSA of the LCM and VAS, Neck Disability Index, symptom duration, gender, BMI, and age of the patients were found.This is the first study to show via ultrasound assessment that patients with cervical radicular pain had smaller bilateral CSA of the LCM in comparison with healthy controls. It is also not clear whether atrophy of the LCM in patients with cervical radicular pain is a consequence or a cause of the pain. Reduction in the stability of the neck due to atrophy of the LCM could make the cervical spine region susceptible to more injuries, which might be prevented by functional and strengthening exercises.III.

Introduction/Background Previous studies have shown atrophy of paravertebral lumbar muscles in patients with lumbar radicular pain, and proposed rehabilitative approaches based on these findings. However, changes of cervical paravertebral muscles in patients with cervical radicular pain are still unknown. The aim of this study was to compare the cross-sectional area (CSA) of longus colli muscle (LCM) in patients with cervical radicular pain and healthy controls via ultrasound measurement. Material and method Twenty patients with more than 4 weeks of cervical radicular pain and 20 healthy matched (for body mass index, age, and gender) control subjects. The CSA of LCM at the level of C5–C6 was measured by ultrasound with the subject in a supine position. Also, Neck Disability Index (NDI), and Visual Analogue Scale (VAS) were reported by patients. Independent sample t-test was used for investigation of differences in cross-sectional area and other variables between both groups. Results Twenty patients with cervical radicular pain with mean (SD) age of 42.4(7) years and 20 healthy matched controls with mean (SD) age of 40.7 (7) years participated in the study. Patients with cervical radicular pain showed smaller CSA of LCM bilaterally compared with controls [mean (SD) difference: 0.37(0.15)] (P-value Conclusion This is the first study which showed that patients with cervical radicular pain had smaller bilateral CSA of LCM in comparison with healthy controls via ultrasound assessment. It is also not clear whether atrophy of longus colli muscle in patients with cervical radicular pain is a consequence or a cause of it. Reduction in the stability of neck due to atrophy of LCM could make the cervical spine region susceptible to more injuries which might be prevented by functional and strengthening exercises.

Background: According to anecdotal findings, some wrestling coaches and wrestlers believe that cauliflower ear might lead to hearing loss. Our preliminary study showed that the prevalence of hearing loss reported by the wrestlers with cauliflower ear is significantly higher than this rate among wrestlers without cauliflower ear. To the best of our knowledge, no other study has confirmed this finding employing hearing tests. Objectives: To evaluate and to compare the prevalence of hearing loss among wrestlers with and without cauliflower ears employing hearing tests. Patients and Methods: The subjects were randomly selected form 14 wrestling clubs in Tehran. Subjects were 201 wrestlers with cauliflower ears (100 wrestlers with one cauliflower ear and 101 wrestlers with two cauliflower ears) and 139 wrestlers without cauliflower ears. All the participants in this study were interviewed to collect information on demographic factors and medical history of risk factors and diseases related to hearing loss. The subjects in both groups underwent otoscopic and audiologic examinations. Results: Audiometric examination results at the frequency range of 0.5 - 8 KHz showed that the prevalence of hearing loss among cauliflower ears was higher than this rate among non-cauliflower ears. Also, the percentage of positive history of ear infections among cauliflower ears (8.4%) was about two times more than this finding among non-cauliflower ears (4.9%). This difference tended to be significant (OR: 1.86, P = 0.06, 95% CI: 0.98 - 3.53). Conclusions: To the best of our knowledge, this is the first study showing that the prevalence of hearing loss among cauliflower ears is higher than this rate among non-cauliflower ears confirmed by audiological tests. This emphasizes that, more preventive measures such as mandatory ear gear for wrestlers are required.

PURPOSE: To compare the lateral abdominal muscle thickness and other possible functional risk factors in young soccer players with and without low back pain (LBP).METHOD: In total, 30 young soccer players between 16 and 20 years old, with and without LBP, from the premier league participated in this study. The thicknesses of external oblique, internal oblique and transversus abdominis on both sides were measured via ultrasound imaging. In addition, hamstring flexibility, active lumbar forward flexion, and isometric muscle endurance of trunk extensors were measured and were compared regarding the history of LBP.RESULTS: Mean ± SD age of the subjects was 17.4 ± 1.1 years. There was no statistically significant difference regarding age, BMI, weekly training hours and age of starting to compete between groups. Subjects with sports-life, last year and last month history ofLBP had a statistically significant lower external oblique muscle thickness in both right and left side, and both dominant and non-dominant feet (p

PURPOSE: Many studies have investigated the prevalence of neck pain (NP) and its risk factors in general population. However, the prevalence of NP among athletes has not been systematically investigated yet. We aimed to systematically review the NP prevalence in athletes. As respects of various definitions of NP, response rates and reliability of studies instruments, we considered risk of bias for including studies. METHODS: A comprehensive search was conducted in Sep 2015, using PubMed, Ovid SP Medline, ISI and Google Scholar. We included studies in English that reported the prevalence of NP in an athletic population in a specifically defined period of time. Two reviewers independently assessed the studies' quality, and performed data extractions. RESULTS: Of 1675 titles identified, 8 articles were assessed for bias risk and 6 with low and moderate risk were included. NP was shown to be prevalent in athletes with a oneweek prevalence ranging from 8% to 45%, a one-year prevalence ranging from 38% to 73% and life-time prevalence about 48%. CONCLUSION: Similar to general population, the prevalence of NP in the athletes is high. Therefore, more studies regarding pain prevalences and risk factors may be useful for planning the educational programs, appropriate rehabilitation protocols, and development of preventive guidelines. Researchers are encouraged to perform epidemiologic studies with low risk of bias in this regard.

Low thickness of Transversus Abdominis, Internal Oblique and External Oblique muscles may play a role in development of low back pain. Ultrasonography is increasingly utilized to measure the thickness of these muscles. Prandial state has recently been proposed as a confounding factor in such measurements. We aimed to compare the reversal time of the postprandial thickness of these muscles with preprandial values. The measurement errors of ultrasonographic values were also assessed in both immediate preprandial and postprandial states.Interventional cross-sectional study.The ultrasonographic thickness of lateral abdominal muscles was measured at rest and during abdominal drawing-in maneuver in 20 healthy participants before and after consumption of a specific meal. Postprandial ultrasound measurements continued every 15 min until their thickness reached 95% of their preprandial values.There was a statistically significant reduction in postprandial thickness of these muscles (all p-values0.001 on both sides). The reversal times were 1.5, 1.3 and 1.2 h for Transversus Abdominis, Internal Oblique, and External Oblique muscles, respectively. Standard Error of Measurement and Smallest Detectable Change were in the range of 0.007-0.013 mm and 0.020-0.035 mm, respectively.To limit the effects of prandial state on the sonographic thickness of lateral abdominal muscles, we recommend measuring these values at least 1.5-2 h after food consumption. For the future studies, controlling the participants according to their prandial state is recommended.

Context: Low back pain (LBP) is among the most prevalent musculoskeletal conditions in the developed countries. It is a common problem causing disability and imposing a huge economic burden to individuals and state organizations. Imaging plays an important role in diagnosis of the etiology of LBP. Evidence Acquisition: The electronic databases included: PubMed (1950 to present), Ovid SP Medline (1950 to present) and ISI (1982 to present) and Google Scholar. In every search engine another search was performed using various permutations of the following keywords: ultrasonography, ultrasound imaging, low back pain, back muscles, paraspinal muscles, multifidus, transverse abdominis, muscle size, spinal canal, sacroiliac joint and spondylolisthesis. Results: Magnetic resonance imaging (MRI) is widely used in evaluation of patients with LBP; however, high costs, limited availability and contraindications for its use have restricted MRI utilization. In a quest for a less expensive and readily available tool to investigate LBP, clinicians and researchers found ultrasonography (US) as an alternative. In this review we discuss the US application in diagnosis of some common causes of non-specific chronic LBP. Discussed topics include evaluation of spinal canal diameter, paraspinal and transabdominal muscles, sacroiliac joint laxity, pregnancy related LBP, sacroiliitis, and spondylolisthesis using US in patients with LBP. Conclusions: While the first researches on employing ultrasound in diagnosis of patients with LBP had been focused on spinal canal diameter, recent studies have been mostly performed to evaluate the role of transabdominal and paraspinal muscles on core stability and thereby LBP occurrence. On the other side, Doppler ultrasonography has recently played an important role in objective measurement of joint laxity as a common etiology for LBP. Doppler imaging also in pregnant patients with LBP has been recommended as a safe and sensitive method. As conclusion, according to recent and most prestigious studies, focusing more on transabdominal muscle thickness can be considered as future approach in investigations.

Background Recently, there is an increasing interest in examining sports injuries among participants of recreational sports. However little data is available about injury rate in Futsal as a popular recreation Worldwide. 1–4 Objective The purpose of this study was to analyseanalyze the incidence and characteristics of injuries recorded in a large recreational centre over a 1-year period. Methods In a prospective design, all injuries in a total of 88 matches of recreational Futsal in 2014–2015 were recorded. A standard questionnaire on injury characteristics was filled for each injured player. Injury rate was calculated as the total number of injuries divided by total player-time (/hour-player). The average time of each match was 90 minutes in duration. Continuous variables were presented in mean (SD) and countable ones were summarised as numbers (percentage). Results A total of 14 injuries (in 13 individuals) were reported in 1185 player records during 88 matches. The injury rate was estimated 1 in 12500 hour-player. Mean and SD of the age and BMI of injured players were 30.38 (9.1) and 25.09 (4.3) respectively. In total of 13 players, 5 (38.5%) were left leg dominant. On site of injury, 4 (28.6%) of injuries were in upper extremity, 9 (64.3%) in lower extremity and 1 (7.1%) in chest wall. About the type of injury, 5 (35.7%) were abrasion or contusion and the rest were more serious injuries including dislocation, fracture, ligament tearing, sprains and strain. Further analysis showed that 10 (71.4%) did not have a history of previous injury at the same site. To address the mechanisms of injury, 12 (85.7%) of injuries were traumatic while the others were overuse injuries; also 7 (53.8%) were due to player-player and 3 (23.1%) were due to player-ground contact. Finally overall missed playing days due to injury was 16 (17.02) days among injured participants. Conclusion Findings showed that injuries were not uncommon among Futsal recreational sport participants. Expectedly the lower extremity was the most likely site of injury followed by upper extremity and trunk. Unfortunately these injuries may be usually grave in nature. Furthermore, most of recreational sport injuries were related to traumatic contacts with opponent players. Finally our data indicated that recreational sport injuries could lead to missing opportunities for participation in recreational activities. Acknowledgment This study was funded and supported by Tehran University of Medical Sciences & health Services grant [Grant No. 88-03-53-9298]. References Finch C, Cassell E. The public health impact of injury during sport and active recreation. Journal of Science and Medicine in Sport 2006; 9 :490–497. Grimmer KA, Jones D, Williams J. Prevalence of adolescent injury from recreational exercise: an Australian perspective. Journal of adolescent health 2000; 27 :266–272. Mummery W, Schofield G, Spence J. The epidemiology of medically attended sport and recreational injuries in Queensland. Journal of Science and Medicine in Sport 2002; 5 :307–320. Mummery WK, Spence JC, Vincenten JA, et al . A descriptive epidemiology of sport and recreation injuries in a population-based sample: results from the Alberta Sport and Recreation Injury Survey (ASRIS). Canadian journal of public health= Revue canadienne de sante publique 1997; 89 :53–56.

Objectives To evaluate the effect of lumbopelvic belts on the thickness of lateral abdominal muscles and the cross-sectional area (CSA) of lumbar multifidus (LM) muscles. Design A single-blinded randomized controlled trial. Setting An academic and tertiary care referral spine and sports medicine center. Participants Sixty healthy volunteers with no history of low back pain in the previous year. Methods The subjects were allocated into belt and control groups. Lumbar belts were given to the subjects in the belt group, and they were asked to use the belts during the study period except during sleeping hours. The subjects were assessed at baseline and at 4 and 8 weeks. Main Outcome Measures The thickness of lateral abdominal muscles and the CSA of the LM muscles were measured by ultrasound with the patient in the hook-lying position on an examination table. Results The thickness of lateral abdominal muscles and the CSA of LM muscles on both sides decreased significantly among healthy subjects in the belt group after 8 weeks. Conclusion The results of this study show that lumbopelvic belts might influence the ultrasonographic measurements of lateral abdominal and LM muscles and thereby spine stability.

The role of transabdominal muscles (external oblique, internal oblique and transversus abdominis) on core stability has been shown previously. Energy restricted diet and abdominal resistance training are commonly used by overweight and obese people to reduce their weight. In this study we investigated the impact of 12 weeks concurrent energy restricted diet and abdominal resistance training on the thickness of the lateral abdominal muscles of 19 obese and overweight women employing ultrasonography in resting and drawing-in maneuvers. The results showed significant increase of the muscle thicknesses during drawing-in maneuver after 12 weeks intervention. Based on our findings, it can be concluded that 12 weeks concurrent abdominal resistance training and energy restricted diet in addition to weight loss lead to improvement of transabdominal muscles thickness in obese and overweight people. Considering the role of these muscles in core stability, using this therapeutic protocol in obese people, particularly in those who have weakness of these muscles might be helpful.

Recently, the roles of transabdominal muscles particularly TrA (transverse abdominis) muscle in spinal stability leading to treatment of low back pain have been suggested. Both in clinical setting and follow up studies, abdominal muscle thickness measurements need to be repeated at a later point in time to demonstrate efficacy of a therapeutic intervention. Different issues have been suggested as source of error in the repeated measurements of abdominal muscle thickness in different days such as patient position and stability of probe location. The level of stomach fullness has not been investigated as a source of error in ultrasonic measurements of transabdominal muscles thickness. This study was performed to evaluate the effect of food consumption on thickness of lateral abdominal muscles. Lateral abdominal muscles thicknesses of 63 healthy volunteer men were measured before and after food consumption. All the measurements were performed in two transducer positions and both sides. Waist circumference and body weight of participants were also measured before and post-food consumption. The thickness measures of all three muscles layers of lateral abdominal muscles (external oblique, internal oblique and transversus abdominis) in both sides and measured positions were significantly reduced after food consumption. We found no correlation between the increase of waist circumference and reduction of muscle layer thicknesses after food consumption. In case of comparison between the values of transabdominal muscle thicknesses over the time, the effect of food consumption on muscle thickness might be assumed as a potential source of error.

Dear Editor: With great interest we read the recent article by Burns et al4 titled “A Treatment-Based Classification Approach to Examination and Intervention of Lumbar Disorders.” We would like to commend the authors’ efforts in providing a treatment-based classification approach to low back pain (LBP) in athletes that involves 3 steps. Additionally, this study suggests matching interventions for athletes according to their stage of LBP, which is very informative and robust. However, we think in this article, some therapeutic interventions in approach to athletes with LBP were missed. As it was mentioned in the article, there is an extensive list of differential diagnosis for LBP8; however, most of the causes are infrequently seen in practice.8 It is reported that about 85% of patients with LBP seen in a primary care have no identifiable cause, and so it is termed nonspecific LBP.7 It seems some treatments, such as acetaminophen, nonsteroidal anti-inflammatory drugs, relative rest, coldness, heating, and massage therapy, can also be used to decrease the intensity of pain in patients with nonspecific LBP, while these treatments were missed in the article by Burns et al. In addition, although the effectiveness of alternative medicine for the treatment of chronic nonspecific LBP is not without dispute,13 it currently plays an indispensible role in management of patients with chronic LBP. Acupuncture as a therapeutic intervention is widely used in treatment of patients with nonspecific LBP.13 The superiority of acupuncture to sham acupuncture for pain relief of patients with LBP has not been established in previous studies.15 However, in well-designed randomized controlled studies with a low risk of bias, the effectiveness of this traditional intervention for symptom relief of LBP has been shown.3,10-12 Furthermore, clinical guidelines of societies such as the North American Spine Society,1 the American College of Physicians,5 and the National Institute for Health and Clinical Excellence14 have also recommended acupuncture as a possible treatment option for patients with LBP. On this base, it seems reasonable to consider acupuncture as an effective therapeutic intervention in approach to patients with LBP.2 We agree with the authors that no treatment should be started for patients with LBP before performing a complete diagnostic evaluation and ruling out the major and sometimes life-threatening diagnoses that are called “red flags.” However, considering acupuncture in approach to patients with chronic LBP, which contain the majority of cases of LBP, seems to be useful. The points commonly used for acupuncture of patients with LBP have been listed before,2 although most of the time, supplemental points will also be selected by the physician according to the medical history and pain location of the patients. In use of acupuncture, there is also a list of contraindications, such as bleeding and clotting disorders and warfarin use, that should be considered by the physicians.6 We can suggest that acupuncture might be more effective in a subgroup of LBP patients. In this regard, a review of the literature reveals the following points: Most of published studies that reported the effectiveness of acupuncture in treatment of LBP were carried out on patients with nonspecific LBP in which patients do not have a radicular pain resulting from nerve root compression.9 In some of these studies radiculopathy has been stated as the exclusion criterion for the participants.3,15 In addition, insertion of needles into trigger and painful points has been reported as a part of acupuncture treatment for patients with chronic LBP.9 Therefore, we believe that in Table 4 of the article by Burns et al,4 acupuncture could be added as a therapeutic intervention in patients in stage I. As it is mentioned above, the preferred criteria for doing this intervention on the patients are patients with persistent (> 6 weeks) nonspecific LBP (no radiculopathy pain) who have positive findings of tender or trigger points in their muscles. Sincerely