Low Back Pain and Core Stabilization Exercise Inservice

John Pineda, SPT July 2, 2015Low Back Pain and Core Stabilization Exercise InserviceLow Back Pain BackgroundAmerican Physical Therapy Association labels low back pain as: Acute (12 weeks)Often associated with: Mobility impairment in the thoracic, lumbar, or sacroiliac regionsReferred or radiating pain into a lower extremityGeneralized pain (dull, sharp, burn)Spasm

PrevalenceApproximately 40% of adults will experience low back pain in their lifetime (Manchikanti et al.)50% of patients will have a recurrence within 12 months Most common cause of job-related disability and a leading contributor to missed work (NIH)Annual cost of $100-200 billion per year due to lost wages, decreased productivity (Carey, Freburger)

APTA Survey

Work Lost due to LBP (2012)Radiating Leg Pain w/ LBP: 17.4 days (~1.5 days/mo)LBP in Past 3 Months: 11.2 day (0.93 days/mo)

Self Reported Prevalence of Pain Female > Male Radiating Leg Pain38%, 33%Lower Back Pain 30%, 27%Age 45-64 4% less Radiating Leg Pain, slightly less Lower Back Pain in older groups (65-74, 74+)Avg Patient Age for LBP Averages fall within 45-64 age group ER visits with youngest patient averageHospital discharges have oldest patient averagePatient EvaluationLimited lumbar ROM Pain at end range of lumbar ROM Segmental hypomobilityDecreased hamstring flexibilityTenderness to palpation in lumbar paraspinals, SI joint Core muscular weakness Core MusculatureGlobal (Superficial)Local (Deep) Cross multiple vertebraeProduce motion and torque Control spinal orientationCreate compression load with strong contraction Counterbalance external forces acting on spine Attach to each vertebral segment Control segmental motion Provide precise motor control Primary spinal stabilizers Large amount of type I muscle fibers for endurance Global Core MusclesRectus abdominus External obliquesInternal obliques (Lateral) Quadratus lumborum Erector spinae Iliopsoas

Deep Core MusclesTransversus abdominis Lumbar multifidus (Deep) Quadratus lumborum Deep rotators

Article 1Chang et al., Core Strength Training for Patients with Chronic Low Back Pain, Journal of Physical Therapy Science, 2015Systematic ReviewInclusion criteria: experimental research studies from 2008-2012, chronic low back pain (CLBP) patients, core strength training interventions, Jadad quality score of 4 or 5 Four articles all criteria Four core strength training exercises were used: Trunk balance StabilizationSegmental Stabilization Motor Control

InterventionsTrunk balance: Strengthening trunk to improve balanceStabilization: Progressive core strength training techniques in different positions (supine, prone, sitting, quadraped, standing)Segmental stabilization: Strengthening various deep core muscles Motor control: Exercises based on motor control theory

Control groups: Typical resistance training for trunk, LE Sit-ups, straight leg raise, push ups, LAQMeasurement ToolsPain: Visual analog scale (VAS), McGill pain questionnaire Disability levels: Range minimum query (RMQ), Oswestry disability questionnaire (OSWDQ), Back performance scale (BPS), Short-Form 12 (physical, mental quality of life)Muscle performance: Pressure biofeedback unit (PBU), Ultrasound

Reduced pain between intervention and control, but not statistically significant Disability level and muscle performance improvement was statistically significant between control and intervention ResultsCore strengthening is easier to learn than typical resistance, but more challenging Typical resistance may injure pts No special equipment, can be performed at home (HEP)Decreased disability is more functionally significant than decreased pain since it relates to ADLs and occupation PBU, ultrasound improvements are objective measures

Article 2Yoon et al., The Effect of Swiss Ball Stabilization Exercise on Pain and Bone Mineral Density of Patients with Chronic Low Back Pain, Journal of Physical Therapy Science, 2013. Study Design36 patients diagnosed with CLBP (and not severe spinal disease) divided into 3 groups of 12Conservative treatment, floor exercise, ball exercise Conservative treatment: Superficial heat (20 mins), IFC (15 mins), deep heat (5 mins) 3x/week for 16 weeks Intervention groups: Supine bridge, sit up, bird dog, side bridge (on floor or Swiss ball)10 hold, 3 rest, 3 sets of 10 reps, 3x/week for16 weeksSwiss ball diameter based on ratio to patients height Exercises

Supine bridge on Swiss ballSide bridge on Swiss ballSit up on Swiss ballBird dog on Swiss ballMeasurement Tools Pain: VAS Bone mineral density: DEXXUM T on L1- L4, three parts of femur Measurements taken before experiment, at 8 and 16 weeks

Results

Statistically significant decrease in pain in both intervention groups, with BEG > FEG L1L2L3L4FEG0.880.990.601.43BEG3.851.641.254.48Total BMD Rate of Change (%)Greater increase with BEG than FEG, but not statistically significant20Article 3OSullivan et al. Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain with Radiologic Diagnosis of Spondylolysis or Spondylolisthesis, Spine, 1997Study Design 44 patients with recurrent LBP symptoms for longer than 3 months with no signs of abating and radiologic diagnosis of spondylolysis or spondylolisthesisMost defects at L5-S1, some at L4-L5Control, Specific Exercise Measures: Pain, functional measures, lumbar spine and hip sagittal ROM in standing, abdominal recruitment patterns

InterventionControl: 10 wk treatment period with general practitionerWeekly general exercise, pain-relieving methods (heat, massage, U/S)Specific Exercise: Weekly session with PT for 10 weeks Train contraction of deep abdominal muscles (drawing in maneuver), co-contract with lumbar multifidus10 contractions for 10 second holds progress by adding low load through leverage on limbs10-15 min program at homeInstructed to co-contract with provoking positions/activities Measurement ToolsPain: McGill pain questionnaire (VAS, pain descriptor, pain body chart), average medication intake Functional measures: Oswestry Disability Index (patients perceived level of disability) ROM: Cybex inclinometer T12 inclinometer [gross motion] PSIS inclinometer [pelvic/hip motion] = lumbar motionAbdominal recruitment: EMG of rectus abdominis and internal oblique during drawing in maneuverResultsSEG with significant difference in pain intensity, pain descriptor score, functional disability7 less subjects taking anti-inflammatory medicine regularly Decreased maintained at 3, 6, 30 month follow up

Oswestry Functional Disability

Pain OutcomesVAS Pain IntensityPain Descriptor ScoresArticle 4Mok et al., Core Muscle Activity During Suspension Exercises, Journal of Science and Medicine in Sport, 2014Suspension Training

TRX Suspension System Multi-planar, multi-joint movements against gravity with body weight resistance One or both limbs are placed in handles (or cradles) at the end of an anchored suspension cableWorkout difficulty is adjusted by altering the working angle (angle of inclination of the body) and/or adding balancing equipmentBenefits: Versatility, simple set-up, low space occupancy, and large variety of workouts

Study Design Eighteen adults (8 men, 10 women) completed four workouts using the TRX suspension system Hip abduction in plank, chest press, 45 deg row, hamstring curl Surface EMG was placed on the rectus abdominis, external oblique, internal oblique/transversus abdominis, lumbar multifidus during the workouts

Exercises

Hip abduction in plank45 DegreerowChest pressHamstring curlProcedure5 minute cycling warm up followed by static stretching Maximum Voluntary Isometric Contraction data was gathered with two 5 contractions against manual resistance EMG was gathered during the middle 3 seconds of the hold

Results Hip abduction in plank and chest press activated more abdominals, while hamstring curl activated multifidusHigher muscle activity with LE exercises than UEBenefits of strengthening, muscle endurance, motor control

Implications in Practice

Alternatives

Implications in Practice Suspension exercises may activate muscles more than comparable exercises performed on stable surfaces or Swiss ballsUse for patients who complete Swiss ball exercises with ease Changing working angle allows for vast modifications to exercisesPotential recommendation for patients as an exercise program to implement after D/C for LBP to remain healthy and pain-free Simple to use, easy to set upQuestionsReferences American Physical Therapy Association. Low Back Pain by the Numbers (Infographic). http://www.moveforwardpt.com/LowBackPain/Infographic/Default.aspx Burden of Musculoskeletal Disease in the United States. Bone and Joint Initiative USA 2014 Report. Carey, T. and Freburger, J. Physical Therapy for Low Back Pain: What Is It, and When Do We Offer It to Patients? Annals of Family Medicine, 2014. Kisner, C. and Colby, L. A. Therapeutic Exercise: Foundations and Techniques, 5th Edition. F. A. Davis Company, 2007. Manchikanti et al. Epidemiology of Low Back Pain in Adults. Neuromodulation, 2012. Mok et al., Core Muscle Activity During Suspension Exercises, Journal of Science and Medicine in Sport, 2014National Institute of Health. Chronic low-back pain research standards announced by NIH task force. Press release, December 11, 2014.OSullivan et al. Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain with Radiologic Diagnosis of Spondylolysis or Spondylolisthesis, Spine, 1997Wolters Kluwer. Evaluation of Low Back Pain in Adults. http://www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults#H1Yoon et al., The Effect of Swiss Ball Stabilization Exercise on Pain and Bone Mineral Density of Patients with Chronic Low Back Pain, Journal of Physical Therapy Science, 2013.