Transcript Low Back Pain and Core Stabilization Exercise Inservice

Low Back Pain and Core Stabilization
Exercise Inservice
John Pineda, SPT
July 2, 2015
Low Back Pain Background
 American Physical Therapy
Association labels low back pain
as:
 Acute (<4 weeks)
 Subacute (4-12 weeks)
 Chronic (>12 weeks)
 Often associated with:
 Mobility impairment in the
thoracic, lumbar, or sacroiliac
regions
 Referred or radiating pain into a
lower extremity
 Generalized pain (dull, sharp,
burn)
 Spasm
Prevalence
 Approximately 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 Pain
• 38%, 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
average
• Hospital discharges have oldest
patient average
Patient Evaluation
 Limited lumbar ROM
 Pain at end range of lumbar ROM
 Segmental hypomobility
 Decreased hamstring flexibility
 Tenderness to palpation in lumbar paraspinals, SI joint
 Core muscular weakness
Core Musculature
Global (Superficial)
Local (Deep)
 Cross multiple vertebrae
 Attach to each vertebral
 Produce motion and
torque
 Control spinal orientation
 Create compression load
with strong contraction
 Counterbalance external
forces acting on spine




segment
Control segmental motion
Provide precise motor
control
Primary spinal stabilizers
Large amount of type I
muscle fibers for
endurance
Global Core Muscles
 Rectus abdominus
 External obliques
 Internal obliques
 (Lateral) Quadratus lumborum
 Erector spinae
 Iliopsoas
Deep Core Muscles
 Transversus abdominis
 Lumbar multifidus
 (Deep) Quadratus lumborum
 Deep rotators
Article 1
Chang et al., Core Strength Training for Patients with Chronic Low
Back Pain, Journal of Physical Therapy Science, 2015
Systematic Review
 Inclusion 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
 Stabilization
 Segmental Stabilization
 Motor Control
Interventions
 Trunk balance: Strengthening trunk to improve balance
 Stabilization: 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, LAQ
Measurement Tools
 Pain: 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
Results
 Core 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 2
Yoon 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 Design
 36 patients diagnosed with CLBP (and not severe spinal
disease) divided into 3 groups of 12
 Conservative 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 weeks
 Swiss ball diameter based on ratio to patient’s height
Exercises
Supine bridge on Swiss ball
Sit up on Swiss ball
Bird dog on Swiss ball
Side bridge on Swiss ball
Measurement 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
Total BMD Rate of Change (%)
L1
L2
L3
L4
FEG
0.88
0.99
0.60
1.43
BEG
3.85
1.64
1.25
4.48
Greater increase with BEG than FEG, but not statistically significant
Article 3
O’Sullivan et al. Evaluation of Specific Stabilizing Exercise in the
Treatment of Chronic Low Back Pain with Radiologic Diagnosis of
Spondylolysis or Spondylolisthesis, Spine, 1997
Study Design
 44 patients with recurrent LBP symptoms for longer than 3
months with no signs of abating and radiologic diagnosis of
spondylolysis or spondylolisthesis
 Most defects at L5-S1, some at L4-L5
 Control, Specific Exercise
 Measures: Pain, functional measures, lumbar spine and hip
sagittal ROM in standing, abdominal recruitment patterns
Intervention
 Control: 10 wk treatment period with general practitioner
 Weekly 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 multifidus
 10 contractions for 10 second holds  progress by adding low
load through leverage on limbs
 10-15 min program at home
 Instructed to co-contract with provoking positions/activities
Measurement Tools
 Pain: McGill pain questionnaire (VAS, pain descriptor, pain
body chart), average medication intake
 Functional measures: Oswestry Disability Index (patient’s
perceived level of disability)
 ROM: Cybex inclinometer
 T12 inclinometer [gross motion] – PSIS inclinometer [pelvic/hip motion] =
lumbar motion
 Abdominal recruitment: EMG of rectus abdominis and
internal oblique during drawing in maneuver
Results
 SEG with significant difference in pain intensity, pain
descriptor score, functional disability
 7 less subjects taking anti-inflammatory medicine regularly
 Decreased maintained at 3, 6, 30 month follow up
Oswestry Functional Disability
Pain Outcomes
VAS Pain Intensity
Pain Descriptor Scores
Article 4
Mok et al., Core Muscle Activity During Suspension Exercises,
Journal of Science and Medicine in Sport, 2014
Suspension 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 cable
 Workout difficulty is adjusted
by altering the “working
angle” (angle of inclination of
the body) and/or adding
balancing equipment
 Benefits: 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 plank
45 Degree
row
Chest press
Hamstring
curl
Procedure
 5 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 multifidus
 Higher muscle activity with LE exercises than UE
 Benefits 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
balls
 Use for patients who complete Swiss ball exercises with ease
 Changing working angle allows for vast modifications to
exercises
 Potential 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 up
Questions
References

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, 2014

National Institute of Health. Chronic low-back pain research standards announced by NIH task
force. Press release, December 11, 2014.

O’Sullivan et al. Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back
Pain with Radiologic Diagnosis of Spondylolysis or Spondylolisthesis, Spine, 1997

Wolters Kluwer. Evaluation of Low Back Pain in Adults.
http://www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults#H1

Yoon 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.