Copy of Evidence-informed management of chronic low back pain with lumbar stabilization exercise

Evidence-informed management of chronic low back pain with lumbar stabilization exercises

Low back pain has been managed many different ways...

Recently, there has been a focus on exercises that aim to maintain stability in the lumbar spine.

This is called lumbar stabilization, core stabilization, or segmental stabilization.

History

• 1980: Bergmark took a mechanical engineering approach to assess the role of the trunk musculature in providing stabilization for the lumbar spine and the specific forces applied to the spine by different muscles.
• 1992: Panjabi proposed that 3 interdependent subsystems function to stabilize the spine: passive, active, and neural.
• 1992: Cresswell reported a series of studies on intra-abdominal pressure and activation of trunk musculature. Pressure was increased during functional tasks and ventral loading occurred.
• 1994: Hides found significant ipsilateral atropy in the lumbar multifidi of individuals with unilateral LBP. He found that patients treated medically had limited recovery of multifidus muscle mass and patients treated with specific exercise had a more substantial recovery of the muscle mass.
• 1995: Richardson and Jull described a specific exercise program to train co-contraction of the deep trunk muscles. This led to what we now know as "core stability" programs.
• 1996: Hodges and Richardson studied the activation pattern of the trunk musculature associated with an alteration of spinal posture induced by movement of an upper limb.
• 2000- on: McGill and others have emphasized stabilization training.

Christopher J. Standaert, MD, Stuart M. Weinstein, MD, John Rumpeltes, PT, ATC

General Description

Clinical Trials

Initial Aim: Achieve isometric co-contraction of the local muscles of the trunk, with activation of the transversus abdominis and multifidi being considered the "basic functional unit of movement skill."

A randomized control trial from Australia compared general exercise, motor control (stabilization) exercise, and spinal manipulative therapy with chronic low back pain.

The general exercise group received an assessment by a PT, supervised group training in stretching and strengthening major muscle groups, and aerobic fitness. The motor control group received training in exercises designed to improve the function of specific trunk muscles felt to control intersegmental motion. The spinal manipulative therapy group received joint mobilizations.

The motor control and spinal manipulative groups had marginally better outcomes short term. Long-term results showed no difference between the 3 groups.

The patients were instructed to draw in the lower abdominal wall while simultaneously contracting the multifidi isometrically.

A strong emphasis is placed on the accurate performance of the maneuvers, and the patients are progressed into functional positions while maintaining muscle activation.

Exercises can be advanced when the patient is able to paintain 10 isometric "holds"for 10 seconds without fatiguing.

6-12 physical therapy sessions in a clinical setting is pretty typical for this treatment protocal.

And Finally

Clinical Trials

A study in the United Kingdom compared stabilization exercises to conventional PT.

The stabilization group received structured endurance training of the deep abdominal and back extensors and functional progression from sitting to standing exercises.The PT group received active exercises, and minimal use of passive modalities.

There was no significant difference in the outcome of the treatment options.

• There is moderate evidence that lumbar stabilization exercises are no more effective than manual therapy in the same population.
• Almost every study uses a group of subjects with nonspecific low back pain.
• Results are "washed out" by using multiple types of subjects.
• There is usually no clear anatomic diagnosis or clinical categorization for the majority of CLBP patients.
• LSE is a useful management tool
• Most research excludes patients with prior surgery.

Theory

Another study from the U.K. compared specific spinal stabilization exercises, manual therapy, and minimal care.

The spinal stabilization group received 10 weekly group exercise sessions of 1 hour, emphasizing neural and active (motor) control pathways and designed to address certain muscle groups. The manual therapy group received 10 treatments from a physical therapist with no exercises. The minimal care group received a pamphlet of exercises and a 3 hour instruction session.

There was no significant differences between groups.

Contraindications

Indications

• When exercise of trunk muscles is not allowed
• Acutely unstable spine injuries
• Significant acute neurological compromise
• Unstable medical presentation
• Acute phase of significant structural injury
• Structural lesions in the spine

• Any patient with chronic low back pain
• Clearly definable structural source of pain
• Reproducible, mechanical pattern of lumbopelvic pain that follows a specific plain of movement or functional task
• Altered activation patterns
• Patients with clearly defined anatomical barriers

Photo based on: 'horizon' by pierreyves @ flickr