Introduction
Chronic non-specific low back pain (LBP) is defined as pain for 3 or more months between the lower ribs and buttock with or without leg pain, excluding any known pathoanatomical cause (Smith et al., 2014). LBP can occur due to many factors including an individual’s health, working conditions, inappropriate static and dynamic working postures, poor manual handling technique, psychological factors and lifestyle (Duthey, 2013). LBP is of interest to several researchers due to its prevalence in society. Over 50% of the global population is either currently affected or has experienced this condition (Chang et al., 2015). This pathology is a costly condition that needs significant allocation of resources from the government, for example, in the United Kingdom; the government spends over £1 billion in mitigating this condition (Smith et al., 2014).
Stabilising core exercises have been developed as a treatment for LBP and can help to relieve pain and improve the functional status of the patient. They are aimed at enhancing neuromuscular control, strength and endurance of the deep muscles of the core, primarily transversus abdominis and multifidus which are intended to maintain spinal stability (Standaert et al., 2008). These exercises re-establish the loss in motor control through regaining usual function of local stability muscles (Luque-Suárez et al., 2012).
There have been arguments over the effectiveness of these exercises. Therefore, the primary objective of this paper is to determine whether stabilising exercises are effective in relieving LBP by analysing four journal articles on this topic.
Akbari et al., 2008
Aims/Objective
This article compares the effects that general exercises and motor control exercises have on pain in patients with LBP.
Design/Methods
This is a double-blinded study. Fifty-eight subjects suffering from non-specific LBP with or without leg pain, were selected randomly and grouped into two. One group was treated using the stabilising motor control exercises while the other group underwent general exercise. Each session lasted 30 minutes and was held twice weekly for eight consecutive weeks. The subjects’ data was collected before and after an eight-week period. A Visual Analog Scale (VAS) from 1-100 was used to assess the improvement in the patients’ pain perception.
Key Findings
No significant difference was reported in groups at baseline. The study found that both exercises decrease pain. However, the subjects under the motor control group witnessed a greater decrease in pain than those under general exercises. Pain in the motor control group decreased significantly after the treatment from 7.25 to 2.5 as compared to the general exercise group where VAS decreased from 8 to 4. Overall the difference between the results of two groups did not reach a significant level (P=0.083).
Critique
This study does not conduct a follow-up test and there is no assurance that the results are long term. A follow-up test is necessary to ascertain the validity of the results (Wang et al.,2012). The study also makes use of a small number of subjects therefore the result cannot be generalised.
Conclusion
Both exercises are efficient in reducing pain. Although stabilising exercises had greater effect on pain reduction, the difference between the groups did not reach significance.
França et al., 2012
Aims/Objectives
This article compares the effects of stretching (ST) of hamstrings and trunk muscles and the segmental stabilisation exercises (SS) on pain in patients with non-specific LBP.
Design/Methods
This study enrolled 30 subjects, both males and females with LBP without leg pain, who were assigned randomly into two groups under which intervention would be performed. The focus for SS group was exercising the lumbar multifidus and the transverse abdominis muscles. The ST group involved the stretches of erector spinae, hamstrings, and triceps surae. The sessions for each group lasted 30 minutes and were held twice weekly for six continuous weeks. Participants were assessed at a baseline and after the study period. The level of pain was determined by a VAS (1-10).
Key Findings
No significant difference was reported in groups at baseline. The study found that both treatment programs are effective in relieving pain. However, SS exercises group yielded better results than the ST program group. Pain in the SS group reduced significantly by 99% while in the ST group pain reduced by 49% in the VAS (P<0.001).
Critique
The study does not do a follow-up of at least six months to validate the results and has a small sample size, therefore the results should be considered with caution and may not be representative of the total population. Although, the study showed that there was reduction in pain in both treatment groups, they did not include the p value to show if there is a significant difference between the results of two groups.
Conclusion
All variables significantly improved with both programs, however SS training group showed greater improvements in pain compared to ST group. SS exercises are effective in reducing pain in individuals with LBP without leg pain.
Moon et al., 2013
Aims/Objectives
This article compares the effect of lumbar dynamic and lumbar stabilisation exercises on LBP.
Design/Methods
The study involved 24 subjects, (12 males and 12 females) with LBP without leg pain. The subjects were placed randomly into lumbar dynamic and lumbar stabilisation exercise groups. The sessions lasted for an hour and were performed twice per week for a consecutive eight weeks. Lumbar dynamic exercises aimed at activating the rectus abdominis and erector spinae muscle groups. Lumbar stabilisation comprised of exercises which are aimed at strengthening the lumbar multifidus, internal oblique and the transversus abdominis muscles. The pain was gauged using a VAS (1-100).
Key Findings
No significant difference was reported in groups at baseline. After the eight weeks, the VAS recorded a decrease in pain for both groups of patients after the treatment and there was no significant difference between these (P=0.66). The VAS score in the lumbar dynamic group decreases from 34.2±17.1 to 14.1± 8.2 while in the lumbar stabilisation exercise group from 33.5 ±18.4 to 16.7± 7.0.
Critique
Small number of patients were used, and they were all relatively young. For this reason, the results cannot be generalized for the rest of the population since the number is not representative. Also, the long-term effects of the study’s results cannot be established since a longer follow-up of the patients was not done. The results of the paper are current and relevant, as they were published within the last five years (Schmitz and Nguyen, 2016).
Conclusion
Both lumbar dynamic strengthening and lumbar stabilisation exercises are equally effective in reducing lower back pain.
Rasmussen-Barr et al., 2009
Aims/Objectives
The article evaluates the effects of the graded stabilising exercise on patients with recurrent LBP compared to the effect of daily walk for the control group.
Design/Methods
The research made use of 71 subjects who were diagnosed with the condition of recurrent LBP excluding patients with any specific pathology and leg pain. They were then placed randomly into two groups, either the daily walk group or the graded stabilising exercise group. The first examination was conducted for 60 minutes. The subjects were informed of the benefits physical activity has in improving the low back pain condition but were not informed which form of physical activity is the best. The sessions were conducted for 45 minutes weekly for eight consecutive weeks. This was followed by a 6, 12, and 36-month follow-up. The primary outcome measure included pain and VAS (1-100) was used to gauge the level of pain.
Key Findings
No significant difference was reported in groups at baseline. The primary outcomes showed that both groups had improvement in pain. At the 12-month follow-up, 55% of the exercise group and 26% of the reference group showed reduction in their pain level by 50% or more (P=0.01). However, no significant positive results were shown for pain over a longer term.
Critique
Blinding is a considerable limitation, both subject and therapist were aware of which group they were in, this may raise subjects bias in recording their pain level and therapist bias in providing treatment. Moreover, the intervention group were individually supervised by the therapist, this explain the higher adherence to the treatment in this group and better results in the short term. Although the intervention showed a trend towards reduced pain at 12 months this did not reach significance. This could be due to the high number of loss to follow up in the control group which means the research did not possess the statistical power to detect a significant clinical difference.
Conclusion
Both graded stabilising exercise program and daily walk decrease pain for patients with nonspecific recurrent LBP in short term. However, little positive change was seen for pain results over a longer term in graded stabilising exercise group, therefore further research is needed.
Overall Conclusion
The question explored in this essay is important in modern physiotherapy practices because the issue of LBP is affecting an increasing number of people (Smith et al., 2014). Low back pain is the biggest cause of work absence and as a result imposes economic difficulties on individuals, families and government. In the United Kingdom, more than 100 million workdays are lost per year due to LBP (Duthey, 2013).
When analysing the results of the articles, key interest was placed on the effect that these programs have on pain perception. All age groups can be affected by non-specific LBP and it can affect their quality of life. Moreover, the pain cannot be explained by a specific pathology (Balagué et al., 2012). The effect of stabilising exercises on treatment of LBP has a strong theoretical foundation and is evidenced by its clinical use. Research suggests that paraspinal muscle groups and multifidus are significantly smaller in patients with LBP (Fortin and Macedo, 2013). Therefore, stabilising muscle exercises play an important role in the effects of LBP. It can be stated that stabilising exercises help reduce LBP. However, there is no overall agreement between the studies that stabilising exercises are better than general exercise for LBP patients and that there is a long-term effect of this program. Therefore, the stabilization exercises cannot be recommended over the general exercises for the reduction of LBP and further research is needed with more variation (Smith et al., 2014).
Patients with high levels of fear avoidance are likely to have lower results with biomedical models of treatments, such as stabilisation exercises and would benefit with a biopsychosocial approach such as education (Zhang, Wan and Wang, 2014). Research found that health education improves the results of pain severity, disability and quality-of-life compared with exercise alone. Patients can be educated about the effects of posture, body weight, life style and psychological health on occurrence of LBP.
All papers can be critiqued on the aspect that pain level was a self-recorded patient outcome, therefore it is possible that this could overestimate the treatment results (Smith et al., 2014). Also, in every article the stabilizing exercises were applied to a wide variety of patient, including patients from different socio-economic groups, different employment and mental health level. Therefore, it can be concluded that stabilising exercises are beneficial for a wide range of patients, but they may show even better results if sub-groups of LBP patients could be found.
It is important that the decision on what is the most effective treatment for LBP is founded on research based evidence with utilisation of clinical experience and patient preference. This will ensure an effective and low cost physiotherapy treatment which aims to reduce patients pain and increase quality of life (Wang et al., 2012).