Research Review: Long Term Effects of Stabilization Exercise for First Episode Low Back Pain
By Jinny McGivern PT, DPT, Certified Yoga Instructor
Edited by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS
Original Citation:
Hides, J. A., Jull, G. A., & Richardson, C. A. (2001). Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine, 26(11), e243-e248. ARTICLE
By LadyofHats Mariana Ruiz Villarreal - i did it myself, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1530655
Why is this relevant?:
In a previous Brookbush Institute research review we discussed a study by Hides, Jull and Richardson (1996, Multifidus Recovery… ) that pain and functional limitations associated with an initial episode of low back pain may resolve without additional interventions beyond medical advice on rest/activity balance and prescription medication for pain relief. However, the associated loss of cross sectional area (CSA) of the lumbar multifidi , an essential stabilizer of the lumbar spine, did not auto-correct and return to pre-injury size. The CSA of the lumbar multifidi did return in the individuals who performed therapeutic exercises specifically designed to retrain the multifidus as part of a 4 week intervention. This study reviewed here, is a 1 and 3 year follow-up with the same subjects from the original research. It provides important information on the long term events that follow an initial episode of low back pain, as well as the long term results of two different approaches to management: one approach using patient education and pain medication and the other using patient education, pain medication and multifidi re-training exercise. Finally, this research provides support for including exercise as a key component to the management of low back pain.
Study Summary
| Study Design | Prospective Randomized Controlled Trial (RCT) - Long Term Follow Up |
| Level of Evidence | Level II - Evidence from a well designed RCT |
| Subject Demographics | 39 individuals with an acute initial episode of low back pain (LBP) were randomly assigned to either a control group (CON - 20 subjects) which received medical management, or an exercise group which received multifidi retraining (MRG - 21 subjects) activities (2x per week for 4 weeks - multifidus contraction confirmed by ultrasounds) and medical management. All subjects underwent full neurological exam & lumbar spine X-ray prior to participation.
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| Outcome Measures | During the initial study, assessments were performed by 2 independent blinded examiners at baseline, then again at the end of week 1, week 2, week 3, and week 4. Outcome measures included:
If patients were low pain to pain-free during all functional activities and demonstrated full lumbar ROM at the end of week 4, they were included in a week 10 follow-up where the following was assessed:
If patients continued to report pain during activity or pain during lumbar movements, they were removed from the study and provided with a complete course of physical therapy treatment. To determine recurrence rates, at long term follow up (1 yr and 3 yrs post) telephone interviews were performed by blinded research assistants. The following items were assessed:
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| Results | Description of Sample at Baseline (initial study):
Outcomes for Weeks 1-4 (initial study)
At 10 week Follow up (initial study) • There was no significant change in multifidus size at the affected level between week 4 measurements and week 10 measurements (p=.02) in either group. At week 4 the CON demonstrated a 16.84% (+/- 9.26%) difference between sides, and at week 10 it was 14.02% (+/- 6.31%). At week 4 the MRG demonstrated a .71% (+/- 2.49%) difference between sides, and at week 10 it was .24% (+/- 3.29%). • There was no significant difference between baseline and week 10 in the scores on the habitual activity questionnaire, indicating that the subjects resumed their regular activities. For more details on the results of the initial study, please click here. At 1 year follow up (current study):
At 3 year follow up (current study):
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| Conclusions | This study demonstrates that early intervention to retrain the stabilizing musculature of the lumbar spine is essential to reduce the frequency and severity of recurrences of low back pain. |
| Conclusions of the Researchers | This study demonstrates that individuals who received specific exercise therapy, in addition to medical management, reported fewer recurrences and reduced severity of the episodes of LBP in the 1-3 years following the initial episode as compared to individuals receiving medical management alone. |
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Review & Commentary:
In this follow-up study, the researchers continued to demonstrate a strong methodology. They utilized blinded research assistants to call and speak with subjects. The design of the questionnaire was thorough and covered frequency, severity and mechanism of injury related to recurrence. There was excellent retention rates for both follow up periods with 100% of subjects responding at year 1 follow-up, and a loss of only three individuals for the year 3 follow up. Having two follow-up periods, as opposed to one, provided additional information on how the recurrence of low back pain evolves and the factors that may have initiated recurrence.
The researchers acknowledge that one weakness of their methodology was an inability to re-image multifidi at follow-up. The researchers acknowledge they cannot be certain that the multifidi CSA improvements observed at weeks 4 and 10 of the initial study period were maintained. Additionally, it may have been beneficial if the researchers coupled EMG analysis of multifidi during functional activities with ultra-sound imaging to provide more clarity regarding muscle structure versus muscle function.
It was interesting to note that between the 1 and 3 year follow-up the number and severity of recurrences plateaued . However, there was a significant difference between groups in the precipitating factors that triggered the episodes. 42% of the recurrences in the CON group were related to a specific trauma (implying that 58% were of insidious or unknown onset), whereas 100% of recurrences in the MRG were related to trauma. The types of trauma reported included motor vehicle accident (MVA), sports injuries and lifting injuries. While a human movement professional cannot do much to limit MVAs, it is possible that the additional component of motor control training during sport and lifting activities may help to further reduce recurrences of low back pain. Additional research is needed to determine the effectiveness of this type of approach, used in conjunction with multifidi re-training, for the various types of trauma that can result in low back pain.
Why is this study important?
This study is important because it demonstrates that despite research that shows similar resolution of symptoms between exercise and non-exercise intervention groups up to 6 months post acute low back pain, key deficits in the muscular stabilizing system of the spine remain. The atrophy of multifidi on the painful side does not return without specific intervention, which may result in an increased risk for recurrence. This study shows at the very least, that specific exercise intervention does produce a significant reduction in the incidences and severity of subsequent episodes. Individuals in this study, continued to reap the benefits of a four week intervention for the subsequent 3 years. This allows us to confidently educate our patients that re-training and exercise does have the power to change the long-term course of low back pain.
How does it affect practice?
A lumbar stabilization exercise intervention may be imperative to long-term recovery from low-back pain. This study provides us with critical information that we can share with our patients about why a lumbar stabilization/multifidi retraining exercise program is important for the long term health of their spine. It provides us with a "sales pitch" to encourage individuals to fully commit to this type of training program. It also serves as a reminder that regardless of our scope of practice, inquiring about a history of low back pain is key. Just because an individual is not painful when we see them, does not mean they have an optimally functioning stabilization system. It is always important to assess an individuals ability to perform basic stabilizing activities before progressing towards more challenging or ballistic physical activity.
How does it relate to Brookbush Institute Content?
This research supports the Brookbush Institute's approach to sequencing of exercise for core stabilization. The Brookbush Institute recommends the performance of isolated activation exercise, before compound, integrated and full body activities. Core progressions should generally begin with appropriate Transverse Abdominis (a.k.a. ISS ) activation. There is a connection between transverse abdominis and multifidus , more specifically these muscles are part of the Intrinsic Stabilization Subsystem - a group of muscles that function together to create inter-segmental stability of the lumbar spine. Various research studies and texts indicate this system becomes inhibited relative to Lumbo Pelvic Hip Complex Dysfunction (LPHCD). Starting a core progression with activation of the ISS encourages optimal function of the "local" intersegmental stabilizing system (including the multifidus ) prior to progressing to more challenging activities which require the coordination of both our intrinsic stabilization systems with global movement synergies. Below is a progression of videos designed to target the ISS . These activities may appear simple, however when special attention is paid to achieving perfect stabilization (i.e. via the softball balance challenge) they become extremely challenging.
Transverse Abdominis TVA Isolated Activation
TVA and Gluteus Maximus Activation and Progressions
Hardest Quadruped Progression Ever Challenge
Quadruped Crawl - NEW VIDEO!!!!
References
© 2015 Brent Brookbush
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