Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function
Various studies have shown that spine stabilisation exercise therapy elicits improvements in symptoms/disability in patients with chronic non-specific low back pain (cLBP). However, few have corroborated the intended mechanism of action by examining whether clinical improvements (1) are greater in patients with functional deficits of the targeted muscles and (2) correlate with post-treatment improvements in abdominal muscle function.
Pre and directly after 9 weeks’ therapy, 32 cLBP patients (44.0 ± 12.3 years) rated their LBP intensity (0–10) and disability (0–24, Roland–Morris; RM) and completed psychological questionnaires. At the same timepoints, the voluntary activation of transversus abdominis (TrA), obliquus internus and obliquus externus during “abdominal-hollowing” and the anticipatory (“feedforward”) activation of these muscles during rapid arm movements were measured using M-mode ultrasound with tissue Doppler imaging.
Pre-therapy to post-therapy, RM decreased from 8.9 ± 4.7 to 6.7 ± 4.3, and average pain, from 4.7 ± 1.7 to 3.5 ± 2.3 (each P < 0.01). The ability to voluntarily activate TrA increased by 4.5% (P = 0.045) whilst the anticipatory activation of the lateral abdominal muscles showed no significant change (P > 0.05). There was no significant correlation between the change in RM scores after therapy and either baseline values for voluntary (r = 0.24, P = 0.20) or anticipatory activation (r = 0.04, P = 0.84), or their changes after therapy (voluntary, r = 0.08, P = 0.66; anticipatory, r = 0.16, P = 0.40). In multiple regression, only a reduction in catastrophising (P = 0.0003) and in fingertip–floor distance (P = 0.0006) made unique contributions to explaining the variance in the reduction in RM scores.
Neither baseline lateral abdominal muscle function nor its improvement after a programme of stabilisation exercises was a statistical predictor of a good clinical outcome. It is hence difficult to attribute the therapeutic result to any specific effects of the exercises on these trunk muscles. The association between changes in catastrophising and outcome serves to encourage further investigation on larger groups of patients to clarify whether stabilisation exercises have some sort of “central” effect, unrelated to abdominal muscle function per se.
KeywordsSpine stabilisation exercise therapy Outcome Chronic low back pain
This work was supported by a grant from the Swiss National Research Program NRP 53 “Musculoskeletal Health-Chronic Pain” of the Swiss National Science Foundation (Project 405340-104787/2) and the Schulthess Klinik Research Funds. We would like to express our thanks to: Prof Beat A. Michel for providing the infrastructure to carry out this work within the Department of Rheumatology and Institute of Physical Medicine, University Hospital Zürich, Switzerland; Deborah Gubler and Valeriu Toma for their assistance with the data collection; the physiotherapists Martin Litschi, Tamar Bon, Konstanze Wagner, Elfi Raffainer, Luca Scascighini, Raymond Denzler, Wiebke Schubien, Manuela Meier, Melanie Knecht, Selina Bühler, Christina Gruber and Diana Brun-Walser for treating the patients and completing the necessary documentation; Doctors Bischoff, Camenzind, Distler, Haltinner, Klipstein, Rörig, Schmidt, Stärkle-Bär, Tamborrini, Thoma, Zimmermann (USZ), Bartanusz, Kramers-de Quervain, Marx, Pihan (Schulthess Klinik), Brunner (Balgrist), Kern, Kurmann, Schuler, Stössel and Zoller (GP practices) for referring patients into the study; all the patients who took part in the study.
Conflict of interest
- 6.Bandura A (1977) Self-efficacy: towards a unifying theory of behaviour change. Psychol Rev 84Google Scholar
- 8.Deyo RA (1998) Low-back pain. Scientific Am August 279:48–53Google Scholar
- 16.Gorbet N, Selkow NM, Hart JM, Saliba S (2010) No Difference in transverse abdominis activation ratio between healthy and asymptomatic low back pain patients during therapeutic exercise. Rehabil Res Practice 459738Google Scholar
- 18.Gubler D, Mannion AF, Schenk P, Gorelick M, Helbling D, Gerber H, Toma V, Sprott H (2010) Ultrasound tissue Doppler imaging reveals no delay in abdominal muscle feed-forward activity during rapid arm movements in patients with chronic low back pain. Spine (Phila Pa 1976) 35:1506–1513CrossRefGoogle Scholar
- 25.Hodges PW, Richardson C (1998) Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. J Spin Disord 11:46–56Google Scholar
- 30.Macedo L, Latimer J, Maher CG, Hodges P, Nicholas M, Tonkin L, McAuley J, Stafford R (2011) The effect of motor control exercise versus graded activity in patients with chronic nonspecific low back pain: immediate aftertreatment results from a randomised controlled trial (ACTRN12607000432415). International Society for the Study of the Lumbar Spine, SwedenGoogle Scholar
- 35.Mannion AF, Pulkovski N, Gubler D, Gorelick M, O’Riordan D, Loupas T, Schenk P, Gerber H, Sprott H (2008) Muscle thickness changes during abdominal hollowing: an assessment of between-day measurement error in controls and patients with chronic low back pain. Eur Spine J 17:494–501PubMedCrossRefGoogle Scholar
- 36.Mannion AF, Pulkovski N, Schenk P, Hodges PW, Gerber H, Gorelick M, Sprott H (2008) “Direction-dependent” feed-forward activation of transversus abdominis during rapid arm movements challenges its unique role in spine stabilisation. International Society for the Study of the Lumbar Spine (Spine Week). GenevaGoogle Scholar
- 37.Mannion AF, Pulkovski N, Schenk P, Hodges PW, Gerber H, Loupas T, Gorelick M, Sprott H (2008) A new method for the noninvasive determination of abdominal muscle feedforward activity based on tissue velocity information from tissue Doppler imaging. J Appl Physiol 104:1192–1201PubMedCrossRefGoogle Scholar
- 39.McGill SM (2004) Appropriate back exercise: from rehabilitation to high performance. 5th Interdisciplinary World Congress on low back and pelvic pain, pp 229–235Google Scholar
- 44.Pinto RZ, Ferreira PH, Franco MR, Ferreira MC, Ferreira ML, Teixeira-Salmela LF, Oliveira VC, Maher C (2011) The effect of lumbar posture on abdominal muscle thickness during an isometric leg task in people with and without non-specific low back pain. Man Ther 16(6):578–584Google Scholar
- 45.Pinto RZ, Ferreira PH, Franco MR, Ferreira ML, Ferreira MC, Teixeira-Salmela LF, Maher CG (2011) Effect of 2 lumbar spine postures on transversus abdominis muscle thickness during a voluntary contraction in people with and without low back pain. J Manipulative Physiol Ther 34:164–172PubMedCrossRefGoogle Scholar
- 47.Pulkovski N, Mannion AF, Caporaso F, Toma V, Gubler D, Helbling D, Sprott H (2011) Ultrasound assessment of transversus abdominis muscle contraction ratio during abdominal hollowing: a useful tool to distinguish between patients with chronic low back pain and healthy controls? Eur Spine J. doi: 10.1007/s00586-011-1707-8
- 49.Richardson C, Jull G, Hodges P, Hides J (1999) Therapeutic exercise for spinal segmental stabilization in low back pain: scientific basis and clinical approach. Churchill Livingstone, EdinburghGoogle Scholar
- 52.Smeets R (2006) Active rehabilitation for chronic low back pain: cognitive-behavioural, physical, or both?. University of Maastricht, MaastrichtGoogle Scholar
- 55.Steiger F, Wirth B, de Bruin ED, Mannion AF (2011) Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. Eur Spine J. doi: 10.1007/s00586-011-2045-6