Who needs stabilization retraining for low back pain?
Stabilization exercises are typically prescribed to those who present with dysfunction with active movement screens as well as when they perform functional tasks. Stabilization doesn’t have to solely relate to those who present with low back pain. It becomes important to see how certain active movements and functions are performed so we can identify the most appropriate exercise prescription. Muscular systems must work in concert to allow individuals to complete specific tasks.
The Rabin et al study looked to determine those who were positive on lumbar stabilization clinical prediction rules (CPR) would exhibit a better outcome compared those who were negative to the CPR.3 Also, the study hypothesized that those who were positive on the CPR would have a better outcome to lumbar stabilization exercises as compared to those receiving manual therapy.3 The lumbar stabilization exercise group received similar exercises from the previous derivation study, however, they added functional movement patterns while performing an abdominal drawing in maneuver and maintaining a neutral lumbar spine; the manual therapy group received exercises that did not duplicate the lumbar stabilization exercise group and were designed to have minimal trunk activation.3 Patients receiving lumbar stabilization exercise demonstrated less disability compared to those who received manual therapy; those who were positive on the CPR experienced less disability by the end of treatment versus those who were negative on the CPR; no interactions or main effects were noted for pain on the MODI; the proportion of those who achieved a successful outcome with a reduction of 50% on the MODI did not differ between the 4 subgroups.3
When combined aberrant movements and a positive prone instability test, there was a significant 2-way interaction between the treatment group and the modified version of the CPR; the modified version indicated that patients receiving lumbar stabilization exercises demonstrated less disability compared to those who were negative on the CPR as well as those receiving lumbar stabilization exercises compared to receiving manual therapy; the modified CPR did not demonstrate final disability and there was no 2-way interaction or main effect.3 Perhaps the modified CPR is giving us more insight to discovering how to identify who may benefit from lumbar stabilization exercises.
I guess a question that I propose is, what really constitutes as stabilization retraining? Are we retraining specific correlating musculature? Or how a person moves? Or even both?
Is it important to assess and treat impairments in the transversus abdominis and multifidus?
It is important to look at the functionality of the stabilization muscle groups in individuals with low back pain. A study performed by Hides et al indicates the multifidi help to provide segmental stabilization and can be affected after injury, weakness, degenerative changes; the multifidi can be dysfunctional following disc surgery.1 According to the study, group 1 received medical management, including advice on bedrest, absence from work, prescription of medication, and advice to resume normal activity as tolerated; Group 2 (specific exercise group) additionally performed specific localized exercises aimed at restoring the stabilizing protective function of the multifidus including isometric holding in cocontraction with the transverse abdominis muscle.1 The short-term results indicated asymmetry of the multifidus muscle with decreased size on the unilateral painful side.1 Muscle recovery was more rapid and complete versus the control group; function and disability outcome measures were similar at the 4-week examination.1 One year after initial episode of back pain, patients in the control group were 12.4 times more likely to experience recurrences of low back pain than patients in the specific exercise group and 9 times as likely to experience low back pain recurrences in years 2-3.1 However, some of the results may be skewed as reports of recurrences of low back pain were manifested from traumatic incidents and heavy lifting accidents.1 Overall those in the experimental group had a lower recurrence of low back pain in contrast the control group. Perhaps maybe we need to concentrate on how the muscle engages, but how it performs with functional tasks.
The question we must as is, do we concentrate on contracting your multifidus and transverse abdominis isometrically during a 300-pound squat?
Global approach, local, or a hybrid?
Global and local approaches to stabilization training certainly have their respective indications. I tend to emphasize more function versus traditional localized retraining of specific areas. This goes back to understanding not only the patient’s impairments and functional limitations, but what are the patient’s wants and needs. What is the patient’s current believe system? What are the patient’s values and expectations? Therefore, we must understand the individual and use that as a guide to provide patient-focused care.
In a study by Koumantakis, they looked at the general exercise with specific stabilization exercises to general exercise only for those with recurrent nonspecific low back pain.2 For all self-report measures used (pain, disability, and all pain belief scales), the interaction of time with exercise class participation were not significant. 2 Both groups improved immediately following intervention and 3 months after for all outcome measures except for the PLC pain control subscale that remained unchanged. 2 The conclusion was that those who participating in general exercise only had a reduction in patient self-reported disability that was more effective immediately after the end of a 2-month exercise period. 2 I found it interesting how heavier load functional tasks were introduced in the last 3 weeks of the stabilization group. Perhaps we need to introduce this earlier in the exercise prescription to help with engaging the stabilizing musculature during functional tasks. As the study indicated they look at individuals with a recurrence of nonspecific low back pain. The ‘recurrence’ may need to be addressed early on.
The Answer?
While each question addressed various subtopics within lumbar stabilization training, the answer really depends on what the patient currently needs at that given point in time. Utilizing evidence- based practice will allow the clinician to better determine a clinical question, locate the highest level of research available, and apply that to the contextual nature of the patient.
Article written by Eric Trauber, PT, DPT, OCS, CSCS, FAAOMPT
References
- Hides JA, Jull GA, and Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. SPINE, 2001, 26(11): E243-E248.
- Koumantakis GA, Watson PJ, and Oldham JA. Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Physical Therapy, 2005, 85(3): 209-225.
- Rabin A, Shashua A, Pizem K, Dickstein R, and Dar G. A clinical prediction rule to identify patients with low back pain who are likely to experience short-term success following lumbar stabilization exercises: a randomized controlled validation study. Journal of Orthopaedic & Sports Physical Therapy, 2014, 44(1): 6-18.