Stabilisation exercises for low back pain: a systematic review

Abstract

Objectives

To examine the literature to determine if stabilisation exercises are effective for the treatment of pain and dysfunction in patients with low back pain.

Data sources

PubMed (MEDLINE), CINAHL, AMED, PEDro and the Cochrane Library were searched up to October 2006.

Review methods

Inclusion criteria were: randomised clinical trials; in English; full publications; subjects were adults with low back pain; one group received specific stabilisation exercises as the primary intervention; and outcome measures included some measure of pain and/or function. Following a systematic search of major databases, articles were scored according to the PEDro criteria for quality. Due to heterogeneity of specific interventions, control groups, duration of follow-up, outcome measures and study population, a meta-analysis was not conducted. A qualitative review was undertaken that focused on study quality, study population and type of control group.

Results

In total, 18 trials were included in the review; a large number of trials were excluded. There was little evidence to support the use of stabilisation exercises for acute low back pain. There was some evidence to support the use of stabilisation exercises in chronic back pain, with the majority of high-quality trials showing a significant difference in favour of stabilisation exercises. Overall, however, the evidence was conflicting, and significant differences favouring stabilisation exercises were less likely when they were compared with active treatment control groups rather than inactive control groups.

Conclusions

There may be a role for specific stabilisation exercises in some patients with chronic low back pain, but these are no more effective than other active interventions.

Introduction

Low back pain is extremely common. Whilst largely benign and self limiting, it is very costly to society as a whole, especially chronic low back pain and disability [1], [2], [3]. Most low back pain is treated conservatively by a range of interventions [4]. Exercises are frequently used by physical therapists for the treatment of low back pain. Specific exercises that activate abdominal and/or back extensor muscles are advocated to reduce pain and disability [5], [6], [7], [8]. It is claimed that there is a link between local muscle dysfunction and low back pain, with the development of clinical instability in which there is an excessive range of abnormal segmental movement without muscular control [6]. Thus, stabilisation exercises have been designed in order to enhance the neuromuscular control system and correct the dysfunction [6], [7], [8]. A number of randomised clinical trials (RCTs) have been performed to evaluate the effectiveness of stabilisation exercises [9], [10], [11], and there are some indications of long-term benefit regarding decreased recurrence of low back pain episodes and healthcare usage [12].

A large number of systematic reviews of exercises for low back pain have been conducted [13], [14], [15], [16], [17], [18], [19], [20]. The general conclusion is that exercises are ineffective for acute low back pain or as effective as other treatments, but are effective for chronic low back pain or more effective than other treatments. However, there is limited evidence for specific rather than general exercises. Strengthening exercises have been considered in some of these reviews [15], [18], [20], and along with stretching exercises have demonstrated the largest improvements compared with controls [21]. These classic trunk strengthening exercises involve activation of abdominal and paraspinal musculature at high levels of contraction. Such gross strengthening exercises differ from stabilisation exercises in which there is preferential training of stabilising muscles, initially with low-level isometric activation followed by progressive integration into everyday activities [6], [8]. If performed incorrectly, classic trunk strengthening exercises may lead to inappropriate muscle coordination patterns and increased risk of further injury [6], [22]. In addition, exercises that are said to preferentially select transversus abdominus and multifidus, as described by Richardson et al. [6] and O'Sullivan et al. [10], are distinguished [23] from general trunk stabilisation exercises, as described by McGill [7].

Two systematic reviews directly relevant to stabilisation exercises were located [24], [25]. One considered ‘therapeutic exercise in treating instability-related lumbar spine pain’ [24]. This review only included seven articles, and of these, only four were RCTs. No attempt was made to judge the quality of the studies, and the emphasis of the review was on the mechanism by which stabilisation exercises may work. The other systematic review [25] was published whilst the current review was in preparation and contained 13 studies. Of these, three were only available as abstracts at that time, one was published in German and one involved patients with neck pain and headache. Thus, eight of these studies would have met the inclusion criteria for the present review; however, the present authors had already located 16 studies so it seemed worth continuing with this more up-to-date review. The aim of this systematic review was to evaluate the effectiveness of stabilisation exercises in the treatment of pain and dysfunction from low back pain.