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Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function

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Abstract

Introduction

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.

Methods

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.

Results

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.

Conclusion

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.

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References

  1. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G et al (2006) Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 15(Suppl 2):S192–S300

    Article  PubMed  Google Scholar 

  2. Allison GT (2003) Trunk muscle onset detection technique for EMG signals with ECG artefact. J Electromyogr Kinesiol 13:209–216

    Article  PubMed  CAS  Google Scholar 

  3. Allison GT, Henry SM (2002) The influence of fatigue on trunk muscle responses to sudden arm movements, a pilot study. Clin Biomech (Bristol, Avon) 17:414–417

    Article  CAS  Google Scholar 

  4. Allison GT, Morris SL (2008) Transversus abdominis and core stability—has the pendulum swung? Br J Sports Med 42:930–931

    Article  PubMed  CAS  Google Scholar 

  5. Allison GT, Morris SL, Lay B (2008) Feedforward responses of transversus abdominis are directionally specific and act asymmetrically: implications for core stability theories. J Orthop Sports Phys Ther 38:228–237

    PubMed  Google Scholar 

  6. Bandura A (1977) Self-efficacy: towards a unifying theory of behaviour change. Psychol Rev 84

  7. Critchley DJ, Coutts FJ (2002) Abdominal muscle function in chronic low back pain patients. Physiotherapy 88:322–332

    Article  Google Scholar 

  8. Deyo RA (1998) Low-back pain. Scientific Am August 279:48–53

    Google Scholar 

  9. Exner V, Keel P (2000) Erfassung der Behinderung bei Patienten mit chronischen Rückenschmerzen. Schmerz 14:392–400

    Article  PubMed  CAS  Google Scholar 

  10. Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, Maher CG, Refshauge KM (2007) Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomized trial. Pain 131:31–37

    Article  PubMed  Google Scholar 

  11. Ferreira PH, Ferreira ML, Hodges PW (2004) Changes in recruitment of the abdominal muscles in people with low back pain: ultrasound measurement of muscle activity. Spine 29:2560–2566

    Article  PubMed  Google Scholar 

  12. Ferreira PH, Ferreira ML, Maher CG, Herbert RD, Refshauge K (2006) Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Aust J Physiother 52:79–88

    Article  PubMed  Google Scholar 

  13. Ferreira PH, Ferreira ML, Maher CG, Refshauge K, Herbert RD, Hodges PW (2010) Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain. Br J Sports Med 44:1166–1172

    Article  PubMed  CAS  Google Scholar 

  14. Flor H (2003) Cortical reorganisation and chronic pain: implications for rehabilitation. J Rehabil Med 41:66–72

    Article  PubMed  Google Scholar 

  15. Franca FR, Burke TN, Hanada ES, Marques AP (2010) Segmental stabilization and muscular strengthening in chronic low back pain: a comparative study. Clinics (Sao Paulo) 65:1013–1017

    Article  Google 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 459738

  17. Greenough CG, Fraser RD (1991) Comparison of eight psychometric instruments in unselected patients with back pain. Spine 16:1068–1074

    Article  PubMed  CAS  Google 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) 35:1506–1513

    Article  Google Scholar 

  19. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML (2011) The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther 90:1099–1110

    Article  Google Scholar 

  20. Henry SM, Teyhen DS (2007) Ultrasound imaging as a feedback tool in the rehabilitation of trunk muscle dysfunction for people with low back pain. J Orthop Sports Phys Ther 37:627–634

    PubMed  Google Scholar 

  21. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G (2000) Development of recommendations for SEMG sensors and sensor placement procedures. J Electromyogr Kinesiol 10:361–374

    Article  PubMed  CAS  Google Scholar 

  22. Hodges PW (2001) Changes in motor planning of feedforward postural responses of the trunk muscles in low back pain. Exp Brain Res 141:261–266

    Article  PubMed  CAS  Google Scholar 

  23. Hodges PW (2003) Core stability exercise in chronic low back pain. Orthop Clin North Am 34:245–254

    Article  PubMed  Google Scholar 

  24. Hodges PW, Moseley G (2003) Pain and motor control of the lumbopelvic region: effect and possible mechanisms. J Electromyogr Kinesiol 13:361–370

    Article  PubMed  Google 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 11:46–56

    CAS  Google Scholar 

  26. Hodges PW, Richardson CA (1996) Inefficient muscular stabilisation of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine 21:2640–2650

    Article  PubMed  CAS  Google Scholar 

  27. Hodges PW, Richardson CA (1999) Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Arch Phys Med Rehabil 80:1005–1012

    Article  PubMed  CAS  Google Scholar 

  28. Jansen JA, Mens JM, Backx FJ, Stam HJ (2009) Changes in abdominal muscle thickness measured by ultrasound are not associated with recovery in athletes with longstanding groin pain associated with resisted hip adduction. J Orthop Sports Phys Ther 39:724–732

    PubMed  CAS  Google Scholar 

  29. Kavcic N, Grenier S, McGill SM (2004) Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine 29:1254–1265

    Article  PubMed  Google 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, Sweden

    Google Scholar 

  31. Mannion AF, Balague F, Pellise F, Cedraschi C (2007) Pain measurement in patients with low back pain. Nat Clin Pract Rheumatol 3:610–618

    Article  PubMed  Google Scholar 

  32. Mannion AF, Helbling D, Pulkovski N, Sprott H (2009) Spinal segmental stabilisation exercises for chronic low back pain: programme adherence and its influence on clinical outcome. Eur Spine J 18:1881–1891

    Article  PubMed  Google Scholar 

  33. Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K, Dvorak J (2001) Active therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy. Spine 26:920–929

    Article  PubMed  CAS  Google Scholar 

  34. Mannion AF, Müntener M, Taimela S, Dvorak J (1999) A randomised clinical trial of three active therapies for chronic low back pain. Spine 24:2435–2448

    Article  PubMed  CAS  Google 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 17:494–501

    Article  PubMed  Google 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). Geneva

  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 104:1192–1201

    Article  PubMed  CAS  Google Scholar 

  38. Mannion AF, Pulkovski N, Toma V, Sprott H (2008) Abdominal muscle size and symmetry at rest and during abdominal hollowing exercises in healthy control subjects. J Anat 213:173–182

    Article  PubMed  CAS  Google Scholar 

  39. McGill SM (2004) Appropriate back exercise: from rehabilitation to high performance. 5th Interdisciplinary World Congress on low back and pelvic pain, pp 229–235

  40. McGill SM, Grenier S, Kavcic N, Cholewicki J (2003) Coordination of muscle activity to assure stability of the lumbar spine. J Electromyogr Kinesiol 13:353–359

    Article  PubMed  Google Scholar 

  41. Meyer K, Sprott H, Mannion AF (2008) Cross-cultural adaptation, reliability, and validity of the German version of the Pain Catastrophizing Scale. J Psychosom Res 64:469–478

    Article  PubMed  Google Scholar 

  42. Misuri G, Colagrande S, Gorini M, Iandelli I, Mancini M, Duranti R, Scano G (1997) In vivo ultrasound assessment of respiratory function of abdominal muscles in normal subjects. Eur Respir J 10:2861–2867

    Article  PubMed  CAS  Google Scholar 

  43. Perneger TV (1998) What’s wrong with Bonferroni adjustments. BMJ 316:1236–1238

    Article  PubMed  CAS  Google 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):578–584

    Google 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 34:164–172

    Article  PubMed  Google Scholar 

  46. Puhl AA, Reinhart CJ, Rok ER, Injeyan HS (2011) An examination of the observed placebo effect associated with the treatment of low back pain—a systematic review. Pain Res Manag 16:45–52

    PubMed  Google 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

  48. Rackwitz B, de Bie R, Limm H, von Garnier K, Ewert T, Stucki G (2006) Segmental stabilizing exercises and low back pain. What is the evidence? A systematic review of randomized controlled trials. Clin Rehabil 20:553–567

    Article  PubMed  Google Scholar 

  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, Edinburgh

    Google Scholar 

  50. Roland M, Fairbank J (2000) The Roland–Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine 25:3115–3124

    Article  PubMed  CAS  Google Scholar 

  51. Rubinstein SM, van Middelkoop M, Kuijpers T, Ostelo R, Verhagen AP, de Boer MR, Koes BW, van Tulder MW (2010) A systematic review on the effectiveness of complementary and alternative medicine for chronic non-specific low-back pain. Eur Spine J 19:1213–1228

    Article  PubMed  Google Scholar 

  52. Smeets R (2006) Active rehabilitation for chronic low back pain: cognitive-behavioural, physical, or both?. University of Maastricht, Maastricht

    Google Scholar 

  53. Smeets RJ, Vlaeyen JW, Kester AD, Knottnerus JA (2006) Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain 7:261–271

    Article  PubMed  Google Scholar 

  54. Staerkle R, Mannion AF, Elfering A, Junge A, Semmer NK, Jacobshagen N, Grob D, Dvorak J, Boos N (2004) Longitudinal validation of the fear-avoidance beliefs questionnaire (FABQ) in a Swiss-German sample of low back pain patients. Eur Spine J 13:332–340

    Article  PubMed  Google 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

  56. Sullivan M, Bishop S, Pivik J (1995) The pain catastrophising scale. Development and validation. Psychol Assess 7:524–532

    Article  Google Scholar 

  57. Teyhen DS, Miltenberger CE, Deiters HM, Del Toro YM, Pulliam JN, Childs JD, Boyles RE, Flynn TW (2005) The use of ultrasound imaging of the abdominal drawing-in maneuver in subjects with low back pain. J Orthop Sports Phys Ther 35:346–355

    PubMed  Google Scholar 

  58. Tsao H, Hodges PW (2008) Persistence of improvements in postural strategies following motor control training in people with recurrent low back pain. J Electromyogr Kinesiol 18:559–567

    Article  PubMed  Google Scholar 

  59. van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, van Tulder MW (2011) A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J 20:19–39

    Article  PubMed  Google Scholar 

  60. Vasseljen O, Dahl HH, Mork PJ, Torp HG (2006) Muscle activity onset in the lumbar multifidus muscle recorded simultaneously by ultrasound imaging and intramuscular electromyography. Clin Biomech (Bristol, Avon) 21:905–913

    Article  Google Scholar 

  61. Vasseljen O, Fladmark AM (2010) Abdominal muscle contraction thickness and function after specific and general exercises: a randomized controlled trial in chronic low back pain patients. Man Ther 15:482–489

    Article  PubMed  Google Scholar 

  62. Vasseljen O, Fladmark AM, Westad C, Torp HG (2009) Onset in abdominal muscles recorded simultaneously by ultrasound imaging and intramuscular electromyography. J Electromyogr Kinesiol 19:e23–e31

    Article  PubMed  Google Scholar 

  63. Vlaeyen JWS, Kole-Snijders AMJ, Rotteveel AM, Ruesink R, Heuts PHTG (1995) The role of fear of movement/(re)injury in pain disability. J Occ Rehab 5:235–252

    Article  Google Scholar 

  64. Waddell G (1996) Low back pain: twentieth century health care enigma. Spine 21:2820–2825

    Article  PubMed  CAS  Google Scholar 

  65. Waddell G, Newton M, Henderson I, Somerville D, Main CJ (1993) A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 52:157–168

    Article  PubMed  CAS  Google Scholar 

  66. Wand BM, O’Connell NE (2008) Chronic non-specific low back pain—sub-groups or a single mechanism? BMC Musculoskelet Disord 9:11

    Article  PubMed  Google Scholar 

  67. Westad C, Mork PJ, Vasseljen O (2010) Location and sequence of muscle onset in deep abdominal muscles measured by different modes of ultrasound imaging. J Electromyogr Kinesiol 20:994–999

    Article  PubMed  Google Scholar 

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Acknowledgments

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.

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Mannion, A.F., Caporaso, F., Pulkovski, N. et al. Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function. Eur Spine J 21, 1301–1310 (2012). https://doi.org/10.1007/s00586-012-2155-9

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