Trunk Muscle Stabilization Training Plus General Exercise Versus General Exercise Only: Randomized Controlled Trial of Patients With Recurrent Low Back Pain

Research Report 䢇 Trunk Muscle Stabilization Training Plus General Exercise Versus General Exercise Only: Randomized Controlled Trial of Patients With Recurrent Low Back Pain Key Words: Exercise, Low back pain, Randomized controlled trial, Rehabilitation, Stabilization. ўўўўў George A Koumantakis, Paul J Watson, Jacqueline A Oldham Physical Therapy . Volume 85 . Number 3 . March 2005 209 ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў APTA is a sponsor of the Decade, an international, multidisciplinary initiative to improve health-related quality of life for people with musculoskeletal disorders. Background and Purpose. The purpose of this randomized controlled trial was to examine the usefulness of the addition of specific stabilization exercises to a general back and abdominal muscle exercise approach for patients with subacute or chronic nonspecific back pain by comparing a specific muscle stabilization– enhanced general exercise approach with a general exercise– only approach. Subjects. Fiftyfive patients with recurrent, nonspecific back pain (stabilization– enhanced exercise group: n⫽29, general exercise– only group: n⫽26) and no clinical signs suggesting spinal instability were recruited. Methods. Both groups received an 8-week exercise intervention and written advice (The Back Book). Outcome was based on self-reported pain (Short-Form McGill Pain Questionnaire), disability (RolandMorris Disability Questionnaire), and cognitive status (Pain SelfEfficacy Questionnaire, Tampa Scale of Kinesiophobia, Pain Locus of Control Scale) measured immediately before and after intervention and 3 months after the end of the intervention period. Results. Outcome measures for both groups improved. Furthermore, selfreported disability improved more in the general exercise– only group immediately after intervention but not at the 3-month follow-up. There were generally no differences between the 2 exercise approaches for any of the other outcomes. Discussion and Conclusion. A general exercise program reduced disability in the short term to a greater extent than a stabilization– enhanced exercise approach in patients with recurrent nonspecific low back pain. Stabilization exercises do not appear to provide additional benefit to patients with subacute or chronic low back pain who have no clinical signs suggesting the presence of spinal instability. [Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Phys Ther. 2005;85:209 –225.] T here is ample evidence that active approaches to the rehabilitation of patients with subacute and chronic low back pain (LBP) are beneficial.1,2 Exercise therapy, as an approach that engages patients in activity, can be useful after the acute stage of LBP; however, positive results have been documented with different types of exercise utilized by physical therapists, suggesting there is little evidence that a particular “type” of exercise is any better than another.3 As new training methods are emerging, a better understanding of the effects of such techniques on patient status is currently considered an important area of research.4,5 What remains currently unknown is whether stabilization exercises are better suited to certain types of patients or whether they can be generally applied to any patient with LBP. Unsubstantiated suggestions that stabilization training may be useful in reducing pain and disability for all patients with nonspecific LBP have appeared in the literature,16 –19 but these assertions have not been definitively demonstrated. No RCT has tested the assertion that stabilization training is beneficial in a sample of patients with subacute or nonspecific chronic LBP using pain and disability as outcomes. In a study of patients with acute nonspecific LBP,20 stabilization training for the multifidus muscle was found to be less effective on its own than when combined with a course of manipulative therapy. Therefore, the particular RCT has shown an additional benefit of manipulative therapy over stabilization exercise prescription for acute LBP, in line with current reviews supporting the use of manipulation at an acute stage of symptoms.3 Some evidence supports the role of stabilization exercises in LBP with respect to symptom recurrence, but the 2 relevant RCTs have been conducted in specific subgroups of patients with LBP.11,12 The first study11 compared stabilization exercise against standardized medical care (analgesics, advice). Participants were required to have acute first-episode unilateral LBP and betweensides asymmetry in multifidus muscle cross-sectional area (CSA) of more than 11%.11 A 3-year follow-up showed a link between improvement in multifidus muscle CSA GA Koumantakis, PT, PhD, MCSP, is Lecturer, School of Physical Therapy, Athens, Greece, and Private Practitioner, Drosopoulou 6, Kypseli, Athens, 112 57, Greece (). Address all correspondence to Dr Koumantakis. PJ Watson, PT, PhD, MCSP, is Senior Lecturer, Division of Anaesthesia and Pain Management, University of Leicester, Leicester, Leicestershire, United Kingdom. JA Oldham, PhD, is Professor, Centre for Rehabilitation Science, University of Manchester, Manchester, Cheshire, United Kingdom. All authors provided concept/idea/research design. Dr Koumantakis provided writing, data collection and analysis, fund procurement, and subjects. Dr Koumantakis and Dr Oldham provided project management. Dr Oldham provided facilities/equipment and institutional liaisons. Dr Watson provided consultation (including review of manuscript before submission). The authors thank Mr Andre Kocialkowski, FRCS(Orths), for his support of the trial and Mrs Fiona Randall, PT, MCSP, for managing the patients who participated in this study. Study approval was obtained from the Central Manchester Ethics Committee at the University of Manchester. This research was presented, in part, at the 14th International Congress of the World Confederation for Physical Therapy; June 7–12, 2003; Barcelona, Spain. This study was primarily funded by the Greek State Scholarships Foundation (IKY), Athens, Greece (grant T104830098), and by a supplementary grant (99/2) from the Hospital Saving Association (HSA), London, United Kingdom. This article was received July 24, 2003, and was accepted August 24, 2004. 210 . Koumantakis et al Physical Therapy . Volume 85 . Number 3 . March 2005 Classic trunk exercises performed in physical therapy activate the abdominal and paraspinal muscles as a whole and at a relatively high contraction level.6,7 Although there are several randomized controlled trials (RCTs) on the usefulness of classic trunk exercises,8 –10 increasing a (...truncated)