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Indian Journal of Physiotherapy and Occupational Therapy

Comparison of Effects of Specific Stabilization Exercises and Conventional Back Extension Exercises in Management of Chronic Disc Prolapse

Author(s): Kaul Rohini, Thakral Gaurav, Sandhu Jaspal Singh

Vol. 1, No. 3 (2007-07 - 2007-09)

Print-ISSN: 0973-5666, Electronic - ISSN: 0973-5674,

(1)Kaul Rohini, (2)Thakral Gaurav, (3)Sandhu Jaspal Singh

(1) MSPT Student, (2)Lecturer, (3)Dean and Head, Department of Sports Medicine and Physiotherapy Guru Nanak Dev University, Amritsar

ABSTRACT

The concept of spinal segmental stabilization in one of the least explored intervention in the management of back pain. The purpose of the study was to examine usefulness of stabilization exercises for athletes with chronic disc prolapse. Twelve subjects who were sport persons (age: 20- 40 yrs) with MRI findings of disc protrusion and were randomly assigned to three groups viz. Group I (n=4) stabilization exercise regimen, Group II (n=4) conventional extension exercise regimen and Group III (n=4) control. The two experimental groups participated in four weeks of treatment program, five times a week. Outcome was based on self reported pain (visual analogue scale), disability (Ronald and Morris disability questionnaire) and custom made barobag testing of transversus abdominis measured immediately before and after intervention program. Outcome measures of self-reported pain and disability were reduced for both experimental groups. Furthermore, motor control deficit was reduced in stabilization exercise group after intervention period.

A 'Specific Stabilization Exercise' treatment approach appears effective in athletes with chronic disc prolapse.

KEYWORDS: Disc prolapse, conventional exercises, stabilization exercises

INTRODUCTION

Athletes are at greater risk of sustaining a lower lumbar spine injury as they perform demanding tasks and sometimes they damage their intervertebral disc because of excessive weight bearing.

Therapists have known for a long time that performing knee rehabilitation without first training the vastus medialis oblique (VMO) which is a local stability muscle can lead to patellofemoral problems and the same concept is being used on patients with low back pain. This concept of retraining the local stability system in people with low back pain has made its way into the physical therapy setting within the last four to five years and is not altogether a new concept. The concept is to create stiffness in the spine before load is placed on the spine, thus controlling mid range or neutral zone. Control of this mid range helps to reduce shear force and compression during movement and spinal loading. When working properly, the local intrinsic musculature fibers before the actual motion of an extremity or of the trunk occurs. Thus pre-contraction of the intrinsic musculature can become delayed or inhibited in the presence of pain or pathology. This delay, or inhibition of the stability system, decreases a patient's ability to control a joint neutral position during movement or under load. (1)

A prolapsed disc was defined as one that protruded beyond the vertebral body margin but contained within an intact annulus. (2) The experiment on cadaveric motion segments showed that compressive damage to the vertebral body endplate alters the distribution of matrix compressive stress in the adjacent intervertebral disc. The annulus is decompressed, and stress peaks appear in the annulus. Subsequent cyclic loading made these changes worse, and there was some evidence to suggest that the annulus was collapsing gradually into the decompressed nucleus. (3)

Adolescent disc herniation is uncommon and is often caused by trauma. The natural history of disc herniation in adolescents is not known. Clinical presentation may be the same as that in adults with less hard neurological signs. Conservative treatment is the mainstream care and has shown the compatible results in treating adolescent lumbar disc herniation in a Tae Kwon Do martial artist, as recorded for surgical interventions. (4)

Specific back exercises that focus on deep stabilizing muscles have proven to reverse motor control deficits that occur after back injury or degenerative change. The most significant finding thus for is that people who do not retrain their deep stabilizing muscles are 12.4 times more likely to have recurrence of back pain within three years.(5)

The typical back exercise programs, like gymbased rehabilitation program, pool therapy, and pilates are too advanced for low back pain patients prior to retraining the tonic holding capacity and isolated co-contraction of multifidus (MF) and transversus abdominis (TrA).(6) With many programs, the stabilizing muscle activity tends to be trained in a phasic pattern, which does not lead to improvement in tonic holding capacity of the deep muscles. (6)

The co-contraction of the TrA and the MF muscles occurred prior to any movement of the limbs. This suggests that these muscles anticipate dynamic forces, which may act on the lumbar spine and stabilize the area prior to any movement. They also showed that the timing of co-ordination of these muscles was very significant, and that back injury patients were unable to recruit their TrA and MF muscles early enough to stabilize the spine prior to movement. (7) Furthermore, the MF muscle showed poor recruitment in back injury patients, again showing how the recruitment of these deep trunk muscles is very important. (8)

The static holding component between the concentric and eccentric phase is critical in inducing muscles hypertrophy during first 10 weeks. The dynamic static training mode has been recommended in order to recruit as many motor units as possible. The result indicated that the physiological adaptations of the MF muscle to pure dynamic and combined static dynamic muscle activity are different, to such an extent that a systematic difference in CSA (Cross Sectional Area) could be found. (9)

The abdominal-hallowing exercise does not produce as much RA (Rectus abdominis) and EO (external oblique) muscle activity as the pelvic tilt. Furthermore, the abdominal-hallowing exercise can be performed, without increased activation of the RA and EO muscles in the standard and legs-supported position. These findings should be considered when selecting rehabilitation exercises for neuromuscular retraining of the abdominal muscles. (10)

The aim of this study was to investigate whether specific stabilization exercises or conventional back extension exercises are effective in athletes with chronic intervertebral disc prolapse. Our experimental hypothesis was that training programs consisting of specific stabilization exercises or conventional back extension exercises would be effective in reducing patient self-reported pain, disability and improving activity of deep stabilizing muscles (Transversus Abdominis and Multifidus) as these muscles undergo atrophy after injury.

MATERIALS AND METHODS

STUDY DESIGN

The present study was different subject experimental design. Sample consisted of twelve sports person (M=6, F=2) with intervertebral disc prolapse in the age group of 20-40 years. Subjects i.e. 3 footballers, 2 basket ballers, 3 weight lifters, 1 judo player and 3 wrestlers were randomly assigned into three groups. Group I (n=4) specific stabilization exercise group, Group II (n=4) conventional back extension exercise group and Group III (n=4) control.

SUBJECTS

Patients were recruited from the Punjab Armed Police headquarters, Jalandhar (Punjab). Patients took part in the study after informed consent had been obtained using inclusion criteria that all subjects were sports person (both males and females) with no cardiovascular disorder. Patients were eligible for the study if they had a history of recurrent episodes of back pain with at least one primary complaint of leg pain. All patients included in the trial had a prior clinical examination by their physician, including magnetic resonance imaging scan. Patients with previous spinal surgery, radiological diagnosis of spondylosis/ spondylolisthesis, lumbar scoliosis and cauda equina compression were excluded.

PROCEDURE

Pain perception was measured using the Visual Analogue Scale (VAS), a responsive pain scale that yields reliable and valid data. (11) Disability was measured using the Ronald-Morris Disability Questionnaire (RMDQ), a 24-item scale (0= 'no disability'), (24= 'highest disability') with clinically acceptable reliability and validity. (12)

Motor control deficit was measured by custommade barobag and its validity, reliability and efficacy in comparison to the standard stabilizer was proved. The indigenous Barobag, being more cost effective and easy to construct, can be used clinically as an alternative to the stabilizer. (13)

BAROBAG

(Self Devised Bio-feedback pressure Cuff Unit) was assembled by connecting a blood bag (JML, Haryana, India) of 450 ml capacity to the pressure dial (measuring 0-300mmHg) and the inflation gauge from the Aneroid Sphygmomanometer (desk model, CE0483). Few modifications were made in the blood bag by ressecting the two needle pipes in the middle and tying multiple knots to prevent air leakage. Further, sufficient opening was made into the two closed corners to take out the sterile solution (CPDA). Then two tubes of adequate length were cut out of TUR Irrigating Arthroscopy tube. To one end of the tube, one valve was inserted whose other end was further inserted into the blood bag opening, while at the other end an inflation gauge was inserted. Then similarly at one end of the second tube a valve was inserted which was further inserted into bag's other opening while the other end of the tube was joined to the pressure dial. These connections were fixed with the help of fixing material. It was made sure that air was not leaking through these connections.

Five tests were performed with barobag.

  • Transversus abdominis activation test (TrAAT) ” The abdominal drawing in test.
  • Progressive leg loading test level 1 task 1 (PLLT-I) ” Single leg slide (leg slide with heel support to full extension and return) with contra lateral leg support.
  • Progressive leg loading test level 1 task 2 (PLLT-II) ” Unsupported single leg slide (the heel held approximately 5cm from the exercise surface) with contralateral leg support.
  • Progressive leg loading test level 2 task 3 (PLLT-III) ” Single leg slide (leg slide with heel support to full extension and return) with contralateral leg unsupported.
  • Progressive leg loading test level 2 task 4 (PLLT-IV) ” Unsupported singe leg slide (the heel is held approximately 5cm from the exercise surface) with contralateral leg unsupported.

Both experimental groups followed two different exercise regimens separately. Experimental group (Group I) performed specific stabilization exercises.

Experimental group (Group II) performed conventional back extension exercises and control group (Group III) was not given any treatment.

Both the intervention periods were for 4 weeks at a frequency of 5 times/week for 30-45 min. Each exercise consists of 3 sets and 10 repetitions (10 sec hold) in each set. Progression was made when a patient was able to perform three sets of 10 to 15 repetitions of an exercise with ease.

WEEK EXPERIMENTAL GROUP I EXPERIMENTAL GROUP II
I
  • Transversus abdominis contraction in crook lying position (Drawing in)
  • 4 point kneeling and trying to hollow the lower abdominal
  • Prone with single arm/ leg lifts
  • Prone with single arm/ leg lifts
  • Prone with alternate arm and leg lifts
  • Alternate supine arm and leg twist
II
  • Transversus abdominis contraction in sitting and standing
  • Heel slides with transversus abdominis contraction
  • Single leg hip rotation/ abduction keeping spine in neutral position
  • Prone on elbows
  • Prone with double-arm/ leg lifts
  • Hip lifts from side lying position
III
  • Abdominal hollowing with legs supported and hips and knees at 90°
  • Bridging with spine neutral position
  • Quadruped exercise, tighten the trunk musculature and hold the spine in neutral Extend one arm/leg
  • Prone on hands
  • Quadruped position and extend one arm/leg
  • Bridging exercise
  • Advanced hip lifts in side lying position
IV
  • Abdominal hallowing with legs unsupported and hips and knees at 90° Quadruped exercise with spine in neutral position and extend alternate arm and leg
  • Single leg bridging with spine in neutral position
  • Single leg bridging
  • Quadruped position and extend alternate arm and leg
  • Prone with both double arm and double leg lifts

STATISTICS

To assess changes within each group after the intervention period and between groups, the raw data were used and analyzed with the student 't'-test and One Way Analysis of Variance (ANOVA). For statistical analysis, the software SPSS 14.0 was used. The level of significance was set at pŁ0.05 for all comparisons.

RESULTS

Table 1 shows the comparison within three groups before and after four weeks of treatment using One Way Analysis of Variance. Further analysis was done using Scheffe's multiple range test.

In case of VAS, significant differences were obtained between Group I-III (F=28.45) and Group II-III (F=32.66). Significant differences were also obtained between Group I-III (F=29.55) and Group II-III (F=13.13) in case of disability. But no significant result between Group I-II in reducing pain and disability. Thus both the experimental groups helped in reducing pain and disability after four weeks of treatment.

For transversus abdominis activation test statistically significant results were obtained between Group I-III (F=70.52) and Group I-II (F=54.61) and no significance between Group II- III. For progressive leg loading test task 1, Group I-III (F=15.25) showed statistical significance and no statistical significance between Group II- III and Group I - II. In case of progressive leg loading test task 2, statistical significance were obtained between Group I-III (F=16.31) and Group I- II (F=19.95). Progressive leg loading test task 3 and task 4 showed statistically significant results between group I-III (F=10.44 and 8.93) respectively.

Thus group I (stabilization exercises) was better in reducing motor control deficit.

DISCUSSION

Some exercise programs (often called 'General Exercise Programs') are designed to enhance trunk performance through the training of long trunk muscles (erector spinae and rectus abdominis), whose primary function is to generate movement. However, current research has shown that in most cases of chronic low back pain, certain muscles of the back (multifidus and transversus abdominis) that stabilize the spine are reflexively inhibited after injury. (14,15) These stability muscles do not simultaneously recover even if patients are pain-free with a return to normal activity levels. Enhancement of function of such muscles may improve trunk muscle strength, endurance and flexibility. Therefore, research examining the effects of exercise programs (often called 'stabilization programs') that aim to improve trunk stability and strength by training such muscles is worthwhile.

Participation in sports appears to be a risk factor for the development of disc degeneration. Every sport places unique demands on the lumbar spine and, in turn, the intervertebral disc. The elite athletes have a greater prevalence and greater degree of lumbar disc degeneration than the normal population. (16) The magnitude of the loads on the L4-5 motion segment during football blocking exceed those determined during fatigue studies to cause pathologic changes in both the lumbar disc and the pars interarticularis. The mechanics of repetitive blocking may be responsible for the increased incidence of lumbar spine injury incurred by football linemen. (17) In another study, forces in the L4-L5 motion segment in competitive weight lifters was measured and the average compressive loads were more than 17,000N. (18) In a similar study when a person performed halfsquat exercises with weights approximately 1.6 times body weight, compressive loads across the L3-L4 motion segment were six to ten times body weight. These investigators found that increasing lumbar flexion was the most influential factor affecting compressive loads. (19)

With the barobag, the subjects to detect lumbar spinal segmental stabilization deficit in deep local muscles of low back performed abdominal drawing in test and four tasks of progressive leg loading tests. (13) The criteria of considering this test of proper transversus abdominis activation as a reduction in mean pressure 6-10 mm of Hg and had used the EMG and real time ultrasound evidence to come to this conclusion. (5) The transversus abdominis activation elicited by drawing in the abdominal wall is associated, with the activation of lumbar multifidus at segmental level.

They evaluated the specific and specialized relationship between these two muscles. (5) The cocontraction of multifidus and transversus abdominis simulate the action of activating a deep muscles corset, which provide mechanical support to the lumbar spinal segments and lumbopelvic region. (20)

The specific stabilization exercises were better in improving motor control deficit and thus prevented recurrent episodes of back pain. (6,21-22)

Specific stabilization exercise approach was more effective than other commonly prescribed conservation treatment programs in patients with chronically symptomatic spondylolysis and spondylolisthesis. (22) In similar study the multifidus muscle recovery was more rapid and more complete in patients with first episode low back pain after receiving specific, localized, exercise therapy. (8) One more study suggested that the lumbar stabilizing exercises improved lumbar function in patients with low back injury and hence their activities of daily living. (23)

Evidence on the role of stabilization modalities in chronic low back pain with respect to symptom recurrence led to controversial conclusions.

In particular, some studies supported the use of stabilization exercise program over general exercise programs for improving the cross- sectional area of the multifidus, (8,21) whereas other studies found the opposite results that an eight week of general exercise program reduced pain in a short term to a great extent that did a stabilization enhanced exercise approach in patients with recurrent non specific low back pain. (24) Most rehabilitation specialists prescribe therapeutic exercises for low back pain that aims to use larger, superficial musculature in an attempt to stabilize the spine. These exercises have recently evolved into functional capacity training. Although this may be appropriate in later stages of rehabilitation especially for athletes and those who perform heavy labor.

In the present study the specific stabilization exercises and conventional back extension exercises were effective in reducing pain and disability. Motor control deficit, a major cause of recurrent episodes of back pain was improved only by specific stabilization exercises. Thus the main aim of rehabilitation programs should improve patient function and quality of life, not just treat pain. They must teach patients how to control their lumbar dysfunction so that pain does not dictate their life-style.

CONCLUSION

It is concluded that both the specific stabilization exercises and conventional back extension exercises are effective in reducing pain and disability. Motor control deficit, a major cause of back pain is significantly reduced by specific stabilization exercises and no significant improvement was seen in conventional exercise group in reducing motor control deficit. In line with evidence from other studies on patients with nonspecific recurrent low back pain, it could be suggested that a specific exercise program may be beneficial for successful management of athletes with chronic intervertebral disc prolapse.

REFERENCES

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  5. Richardson C, Jull G, Hodges P. Therapeutic exercise for spinal segmental stabilization in low back pain. Scientific Basis and Clinical Approach. Churchill Livingstone. 1999; pp. 61-96.
  6. Kermode, F. Benefits of utilizing real time ultrasound imaging in the rehabilitation of the lumbar spine stabilizing muscles following low back injury in the elite athlete - a single case study. Phys Ther in Sports. 2004; 5: 13-16.
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  9. Danneels LA, Vanderstraeten GG, Cambier DC. Effects of three different training modalities on the cross sectional area of the lumbar multifidus muscle in patients with chronic low back pain. Br J Sports Med. 2001; 35: 186-191.
  10. Drysdale Cheri L, Earl Jennifer E. Surface electromyographic activity of the abdominal muscles during pelvic-tilt and abdominal hollowing exercises. J Athletic Training. 2004; 39(1): 32-36.
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  15. Hultman G, Nordin M, Saraste H. Body composition, endurance, strength, cross sectional area, and density of MM erector spine in men with and without low back pain. J Spinal Disord. 1993; 6(2): 114-123.
  16. Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic games. Br J Sports Med. 2003; 37: 263-266.
  17. Gatt CJ, Hosea TM, Palumbo RC. Impact loading of the lumbar spine during football blocking. Am J Sports Med. 1997; 25(3): 317-321.
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Tables

Table-1: Comparison of scores between group I, group II and group III using One Way Analysis of Variance

  Sum of
Squares
df Mean
Square
F Sig.
Vas_pre Between Groups 167 2 083 100 906
  Within Groups 7.500 9 833    
  Total 7.667 11      
Vas_post Between Groups 35.167 2 17.583 20.419 000
  Within Groups 7.750 9 861    
  Total 42.917 11      
Dis_pre Between Groups 167 2 083 033 968
  Within Groups 22.750 9 2.528    
  Total 22.917 11      
Dis_post Between Groups 94.500 2 47.250 15.324 001
  Within Groups 27.750 9 3.083    
  Total 122.250 11      
Trat_pre Between Groups 4.160 2 2.080 1.603 254
  Within Groups 11.680 9 1.298    
  Total 15.840 11      
Trat_post Between Groups 59.627 2 29.813 42.056 000
  Within Groups 6.380 9 709    
  Total 66.007 11      
task1_pre Between Groups 18.960 2 9.480 800 479
  Within Groups 106.640 9 11.849    
  Total 125.600 11      
task1_post Between Groups 33.707 2 16.853 8.034 010
  Within Groups 18.880 9 2.098    
  Total 52.587 11    
task2_pre Between Groups 7.280 2 3.640 857 456
  Within Groups 38.240 9 4.249    
  Total 45.520 11      
task2_post Between Groups 66.502 2 33.251 12.151 003
  Within Groups 24.628 9 2.736    
  Total 91.129 11      
task3_pre Between Groups 34.940 2 17.470 1.200 345
  Within Groups 131.060 9 14.562    
  Total 166.000 11      
task3_post Between Groups 143.007 2 71.503 5.231 031
  Within Groups 123.030 9 13.670    
  Total 266.037 11      
task4_pre Between Groups 827 2 413 046 955
  Within Groups 80.720 9 8.969    
  Total 81.547 11      
task4_post Between Groups 46.107 2 23.053 5.571 027
  Within Groups 37.240 9 4.138    
  Total 83.347 11      

Table 2: Comparison of VAS, RMDQ, TrAAT, PLLT-I, PLLT-II, PLLT-III and PLLT-IV before and after four weeks of treatment in group I

I WEEK IV WEEK T value
Mean ± SD Mean ± SD
VAS 8 ± 0.81 4±0.81 6.92**
RMDQ 14.5±1.73 6.75±1.5 6.2**
TrAAT 8.6±0.95 4±0.83 8.13***
PLLT-I 7.9±2.73 4±1.13 3.85*
PLLT-II 9.5±1.80 3.4±0.86 4.78*
PLLT-III 8.1±1.73 2.8±1.46 4.48*
PLLT-IV 7.3±1.0 4.2±0.4 5.39*
* £ 0.05; ** £ 0.01; *** £0.001

Table 3: Comparison of VAS, RMDQ, TrAAT, PLLT-I, PLLT-II, PLLT-III and PLLT-IV before and after four weeks of treatment in group II

  I WEEK IV WEEK T value
Mean ± SD Mean ± SD
VAS 8.25±0.95 3.75±1.25 15.58**
RMDQ 14.25±1.70 9.0±2.0 7**
TrAAT 9.0±1.23 8.4±0.96 4.24
PLLT-I 4.9±4.34 6.8±0.97 0.81
PLLT-II 8.7±1.06 8.65±1.02 0.09
PLLT-III 7.15±3.48 7.3±2.07 0.11
PLLT-IV 7.9±2.55 8.2±1.15 0.24
* £ 0.05; ** £ 0.01; *** £0.001

Table 4: Comparison of VAS, RMDQ, TrAAT, PLLT-I, PLLT-II, PLLT-III and PLLT-IV before and after four weeks of treatment in group III

  I WEEK IV WEEK T value
Mean ± SD Mean ± SD
VAS 8.25±0.95 7.5±0.57 1.56
RMDQ 14.5±1.29 13.5±1.73 2.44
TrAAT 10±1.21 9.0±0.70 2.82
PLLT-I 7±3.01 8±2.01 1.98
PLLT-II 7.6±2.8 8.15±2.53 1.61
PLLT-III 11.15±5.33 11.25±5.87 0.25
PLLT-IV 7.4±4.4 8.5±3.3 1.61

Distribution of mean values of VAS and RMDQ Scores

Fig. 1: Distribution of mean values of VAS and RMDQ Scores before and after four weeks of training in Group I, Group II and Group III

Distribution of mean values of TrAAT Scores

Fig. 2: Distribution of mean values of TrAAT Scores before and after four weeks of training in Group I, Group II and Group III

Distribution of mean values  of PLLT-II Scores

Fig. 3: Distribution of mean values of PLLT-I and PLLT-II Scores before and after four weeks of training in Group I, Group II and Group III

Distribution of mean values of PLLT-IV Scores

Fig. 4: Distribution of mean values of PLLT-III and PLLT-IV Scores before and after four weeks of training in Group I, Group II and Group III

Corresponding Author: Kaul Rohini, MSPT Student,
Department of Sports Medicine and Physiotherapy, Guru Nanak Dev University, Amritsar
Ph No. 91-9988060152
E-mail: rohinikaul_22(at)yahoo.co.in

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