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Role of Postural Control Exercises and Pelvic Floor Strengthening Exercises on Chronic Low Back Pain of Women with Sitting Jobs
Abstract
A lot of factors can give rise to low back pain and spinal instability attributes to one of them. Stability of spine is directly dependent on the strength of postural muscles which can be linked easily with postural control. Hence, postural control is likely to directly alter the spinal stability. Muscles of pelvic floor function along with muscles of back and abdomen to support the spine. This study aims to evaluate the effect of exercises to strengthen pelvic floor muscles and exercises for postural control in the treatment of chronic LBP and on posture, pain, and quality of life. [Subjects and Methods] Sample size of twenty-five participants was taken based on inclusion and exclusion criteria and divided to three groups namely PFM exercises group (n = 8), postural control exercises group (n = 8) and the control group (n = 9). All the three groups were given treatment for half an hour a day, thrice a week for 5 weeks. Conventional treatment that includes electrotherapy and general exercises was given to control group. Experimental groups received conventional treatment and additional exercises for pelvic floor muscles and posture control. [Results] Pain and functional disability was significantly reduced after treatment (p < 0.01) in all the three groups, but there was no significant difference (p > 0.05) found in both experimental groups. All the outcome measures were improved significantly (p < 0.01) in all groups although both experimental groups demonstrated significant improvement in Visual Analog Scale scores, and World Health Organization Quality of Life Assessment-BREF scores in contrast to control group. [Conclusion] Study concluded that the exercises to strengthen the pelvic floor muscles combined with conventional treatment and exercises for postural control combined with conventional treatment can provide better outcome as compared to conventional treatment alone in patients with chronic low back pain. Controlling the posture and muscular activities through these exercises also improves the patients’ quality of life.
... Table 1 outlines the basic characteristics of seven studies that investigated the effect of PFMT on CLBP. The studies found that combining PFMT with standard physiotherapy treatment resulted in better outcomes for managing CLBP compared to standard physiotherapy alone, which typically includes ultrasound therapy, transcutaneous electrical nerve stimulation, thermotherapy, infrared light therapy, shortwave diathermy, and various exercises for strengthening flexors, extensors, and trunk stabilizers (Bhatnagar and Sahu, 2017;Bi et al., 2013;Dsingh and Kaur, 2020;Ghaderi et al., 2016;Kumar et al., 2015;Mohseni-Bandpei et al., 2011;Rathi, 2013). Adding PFMT to standard treatment improved initial and final pain scores and functionality in most included studies (Bhatnagar and Sahu, 2017;Bi et al., 2013;Dsingh and Kaur, 2020;Ghaderi et al., 2016;Kumar et al., 2015;Rathi, 2013). ...
... The studies found that combining PFMT with standard physiotherapy treatment resulted in better outcomes for managing CLBP compared to standard physiotherapy alone, which typically includes ultrasound therapy, transcutaneous electrical nerve stimulation, thermotherapy, infrared light therapy, shortwave diathermy, and various exercises for strengthening flexors, extensors, and trunk stabilizers (Bhatnagar and Sahu, 2017;Bi et al., 2013;Dsingh and Kaur, 2020;Ghaderi et al., 2016;Kumar et al., 2015;Mohseni-Bandpei et al., 2011;Rathi, 2013). Adding PFMT to standard treatment improved initial and final pain scores and functionality in most included studies (Bhatnagar and Sahu, 2017;Bi et al., 2013;Dsingh and Kaur, 2020;Ghaderi et al., 2016;Kumar et al., 2015;Rathi, 2013). It also increased the endurance and strength of PFM (Ghaderi et al., 2016;Mohseni-Bandpei et al., 2011) and abdominal muscles (Ghaderi et al., 2016;Kumar et al., 2015). ...
... PFMT has been proven effective when integrated with other interventions. In most of the reviewed studies (Bhatnagar and Sahu, 2017;Bi et al., 2013;Dsingh and Kaur, 2020;Ghaderi et al., 2016;Mohseni-Bandpei et al., 2011;Rathi, 2013), PFMT was used in combination with back or abdominal muscle strengthening exercises, except in one study (Kumar et al., 2015) where PFMT was applied without other exercise interventions. Combining PFMT with core muscle strengthening exercises is reasonable to include in physiotherapeutic treatment of individuals with CLBP (Sapsford and Hodges, 2001) due to the indispensable connection between core muscles (especially the multifidus and transverse abdominal muscles) and PFM. ...
... By definition, chronic pain lasts over 3-6 months [7] and is not solved with treatment [8]. Its origin may be nociceptive or neuropathic [7,9], and it can be triggered by various causes (chronic musculoskeletal pain [10,11], chronic low back pain [12], fibromyalgia [13], tension-type headache [14], osteoarthritis [15], whiplash [16], heart and respiratory systems [7,17], endometriosis [18], etc.). Once developed, it may become resistant to standard treatments, greatly affecting patient quality of life [4]. ...
Non-oncologic chronic pain is a common high-morbidity impairment worldwide and acknowledged as a condition with significant incidence on quality of life. Pain intensity is largely perceived as a subjective experience, what makes challenging its objective measurement. However, the physiological traces of pain make possible its correlation with vital signs, such as heart rate variability, skin conductance, electromyogram, etc., or health performance metrics derived from daily activity monitoring or facial expressions, which can be acquired with diverse sensor technologies and multisensory approaches. As the assessment and management of pain are essential issues for a wide range of clinical disorders and treatments, this paper reviews different sensor-based approaches applied to the objective evaluation of non-oncological chronic pain. The space of available technologies and resources aimed at pain assessment represent a diversified set of alternatives that can be exploited to address the multidimensional nature of pain.
Background
Low back pain is a musculoskeletal disorder (MSD), and Kegel exercise is considered as one of the non-surgical management methods. Therefore, the present systematic review and meta-analysis aimed to estimate the results of randomized clinical trials (RCT) about the effect of pelvic floor muscle-strengthening exercises on reducing low back pain.Methods
The present study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline (2020) to January 2022. The relevant studies were searched in the MagIran, SID, PubMed, Embase, Web of Science (WoS), Scopus, ClinicalTrials.gov databases and Google Scholar motor engine using related MeSH/Emtree terms, which were combined with free text word. The heterogeneity of the studies was checked using I2 statistic.ResultsFinally, 19 RCTs with a sample size of 456 subjects in the intervention group and 470 in the control group were included in the meta-analysis. The low back pain intensity in the intervention group decreased up to 1.261 ± 0.213 (SMD ± 95% CI) with I2 = 87.60 more than that in the control group (P <0.001). The low back pain intensity in postpartum women decreased up to 1.614 ± 0.312 (95% CI) followed by pregnant women as 1.282 ± 0.479 (SMD ± 95% CI) more than that in other populations. But due to high the heterogeneity in all sub-groups (I2 > 80%) this result should be considered with caution. Meta-regression analysis showed the effect of pelvic floor muscle-strengthening exercises increased by increasing the year of publication, quality assessment score of the article, and the number of weeks of intervention (P<0.05).Conclusion
Based on the results of the present meta-analysis, pelvic floor muscle-strengthening exercises significantly reduce the low back pain intensity. Therefore, these exercises can be regarded as a part of a low back pain management plan.
Purpose:
This pilot study systematically examined the correlations between the outcome variables pain intensity, disability and health-related quality of life (HRQOL) and between these outcomes and known psychological risk factors for chronic low back pain (CLBP), such as depression, trait anxiety, avoidance- and endurance-related pain responses at two different assessment points.
Method:
Data from 52 CLBP inpatients treated in an orthopedic clinic were investigated at two points in time: during the first days after admission and 6 months after the termination of the inpatient treatment. Bivariate relationships between pain intensity, disability, HRQOL and psychological variables were examined with the help of Pearson product moment correlations. Furthermore, the differences that exist between correlations at baseline and follow-up were tested for significance.
Results:
Significant and large differences were found between the correlations with low correlations at baseline and high correlations at the follow-up. Furthermore, HRQOL showed a positive correlation with endurance-related and a negative correlation with avoidance-related pain responses.
Conclusions:
Focusing on a systematic comparison of two significant assessment time points in CLBP with an acute exacerbation at baseline, the results of this study underlined the recurrent course of LBP. The results highlight that the assessment time points play an important role in CLBP.
Implications for rehabilitation:
• Low back pain is a major public health problem with high direct and indirect back-pain-related costs. • Chronic low back pain is a disabling disease which restricts quality of life. • Psychological factors may have a larger impact on disability and quality of life than pain itself. • The recurrent course of low back pain highlights the importance of multidisciplinary pain management even during acute exacerbations of pain.
Over the past 20 years, the center of pressure (COP) has been commonly used as an index of postural stability in standing. While many studies investigated COP excursions in low back pain patients and healthy individuals, no comprehensive analysis of the reported differences in postural sway pattern exists. Six online databases were systematically searched followed by a manual search of the retrieved papers. The selection criteria comprised papers comparing COP measures derived from bipedal static task conditions on a force-plate of non-specific low back pain (NSLBP) sufferers to those of healthy controls. Sixteen papers met the inclusion criteria. Heterogeneity in study designs prevented pooling of the data so only a qualitative data analysis was conducted. The majority of the papers (14/16, 88%) concluded that NSLBP patients have increased COP mean velocity and overall excursion as compared to healthy individuals. This was statistically significant in the majority of studies (11/14, 79%). An increased sway in anteroposterior direction was also observed in NSLBP patients. Patients with NSLBP exhibit greater postural instability than healthy controls, signified by greater COP excursions and a higher mean velocity. While the decreased postural stability in NSLBP sufferers further appears to be associated with the presence of pain, it seems unrelated to the exact location and pain duration. No correlation between the pain intensity and the magnitude of COP excursions could be identified.
This study determines the efficacy of two such multimodal treatments in the management of lumbar pain syndrome in males and females.
Total subjects of 141 male or female were randomized to treat either with conventional treatment or by DMST (dynamic muscular stabilization techniques). After stratification on the basis of gender (51 male and 21 female) were found in DMST group whereas (40 male and 29 female) were found in conventional group. The primary outcome measures were pain severity, physical strength (BPC and APC), functional ability (Walking, Stairs climbing and Stand-ups) and QOL. All patients were assessed at baseline (day 0), 10 days, 20 days, 90 days and at the end treatment or follow up (day 180).
In this study the improvement of pain, BPC, APC, Walking, Stair climbing and stand-ups in females and males were 22.5% and 29.0%, 60.9% and 53.7%, 42.0% and 51.9%, 49.8% and 49.3%, 54.2% and 48.7%, 52.3% and 39.7%, higher respectively in DMST as compared to CONV whereas QOL in females of DMST improved by 53.6% more than the females of CONV while males of DMST improved by 57.9% more than the males of CONV.
DMST as well as CONV treatments are more effective in males than the females. Study also concluded that subgroup "female" may need more clinical attention during the management of LBP.
Low-back pain is a common and costly problem. We estimated the effectiveness of a group cognitive behavioural intervention in addition to best practice advice in people with low-back pain in primary care.
In this pragmatic, multicentre, randomised controlled trial with parallel cost-effectiveness analysis undertaken in England, 701 adults with troublesome subacute or chronic low-back pain were recruited from 56 general practices and received an active management advisory consultation. Participants were randomly assigned by computer-generated block randomisation to receive an additional assessment and up to six sessions of a group cognitive behavioural intervention (n=468) or no further intervention (control; n=233). Primary outcomes were the change from baseline in Roland Morris disability questionnaire and modified Von Korff scores at 12 months. Assessment of outcomes was blinded and followed the intention-to-treat principle, including all randomised participants who provided follow-up data. This study is registered, number ISRCTN54717854.
399 (85%) participants in the cognitive behavioural intervention group and 199 (85%) participants in the control group were included in the primary analysis at 12 months. The most frequent reason for participant withdrawal was unwillingness to complete questionnaires. At 12 months, mean change from baseline in the Roland Morris questionnaire score was 1.1 points (95% CI 0.39-1.72) in the control group and 2.4 points (1.89-2.84) in the cognitive behavioural intervention group (difference between groups 1.3 points, 0.56-2.06; p=0.0008). The modified Von Korff disability score changed by 5.4% (1.99-8.90) and 13.8% (11.39-16.28), respectively (difference between groups 8.4%, 4.47-12.32; p<0.0001). The modified Von Korff pain score changed by 6.4% (3.14-9.66) and 13.4% (10.77-15.96), respectively (difference between groups 7.0%, 3.12-10.81; p<0.0001). The additional quality-adjusted life-year (QALY) gained from cognitive behavioural intervention was 0.099; the incremental cost per QALY was 1786 pound sterling, and the probability of cost-effectiveness was greater than 90% at a threshold of 3000 pound sterling per QALY. There were no serious adverse events attributable to either treatment.
Over 1 year, the cognitive behavioural intervention had a sustained effect on troublesome subacute and chronic low-back pain at a low cost to the health-care provider.
National Institute for Health Research Health Technology Assessment Programme.
Pelvic floor muscle (PFM) dysfunction has been recently associated with the development of low back pain (LBP). Transabdominal ultrasound imaging has been established as an appropriate method for visualizing and measuring PFM function. No study has directly evaluated PFM function in individuals with and without LBP. The purpose of this study was to investigate the PFM function in women with and without LBP using transabdominal ultrasound. Convenience sample of 40 non-pregnant female participated in the study. Subjects were categorized into two groups: with LBP (n = 20) and without LBP (n = 20). The amount of bladder base movement on ultrasound (normalized to body mass index) was measured in all subjects and considered as an indicator of PFM function. Statistical analysis (Independent t-test) revealed significant difference in transabdominal ultrasound measurements for PFM function between the two groups (P = 0.04, 95% CI of difference: 0.002-0.27). The results of this study indicate PFM dysfunction in individuals with LBP compared to those without LBP. The results could be beneficial to clinicians when assessing and prescribing therapeutic exercises for patients with LBP.
The objectives of this study were to compare the effects of three different Pilates regimes on chronic, mild low back pain symptoms and to determine whether the efficiency of load transfer through the pelvis is improved by those exercises. A between subjects equivalent group experimental design was used. The independent variable was the type of exercise training (three groups) and the two-dependent variables were low back pain symptoms and load transfer through the pelvis. The outcome measures of the first-dependent variable were a comparison between modified Oswestry Disability Questionnaires (one of the standard pain instruments) completed pre- and post-program and frequency, intensity and duration of low back pain. The outcome measure of the second-dependent variable, efficiency of load transfer through the pelvis was the Stork test (one-legged standing test) in weight bearing. Although all groups experienced statistically significant reductions in frequency, intensity and duration of low back pain across the weeks of exercising, there were no significant differences between the groups relative to each other.
Objectives: To describe postural sway and its associations to background factors, low back pain and functional capacity. To evaluate the changes in postural sway after three months of therapeutic exercise in the gym or at home.
Design: A one-year randomized experimental trial evaluated postural sway in three study groups: intensive training, home exercise and control group.
Setting: Subjects were recruited from seven local occupational health care centres in Central Finland and were examined at Central Finland Hospital by medical doctors. Measurements and therapeutic exercise programmes were carried out in the Research Laboratory of Sport and Health Sciences at Jyväskylä University.
Subjects: Initially, 49 male and 41 female subjects (aged 20–55 years) with nonspecific and subacute low back pain were examined.
Main outcome measures: Postural sway using a force platform, the Oswestry Index, as well as a measure of low back pain intensity were measured at the initial stage of the study, directly after interventions, as well as at three and nine months after the interventions.
Results: The background variables were not strongly correlated with postural sway. No changes occurred in the amplitude of sway during the study, but the sway velocity of the home exercise group increased.
Conclusions: Postural sway measurements with a force platform may be suitable for detecting impairments of balance performance among subjects with pronounced functional or activity limitations and severe low back pain problems. In order to enhance balance performance, specific and customized exercise programmes are required.
Spinal trunk list is a common occurrence in clinical practice, but few conservative methods of spinal rehabilitation have been reported. This study is a non-randomized clinical control trial of 63 consecutive retrospective subjects undergoing spinal rehabilitation and 23 prospective volunteer controls. All subjects presented with lateral thoracic-cage-translation posture (trunk list) and chronic low back pain. Initial and follow-up numerical pain rating scales (NRS) and AP lumbar radiographs were obtained after a mean of 11.5 weeks of care (average of 36 visits) for the treatment group and after a mean of 37.5 weeks for the control group. The radiographs were digitized and analyzed for a horizontal displacement of T12 from the second sacral tubercle, verticality of the lumbar spine at the sacral base, and any dextro/levo angle at mid-lumbar spine. Treatment subjects received the Harrison mirror image postural correction methods, which included an opposite trunk-list exercise and a new method of opposite trunk-list traction. Control subjects did not receive spinal rehabilitation therapy, but rather self-managed their back pain. For the treatment group, there were statistically significant improvements (approximately 50%) in all radiographic measurements and a decrease in pain intensity (NRS: 3.0 to 0.8). For the control group, no significant radiographic and NRS differences were found, except in trunk-list displacement of T12 to S1, worsened by 2.4 mm. Mirror image (opposite posture) postural corrective exercises and a new method of trunk-list traction resulted in 50% reduction in trunk list and were associated with nearly resolved pain intensity in this patient population. The findings warrant further study in the conservative treatment of chronic low back pain and spinal disorders.
The human postural system operates on the basis of integrated information from three independent sources: vestibular, visual and somatosensory. It is conceivable that a derangement of any of these systems will influence the overall output of the postural system. The peripheral proprioceptive system or the central processing of proprioceptive information may be altered in chronic low back pain (CLBP). We therefore investigated whether patients with CLBP exhibited an altered postural control during quiet standing. Dynamic posturography was performed by 12 CLBP patients and 12 age-matched controls. Subject's task was to stand quietly on a computer-controlled movable platform under six sensory conditions that altered the available visual and proprioceptive information. While the control of balance was comparable between the two groups across stabilized support surface conditions (1-3), CLBP patients oscillated much more than controls in the anterior-posterior (AP) direction in platform sway-referenced conditions (4-6). Control experiments ruled out that increased sway was due to pain interference. In CLBP patients, postural stability under challenging conditions is maintained by an increased sway in AP direction. This change in postural strategy may underlie a dysfunction of the peripheral proprioceptive system or the central integration of proprioceptive information.
A cohort study in pregnancy.
To differentiate between pregnancy-related pelvic girdle pain (PPGP) and lumbar pain, and to study the prevalence of each syndrome and its consequences in terms of pain, functioning, and health.
When studying prevalence, etiology, and consequences, differentiation between PPGP and lumbar pain is important, and, to our knowledge, its consequences for functioning and health during pregnancy have not previously been studied.
All women answered questionnaires (demographic data, EuroQol). Women with lumbopelvic pain completed the Oswestry Disability Index, pain intensity measures, in addition to undergoing a mechanical assessment of the lumbar spine, pain provocation tests, and active straight leg raising test.
Of 313 women, 194 had lumbopelvic pain. The PPGP subgroup comprised 54% of those women with lumbopelvic pain, lumbar pain 17%, and combined PPGP and lumbar pain 29%. Women having both PPGP and lumbar pain reported the highest consequences in terms of health and functioning.
Pain intensity, disability, and health measurements differentiate subgroups of lumbopelvic pain in pregnancy.
Objective: The aim of this study was to demonstrate that core stability training could produce more beneficial effects than conventional exercise in patients with chronic low back pain. Methods: Sixty patients with low back pain were randomly allocated into core stability training group and control group. Control group received conventional exercise, training group received core stability training. Subjects were asked to exercise 3 times a week (40min/time) for 12 weeks. In the pre- and post-training sessions, all participants performed tests of pain scale, Oswestry Low Back Pain Disability Questionnaire and trunk muscle endurance test. Results: Five of the 60 participants (training group, n=29; control group, n=26) completed the 12 weeks program. Pain index, Oswestry Low Back Pain Disability Questionnaire and trunk muscle endurance in the training group were significantly better than those in the control group after 8 weeks (P< 0.05). Conclusions: Our results demonstrate that core stability exercise using unstable, can be more effective decreasing pain, improving trunk muscle endurance and reducing the disability of daily life dysfunction.
Low back pain is a widespread debilitating problem with a lifetime prevalence of 80%, with the underlying pain mechanism unknown in approximately 90% of cases. We used the painDETECT neuropathic pain screening questionnaire to identify likely pain mechanisms in 343 patients with low back pain with or without leg pain in southeastern England referred for physiotherapy. We related the identified possible pain mechanisms nociceptive, unclear, and neuropathic to standardised measures of pain severity (Numeric Rating Scale), disability (Roland Morris Low Back Pain Disability Questionnaire), anxiety and depression (Hospital Anxiety and Depression Scale), and quality of life (Short Form 36 Health Survey Questionnaire Version 2). In addition, we investigated any relationship between these possible pain mechanisms and leg pain, passive straight leg raise, and magnetic resonance imaging evidence confirming or eliminating nerve root compression. A total of 59% of participants (n=204) reported likely nociceptive pain, 25% (n=85) unclear, and 16% (n=54) possible neuropathic pain. The possible neuropathic pain group reported significantly higher pain, disability, anxiety, and depression, reduced quality of life and passive straight leg raise compared to the other pain groups (P<.05). A total of 96% of participants with possible neuropathic pain reported pain radiating to the leg (76% below the knee); however, leg pain was still more common in patients with nociceptive pain, suggesting that leg pain is sensitive to, but not specific to, possible neuropathic pain. No relationship was demonstrated between possible neuropathic pain and evidence for or absence of nerve root compression on magnetic resonance imaging scans. These findings suggest possible neuropathic pain is less common in low back pain patients referred through primary care and clarifies the usefulness of clinical tests for identifying possible neuropathic pain.
To examine the correction of posture, increase in strength and decrease in shoulder pain and dysfunction in varsity swimmers.
Randomised clinical trial.
Twenty-eight National Collegiate Athletic Association division I varsity swimmers.
Two testing sessions were conducted before and after an 8-week time period. Posture, strength and shoulder pain and function were assessed. Forward head angle was measured using a digital inclinometer, forward head translation was measured using a ruler and total scapular distance was measured with unmarked string. Average and peak values (N) of strength were measured with the hand-held dynamometer. The intervention subjects then participated in an 8-week exercise training programme to correct posture. The procedures were then repeated in the post-test.
Significant group by time interactions (p<0.05) were found in forward head angle and forward shoulder translation indicating a decrease in forward head angle and forward shoulder translation. Significant main effects for time (p<0.05) were found in strength measures for all muscle groups indicating increased strength for shoulder girdle muscles tested.
The exercise intervention was successful at decreasing forward head and rounded shoulder postures in elite swimmers. This study supports the theoretical basis for clinical rehabilitation of posture and the shoulder.
Abnormal postural alignment can be detrimental to muscle function, is aesthetically unpleasing, and might contribute to joint pain. It has been unclear as to whether stretching or strengthening exercises can correct faulty posture such as abducted scapulae. It has been postulated that short and tight scapular abductor muscles or weak and lengthened scapular retractor muscles or a combination cause an abducted scapulae posture and that exercise can correct this condition. The purpose of this review was to compile the information on factors influencing scapular position at rest, examine the effectiveness of exercise interventions in altering scapular position, and make recommendations for future research. When examining the different methods that have been used to determine the position of the scapula, attention should be paid to their respective reliability and validity. Correlational studies have failed to detect a significant association between muscle strength and scapular position but found a significant relationship between muscle length and scapular position. Prospective intervention studies have shown that stretching the anterior chest muscles on its own or in combination with strengthening the scapular retractors can alter the position of the scapula at rest in individuals with abducted scapulae. Although these results are encouraging, there is a dearth of high-quality studies and more research is required to address the limitations of the studies. None of the intervention studies measured strength or flexibility pre or post intervention, so it is unclear how effective the intervention was in changing these factors and the actual mechanism behind the change. To determine which component of the intervention is most effective and whether the results are additive, future research should include stretching only, strengthening only, and combined stretching and strengthening groups. Follow-up measurements at some period after completion of the intervention would also provide important information as to the permanency of any changes. The practical implication is that caution must be displayed when considering the promotion of strengthening exercises to try and correct for abnormal scapular posture until further evidence becomes available.
Pregnancy-related lumbopelvic pain is common. More than 30% of women have persistent pain 3 months after giving birth. There is no consensus regarding the pathology. However, coordination of muscle activity by appropriate timing and amplitude is necessary for maintaining adequate stability in the lumbopelvic area. The aim was to develop a method using surface electromyography to detect a feed-forward response in the pelvic floor muscles during limb movements performed at a comfortable speed applicable in future studies for women with lumbopelvic pain.
Ten parous women with no lumbopelvic pain in the past 12 months were included. Surface electromyographic activity was recorded from the pelvic floor muscles and unilaterally from transversus abdominis/internal oblique, rectus abdominis, erector spinae, hip adductors, rectus femoris and deltoid. The subjects performed leg lift in supine and arm lift from standing. The electromyographic onset was related to the initiation of the movement.
In the majority of the women the electromyographic onsets of the pelvic floor muscles occurred before the movement was initiated, regardless of whether it was a leg or an arm lift. In addition, electromyographic onsets for the other muscles, except the rectus abdominis during the arm lift, also occurred prior to the movements.
The findings suggest a feed-forward response in the pelvic floor muscles during leg and arm lifts in women who had previously given birth and were without lumbopelvic pain. Movements performed at a comfortable speed seem to be useful in order to detect such a response.
The exercise and smoking habits of low back or leg pain sufferers vs. persons not having low back or leg pain are compared. The type, frequency and length of exercise is determined from a study of 576 low back or leg pain sufferers compared to 50 persons who state they are symptomatic. The same was done for smoking habits. Thirty-three percent of low back or leg pain sufferers smoked as compared to 14% of those without pain. Forty-seven percent of low back or leg pain sufferers as compared to 86% of non-sufferers exercised regularly. The level of physical activity and general exercise have been found to improve strength, mobility and endurance; this might prevent future back injury. Our study is to determine differences in the exercise habits of persons with low back and/or leg pain vs. those who do not have pain, with the intention being to see if pain sufferers exercise less.
Numerous methods have been developed for the rehabilitation of low back pain patients, including spinal flexion and extension exercises, lumbar spine locking in an intermediate position, enhancement of spinal and pelvic proprioceptive sensibility, swimming pool therapy, back schools, and functional restoration. Each seeks to achieve a goal assumed to be central to the prevention of a first or recurrent episode of low back pain. Goals include short-term pain relief, an improved ability to achieve self-sedation, abdominal and lumbar muscle strengthening, increased hip and lumbar spine mobility, improved lumbar and pelvic proprioceptive sensibility, intervertebral joint stabilization, lumbar posture modification and improved general fitness. Less than 30 studies meeting widely accepted validity and applicability criteria for therapeutic trials have addressed the clinical efficacy of rehabilitation in low back pain patients. Most studies of the back school approach have found no benefit. Spinal flexion and extension exercise programs have yielded short-lived improvements, with no differences across methods. There is evidence that functional restoration programs based on graded activity may provide long-term benefits including better social and occupational outcomes. We have evaluated the physical therapy methods most commonly taught to and used by physical therapists in France.
Although the literature is filled with information about the prevalence and incidence of back pain in general, there is less information about chronic back pain, partly because of a lack of agreement about definition. Chronic back pain is sometimes defined as back pain that lasts for longer than 7-12 weeks. Others define it as pain that lasts beyond the expected period of healing, and acknowledge that chronic pain may not have well-defined underlying pathological causes. Others classify frequently recurring back pain as chronic pain since it intermittently affects an individual over a long period. Most national insurance and industrial sources of data include only those individuals in whom symptoms result in loss of days at work or other disability. Thus, even less is known about the epidemiology of chronic low-back pain with no associated work disability or compensation. Chronic low-back pain has also become a diagnosis of convenience for many people who are actually disabled for socioeconomic, work-related, or psychological reasons. In fact, some people argue that chronic disability in back pain is primarily related to a psychosocial dysfunction. Because the validity and reliability of some of the existing data are uncertain, caution is needed in an assessment of the information on this type of pain.
To determine the outcome 10 years after an individual course of pelvic floor muscle (PFM) exercises for genuine stress incontinence.
Postal questionnaires were sent to 52 women who had undergone PFM training 10 years earlier, and their medical files were reviewed. The main outcome measures were the patients' self-assessment of therapy outcome, the frequency of PFM exercises at home, and the demand for surgery after physiotherapy.
Forty-five women (87%; mean age 61 years) were suitable for analysis. On completing the course of PFM exercises, physiotherapy had been apparently successful in 24 (53%), and considered to have failed in 21 women (47%). Sixteen of the 24 successful patients remained satisfied with their urinary continence when reassessed 10 years later; two women had undergone surgery (8%). In the group where physiotherapy initially failed, five women (24%) who had not had surgery claimed to be much improved; 13 women (62%) had undergone surgery. Overall, women in whom the conservative treatment of stress incontinence had produced an improvement over the 10 years had practised PFM exercises more regularly (76%) than the others (55%; not significant). However, an active voluntary PFM contraction before a sudden intra-abdominal pressure rise ('perineal lock') appeared to be responsible for most of the success.
When PFM training is initially successful, there is a 66% chance that the favourable results will persist for at least 10 years.
Low back pain (LBP) constitutes one of the most difficult and costly medical problems in industrial countries, with a prevalence of 25 to 30% in an adult lifetime span and an incidence of about 5% per year.
Based on risk factors cited in the pertinent literature, the evaluation, diagnosis and therapeutic options for LBP are outlined. Especially the latter can be highlighted on the basis of a large number of systematic reviews.
Bed rest is no longer regarded as an effective treatment for episodes of acute LBP, except when the patient has evident clinical signs of nerve root compression. Exercise therapy comprises a wide range of concepts and underlying physiological principles. Different concepts are discussed. Evidence suggests no specific effects of exercise therapy in acute LBP. In chronic LBP, exercise as well as combined treatment with several modalities appear to be superior to conventional medical care. In the past decade, reconditioning of the paraspinal muscles is being given increasing importance in research. Several studies indicate the effectiveness of vigorous strengthening of paraspinal and trunk muscles on pain and even disc surgery. Different underlying pathologies seem to respond equally well to this concept. Back school concepts are not proven to have long-term effects on LBP. The literature on electrotherapy and massage in LBP is generally sparse. Nevertheless, some studies suggest the effectiveness of electrotherapy on pain reduction at least in the short term. Spinal mobilization seems to be effective in reducing pain.
Based on these evidence-based conclusions, the patient's medical history, the investigation and the diagnosis the clinician has to devise an individual treatment plan that takes the deficiencies and requirements of the patient into account.
To determine the extent of pelvic obliquity and lateral sacral base angle in subjects with and without chronic low back pain (LBP) by using postural radiographs.
Cross-sectional, controlled.
A Veterans Administration hospital.
Veterans and employees with (n=93) and without (n=76) chronic LBP.
Postural radiographs.
Differences between the mean extent of pelvic obliquity and the lateral sacral base angle in subjects with and without chronic LBP.
The z scores showed no significant statistical differences in the extent of pelvic obliquity or lateral sacral angle in subjects with and without chronic LBP.
Correction of pelvic obliquity by the use of heel lifts has been used as a modality of treatment for patients with chronic LBP. The majority of the patients in our clinics for whom this modality is used report at least some improvement in their pain symptoms. Because the extent of pelvic obliquity is similar in the subjects with and without chronic LBP, other factors must account for those who benefit from correction of their pelvic obliquity.
In conclusion, core stability exercise is an evolving process, and refinement of the clinical rehabilitation strategies is ongoing. Two major foci are addressed in contemporary core stability programs: motor control and muscle capacity. Both of these factors have considerable foundation in the literature and can be seen as a progression of exercise rather than conflicting approaches. Importantly, the clinical efficacy of these approaches is being realized in clinical trials. Further work is required, however, to refine and validate the approach, particularly with reference to contemporary understanding of the neurobiology of chronic pain.
Exercise therapy is widely used as an intervention in low-back pain.
To evaluate the effectiveness of exercise therapy in adult non-specific acute, subacute and chronic low-back pain versus no treatment and other conservative treatments.
The Cochrane Central Register of Controlled Trials (Issue 3, 2004), MEDLINE, EMBASE, PsychInfo, CINAHL databases to October 2004; citation searches and bibliographic reviews of previous systematic reviews.
Randomized controlled trials evaluating exercise therapy for adult non-specific low-back pain and measuring pain, function, return-to-work/absenteeism, and/or global improvement outcomes.
Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short, intermediate, and long-term follow-up.
Sixty-one randomized controlled trials (6390 participants) met inclusion criteria: acute (11), subacute (6) and chronic (43) low-back pain (1 unclear). Evidence was found of effectiveness in chronic populations relative to comparisons at all follow-up periods; pooled mean improvement was 7.3 points (95% CI, 3.7 to 10.9) for pain (out of 100), 2.5 points (1.0 to 3.9) for function (out of 100) at earliest follow-up. In studies investigating patients (i.e. presenting to healthcare providers) mean improvement was 13.3 points (5.5 to 21.1) for pain, 6.9 (2.2 to 11.7) for function, representing significantly greater improvement over studies where participants included those recruited from a general population (e.g. with advertisements). There is some evidence of effectiveness of graded-activity exercise program in subacute low-back pain in occupational settings, though the evidence for other types of exercise therapy in other populations is inconsistent. There was evidence of equal effectiveness relative to comparisons in acute populations [pain: 0.03 points (95% CI, -1.3 to 1.4)].Limitations: This review largely reflects limitations of the literature, including low quality studies with heterogeneous outcome measures, inconsistent and poor reporting, and possibility of publication bias.
Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in healthcare populations. In subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.
Low back pain is associated with abnormal movement strategies due to changes in neuromuscular control. A plausible contributing factor to low back pain is poor control of trunk muscles, thus understanding motor control alterations in this population can guide rehabilitation. Quantification of postural responses following support surface translations is one way to examine motor control impairments in people with low back pain.
Twenty-four healthy subjects [mean 33 (SD 11) years] who had no low back pain and 26 subjects [mean 39 (SD 13) years] with chronic, recurrent low back pain were instructed to stand with feet placed on separate force plates, which were mounted on a moveable platform. The platform was translated unexpectedly in one of 12 directions for a total of 72 trials. For both the sagittal and frontal planes, the net center of pressure displacement was derived and the total body center of mass was calculated by combining kinematic and anthropometric data.
For sagittal plane responses, subjects with low back pain had reduced and delayed sagittal plane center of pressure responses (P<0.01) compared to the subjects without low back pain. In contrast, the sagittal plane center of mass responses were larger in magnitude (P=0.03) yet similarly delayed in onset (P=0.04) for the low back pain group. Frontal plane responses did not differ between groups.
Subjects with low back pain have altered automatic postural coordination, both in terms of magnitude and timing of responses, indicating alterations in neuromuscular control.
Despite an increasing clinical interest in female pelvic floor function, there is a lack of data with respect to the knowledge of average adult women about the physiological role of the pelvic floor and their ability to contract pelvic floor muscles (PFM) voluntarily. It was the aim of our study to evaluate the percentage of PFM dysfunction in adult women and the impact of risk factors, such as age, body mass index (BMI), number of children delivered, and the influence of previous PFM training. A total of 343 Austrian adult women (mean age, 41.2 +/- 14.6 years; range, 18-79 years), selected at random, were examined to test their ability to contract the PFM. The examination was carried out by three independent gynecologists during the course of a routine gynecological visit. The ability to contract the PFM voluntarily or involuntarily was assessed by digital intravaginal palpation with the patients in a supine position. The muscle strength was graded according to the Modified Oxford Grading Scale by Laycock. A high percentage (44.9%) of the women was not able to voluntarily perform a normal PFM contraction. In only 26.5%, an involuntary contraction of the pelvic floor was present before an increase in intra-abdominal pressure. The inability to contract the PFM did not correlate with women's age but revealed a weak relationship with the number of childbirths and the patient's BMI. A significant correlation was found between the Oxford Grading Scale rating and the patient's report about previous PFM training.
Persons with recurrent low back pain (LBP) have been observed to have altered proprioceptive postural control. These patients seem to adopt a body and trunk stiffening strategy and rely more on ankle proprioception to control their posture during quiet upright standing. The aim of this study is to determine the effect of changing postural condition (stable and unstable support surface) on postural stability and proprioceptive postural control strategy in persons with recurrent LBP. Postural sway characteristics of 21 persons with recurrent LBP and 24 healthy individuals were evaluated in upright posture with or without standing on "foam" for the conditions as follows: (1) control (no vibration); (2) vibration of the triceps surae muscles; (3) paraspinal muscle vibration; (4) vibration of the tibialis anterior muscles. Vision was occluded in all conditions except for one control trial. All trials lasted 60 s. Vibration (60 Hz, 0.5 mm), as a potent stimulus for muscle spindles, was initiated 15 s after the start of the trial for a duration of 15 s. Persons with recurrent LBP showed significantly different postural control strategies favoring ankle muscle proprioceptive control (ratio closer to 1) instead of paraspinal muscle proprioceptive control (ratio closer to 0) for both standing without foam (ratio ankle muscle/paraspinal muscle control = 0.83) (P < 0.0001) and on foam (ratio ankle muscle/paraspinal muscle control = 0.87; P < 0.0001) compared to healthy individuals (0.67 and 0.46, respectively). It is concluded that young persons with recurrent LBP seem to use the same proprioceptive postural control strategy even in conditions when this ankle strategy is not the most appropriate such as standing on an unstable support surface. The adopted proprioceptive postural control strategy might be effective in simple conditions, however, when used in all postural conditions this could be a mechanism to undue spinal loading, pain and recurrences.
Backache, borne of modern lifestyle
- R Suryapani