Effects of Core Stabilization Exercises on Low Back Pain, Disability and Back Muscle Endurance in Patients with Lumbar Disc Herniation

Abstract

Background: Lumbar disc herniation is a common musculoskeletal disorder leading to spinal degeneration. Core stability influences lumbar biomechanics, which improves muscle endurance through decreased pain of the lower back leading to minimal chances of disability. Objective: To determine the effects of Core stabilizing exercises on low back pain, disability and endurance of back muscles in Lumbar Disc Herniation patients. Methods: Randomized controlled trial was conducted on 52 patients . it was conducted 3 times a week for 30 minutes for 6 months. Participants allocated into two equal groups by lottery method. Group A was treated with controlled conventional treatment and core stabilizing exercises. Group B received only conventional treatment. This information was collected using NPRS and ODI. Besides this Biering-Sorenson and trunk flexion endurance tests were used. Probability sampling was used .Settings included AMTH, PSRD and NHMC. The study was conducted for 6 months. Ethical permission by ethical review board. data analysis by SPSS. This included male and female patients, age 20 to 60 years with disc herniation. Participants with recent surgery, inflammatory arthritis, cauda equina syndrome and spinal tumor were excluded. Results: After 8-weeks of core stabilization exercises, values of Group A are 1.93 for pain, 16.08 for disability, 1.27 and 40.54 for endurance whereas Group B showed values of 4.74 for pain, 34.08 for disability, 2.15 and 34.81 for endurance. Independent t-test showed significant difference between 2 groups with p value < 0.05. Results of current study showed considerable reduction in low back pain and disability, and a significant increase in back muscles endurance in the treatment group. Conclusion: Core stabilization exercises were effective in improving function, reducing pain, reducing functional disability and enhancing endurance in patients of lumbar disc herniation and lower back pain

Full text

Introduction
isc herniation pain is defined as radiating back
Dpain from lumbar region to the dermatomal nerve
root along the sciatic or femoral nerve trunk and is the
1
commonest disorder of musculoskeletal in individual.
A vast majority accounting for about 90% faces the low
backache which is the most frequent type of low back
2
pain. Another research project stated that prevalence
3
of life time disc herniation is estimated around 10%.
While anatomical evidences stated that about 20% -
Effects of Core Stabilization Exercises on Low Back Pain, Disability and Back
Muscle Endurance in Patients with Lumbar Disc Herniation
1 2 3 4
Mohammad Abbas Jamil, Muhammad Salman Bashir, Rabiya Noor, Rehana Niazi,
5 6 7
Nazeer Ahmad, Shahzad Ahmad, Haseeb Ullah Ahmad
Abstract |
Background: Lumbar disc herniation is a common musculoskeletal disorder leading to spinal degeneration.
Core stability influences lumbar biomechanics, which improves muscle endurance through decreased pain of
the lower back leading to minimal chances of disability.
Objective: To determine the effects of Core stabilizing exercises on low back pain, disability and endurance
of back muscles in Lumbar Disc Herniation patients.
Methods: Randomized controlled trial was conducted on 52 patients . it was conducted 3 times a week for 30
minutes for 6 months. Participants allocated into two equal groups by lottery method. Group A was treated with
controlled conventional treatment and core stabilizing exercises. Group B received only conventional treatment.
This information was collected using NPRS and ODI. Besides this Biering-Sorenson and trunk flexion endurance
tests were used. Probability sampling was used .Settings included AMTH, PSRD and NHMC. The study was
conducted for 6 months. Ethical permission by ethical review board. data analysis by SPSS. This included
male and female patients, age 20 to 60 years with disc herniation. Participants with recent surgery, inflammatory
arthritis, cauda equina syndrome and spinal tumor were excluded.
Results: After 8-weeks of core stabilization exercises, values of Group A are 1.93 for pain, 16.08 for disability,
1.27 and 40.54 for endurance whereas Group B showed values of 4.74 for pain, 34.08 for disability, 2.15 and
34.81 for endurance. Independent t-test showed significant difference between 2 groups with p value < 0.05.
Results of current study showed considerable reduction in low back pain and disability, and a significant
increase in back muscles endurance in the treatment group.
Conclusion: Core stabilization exercises were effective in improving function, reducing pain, reducing
functional disability and enhancing endurance in patients of lumbar disc herniation and lower back pain.
Corresponding Author | Dr. Mohammad Abbas Jamil, Assistant Professor, Rashid Latif College of Physical Therapy. Lahore
Email: abbasjamil525@gmail.com
Keywords | Core stabilization, Herniated disc, Low Back pain, Physical endurance.
1,4,5 2,3
Rashid Latif College of Physical Therapy. Lahore; Riphah College of Rehabilitation and Allied Health Sciences.
6 7
Lahore; National Hospital and Medical Centre, Lahore; Pakistan Society for the Rehabilitation of the Disabled
April - June 2023 | Volume 29 | Issue 02 | Page 1

40% disc herniation is present asymptomatically with
4
an imaging test. 2-5% of patients presented for a medical
treatment thought to be disc herniation while 40% of
5
patients seeking for help suffered from disc herniation.
With aging, the incidence of the degeneration process of
disc gradually increases due to loss of osmotic pressure
6
in the nucleus. The underlying mechanism as evident
from numerous studies connotes that the cell plates
undergo thinning which forms fissure and sclerosis of
7
the subchondronal bone occurs leading to cell necrosis.
Some risk factors of disc degeneration are genetic or
inherited like poliomyelitis that is the leading causes
of disc degeneration. Other factors include age along
with some environmental factors like loading history
7
that leads to degeneration of the disk. Some of the phy-
sical risk factors are obesity, smoking, poor general
8,9
health status and psychological distress. Other causes
of disc herniation are lifting heavy weight, prolonged
incorrect posture, and decreased flexibility as well as any
2
trauma or injury can cause the disc herniation disease.
The studies conducted to assess the efficacy of different
treatment options viable to treat low back pain inculcated
10
that oxygen therapy was more effective treatment.
One of the studies stated that Conservative treatments
like core stabilization exercises for lumbar spine are
11
useful to relieve pain and improve performance.
Sorensen Biering and Trunk Flexion Test are used to
assess the endurance in patients with low back pain.
Basically, Sorensen Biering Test gives distinguished
measures in terms of position holding duration. It is used
to differentiate between participants with and without
low back pain. The reliability of Biering Sorensen Test
12
is 72.8%. Large number of studies were conducted
to show the effect of core stability exercises on pain
and disability but there is insufficient data available on
the effectiveness of core stability exercises on patients
with disc herniation presenting with low back ache.
These manuavers will help to decrease low back pain
and disability in the patients with lumber disc herniation.
Additionally, there is need to clarify the impact of core
stability on global as well as segmental muscle stabi-
lizers. There is no literature available regarding the
effectiveness period of the stabilization exercises. Hence,
my study targeted to assess the effectiveness of core
stabilization exercises on Low Back pain in patients
with disc herniation along with the estimation of effec-
tiveness duration of the aforementioned exercises.
Methods:
This was a randomized controlled trial. Sampling tech-
nique used in this study was probability sampling. Two
groups were allocated for the participants through rando-
mization using the lottery method. Participants were
recruited following the recommendation of consultant
physiotherapist at Arif memorial teaching hospital,
Pakistan society for the rehabilitation of disabled (PSRD)
and National hospital and medical centre. The study was
conducted in a time frame of 6 months. Calculated
Sample size was 52 that was measured using G- Power
3.1.92 software by assuming 5% degree of freedom
and 5% attrition rate with 0.80 power. The allocation
ratio N2/N1 = 1 which calculated total sample size of
52 including both group A and B 26. The included parti-
cipants were male and female patients with age 20 to
60 years already diagnosed with disc herniation by
radiologist through MRI. All participants with recent
surgery, inflammatory arthritis, cauda equina syndrome
and spinal tumor were excluded. Bi-lingual Informed
consent was signed by each patient participating in
the study. After group allocation on the patients' first
visit, a detailed history and physical examination was
conducted. Baseline measurements were taken for all
the patients matching the inclusion criteria. Demogra-
phic data for each participant was acquired through a
self-developed questionnaire. The study participants
were kept blind about groups and treatment protocol.
Two groups A and B were given interventions based
on outpatient rehabilitation program. The participants
of group A were given Conventional Treatment along
with Core stabilization exercises where as participants
of group B was given only conventional therapy (shown
in Figure 1).
The intensity of pain was measured by a numerical pain
rating scale (NPRS), which is an accurate and reliable
13
tool for measuring pain intensity.
Disability in functional activities was assessed by an
accurate and reliable questionnaire, i.e., Oswestry dis-
ability index (ODI), which has been in clinicians’ use
14
since 1980s.
Modified Biering-Sorensen test was used to measure
muscle endurance of spine. Patient position was prone
with his pelvis at the edge of the couch, cross position
April - June 2023 | Volume 29 | Issue 02 | Page 2

of the hands over his chest and horizontal position of
the upper trunk outside the edge of the table. Therapist
commanded the participant to maintain the aforemen-
tioned position. Duration was recorded as the participant
maintained the position. This duration was noted as
point of spine extensor muscles endurance.
Trunk flexion test was incorporated to assess the endu-
rance of abdominals. The patient was in a sitting posi-
tion with knees and hip in 90° flexion and hands on
shoulders with arms crossed in front of chest. To main-
tain this position assistant had grabbed the legs. When
the patient lost endurance his time was noted.
Group A was treated with conventional treatment which
included baseline treatment by using hotpack and then
by using modality (therapeutic ultrasound) and core
stabilizing exercises. The core stabilization included
stretching exercises: Prone position Quadriceps stret-
ching, hip flexors, Adductors and Hamstring Stretching
in standing position for low back muscles and abdominal
muscles. Additionally it included strengthening exer-
cises: Abdomen pull in (tummy tucks) in supine position,
Abdomens pull in (tummy tucks) with knee flexion
into the chest in supine position, Abdomen pull in
(tummy tucks) by heel sliding on the couch in supine
position, prone cobra position, Supine superman posi-
tion and Planks. Treatment was given 3 times a week
for the duration of 30 minutes including electrotherapy
treatment. The final outcome was noted following a
follow up that was conducted after the 8 weeks-treatment.
Group B received only treatment for the eight weeks.
Treatment included ultrasound therapy in continuous
2
mode, frequency of 1 MHz and intensity of 1.0 W/cm
for 5 minutes, diclofenicvoltral gel was used. Moist
heat pack, in combination with TENS, was applied for
10 minutes. The wet heat pack was pre-immersed in a
hydro collator having a set temperature of 60°C and
then wrapped in 6 layers of the towel before application
to the patient. The number of towel layers was increased
or decreased according to the patient's tolerance level.
Comfy Combo TENS was used with following para-
meters; Mode = Burst, Numbers = 5HZ, Pulse Width
= 150us, Output Intensity = 20-40mA (as tolerated by
the patient)
After having collected the data was analysed using SPSS
for Windows software version 21. All qualitative vari-
ables were shown in frequency tables and percentages.
The normality of the data was assessed by Kolomogrov-
Smrinov Test. Parametric test (Independent-T test);
parametric test are based on assumption about distri-
bution of population. Test of mean comparison was
selected to apply for measuring difference of the two
groups.
Results:
Comparison of both study groups baseline measure-
ments for numeric pain rating scale score, Oswestry
Disability Index, Biering Sorensen Test and Trunk
Flexion Endurance Test are illustrated in Table 1, which
shows that both groups were comparable. Out of the
52 participants included in study, the minimum age
was 20 years and maximum age was 60 years where
the mean age of Core Stabilization Exercises Group
was 35.53±6.68 years and 36.00± 6.94 years. Comparing
the pre and post treatment pain, it was evaluated using
Independent T Test that there is significant difference
between 2 groups with p value < 0.05 as shown in Figure
2. There is improvement in pain as evident by the inde-
pendent T test with mean value of 1.93 in core stabili-
zation exercise group which was clinically more signifi-
cant as compared to 4.74 in conventional group, Biering-
Sorenson test showed significant difference in endurance
between 2 groups with p value < 0.05 . In Figure 3, the
endurance with mean value of 1.26 in core stabilization
exercise group was clinically more significant to 2.15
in conventional group. The increase in mean of endurance
in core stabilization exercise group was 40.54 compared
April - June 2023 | Volume 29 | Issue 02 | Page 3
Figure 1: Flow chart of study

to 17.51 in conventional treatment group which was
clinically more significant in core stabilization group
as shown in Figure 4.
Figure 2: Bar Chart of NPRS Score
Figure 3: Bar Chart of Biering Sorenson test
Figure 4: Bar Chart of Trunk flexion endurance test
Discussion
In the present study the effects of core stabilization
exercises were seen on patients with lumbar disc hernia-
tion having Low Backache. For this purpose participants
were grouped into experimental and control. Control
Group received only conventional treatment whereas
Conventional treatment plus Core Exercises was given
to the experimental group. Trunk flexion Test and Bie-
ring Sorensen Test were used to evaluate the outcomes.
During the current course of the study, efficacy of core
stabilization exercises was checked in lumbar disc
herniation patient with low back pain.
Oswestry Disability Pain index ODI was used to check
level of functional disability. This questionnaire included
total 10 sections, each section having 5 further state-
ments regarding daily routine activities; lifting, washing,
walking etc. The total possible score is 5 for each section.
If the first statement is marked the score will be zero,
while marking the last statement of a section then the
score will be 5. When all the sections were completed
15
then the score would be calculated. To check endurance
Trunk Flexion endurance tests and Biering Sorensen
Test were used. These tests are used to check the iso-
metric resistance of hip and back extensor muscles.
This test has different hold-time durations for healthy,
prior to low backache and current low backache partici-
pants. Maximum time to hold this position is 4 minute.
VAS and Oswestry Disability index were taken to assess
the intensity of pain and to check Functional disability
level in lumbar disc herniation patients with low back
pain.
Chaoqun et al conducted a study on young patients
suffering from Lumbar disc Herniation. To check the
level of pain and Functional disability, he compared
April - June 2023 | Volume 29 | Issue 02 | Page 4
Table 1: Base line measurement for numeric pain rating
scale score, Oswestry Disability Index, Biering Sorensen
Test and Trunk Flexion Endurance Test.
Conventional
treatment + Core
Stabilization
Exercises
(n=26)
Conventional
Treatment
(n=26) P-
value
Mean ± SD Mean ± SD
Age of Participants 35.43 years 36.00 years 0.760
Numeric Pain
Rating Scale 7.12±1.15 7.35±1.13 0.467
Oswestry Disability
Index 53.54±10.96 52.62±15.14 0.802
Biering Sorensen
Test 2.77±0.43 minutes 2.81±0.41
minutes 0.740
Trunk Flexion
Endurance Test
13.74±4.75
seconds
15.72±5.83
seconds 0.185

core stabilization exercises with General exercises.
Visual Analogue Scale was scale of choice to assess
intensity of pain and Oswestry Disability index was
valid to assess functional limitation. He concluded that
core stabilization exercises are efficacious to lessen
11
pain as compared to general exercises.
The results of this study were persistent with the findings
of the earlier studies that analysed the positive impact
of core stabilization exercises on disc herniation with
low back pain.
Daekaun conducted a study to check the effectiveness
of lumbar stabilization exercises in lumbar disc hernia-
tion patients. In his study, he divided the participants
into two groups; Balance centre resistant stabilization
exercise group, three dimensional stabilization exercises
group. The impact of the intervention was recorded
through disc herniation index. He reached the conclusion
that lumbar stabilization exercises have significant
16
effects on lumbar disc herniation. Results of the current
study were similar to the results of DaeKaun’s study
that lumbar stabilization exercises have tendency to
lessen low back pain but this study also decrease in
disability in lumbar disc herniation patients.
There are some limitations of this study. First, due to
small sample size, the findings may not be generalized.
Secondly, therapists were not blinded to the therapy
options; however outcomes were measured by a resear-
cher unaware of the treatment group allocation.
Conclusion
Core stabilization exercises were effective in improving
function, reducing pain, reducing functional disability
and enhancing endurance in patients of lumbar disc
herniation and lower back pain.
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