*corresponding author: Lecturer I, Department of Physiotherapy, Faculty of Medicine, Bayero University, Kano. ABSTRACT

Transcription

1 International Society of communication and Development among universities ATV Sport, ISSN: EFFECTS OF LUMBAR STABILIZATION EXERCISES AND TREADMILL WALK ON MULTIFIDUS ACTIVATION, PAIN AND FUNCTIONAL DISABILITY IN INDIVIDUALS WITH CHRONIC MECHANICAL LOW BACK PAIN * Bashir Bello 1 and Adeniyi Ade Fatai 2 1 Lecturer, Physiotherapy Department, Faculty of Medicine, Bayero University, Kano, Nigeria 2 Senior Lecturer, Physiotherapy Department, College of Medicine, University of Ibadan, Nigeria *corresponding author: Lecturer I, Department of Physiotherapy, Faculty of Medicine, Bayero University, Kano. ABSTRACT Chronic Mechanical Low Back Pain (CMLBP) is a common disabling health problem among the general population. Multifidus muscle inhibition accompanying CMLBP plays a major role in perpetuating the pain and functional disability. Lumbar stabilisation and treadmill exercises are established treatments for CMLBP. However, it is not known which is more effective. This study compared the effects of lumbar stabilisation and treadmill walk on multifidus activation, pain and functional disability in individuals with CMLBP. Fifty-three individuals (23 females and 30 males) with CMLBP participated in this single blind randomised clinical trial. Consecutive participants were recruited and randomly assigned to Lumbar Stabilisation Group (LSG; n = 27) and Treadmill Walk Group (TWG; n = 26). However, 50 participants, (LSG: n = 25; and TWG: n = 25) completed the eight week study. Participants in the LSG had lumbar stabilisation exercises using McGill protocol while those in the TWG had walking exercise on a treadmill using the Bruce protocol. Outcomes assessed were: Pain Intensity (PI) using Visual Analogue scale, Functional Disability (FD) using Oswestry Disability Index Questionnaire; and Multifidus Muscle Activation (MMA) level using a surface electromyography machine. Data were analysed using descriptive statistics, paired and independent t-tests at α Participants in both groups were comparable in age (46.60±11.60 vs 45.20±12.91) years. At baseline, PI, FD and MMA values were comparable in both groups. At the end of eighth week of the study, the LSG when compared with the TWG, had lower scores in PI (2.60±0.48 vs 4.50±0.12), FD (24.20±4.06 vs 40.00±10.56), with a significant higher MMA levels (40.00±4.16 vs 26.95±4.04). Lumbar stabilisation exercises are more effective than treadmill walk in the activation of multifidus muscle, reduction in pain and functional disability in individuals with CMLBP. Lumbar stabilisation exercises are 2016 The Authors. Published by European Science publishing Ltd. Selection and peer-review under responsibility of the Organizing Committee of European Science publishing Ltd.

2 2 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 recommended in the management of chronic mechanical low back pain. Keywords: Lumbar Stabilization Exercise, Multifidus muscle, chronic low back pain Background Low Back Pain (LBP) is a common and disabling health problem with 60 90% of people experiencing an episode in their lifetime (Unsgaard-Tøndel, et al., 2010). An acute episode of LBP usually resolves over a period of two to four weeks for 90% of patients. However, the recurrence rate of an acute episode is high especially within the following 12 months (Hides et al., 1996) but little is known about the factors that lead to recurrence. Lack of localized muscle support may be one reason for the high recurrence rate of low back pain following the initial episode (Hides et al., 2001). The multifidus muscle has garnered increased attention over the years as an important contributor to LBP as it has been shown to undergo atrophy and inhibition following a first episode LBP (Hides et al., 1996). Although symptoms may improve, multifidus inhibition persists; leading to the premise that recurring low back pain may be due to inhibition of the multifidus muscle (Slosberg, 2012; Hides et al., 2001; Hides et al., 1996). Several studies have suggested that activity of the trunk muscles is altered in the presence of lower back pain (Van Tulder, et al., 2002; Keigler, et al., 1998). A previous study by MacDonald, et al (2009) provided some of the first evidence of a connection between altered deep muscle activity and recurrent low back episodes. The study assessed whether the control of the deep muscles (multifidus) differed between the normal population and those with unilateral recurrent low back pain. The electromyography (EMG) onset of the muscles occurred later

3 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 3 (delayed) in participants with recurrent low back pain than in normal individuals. Since the multifidus muscle is a stabilizer of the spine, any delay in muscle firing may lead to abnormal biomechanics. MacDonald, et al (2010) assessed the impact of unpredictable loading on muscle activation and found that both the deep and superficial fibers of the multifidus muscle had less EMG in people with recurrent than with healthy subjects. LSE have been shown to be an important biomechanical component that influences symptoms amongst patients with CLBP. Hides et al (1996) found that even after pain remission in patients with low back pain, proper deep muscle reestablishment often did not happen and that specific physical therapy focusing on those muscles was necessary. In addition, research has shown that there is inhibition of contralateral corticomotor neurons, which demonstrate an increased threshold and reduced responsiveness to electrical stimuli on the contralateral side of the brain from the inhibited and progressively atrophying erector spinae and multifidus muscles (MacDonald, et al 2010). Wallwork et al (2009) revealed that not only do these muscles exhibit reduced cross-sectional area and fibrofatty infiltration, they also display a reduce ability to contract when activated. Hence, multifidus muscle inhibition has been considered one major contributor leading to recurrence of LBP (Croft, et al., 1998). Despite the numerous claims of the effectiveness of LSE, there is still limited evidence that shows corresponding changes in the multifidus muscle function among individuals with CMLBP. This study was therefore carried out to compare the effects of LSE and treadmill walk (TW) in the activation of multifidus muscle among CMLBP individuals. MATERIALS AND METHODS

4 4 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 PARTICIPANTS Fifty participants with CMLBP attending outpatient Physiotherapy clinic of Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria, who volunteered and gave consent to participate in this study and were recruited. The participants were sampled from an adult age group of years. Individuals were recruited if they had LBP that was of mechanical origin and has been present for 3 months or more and also have a Modified Oswestry Disability Index (ODI) score of at least 20% to indicate minimal level of disability due CMLBP as well as having the ability to assume 4- point kneeling position for at least 1 minute to allow for pre intervention EMG recording. Prospective participants were excluded from the study if they had prior surgery to the lumbosacral spine, had any neurological deficit in the lower limbs, very acute symptoms, spondylolisthesis, evidence of systemic disease, carcinoma, organ diseases or had a BMI > 35Kg/m 2 this is to reduce the influence of fatty tissues in the recording of EMG. Ethical approval was sought and received from the University of Ibadan and University College Hospital Joint Health Research Ethics Committee and from the Ethical Committee of Aminu Kano Teaching Hospital, Kano, Nigeria where the study was carried out. The purpose and procedure of the study was explained to participants and they were also informed of their right to withdraw anytime they feel unable to cope with the study. STUDY DESIGN: The research design is a pretest-posttest, randomized clinical trial. RANDOMIZATION Participants were allocated to groups using a consecutive assignment. The first pair of available

5 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 5 participants were assigned into either of the 2 groups using the toss of the coin where the person who tossed tail was assigned to the LSG and the head to the TWG. Consecutively, participants were then assigned to the alternate groups. Initial assessment All consenting participants were screened for red and yellow flags on their first appointment by the researcher to ascertain diagnosis of CMLBP. An initial assessment of each participant was carried out to determine the disability and pain intensity levels using the ODI and VAS respectively before they were sent for the EMG recordings. Participants in both group received a 15 minutes shortwave diathermy therapy before commencing on the exercise. Interventions Participants attended a 3 treatment sessions per week over an eight week period. The treatments were implemented as follows: TRAEDMILL WALK Treadmill Walk (TW) was based on the assumption that a reduced aerobic capacity and muscle deconditioning and disuse, especially of the deep lumbar extensor muscles (multifidus muscle) are present among CMLBP individuals. The TW consisted of aerobic training using a treadmill using Bruce protocol. Participants in the Treadmill Walk Group (TWG) undertook a 30 minutes walking exercise on the treadmill targeting performance at 65 to 80% of the maximum heart rate (HRmax) as follows: Warm-up: Speed 3.3 miles per hour (mph), 0% inclination and duration of 5 minutes. Weeks 1 4: Speed: mph (increase 0.5mph/ minute for 10 minutes), 1-4 % inclination (increase 1% per week) and total duration of 20 minutes. Weeks 5 8:

6 6 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 Speed: mph (increase 0.5mph/ 2minutes 20 minutes), 5-8 % inclination (increase 1% per week) and total duration of 30 minutes. Cool down phase: Speed 3.3 miles per hour (mph), 0% inclination and total duration of 5 minutes. LSE Group Participants in the LSG undertook the McGill stabilization exercises which lasted for 30 minutes per session. LSE program described by McGill [13] was used. The exercise began with a motion exercise (cat-camel motion exercise). The cat-camel exercise was followed by the curl-up exercises, in which the participant was instructed to flex one knee to 90 0 while keeping the other straight. A rolled towel was placed under the lumbar spine to preserve a neutral spine posture. The participant was then instructed to raise both shoulders and the head up of the pillow. This position was sustained and maintained for 7 seconds. The exercise was repeated 10 times with a 1 minute rest between repetitions. As the subjects endurance improves, the exercise variant was progressed to a more difficult position; where the participant was instructed to lift the already extended lower limb together with both shoulders and the head. The position was also maintained for 7 seconds. The curl up exercise was followed by the side-bridge exercise. The participant was positioned as follows: lying on the side supported on his/her elbow and hip, the knees were bent to 90⁰. The free hand was placed on the opposite hip. The participant was instructed to raise his/her trunk until the body was supported on the elbow and the knee. This position was sustained and maintained for 7 seconds. The exercise was repeated 10 times with a 1 minute rest between repetitions. Upon successful performance of the side bridge exercise, the bird-dog exercise was carried out. In this exercise, the opposite arm and leg were extended in the quadruped position. The position was sustained and maintained for 7 seconds. The exercise was repeated 10 times with a 1 minute rest between repetitions. As the subjects endurance

7 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 7 improves, the exercise variant was progressed to a more difficult position which involved dynamic movement of the extended upper and lower limbs. Participants performed one set of 10 repetitions for each LSE, with a 1minutes rest between each set during every exercise session. All isometric holds were not allowed to last longer than 7 seconds as recent evidence from near infrared spectroscopy has indicated rapid loss of available oxygen in the back muscles when contracting isometrically beyond 7 seconds (McGill, 2003). OUTCOME MEASURE TESTING Data collection monitored the EMG activity of the multifidus muscle, pain intensity and functional disability status of the participants. The EMG activity was monitored and recorded by an independent assessor who was blinded to group allocation of the participants. EMG RECORDING: After appropriate skin preparation by cleaning of the skin with alcohol to reduce skin impedance (typically 10 kohms), disposable electrodes (Ag/AgCl, Blue sensor P- 00-S, Medicost, Brasil) were placed on the skin over the paraspinal muscles (the superficial fibres of the lumbar multifidus muscle) at the level of lumbar vertebral segment 2/3 (L2/3) and 4/5 (L4/5). The quadruped kneeling posture was maintained for 30 seconds during recording. The EMG signal was amplified, filtered (low pass: 200 Hz, high pass filter: 10 Hz, and 50 Hz notch) using two single amplifiers (Bio Amp, ML132, ADInstruments, Castle Hill, NSW). The raw data was sampled at 1k Hz. The data was then transferred to a text file for further biosignal analysis using software (Matlab for windows, version 6.5, Mathworks, MA, US) software. Only signal recorded after the point where the posture was considered to be held stable was used for the analysis. Maximum Voluntary Isometric Contraction (MVIC) scores of the multifidus muscle were sent to the researcher through each participant in a sealed envelope and were recorded in

8 8 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 percentages. Pain intensity outcome: Visual Analogue Scale (VAS) was used to measure participant s pain intensity level at baseline and after 8 weeks of intervention. Functional Disability Outcome: Functional disability was evaluated with ODI. A translated Hausa version was also used for participants who don t comprehend English language. Statistical Analysis: Statistical analysis was performed using SPSS Results were considered statistically significant if the p value was 0.05 Subjects characteristics such as age, height and body mass, were compared between groups prior to the treatment intervention using unpaired t test. Outcome measures following the 8 week treatment intervention period were compared within the groups using a paired t test and between the 2 groups using an independent t test. RESULTS Participants were recruited over a 6- month period. The treatment intervention took place over an 8 week period from the time of randomization. Analysis indicated no significant difference between groups regarding participants characteristics at baseline (table 1). A total of 50 participants took part in the study. Each group is comprised of 25 participants. The age and anthropometric indices of the two groups are shown in Table 1. The mean age of participants in the LSG is years, while the mean age of participants in the TWG is years. The mean height of participants in TWG is m while that of LSG is m. The mean weight of participants in TWG and LSG are kg and kg respectively. While the mean body mass index of the TWG is kg/m 2,

9 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 9 and that of the LSG is kg/m 2. Table 1: showing comparison of demographic and anthropometric indices of participants in TWG and LSG. Variables TWG LSG t p-value n=25 n= 25 x + S.D x + S.D Age (yrs) Height (m) Weight (kg) BMI (kg/m 2 ) At baseline, the mean pain intensity (PI), functional disability (FD) and multifidus muscle activation (MMA) scores of both groups are shown in Table 2 and no significant difference was observed between the groups. The mean MMA, PI and FD of TWG: (%); (cm); (%) respectively while that of LSG are; (%); (cm); (%) respectively. No significant difference was observed in the pain intensity, functional disability and EMG indices of both the experimental and the control groups at baseline. Table 2 showing comparison of mean MMA levels, pain intensity and functional disability

10 10 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 scores of participants in both groups at baseline. VARIABLES TWG LSG t p-value n=25 n=25 X±SD X±SD MMA Levels (%) PI Scores (cm) FD levels (%) KEY: MMA multifidus muscle activation PI pain intensity FD functional disability Result of the study indicated a significant reduction in the mean PI scores of participants in TWG between the baseline score ( ) and at the end of eight week aerobic exercise ( ) with p<0.05. The ODI also showed a reduction that was significant between the mean functional disability at baseline ( ) and at the end of the exercise programme ( ) with p<0.05.

11 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_ Table 3 showing mean changes of pain intensity, functional disability and MMA indices of participants of TWG at baseline and at end of week viii VARIABLES Baseline Week viii t p-value n=25 n=25 X±SD X±SD MMA Levels (%) * PI Scores (cm) * FD levels (%) * Key: MMA Multifidus muscle activation PI Pain intensity FD Functional disability *significant difference at p 0.05 The MMA levels, pain intensity and functional disability scores of participants in LSG are shown in Table 4. There was a significant difference in the mean %MVIC of the multifidus between baseline ( %) and at the end of eight week exercise ( %) with p<0.05. There was equally a significant reduction in the mean PI scores of participants in this group between the baseline ( cm) and at the end of eight week exercise ( ), p<0.05. Similarly, there was a significant difference in FD scores between the baseline ( ) and at the end of the LSE programme ( ) with p<0.05.

12 12 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 Table 4 showing mean changes in MMA levels, pain intensity and functional disability scores of participants in LSG at baseline and at end of week viii VARIABLES Baseline Week viii t p-value n=25 n=25 X±SD X±SD MMA Levels (%) * PI Scores (cm) * FD levels (%) * Key: MMA Multifidus muscle activation PI Pain intensity FD Functional disability *significant difference at p 0.05 Results of the study indicated a significant between group differences in the post intervention scores. Participants in the LSG demonstrated a higher mean activation of the multifidus muscle (40.00±4.16) when compared to that of the TWG (26.95±4.04). This is similar in other clinical variables of PI and FD assessed. See table 5. Table 5 showing between groups mean changes in MMA levels, pain intensity and functional disability scores of TWG and LSG after 8 weeks interventions.

13 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_ VARIABLES TWG LSG t p-value n=25 n=25 X±SD X±SD MMA Levels (%) * PI Scores (cm) * FD levels (%) * Discussion The main finding of this study was that a McGill LSE directed at stabilizing the back and retraining of neuromuscular control, provided by a physiotherapist, was more effective in activating multifidus muscle, reducing pain intensity and functional disability among individuals with CMLBP when compared to an aerobic exercise. In this study there were significant within group differences in mean average MMA levels, pain intensity and functional disability scores in both LSG and TWG following the interventions. It was observed in this study that there was variation in participants response to pain intensity, functional disability and MMA level with aerobic exercises. This is in agreement with findings of Shnayderm and Katz-Leurer (2013) that affirmed that when people walk actively, abdominal and back muscles work in much the same way as when they complete exercises that target these areas. This is a possible pathway in which aerobic exercise can help activate the multifidus muscle and prevent recurrent LBP. Previous researches have also shown that aerobic exercise helps in enhancing muscle endurance which is important in preventing

14 14 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 chronic low back pain (Velde and Mierau, 2000; Chok et al., 1999). Result of this study showed that individuals in the TWG displayed a significantly reduced PI, FD scores and higher MMA after 8 weeks of the exercise in comparison with their pre-intervention scores. This could suggest that although, TWG do not particularly target the multifidus muscle but may help stimulate the multifidus along other global back muscles by enhancing their muscular endurance. Findings of this study thus, corroborated previous study indicating the benefits of aerobic exercise in the management of CMLBP (Shnayderm and Katz-Leurer, 2013; Velde and Mierau, 2000; Chok et al., 1999 ). Panjabi (1992) theorized that despite the stability provided by osseous-ligamentous structures, the spinal column devoid of musculature is incapable of carrying normal physiological loads. This implies that treadmill walk was able to affect the active subsystem of the Panjabi s spinal stabilization model therefore, leading to the aforementioned benefits. The results of this study also showed that participants in the LSG demonstrated a higher MMA levels, pain intensity and functional disability scores. These are in agreement with the findings of O Sullivan et al (1997) who found out that a training approach that followed the principles of segmental stabilization and neuromuscular control was effective in reducing pain and disability in a group of individuals with CLBP related specifically to radiological instability. The current study demonstrates that an exercise training approach similarly addressing neuromuscular control mechanisms is more effective in decreasing pain and improving function in an identified group with CMLBP when compared to an TW. The subjects in the O Sullivan et al (1997) study were trained in stabilization exercises designed to enhance local muscular stability of the intervertebral segment. Although the theoretical rationale of training muscle

15 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_ activation and control was similar in both studies, the training approach in the current study necessarily differed and addressed different components of neuromuscular dysfunction. The subjects in the current study did not demonstrate a primary segmental instability but clinically appeared to display problems in control of the muscles thought to stabilize the lumbopelvis complex. It was observed in this study that there were significant within group differences in participants MMA level, PI and FD scores when the baseline scores were compared with scores at the end of eight week of LSE, p< 0.05 respectively. This is the same with most previous study using stabilization exercise in the management of CLBP (Charbonneau and Laurel, 2014; Moon et al., 2013; Wang et al., 2012; Kumar, 2011; Ammar et al, 2011). Improvements of participants in the LSG can be attributed to better training of abdominal and back muscles without imposing high loads. Results of this study also supported previous work of Callaghan et al., (1998); Axler and McGill (1997). These authors tested various types of therapeutic exercises and showed that McGill exercises can enhance muscular work without high spinal loads (<3400 Newtons) in healthy subjects. Results of this study further indicated a greater level of activation of the multifidus muscle as well as other clinical variables when the post intervention scores were compared between the 2 groups. This might be due to the direct and specific stimulation of the multifidus muscle that helps stabilize the spine and prevents it from further damage. The benefits of spinal stabilization exercises have been linked to improved pattern of activation and onset of activity (in the transversus abdominis muscle and the multifidus muscles), decreased muscular fatigability, and

16 16 Bashir Bello, Adeniyi Ade Fatai/ ATV Sport, ISSN: (2017)101_118 restoration of muscle size following muscle atrophy caused by pain and reflex inhibition (Hides et al, 1996). Findings of this study therefore, showed that there was an improved pattern of MMA which must have led to reduced pain and functional disability among individuals with CMLBP. Sokunbi et al (2002) also reported a 17% increase in plasma serotonin levels in patients with CLBP after 30 minutes of LSE. Thus, serotonin may also have been involved in the mechanism of LSE-induced analgesia. In addition, LSE may aid patients with a better coping strategy for dealing with their pain since it does not require any sophisticated gadget and several visits to the clinic. A do- it- yourself approach may have enhanced compliance of the exercise protocol. In general, participants in LSG have a shown a higher activation of MMA levels and a better reduction in PI and FD scores that is almost twice the scores observed in the TWG. Indicating a LSE would be a preferred exercise choice when reactivating inhibited muscles and managing clinical symptoms of individuals with CMLBP. CONCLUSION: Lumbar stabilisation exercises resulted in higher activation of multifidus muscle, better reduction in pain intensity and functional disability than the aerobic exercises in participants with chronic mechanical low back pain. Lumbar stabilization exercises should therefore be part of exercise therapy program for patients with chronic mechanical low back pain. REFERENCES Unsgaard-Tøndel M, Fladmark AM, Salvesen Ø, Tom-Ivar, L. N., Jon, M., and Ottar, V (2010). Motor control exercises, sling exercises, and general exercises for patients with Chronic low back pain: a randomized controlled trial with 1-year follow-up. Physical Therapy; 90:1426

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