1. John Pineda, SPT July 2, 2015 Low Back Pain and Core Stabilization Exercise Inservice

2. Low Back Pain Background American Physical Therapy Association labels low back pain as: Acute (<4 weeks) Subacute (4-12 weeks) Chronic (>12 weeks) Often associated with: Mobility impairment in the thoracic, lumbar, or sacroiliac regions Referred or radiating pain into a lower extremity Generalized pain (dull, sharp, burn) Spasm

3. Prevalence Approximately 40% of adults will experience low back pain in their lifetime (Manchikanti et al.) 50% of patients will have a recurrence within 12 months Most common cause of job-related disability and a leading contributor to missed work (NIH) Annual cost of $100-200 billion per year due to lost wages, decreased productivity (Carey, Freburger)

4. APTA Survey

5. Work Lost due to LBP (2012) Radiating Leg Pain w/ LBP: 17.4 days (~1.5 days/mo) LBP in Past 3 Months: 11.2 day (0.93 days/mo)

6. Self Reported Prevalence of Pain Female > Male Radiating Leg Pain 38%, 33% Lower Back Pain 30%, 27% Age 45-64 4% less Radiating Leg Pain, slightly less Lower Back Pain in older groups (65-74, 74+) Avg Patient Age for LBP Averages fall within 45-64 age group ER visits with youngest patient average Hospital discharges have oldest patient average

7. Patient Evaluation Limited lumbar ROM Pain at end range of lumbar ROM Segmental hypomobility Decreased hamstring flexibility Tenderness to palpation in lumbar paraspinals, SI joint Core muscular weakness

8. Core Musculature Global (Superficial)Local (Deep) Cross multiple vertebrae Produce motion and torque Control spinal orientation Create compression load with strong contraction Counterbalance external forces acting on spine Attach to each vertebral segment Control segmental motion Provide precise motor control Primary spinal stabilizers Large amount of type I muscle fibers for endurance

9. Global Core Muscles Rectus abdominus External obliques Internal obliques (Lateral) Quadratus lumborum Erector spinae Iliopsoas

10. Deep Core Muscles Transversus abdominis Lumbar multifidus (Deep) Quadratus lumborum Deep rotators

11. Article 1 Chang et al., Core Strength Training for Patients with Chronic Low Back Pain, Journal of Physical Therapy Science, 2015

12. Systematic Review Inclusion criteria: experimental research studies from 2008- 2012, chronic low back pain (CLBP) patients, core strength training interventions, Jadad quality score of 4 or 5 Four articles all criteria Four core strength training exercises were used: Trunk balance Stabilization Segmental Stabilization Motor Control

13. Interventions Trunk balance: Strengthening trunk to improve balance Stabilization: Progressive core strength training techniques in different positions (supine, prone, sitting, quadraped, standing) Segmental stabilization: Strengthening various deep core muscles Motor control: Exercises based on motor control theory Control groups: Typical resistance training for trunk, LE Sit-ups, straight leg raise, push ups, LAQ

14. Measurement Tools Pain: Visual analog scale (VAS), McGill pain questionnaire Disability levels: Range minimum query (RMQ), Oswestry disability questionnaire (OSWDQ), Back performance scale (BPS), Short-Form 12 (physical, mental quality of life) Muscle performance: Pressure biofeedback unit (PBU), Ultrasound Reduced pain between intervention and control, but not statistically significant Disability level and muscle performance improvement was statistically significant between control and intervention

15. Results Core strengthening is easier to learn than typical resistance, but more challenging Typical resistance may injure pts No special equipment, can be performed at home (HEP) Decreased disability is more functionally significant than decreased pain since it relates to ADLs and occupation PBU, ultrasound improvements are objective measures

16. Article 2 Yoon et al., The Effect of Swiss Ball Stabilization Exercise on Pain and Bone Mineral Density of Patients with Chronic Low Back Pain, Journal of Physical Therapy Science, 2013.

17. Study Design 36 patients diagnosed with CLBP (and not severe spinal disease) divided into 3 groups of 12 Conservative treatment, floor exercise, ball exercise Conservative treatment: Superficial heat (20 mins), IFC (15 mins), deep heat (5 mins) 3x/week for 16 weeks Intervention groups: Supine bridge, sit up, bird dog, side bridge (on floor or Swiss ball) 10” hold, 3” rest, 3 sets of 10 reps, 3x/week for16 weeks Swiss ball diameter based on ratio to patient’s height

18. Exercises Supine bridge on Swiss ball Side bridge on Swiss ball Sit up on Swiss ball Bird dog on Swiss ball

19. Measurement Tools Pain: VAS Bone mineral density: DEXXUM T on L1- L4, three parts of femur Measurements taken before experiment, at 8 and 16 weeks

20. Results Statistically significant decrease in pain in both intervention groups, with BEG > FEG L1L2L3L4 FEG0.880.990.601.43 BEG3.851.641.254.48 Total BMD Rate of Change (%) Greater increase with BEG than FEG, but not statistically significant

21. Article 3 O’Sullivan et al. Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain with Radiologic Diagnosis of Spondylolysis or Spondylolisthesis, Spine, 1997

22. Study Design 44 patients with recurrent LBP symptoms for longer than 3 months with no signs of abating and radiologic diagnosis of spondylolysis or spondylolisthesis Most defects at L5-S1, some at L4-L5 Control, Specific Exercise Measures: Pain, functional measures, lumbar spine and hip sagittal ROM in standing, abdominal recruitment patterns

23. Intervention Control: 10 wk treatment period with general practitioner Weekly general exercise, pain-relieving methods (heat, massage, U/S) Specific Exercise: Weekly session with PT for 10 weeks Train contraction of deep abdominal muscles (drawing in maneuver), co-contract with lumbar multifidus 10 contractions for 10 second holds  progress by adding low load through leverage on limbs 10-15 min program at home Instructed to co-contract with provoking positions/activities

24. Measurement Tools Pain: McGill pain questionnaire (VAS, pain descriptor, pain body chart), average medication intake Functional measures: Oswestry Disability Index (patient’s perceived level of disability) ROM: Cybex inclinometer T12 inclinometer [gross motion] – PSIS inclinometer [pelvic/hip motion] = lumbar motion Abdominal recruitment: EMG of rectus abdominis and internal oblique during drawing in maneuver

25. Results SEG with significant difference in pain intensity, pain descriptor score, functional disability 7 less subjects taking anti-inflammatory medicine regularly Decreased maintained at 3, 6, 30 month follow up Oswestry Functional Disability

26. Pain Outcomes VAS Pain IntensityPain Descriptor Scores

27. Article 4 Mok et al., Core Muscle Activity During Suspension Exercises, Journal of Science and Medicine in Sport, 2014

28. Suspension Training

29. TRX Suspension System Multi-planar, multi-joint movements against gravity with body weight resistance One or both limbs are placed in handles (or cradles) at the end of an anchored suspension cable Workout difficulty is adjusted by altering the “working angle” (angle of inclination of the body) and/or adding balancing equipment Benefits: Versatility, simple set-up, low space occupancy, and large variety of workouts

30. Study Design Eighteen adults (8 men, 10 women) completed four workouts using the TRX suspension system Hip abduction in plank, chest press, 45 deg row, hamstring curl Surface EMG was placed on the rectus abdominis, external oblique, internal oblique/transversus abdominis, lumbar multifidus during the workouts

31. Exercises Hip abduction in plank 45 Degree row Chest press Hamstring curl

32. Procedure 5 minute cycling warm up followed by static stretching Maximum Voluntary Isometric Contraction data was gathered with two 5” contractions against manual resistance EMG was gathered during the middle 3 seconds of the hold

33. Results Hip abduction in plank and chest press activated more abdominals, while hamstring curl activated multifidus Higher muscle activity with LE exercises than UE Benefits of strengthening, muscle endurance, motor control

34. Implications in Practice

35. Alternatives

36. Implications in Practice Suspension exercises may activate muscles more than comparable exercises performed on stable surfaces or Swiss balls Use for patients who complete Swiss ball exercises with ease Changing working angle allows for vast modifications to exercises Potential recommendation for patients as an exercise program to implement after D/C for LBP to remain healthy and pain-free Simple to use, easy to set up

37. Questions

38. References American Physical Therapy Association. Low Back Pain by the Numbers (Infographic). http://www.moveforwardpt.com/LowBackPain/Infographic/Default.aspx Burden of Musculoskeletal Disease in the United States. Bone and Joint Initiative USA 2014 Report. Carey, T. and Freburger, J. Physical Therapy for Low Back Pain: What Is It, and When Do We Offer It to Patients? Annals of Family Medicine, 2014. Kisner, C. and Colby, L. A. Therapeutic Exercise: Foundations and Techniques, 5 th Edition. F. A. Davis Company, 2007. Manchikanti et al. Epidemiology of Low Back Pain in Adults. Neuromodulation, 2012. Mok et al., Core Muscle Activity During Suspension Exercises, Journal of Science and Medicine in Sport, 2014 National Institute of Health. Chronic low-back pain research standards announced by NIH task force. Press release, December 11, 2014. O’Sullivan et al. Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain with Radiologic Diagnosis of Spondylolysis or Spondylolisthesis, Spine, 1997 Wolters Kluwer. Evaluation of Low Back Pain in Adults. http://www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults#H1 Yoon et al., The Effect of Swiss Ball Stabilization Exercise on Pain and Bone Mineral Density of Patients with Chronic Low Back Pain, Journal of Physical Therapy Science, 2013.