Effectiveness of Core Stabilization Exercises Versus Mckenzie’s Exercises in Chronic Lower Back Pain

1. Shahzad Ali 2. Syed Murtaza Ali 3. Khalida Naz Memon

1. Musculoskeletal Physiotherapist, Dept. of Physical Therapy, DUHS, Karachi
2. Deputy Director, Institute of Physiotherapy and Rehabilitation Sciences, PUMHS, Nawabshah
3. Assoc. Prof. of Community Medicine, LUMHS, Jamshoro

ABSTRACT

Objective: To determine the effectiveness of core stabilization and McKenzie's exercises on intensity of pain, disability and lumbo-pelvic stability was compared in non-specific chronic low back pain (CLBP) patients.

Study Design: Randomized controlled trial study

Place and Duration of Study: This studywas conducted at Departments of Physical Therapy, Institute of Physical Medicine and Rehabilitation, Dow University of Health Sciences Karachi andPeoples University of Medical & Health Sciences, Nawabshah during 2012-13.

Materials and Methods: Thirty patients with non-specific CLBP were enrolled through convenience sampling and were randomly assigned core stabilization and McKenzie exercises. Intensity of pain, disability, and lumbo-pelvic stability were evaluated by Visual Analouge Scale, The Oswestry disability Questionnaire, and Stibilizer Pressure Biofeedback Unit, respectively.  Eighteen sessions were done for both groups. t-tests and ANCOVA test were used for statistical analysis (p<0.05).

Results: Although the score of pain decreased in both groups (p<0.05), the decrease of intensity of pain was more than in Core Stabilization Exercises Group (p<0.05). The score of disability questionnaire decreased in stabilization exercise group (p<0.05). During Knee Lift Abdominal and Bent Knee Fall Out maneouvres, pressure of biofeedback unit did not significantly differ before and after interventions, in both groups (p>0.05).

Conclusion: The stabilization exercises can reduce pain and disability in nonspecific CLBP patients.

Key Words: Low Back Pain, Core Stabilization, McKenzie’s exercises, Pakistan.


INTRODUCTION

Chronic low back pain (CLBP) is one of the major public health problems, with high economic and social costs, loss of job and disability in many of communities1,2. As a result, rehabilitation approaches and exercises have focused on management or treatment of low back pain3. Accordingly, some of exercises could be utilized for spinal stabilization due to improved spinal stability and to increase control of the spine4. It is proposed that specific stabilization exercises program might lead to change in central motor program and automatically feed forward recruitment of deep core muscles5. Therefore, stabilization exercises are more effective than conventional treatments to decrease pain and disability in CLBP6,7. However, Some authors found that general exercises with or without stabilization exercises could exhibit the same outcome on improvement of pain and disability in subjects with CLBP8,9. Another approach is McKenzie's method which focuses on sustained postures or repeated movements10,11. Although McKenzie's exercises could improve pain intensity in acute, subacute and CLBP12 . Some studies found that there are no difference between McKenzie's exercises, strengthening exercises and primary care in reduction of pain, and disability in patients with acute and CLBP11. Very little research is done on comparing effectiveness of stabilization and McKenzie's exercises in non-specific CLBP. As mentioned above, based on lack of consensus on appropriate treatment method, lack of sufficient objective evidences about the effects of stabilization exercises on the lumbo-pelvic stability in CLBP, lack of a comparative study between Mackenzie's and stabilization exercises in non specific CLBP, the main goal of this study was to compare the effects stabilization and McKenzie's exercises on pain intensity, disability and lumbo-pelvic stability in non-specific CLBP subjects.

MATERIALS AND METHODS

This study was a randomized controlled trial study. to Departments of Physical Therapy, Institute of Physical Medicine and Rehabilitation, Dow University of Health Sciences Karachi andPeoples University Of Medical & Health Sciences, Nawabshah, participated in this interventional study.

Thirty non-specific CLBP patients, referred to above mentioned institutes during the period 2012-1 were enrolled for the study. All participants sign written informed consents. Patients were enrolled through simple non-probability sampling and were randomly assigned into two groups: McKenzie's exercises group (n=15) and Stabilization exercises group (n=15). The examiner who assessed the outcomes was blinded to group assignment.

Thirty patients with age between 18-50 years, non-specific CLBP in the area between the costal margin and buttocks, with or without reference to the lower extremity in previous three months were included in this study. Patients were excluded who reported a history of recent fracture, trauma or previous surgery at lumbar region, spondylosis or spondylosthesis, spinal stenosis, neurological disorders, systemic diseases, pregnancy, cardiovascular diseases, concomitant treatment with physical therapy modalities.

Data collection: At baseline and after last treatment session, Visual Analouge Scale (VAS) and The Oswestry disability Questionnaire (ODQ) were used for outcome measures, based on following procedures

Pain assessment: The VAS was used for pain assessment; whereby pain was rated from 0 to 100 mm, in which the 0 represented no pain and 100 represented maximum pain tolerance. Subjects were indicated the best number described for their pain12 .

Disability assessment: The ODQ was completed to assess percentage of functional disability in patients with CLBP. This questionnaire is a gold standard tool to indicate ability of patients with CLBP13. It consists of 10 sections and each of the section includes 6 rates, from zero to five. The first section of this questionnaire rates pain and the other sections assess activities of daily living. Total score of questionnaire was recorded as percentage14.

Lumbo-pelvic stability assessment: Stability of lumbo–pelvic region was assessed by the Stabilizer PBU, Chattanooga, Australia7. This device measures pressure changes from 0 to 200 mmHg with accuracy of 2 mmHg7. Monitoring of lumbopelvic motion was performed by recording the pressure changes during Knee Lift Abdominal Test (KLAT) and Bent Knee Fall Out Test (BNFOT) 7. The baseline pressure was set to 40 mmHg 15. The pressure values was recorded at the end of the manoeuvres. Inter-observer reliability correlations for KLAT and BNFOT were 0.85 and 0.87, respectively15.

Intervention: For warming up, participants pedaled a stationary bike for 5 minutes and performed stretching exercises for 10 minutes8. Then, Patients were randomaly assigned in stabilization exercises group or McKenzie’s exercises group.The training program was scheduled 18 sessions in 6 weeks for both groups.

Core Stabilization exercises group: The stabilization exercises were performed in 6 steps: 1- Segmental Control Exercises (SCE) with emphasis on training the isolated contraction of Transverse Abdominis (TrA), Multifidus (MF), and pelvic floor muscles, 2- SCE with emphasis on co-contractions of TrA, MF, and pelvic floor muscles in the prone, supine, and four foot kneeling positions, 3- SCE in closed kinematic chain, 4- SCE in open chain exercise applied by adding leverage of the limbs, 5- SCE in functional situations, 6- Co-contraction of TrA and MF muscles while external load, complication of movements and light aerobic activities10.

McKenzie's exercises group: In the Mckenzie's group, six exercises were performed: four extension type and two flexion type exercises. The extension type exercises were performed in prone and standing positions and the

flexion type exercises were carried out in the supine and sitting positions. The final position of each exercise was maintained for 10 seconds13. The McKenzie's exercises were  repeated 80 and 100 times14.

Statistical analysis: Results were computed as mean values and standard deviation (SD). Criterion of significance was set as p<0.05. Kolmogrov Smirnov test was used to describe normal distribution. ANCOVA test was used to compare variables between McKenzie's and the stabilization groups. Paired t-test was used to compare variables before and after interventions.

RESULTS

Thirty patients with non-specific CLBP participated in this study. The demographic features of patients are listed in Table 1 & Chart I. The patients in stabilization exercises group did not differ from the McKenzie's exercises group, before intervention.

Within group comparison: Paired t-test was used to compare intra-group variables, before and after interventions. After intervention, the score of pain decreased in both groups (p <0.05). The mean score of disability decreased in stabilization group (p <0.05). The mean values of motor control tests did not show significant differences in both groups (p> 0.05)
(Table 2).

Between group comparison: Inter-group comparison was done by ANCOVA. The mean score of disability and mean values of lumbo-pelvic stability did not showed significant differences between two groups
(p >0.05). However, the score of pain differed from in both groups (p <0.05). The decrease of pain was more in stabilization exercises group (p <0.05) (Table 2).

Table No.1: Inter-group comparison of subjects’ characteristics

 

Stabilization Group

McKenzie’s Group

p-valuec

Age  (y)

40.13± 10.82b

36.60  ±  8.21

0.323

Height(cm)

170.53 ± 8.54

172.13 ± 7.98

0.600

Weight(kg)

74.96 ± 4.10

26.66 ± 4.74

0.432

BMIa

25.80 ± 4.10

26.66 ± 4.74

0.600

a BMI= Body Mass Index.

b Values are Means and Standard Deviation.

c Statistically significant results at p ≤ 0.05.


 

Table No.2: Inter-group & intra-group comparison of outcome variables

Outcome Variables

Stabilization Group

Mckenzie's Group

Inter-Group Comparison

Before

After

Before

After

p-value

Pain (ordinal)

4.33 ± 1.58b

1.53 ± 1.40

4.40  ± 1.95

2.66 ± 1.39

0.033c

Functional (ordinal)

20.66 ± 10.51

12.26 ± 8.87

31.60 ± 17.09

22.93 ± 13.51

0.073

Rt KLAT (mmHg)a

61.06 ± 12.51

60.60 ± 11.33

59.80 ± 7.82

58.33 ± 9.17

0.622

Lt KLAT (mmHg)

62.93 ± 10.03

62.66 ± 11.91

58.53 ± 9.72

59.46 ± 9.97

0.894

Rt BNFOT (mmHg)

29.86 ± 1.76

29.33 ± 2.71

29.60 ± 2.77

29.06 ± 2.78

0.887

Lt BNFOT (mmHg)

30.20 ± 1.37

29.26 ± 2.40

29.20 ± 2.33

28.33 ±2.46

0.428

a  Rt KLAT= Right Knee Lift Abdominal Test, Lt KLAT= Left Knee Lift Abdominal Test,

   Rt BNFOT= Rt Bent Knee Fall Out Test, Lt BNFOT= Lt Bent Knee Fall Out Test.

b  Values are Means and Standard Deviation.

c   p- value for difference between group.


Chart No.1: Characteristics of stabilization group

Chart No.2: Scores of pain before and after core stabilization and McKenzie’s exercises

DISCUSSION

The McKenzie's exercises reduced pain and stabilization exercises reduced pain and disability. However, lumbo-pelvic stability did not change after intervention in both groups. Many clinical researchers have focused on the managment of Low Back Pain12,15. Although McKenzie's method is a common approach of low back pain management16, there are a few studies with regard to effectiveness of McKenzie's method on LBP11,17. Currently, stabilization exercises have been used for management of patients with CLBP. Researchers confirmed that stabilization exercises have been influenced on pain and function in CLBP patients12,15. It was showed that stabilization and McKenzie's exercises reduced the score of pain and disability. These results are in accordance with several studies which supported McKenzie's exercises or stabilization exercises could decrease intensity of pain and improve the score of disability in patients with CLBP12,15. Our results showed that decrease of intensity of pain was more than in stabilization group. Superiority of stabilization exercises to decrease of pain is in accordance with several studies which supported stabilization exercises are more effective than other treatment in CLBP6,7. This study supported that stabilization exercises are effective exercises to reduce intensity of pain and improve functional ability in patients with CLBP. It is proposed that the efficient neuromuscular control is necessary for trunk stability and correct patterns of muscle recruitement18,19. Furthermore, it is reported that central motor program can change after performing stabilization exercises20. However, no alternation in lumbo-pelvic stability after intervention in both groups was evident. In addition, the motor control is a complex process that involves multiple systems and subsystems21. Therefore, to change a movement pattern, changes in musculoskeletal system, neural systems, and coordination between systems are necessery22. Therefore, based on these results, we propose that KLAT and BNFOT maneuvers and PBU instrument are not sensitive enough to measure the lumbo-pelvic stability. Accordingly, lack of change in lumbo-pelvic stability might be due to short duration of exercises protocol which could not lead to learning effects. Another study with similar objectives concluded that a 4-week spinal stabilization exercise program significantly improved functional status in patients presenting with CLBP23. Kofotolis N & Kellis E also endorsed the same result24. However, Roussel N et al cited that the intra-observer reliability of this evaluation method was still a challenge & it needed further research on this subject25

CONCLUSION

The study supported that stabilization exercises can reduce pain and disability in CLBP patients. However, these exercises do not change lumbo-pelvic stability. The presented method in this research will need further research to evaluate lumbo-pelvic stability with either more sensitive instrument or better maneuvers.

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Address for Corresponding Author:

Dr: Khalida Naz Memon

Associate Professor, of Community Medicine, LUMHS, Jamshoro.Address: 11-A, Mohammadi Town, Wadhoo Wah Road, Hyderabad.

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