|Year : 2019 | Volume
| Issue : 1 | Page : 23-29
Effect of core stability and treadmill walk exercises on the functional status of postlumbar - Surgical patients with low back pain: A pilot study
Farida Garba Sumaila, Ganiyu O Sokunbi
Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University Kano, Kano, Kano State, Nigeria
|Date of Web Publication||13-Sep-2019|
Dr. Farida Garba Sumaila
Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University Kano, PMB 3011, Kano, Kano State
Source of Support: None, Conflict of Interest: None
Background: Low back pain (LBP) is one of the most common musculoskeletal disorders for which patients consult medical care. It is also the most important cause of disability and absenteeism with increasing prevalence leading to a major socioeconomic impact on society. These facts highlight the importance of finding effective and validated treatments for this disabling condition. Stabilization Exercises and Treadmill Walk Exercise are widely reported to be effective in the management of LBP. However, their effects on Post -Surgical LBP have not been widely reported. Materials and Methods: The study was a pre test- post test quasi-experimental research design undertaken as a pilot study prior to a large randomized controlled trial. Eleven (11) Participants met the study criteria and therefore participated in the study via consecutive sampling, they received Core stability exercises and Treadmill walk exercises (Bruce protocol) three times in a week for a period of six 6 weeks. Assessment of Pain intensity, Functional Disability, Quality of Life and Fear avoidance belief was carried out. Data obtained was summarized using descriptive statistics and analysed using t-test and Wilcoxon sign rank test. Results: Mean age (years) was 51.91 ± 12.44 and mean body mass index (kg/m2) was 23.56 ± 2.52. A statistically significant decrease in pain and functional disability was found among the participants (P < 0.05) with a large effect size. Significant improvement was found in the quality of life and fear avoidance (P < 0.05) with large effect size. Conclusion: It is concluded that Core stability exercises and Treadmill walk training are effective in the reduction of pain and improvement of functional ability, quality of life and fear avoidance of individuals with Post-surgical LBP.
Keywords: Core stability exercise, post-surgical LBP, treadmill walk exercise
|How to cite this article:|
Sumaila FG, Sokunbi GO. Effect of core stability and treadmill walk exercises on the functional status of postlumbar - Surgical patients with low back pain: A pilot study. Niger J Exp Clin Biosci 2019;7:23-9
|How to cite this URL:|
Sumaila FG, Sokunbi GO. Effect of core stability and treadmill walk exercises on the functional status of postlumbar - Surgical patients with low back pain: A pilot study. Niger J Exp Clin Biosci [serial online] 2019 [cited 2019 Oct 17];7:23-9. Available from: http://www.njecbonline.org/text.asp?2019/7/1/23/266839
| Introduction|| |
Low back pain (LBP) is a disorder that occurs worldwide, which has a lifetime prevalence of 84% as reported by the World Health Organization. The incidence of the disease reaches a peak level at the age of 30–50 years and it affects females more than males. Review of literature has shown that patients who suffer from low back disorders respond well to conservative treatment, but for some amount of them, the surgery could be considered if conservative care is failed after 6 weeks. There is no specific guideline based on sound empirical knowledge from a carefully designed randomized controlled trial (RCT) and/or systematic review on the most effective rehabilitation protocol for the myriads of patients with postspinal surgical cases either in the form of what mode of exercises, specific type or combination of type, frequency, and duration of exercises that will be most effective. It appears that treatment in the form of rehabilitation of these patients has been based largely on individual therapist opinion rather than on sound empirical evidence from research studies.
Stabilization exercise reduces the effect of destructing force generated in the spine during the functional movement. However, the effect of this exercise approach could be multifactorial involving physiological, psychological, and other mechanisms that are not yet investigated., Stabilization exercise program produces short-term improvements in the global impression of recovery and in activity for people with LBP, and the results are maintained after 6 months and 12 months as reported. The improved pattern of activation and onset of activity in the transversus abdominis muscle and the multifidus muscles, decreased muscular fatigability, and restoration of muscle size following muscle atrophy caused by pain, and reflex inhibition have been linked to the benefits of spinal stabilization exercises. In addition, core stability exercises (CSEs) may empower the patient with a better coping strategy for dealing with the pain.
Rehabilitation of postsurgical spinal patients should not solely focus on core muscle strengthening, flexibility, and body mechanics. Muscular and general body endurance of the surrounding musculature is also important to consider. Trunk muscles are activated when sitting, standing, lifting, walking, or rolling over. Therefore, they are needed to sustain low levels of activity for an extended duration.
The therapeutic benefits of treadmill exercises for treating chronic LBP, besides improving cardiovascular fitness and general wellness, might be similar to the benefits of CSEs, especially as patient rehabilitation with treadmill walking performed on an inclined surface potentially make the patient to walk on a platform with a reduced stability, and this may result into challenging the muscles of the core stability.
Even though stabilization exercises and treadmill training are widely reported to be effective in the management of LBP, studies on the effects of stabilization exercises and treadmill walking exercises for treating spinal postsurgical patients with LBP are limited. It is, therefore, not clear whether spinal stability exercise and treadmill training applied either singly or in combination will provide greater benefits in terms of pain reduction, improvement of functions, and higher quality of life among LBP spinal postsurgery patients.
To the best of our knowledge, there is a gross paucity of empirical research studies on the efficacy of spinal stabilization exercise and treadmill exercise in the management of postsurgical spinal patients with LBP. Thus, this pilot study has been carried out in preparation of a larger RCT and qualitative study on the impact of the exercises used in this pilot study in the management of Post Lumbar - Surgical patients with low back pain.
| Materials and Methods|| |
The research design for this Pilot study was a pre and post intervention quasi-experimental design. A consecutive sample of individuals with postsurgical spinal pain who met the inclusion criteria were recruited, assessed, and treated as they become available.
Participants that were recruited for this study were all adults with low back pain who had undergone spinal surgery, within the age group of 18 years and above and comprising of both genders. They were recruited from Aminu Kano Teaching Hospital and National Orthopaedic Hospital, Dala (NOHD). The participants were recruited based on the following inclusion and exclusion criteria. Consecutive sampling technique was used for this study. A sample size of 11 participants was selected, and they received both core stability and treadmill walking exercises. The sample size is considered appropriate.
Participants for this study were at least 18 years old, had undergone a spinal surgery, and a history of chronic and/or recurrent LBP (repeated episodes of pain in the past year collectively lasting for ≥3 months), with or without leg pain, and is presenting with recurrent LBP. They should be able to read/understand the English and/or Hausa languages. Participants should be at Phase IV which is the recovery phase (20 weeks to 1 year postsurgery) according to the recommendations for the rehabilitation of postsurgical spinal patients by Maxey and Magnusson.
Participants with LBP caused by red flag factors such as cancer, tuberculosis, tumor, and other serious spinal pathological conditions as outlined in the clinical standards advisory group report for back pain  and also those patients with any organic pathologies such as spinal cord injury, systemic inflammatory diseases, disc prolapse, radiculopathy, inflammatory arthritis, pregnancy related, fractures, infections osteoporosis, spondylolisthesis, spinal stenosis, morbid obesity, uncontrolled diabetes, uncontrolled hypertension, or heart problems were excluded from the study.
Permission to carry out the study was sought and obtained from the Research and Ethics Committee of Aminu Kano Teaching Hospital and NOHD. Detailed information about this study was made known to the patients through participants' information sheet, and their consent was sought and obtained through an informed consent form prior to the study.
All participants were interviewed and examined by the gate keeper to ensure that the inclusion and exclusion criteria of the study were fulfilled.
The following preintervention assessments were carried out on all the participants:
- Demographic variables: demographic data of the participants were collected using a pro forma, their weight was measured using a bathroom weighting scale, and their height was assessed using a height meter, all as described above
- Pain intensity: participants were assessed using Numeric Rating Scale (NRS) for their pain level as described above. NRS has a high test–retest reliability in both literate and illiterate patients with rheumatoid arthritis (r = 0.96 and 0.95, respectively) before and after medical consultation. For construct validity, the NRS was shown to be highly correlated to the visual analog scale in patients with rheumatic and other chronic pain conditions (pain ≥6 months): correlations range from 0.86 to 0.95
- Measurement of functional disability: Roland-Morris Disability Questionnaire (RMDQ) was used to assess the functional disability of the participants with LBP as described above. This questionnaire has shown reliability, validity, and sensitivity and has been used in trials of LBP therapy. Test–retest reliability 24-item: intraclass correlation (ICC) ranges from 0.42 to 0.91. An ICC coefficient which ranges from 0.42 to 0.53 has been reported for the use of RMDQ
- Measurement of quality of life: SF-12 questionnaire was used to assess the quality of life in the participants with LBP as described above. The SF-12 has good internal consistency and test–retest reliability. Studies have demonstrated that the SF-12 is reliable, exceeding the recommended Cronbach alpha level of 0.70.
All the interventions in this study (stabilization exercises and treadmill training) were conducted by the researcher and two research assistants. The research assistants were physiotherapists in the orthopedics field of specialization with at least 5 years of working experience. Participants carried out the stabilization exercise protocols described by Sokunbi et al.,, and a modified Bruce protocol for the treadmill was carried out as described by Bruce protocol.,
Frequency and duration of exercise
Stabilization exercises and treadmill walking exercises were carried out two times per week for 6 weeks; this is considered appropriate by systematic review on guidelines for the management of LBP.
Assessment of pain intensity, functional disability, and quality of life was carried out at the end of 6 weeks treatment as previously described.
Data analysis procedure
The Statistical package for the Social Sciences (SPSS 20.0, SPSS Inc., Chicago, IL, NY, USA) software was used for the input and the analysis of the data. Gender, occupation, type of surgery, place of surgery, and cause of surgery were presented as frequencies and percentages, whereas age, height, weight, body mass index (BMI), duration of LBP, and duration of surgery were presented as a mean ± standard deviation. Pain and functional disability were analyzed using paired t-test to test the effect of therapy pre- and post-treatment within the group. Quality of life and fear of pain were analyzed using the Wilcoxon signed-rank test.
| Results|| |
A total of 11 participants met the study criteria and therefore participated in the pilot study, none dropped from the study which lasted for 6 weeks. Males were four and females were seven. [Table 1] below shows the characteristics of the study participants. Their mean age (years) was 51.91 ± 12.44, mean height (m) was 1.64 ± 0.09, mean weight (kg) was 66.36 ± 13.16, mean BMI (kg/m2) was 23.56 ± 2.52, mean duration of LBP (years) was 2.00 ± 1.00, and mean duration of time after surgery (months) was 1.45 ± 0.69.
Females accounted for the higher number of the participants 7 (63.6%), majority were civil servants 5 (45.5%), discectomy was the major surgical procedure underwent by the participants 7 (63.6%), and lumbar disc herniation was the major cause of the surgery (63.6%), most of the surgeries took place in the NOHD 5 (45.5%).
Effect of combined interventions of stabilization exercise and treadmill walk training on pain, functional disability, quality of life, and fear avoidance belief
A statistical significant decrease in pain was found among the participants (P < 0.05) as shown in [Table 2], at 95% confidence interval (CI) of 3.34–5.02 and a mean difference of 4.18. Effect size (η2) was determined to be a large effect size (0.92) according to the power analysis. Significant decrease in functional disability was also observed among the participants (P < 0.05), at 95% CI of 3.30–8.15 and a mean difference of 5.73. The effect size for the functional disability was also found to be a large effect size (0.73) using Cohen power analysis [Table 2].
|Table 2: Differences in the variables of interest between pre- and post-treatment (n=11)|
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For the quality of life, there was a significant improvement in the physical component summary domain of the quality of life (P < 0.05) with a large effect size (η2 = 0.71). A significant improvement was also noted in the mental component summary domain of the quality of life (P < 0.05) with an increase in the median value from the pretreatment (47.90) to posttreatment (53.20), and the effect size was also found to be large (η2 = 0.89).
A significant decrease in fear was also observed (P < 0.05) in the physical activity (PA) domain of the fear avoidance from pretreatment median (15.00) to posttreatment median (9.00). Similarly, a significant decrease in fear is also revealed during work (work domain) of the fear avoidance (P < 0.05) as the pretreatment median (21.00) drastically reduced to posttreatment (12.00). A large effect size was found (η2 = 0.89) in both the PA and work as shown in [Table 2].
| Discussion|| |
From the results of this study, majority of the participants were female, within normal weight, the mean age was 51 years, and more than half were civil servants this in agreement with the existing literature which noted that across the populace, the elderly, and sedentary workers including the chief executives, professional drivers, and weight lifters are all apt to develop LBP at one time or the other. LBP affects both men and women. The incidence of the disease reaches a peak level at the age of 30–50 years, and it affects females more than males.
Duration of LBP among the participants was found to be 2 years while the duration of surgery (time taken after surgery) was 14 months; major cause of surgery was found to be lumbar disc herniation with discectomy as the major type of surgeryand majority of the surgeries were done at NOHD, Kano. A discectomy (also called open discectomy) is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord. The procedure involves removing the central portion of an intervertebral disc, the nucleus pulposus, which causes pain by stressing the spinal cord or radiating nerves.
Lumbar disc herniation and the acute radicular syndrome that occasionally ensues are common occurrences. About 35% of patients with lumbar disc herniation develop true sciatica. However, not all lumbar disc herniations produce symptoms. In patients younger than 60 years, 20%–35% of lumbar disc herniations are asymptomatic. Furthermore, 90% of those with their first episode of sciatica improve with conservative care. In patients with radicular symptoms, surgery may be considered if certain criteria are met.
The results of this study showed a significant improvement in pain and functional disability among postsurgical LBP patients after 6 weeks of CSEs and treadmill training, this is in conformity with the work of Sokunbi et al. who stated that the stabilization exercise program has become the most popular treatment method in spinal rehabilitation since it has shown its effectiveness in some aspects related to pain and disability. The spinal stabilization exercise model is an active approach to the management of LBP based on a program of motor control exercises. The main mechanisms behind the pain relieving and functional restoration effects of this exercise program on patients with LBP have been largely attributed to its ability to ameliorate the impairment or deficit in motor control around the neutral zone of the spinal motion segment, by restoring the normal function of the local stabilizer muscles  and also reported that there is a likelihood of muscular contraction during spinal stabilization exercises providing sensory input to activate different pain inhibitory mechanisms in the central nervous system leading to an increase in the plasma serotonin level, as a possible mechanism of the spinal stabilization exercises-induced analgesia.
The therapeutic benefit of treadmill exercises for treating chronic LBP, besides improving cardiovascular fitness and general wellness, might be similar to the benefits of CSEs, especially as patient rehabilitation with treadmill walking performed on an inclined surface potentially make the patient to walk on a platform with a reduce stability, and this may result in challenging the muscles of the core stability.
A systematic review involving 895 participants conducted by Gomes-Neto et al. reported that stabilization exercises were as efficacious as manual therapy in decreasing pain and functional disability in patients with LBP. The study, however, did not specify the type of LBP. It was reported by Brumitt et al. that stabilization exercises help to decrease pain and functional disability in patients with LBP. Another Systematic review involving 414 participants reported that CSE is more effective in relieving pain and improving functional disability among patients with chronic LBP.
In contrast, Smith et al. conducted a systematic review on 2258 patients with nonspecific LBP comparing CSEs and other forms of exercises; they concluded that CSEs are not more effective than any other form of exercise. However, exercises used as a comparator, and for control are not specified.
It was also concluded by Lawford et al. that there is low-quality evidence to suggest that treadmill walk exercise was more effective than other exercises on pain among chronic LBP patients. The systematic review involved 869 patients with chronic LBP, however, it is not clear, what the usual care and general exercises are for the study. Treadmill walk exercise was found to be effective on chronic LBP by reducing pain, improving functional disability, and increasing the low back extensor strength as reported by Cho et al. The study is, however, limited as the RCT was conducted on only 20 participants and it is of low-quality evidence.
Shnayderman and Katz-Leurer concluded that treadmill exercise was as effective as specific low back exercises. The RCT involved 52 participants has a high-quality evidence though the low back exercises were not specified in the study. Treadmill walk exercise is an effective adjunct treatment method to standard care for decreasing pain and increasing function in LBP patients as reported by Joffe et al.
In this study, quality of life and fear avoidance have been shown to be improved among postsurgical LBP patients after 6 weeks of CSEs and treadmill walk training, this could be because the benifit of spinal stabilization exercises have been linked to improve the pattern of activation and onset of activity in the transversus abdominis muscle and the multifidus muscles, decreased muscular fatigability, and restoration of muscle size following muscle atrophy caused by pain and reflex inhibition. It has been reported at least 17% increase in plasma serotonin levels in patients with chronic LBP after 30 min of CSEs. In addition, CSEs may empower the patient with a better coping strategy for dealing with the pain.
While treadmill exercises are more commonly known for improving cardiovascular endurance, benefits to muscular endurance and flexibility are seen as well. This exercise can minimize the loading of the spine and increase the strength of the surrounding musculature, while improving muscular endurance and preventing fatigue. Research has found that by preventing muscles from fatiguing, improper body mechanics may also be avoided. This effect of treadmill walk exercise can also have a psychological effect on pain by improving mood and causing an overall feeling of well-being.
Treadmill walk exercises are a good choice for an exercise routine, because walking is well tolerated by most individuals regardless of finess level and back condition. Itprovides a straightforward, efficient aerobic workout, and its effects might be used to compliment that of CSE in the exercises rehabilitation of spinal conditions.
The effect of the combine treatment protocol of spinal stability exercise and treadmill walk training on postsurgical LBP patients was found to be effective; this might influence the choice of the combination of core stability and treadmill exercises in the management of postsurgical spinal patients with LBP. The result of this pilot study was useful to estimate sample size, and the workability for mixed method encompassing RCT, and the qualitative study which when completed might provide a empirical evidence for the choice of these particular treatment approach rather than depending on the preference of the clinician to influence the choice and methods of rehabilitating this group of patients.
The obvious limitation to this study includes the low sample size, lack of randomization, and blinding. The long-term effects of the intervention were not established in the present study. This sample is considered appropriate for a pilot study by Creswell. However, in the large randomized controlled trial, currently being undertaken, an appropriately powered sample size of patients was involved, and 3-month follow-up assessments will be carried out to establish the long-term effects of the interventions used in the study.
| Conclusion|| |
The present pilot study has demonstrated that CSEs and treadmill walk training are effective in the reduction of pain and improvement of functional ability, quality of life, and fear avoidance of individuals with postsurgical LBP.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]