Journal of Back and Musculoskeletal Rehabilitation 25 (2012) 7379 DOI 10.

3233/BMR-2012-0312 IOS Press

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Effect of dynamic muscular stabilization technique on low back pain of different durations
Suraj Kumara,, Vijai P. Sharmaa, Anoop Aggarwalb , Rakesh Shuklac and Ravi Devc
Department of Physical Medicine and Rehabilitation, Chatrapati Sahuji Maharaj Medical University, Lucknow, India b Department of Physiotherapy, Pt.DDU IPH, New Delhi, India c Department of Neurology, Chhatrapati Sahuji Maharaj Medical University, Lucknow, India
a

Abstract. Background: Low back pain (LBP) has multi-factorial origin and its treatment varies considerably. Multidisciplinary pain programs have shown their effectiveness in the management of LBP but it is not documented whether subjects with difference in chronicity (duration) of pain will respond differently to these regimes. Dynamic muscular stabilization technique (DMST) is an active approach of stabilizing training for lumbar area which involves the training for the co-contraction of the transverse abdominis and multidus muscles. Aim: This study determines the efcacy of Dynamic Muscular Stabilization Technique (DMST) in LBP of different durations. Design: Follow-up, comparative study. Setting: Physical medicine and rehabilitation department (PMR) of university. Methods: Total 72 patients were categorized in 5 groups on the basis of duration (chronicity) of their low back pain. The documentation of chronicity was done on the basis of subjective questionnaire. All subjects were treated with DMST. Pain was the primary outcome measure while physical strength (back pressure change: BPC, abdominal pressure changes: APC), physical ability (walking, stair climbing, stand ups) and quality of life (QOL) were the secondary. Variables were assessed at baseline (day 0), 3 months (day 90) and at the end of the follow up (day 180). Results: Variables (Pain, BPC, APC, Walking, Stair climbing, Stand ups and QOL) signicantly improved on 90th and 180th day while compared to the baseline. Therefore irrespective of the chronicity of pain, all chronic pain patients will respond positively to the DMST treatment. Conclusions: This study concludes that DMST intervention is an effective rehabilitation technique for all chronic low back pain patients irrespective of the duration (chronicity) of their pain. Keywords: Low back pain, physiotherapy, rehabilitation, stabilization

1. Introduction The LBP (low back pain) is a general term which refers to pain occurring in the region between L1 vertebrae and sacrum. The LBP may be acute (< 6 weeks), sub acute (612 weeks) or chronic (> 12 weeks) and is location specic and duration dependent [7,10]. Gen Address for correspondence: Dr. Suraj Kumar, Department of Physiotherapy, PtDDUIPH, 4VD Marg, New Delhi-110002, India. E-mail: surajdr2001@yahoo.com.

eral practitioners usually term it as lumbago, physiotherapists as hyperextension; manual therapists as facet joint disorder and orthopedic surgeons as degenerative disc problems. In fact as yet no reliable and valid classication system exists for the diagnosis and prognosis of LBP. However, researches have suggested different predictors (back pressure changes, Abdominal pressure changes, walking, disability, physical functions, quality of life, stress, stand-ups, stairs climbing, depression, work losses, cognitive factors, sitting, and pain etc.) for LBP. Among the predictors, pain had been considered to be the most useful indicator variable [5].

ISSN 1053-8127/12/$27.50 2012 IOS Press and the authors. All rights reserved

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S. Kumar et al. / Effect of dynamic muscular stabilization technique on low back pain of different durations

Based on the history and physical examination, LBP is classied into nonspecic and specic types. Non specic variety is the most common type of chronic low back pain (CLBP) and lumbago is the most common referred form, with a prevalence of about 90% to 95% in the early phase of the chronic condition [1]. Specic LBP are those, which have known cause such as infection, trauma, neurological disorder, cancer, fracture, inammatory disorder and cauda equine syndrome etc. Due to injury, the deep stabilizing muscles of the lower back remain impaired for about 46 weeks until pain subsides. These impaired deep stabilizing muscles provide poor segmental stiffness, and thus predisposes spine to re-injury and provoke the recurrence of pain. Therapeutic exercise, as part of rehabilitation for patient with LBP, is one of the treatment modalities most commonly used by physiotherapist [10]. In the management of such cases, the dynamic muscular stabilization techniques (DMST) were also found to be effective [9]. In DMST, adequate dynamic control of lumbar spine forces is achieved which reduces the repetitive injury to the structures of the spinal segments and related structures. Specic trunk stabilizing exercises with co-contraction of deep abdominal (transversus abdominis) and lumbar multidus muscles enhance the spinal segmental support and control [12]. Physical exercises have also been proved to be effective in the management of LBP both in short term and long term [3]. In our earlier studies, we have found that DMST is more effective than Conventional treatment in the management of sub-acute and chronic low back pain (CLBP) [68]. Even in the CLBP population there may be further subgroups who might be having the different onset of their pain. These subgroup individuals may respond differently to the rehabilitation regime. Though stabilization techniques were found suitable for the chronic low back pain, but the effectiveness of this form of treatment among different subgroups of CLBP with differences in the duration (chronicity) of pain is not well document. Chronicity of pain is dened as the time of onset of pain in regular or recurrence pattern. We hypothesized that DMST may improve equally in different groups categorized on the basis of duration of chronic low back pain. 2. Methods 2.1. Subject A total 72 patients of non specic CLBP (chronic low back pain) who were free from any other neuro-

Fig. 1. Distribution of patient in different groups on the basis of duration of chronic low back pain.

logical involvement and were aged 2040 and diagnosed by a physician, were included for this study from Department of Physical Medicine and Rehabilitation, CSM Medical University, Lucknow. In this study the selected 72 subjects were stratied (rather than randomization) into ve different groups on the basis of duration of their LBP (for how long they were having pain). Categorization of group (as in Fig. 1) as pain duration of three months to eight months group A, nine months to fourteen months group B, fteen months to twenty months group C, twenty one months to twenty seven months group D and twenty eight or more months considered as a group E. Subjects were excluded from the study if they suffered from any known specic neurological disorder or muscular degenerative condition such as muscular dystrophy or if they had history of any lumbar spine surgery, infection, vascular problem. They were also excluded if they had leg pain/or low back pain for less than three months. All subjects included in this study had chronic (pain duration 3 months) and non specic origin of pain. The present study had the approval of the Institutional Ethics Committee of CSM Medical University (reference letter no. 734/R-cell-07). Informed consent was obtained from all the participants. 2.2. Approach The outcome measures were pain intensity, physical strength (Back pressure change-BPC and abdominal pressure change-APC), physical ability (Walking, Stair climbing and stand-ups) and quality of life (QOL). After baseline data recording (day 0) they attended 20 days regular exercise sessions of DMST at the department. After that they were followed up at intervals of 15 days each. The next data was recorded after 3 months (90 days) and at the end of the follow

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up (180 days) from the baseline (day 0). All of these were assessed by same tester and same physiotherapist supervising the test procedure. Test and retest of each group were conducted in the same place, in same environment and at the same time of the day. Before experimentation, all subjects were well explained about the measurement variables and were also informed about the experimental risks, if any. 2.3. Procedure All subjects were treated with DMST treatment by the same physiotherapist with the same intensity and capacity in all the patients on 20 regular days. The duration of each individual treatment session was about 40 minutes per day for each subject. In DMST, those muscles were trained which have direct attachment to lumbar spinal segment and stabilize the joints neutral zone. Details of exercise, which were given in four stages, were presented elsewhere [6,7]. The subjects were not allowed to take any other treatment and medication during the treatment. 2.4. Outcome variables The level of pain intensity was assessed by visual analogue scale (VAS: 010 cm) [4] while functional ability (Walking, Stair climbing and Stand up) was assessed according to Waddle functional evaluation test [13]. The Physical Strength were (BPC and APC) measured by Pressure measuring device [6] and overall QOL by SF-36 questionnaire. The measuring details of variables in brief are summarized as follows. 2.4.1. Visual analogue scale (VAS) This is a 10 cm calibrated line with 0 representing no pain and 10 representing worst pain. The subjects were asked to make a mark or point on the scale that best represents his/her intensity of pain experienced on the same day. 2.4.2. Walking The distance walk up and down between marks 10 meter apart in 5 minute. The corridor was quiet and empty with non-slip surface or hard carpet. Patient was not allowed to use any walking aid but could use the walls for support whenever needed. Regular information about the time was given to the patient between walking.

2.4.3. Stair climbing Climbing up and down of stairs with one handrail and opposite wall within easy reach were used. Stair climbing counts of a patient was taken as total steps ups and downs completed in one minute for example a patient can up stairs 10 steps and down 18 steps, the total counts are 28. 2.4.4. Stand ups The number of times the patient could stand up from a chair in 1 minute is his/her score. The chair was rm, upright with a backrest but no armrest. The seat height of chair was 45 centimeter. During stand up there was no support within reach so that patient cannot use any support. 2.4.5. Physical strength The physical strength (BPC and APC) was measured by pressure measuring device (PMD). The measuring details of BPC and APC by using PMD were presented elsewhere [6]. All the measurements were taken at baseline (day 0), day 90 and at the end of the follow-up (day 180). 2.4.6. SF 36 quality of life It is a multipurpose, self administered, short form (SF) health survey with 36 questions which measures generic health status on general population. These questions consists physical functioning, role functioning, bodily pain, general health, vitality, social functioning, role functioning and mental health. Response choices are numbered from left to right, starting with 1. The maximum scores obtained from 36 questions were 151 represents worst QOL whereas minimum score 36 represents the best. 2.5. Statistical analysis Data was analyzed using the mean values, and percentage improvement from the baseline values. The improvement for each outcome variable in each group was evaluated as the respective average scores over the follow up periods (3 month and 6 month) minus baseline score (day 0). Microsoft EXCEL (MS Ofce 2007 version) was used for this analysis. 3. Results 3.1. Distribution of subjects There were 19 subjects in group A (26%), 10 (14%) in group B, 5 (7%) in group C, 11 (15%) in group D and 27 (38%) in group E (Table 1).

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S. Kumar et al. / Effect of dynamic muscular stabilization technique on low back pain of different durations Table 1 Distribution of all subjects (n = 72) as per duration of chronic low back pain Groups as per duration in months A (38) B (914) C (1520) D (2127) E (28 and more) Subjects (no.) 19 10 5 11 27 Subjects (%) 26 14 7 15 38

Table 2 Distribution of all subjects (n = 72) as per duration of chronic low back pain Variables Pain BPC APC Walking Stair Climbing Stand Up QOL Periods Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Group A 6.95 1.66 14.21 30.86 6.89 15.76 235.36 275.29 26.32 37 14.32 24 101.79 66.63 Group B 7.3 1.7 13.2 24.4 5.2 13.6 231.5 281.5 25.5 37.9 15.4 25.7 98.0 67.1 Group C 5.8 1.3 19.8 40.8 12.0 19.3 256.0 294.5 28.8 37 14.6 21.8 102.2 66.8 Group D 6.09 1.77 16.8 31.91 8.27 17.09 247.09 286.4 25.18 36.54 14.18 23.09 103.55 68.27 Group E 6.37 1.68 17.7 33.37 7.37 16.64 249.33 287.3 29.19 40.52 13.7 24.28 97.74 66.52

Keys: BPC- back pressure changes (mm Hg); APC- abdominal pressure changes (mm Hg); QOL- quality of life score.

3.2. Outcome measures Table 2 shows the baseline readings (day 0) and the post-test readings (average of scores at 3 month and score at 6 month). Figure 2 represents graphical presentation of improvement of each of seven variables score in each of the ve groups. For pain score the maximum improvement in group B (23%) and minimum improvement in Group C and Group D (18%) both. For BPC score the maximum improvement was found in group C (25%) and minimum in the group D and Group E(18%) both. For APC score the maximum improvement was found in group E (22%) and minimum in the group C (17%). For walking performance the maximum improvement was found in group B (24%) and minimum in the group A,C,D and group E (19% each). For standing the maximum improvement was found in group B (22%) and minimum in the group C (15%). For Stair climbing score the maximum improvement was found in group E (24%) and minimum in the group C (15%). Whereas QOL score the maximum improvement was found in group A,C and D (21% each) and minimum in the group B(18%). Overall we can say that group wise no specic pattern of improvement was observed in either of the group for any variable.

3.2.1. Effect of treatment The pre and post outcome measures data were summarized in Table 3 and also shown graphically by Fig. 3. Figures 3 and 4 show graphical representation of within group and between group changes in score of each variable at three data recording sessions (day 0, day 90 and day 180). They also show the overall improvement during follow up period in the scores from the baseline. The ascending order of group wise effect of the treatment on different variables, is as follows: Pain: Group D = group C < group E < group A < Group B BPC: Group D = group E < group B < group A < Group C APC: Group C < group B = group D < group A < Group E Walking: Group A = group C = group D = group E < Group B Stand ups: Group C < group D < group A < group B < Group E Stair climbing: Group C < group A < group D = group E < Group B QOL: Group B < group E < group A = group C = Group D

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Fig. 2. Shows percentage improvement of each variables (Pain intensity, BPC, APC, Walking, Stair climbing, and QOL) in each of the 5 groups (A, B, C, D and E).

Fig. 3. Shows within group improvement over three sessions (Day 0, 3 months and 6 months) and between group treatment effect for score of pain BPC and APC.

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S. Kumar et al. / Effect of dynamic muscular stabilization technique on low back pain of different durations

Fig. 4. Shows within group improvement over three sessions (Day 0, 3 months and 6 months) and between group treatment effect for score of walking, stair climbing, standing and QOL.

Above order shows that treatment effect does not show any consistency for different variables. However, from Figs 3 and 4 it is very clear that irrespective of the group (that is irrespective of the chronicity of pain) all variables signicantly improved on 90th and 180th day while compared to the baseline. Therefore irrespective of the chronicity of pain all chronic pain patients will respond positively to the DMST treatment. 4. Discussion In the present study DMST is found to be effective for the management of chronic low back pain irrespective of the different duration of the pain. The hypothesis that the treatment DMST is effective in all kind of chronic low back pain was found to be true. In this study there is maximum improvement in group B (23%) for pain, group C (25%) for BPC, group E (22%) for APC, group B (24%) for walking, group B (22%) for walking, E (24%) for stand up whereas group A,C and D (21% each) for QOL . There is no consistent pattern of improvement in any of the group for any variable. Possible reason for this may be that the restoration of muscle strength by DMST training occurs to equal extent irrespective of the chronicity of low back pain. In present study, the dynamic muscular stabilization training program has been found to be efcacious for

the management of the patients with chronic low back pain disorder. The spinal physiotherapy programme was concerned with the activation of stabilizer muscles, and the progression of implementation contraction of these muscles into every day postures and positions, especially those associated with pain or functional disability. As a component of musculoskeletal rehabilitation, the spinal stabilization programme is more effective than manually applied therapy or an education booklet in treating low back disorder over time [2]. Correct and timely rehabilitation is a vital component of the treatment of LBP patients. The goals of rehabilitation include restoring function, restoring pain free full range of motion, and achieving full muscle strength and endurance. This paper discusses the rehabilitation of LBP with the application of DMST special focus on the transverses abdominus (TA and multidi (MF) muscles which are necessary part of physical therapy management for low back pain. Previous studies warrant the need of this type of comparative study for LBP rehabilitation. Exercise programs may play an important role in muscle strengthening and prevention of future or recurrent injuries, which may have psychological benets also. Lumbar stabilization exercises are aimed at sensorimotor re-programming of spine stabilizer muscles intended to improve their motor control skill and delay of response and consequently to compensate for weakness of the passive stabilization system. Our results can be generalized to CLBP

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patients. Before implementing on general population it should be conrmed on more subjects, which is our future objective. Previous Clinical trials aiming to evaluate the efcacy management programs for managing chronic nonspecic low back pain, have shown the variable degree of effectiveness of these management programs. The various causes of this variability could involve: differences in the intervention design, heterogeneous groups, different treatment needs of the involved patients, and the differences in the sample size [14]. In our present study the main limitation could include the inability to get an exclusive and denite pattern of the recovery of considered variables upon DMST intervention. The prime reason of this was the differences in the sample size among different subgroups (only 5 subjects having pain since 1520 months, while about 27 patients had pain since over 28 months). Future studies aiming to evaluate the importance of chronicity of CLBP in LBP rehabilitation, may consider the larger population size in each of the groups based on chronicity. The homogeneity of the sample size would bring a better clarity regarding the pattern of response of different variables upon intervention of DMST. In our present study ther grouping of patients was done with the chronicity interval of 5 months (initial 5 months pain patients considered in group A; 814 months pain patients were considered in group B and so on. Further studies may include the groups with lesser interval span of the pain chronicity (less than 5 months interval between groups). This would bring more number of groups and will bring better clarity regarding the pattern of response of various variables. 5. Conclusion This study concludes that DMST intervention is an effective rehabilitation technique for all chronic low back pain patients irrespective of the duration (chronicity) of their pain. Walking and Quality of life are indicator of functional status and both of them improve to similar extent by DMST training in all chronic low back patients having pain of any duration (chronicity).

Acknowledgements We acknowledge Mr. Vishal and Mr. Lal Bahadur for their help during different phases of work. Authors want to acknowledge all the participants who participated in the study. Author (SK) acknowledges to ICMR, New Delhi for providing a Senior Research fellowship (letter no. 3/1/2/1/ADR/2007-NCD-I). This study has no conict of interest. References
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