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Volume 25 |
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Number 2 |
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Published by : PROFESSIONAL MEDICAL PUBLICATIONS |
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ORIGINAL ARTICLE |
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Volume 25 |
April - June 2009 (Part-I) |
Number 2 |
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The effects of consecutive supervised stability training on
postural balance in patients with chronic low back pain
Noureddin Karimi1, Ismaeil Ebrahimi2,
Kamran Ezzati3,
Sedigheh Kahrizi4, Giti Torkaman5, Amir Massoud Arab6
ABSTRACT
Objective: To examine the effects of consecutive supervised stability training on postural control of Chronic Low Back Pain (CLBP) population.
Methodology: Thirty-eight subjects with Chronic Low Back Pain (CLBP) were randomly assigned to one of two groups: Concise Supervised Stability Training (CSST) group (n=20) and electrotherapy (E) group (n=18). Bilateral and unilateral stance ability with eyes open or closed was assessed by using Biodex Balance System. Postural indices including overall, anterior/posterior, medial/lateral stability indices and limit of stability parameters as time to complete and functional performance of subjects were recorded.
Results: Qualitative and quantitative variables were not significant between groups before treatment. Most postural indices showed significant decrease after stability training comparing with E group.
Conclusions: CSST may improve postural balance in patients with Chronic Low Back Pain (CLBP) because of facilitating feed forward mechanism, proprioception and postural strategies. Nevertheless, more investigations are needed to evaluate the effects of CSST in Chronic Low Back Pain (CLBP) patients.
KEYWORDS:
Low back pain, Stability training, Postural balance.Pak J Med Sci April - June 2009 Vol. 25 No. 2 177-181
How to cite this article:
Karimi N, Ebrahimi I, Ezzati K, Kahrizi S, Torkaman G, Arab AM. The effects of consecutive supervised stability training on postural balance in patients with chronic low back pain. Pak J Med Sci 2009;25(2): 177-181
1. Noureddin Karimi, PT, PhD
Assistant Professor,
2. Ismaeil Ebrahimi, PT, PhD
Professor, Faculty of Rehabilitation,
Iran University of Medical Sciences, Tehran, Iran.
3. Kamran Ezzati, PT, M.Sc
Special Medical Center,
4. Sedigheh Kahrizi, PT, PhD
Assistant Professor,
5. Giti Torkaman PT, PhD
Assistant Professor,
5,6: Tarbiat Modares University Tehran, Iran.
6. Amir Massoud Arab, PT, PhD
Assistant Professor,
1,6: University of Social Welfare & Rehabilitation Sciences,
Tehran, Iran.
Correspondence
Ismaeil Ebrahimi, PT, PhD
Professor,
Faculty of Rehabilitation,
Iran University of Medical Sciences,
Tehran, Iran.
E-mail: takamjan@iums.ac.ir
* Received for Publication: October 25, 2008
* Revision Received: March 11, 2009
* Revision Accepted: March 16, 2009
INTRODUCTION
Low back pain is a very common health care problem affecting 85% of population.
1 Spine rehabilitation programs vary in subjects with chronic low back pain (CLBP), but core stability training is often the treatment of choice.2,3 In addition, frequency of treatment traditionally is three times per week and home-based most of the time.4 Little is known about concise and supervised training in the treatment of CLBP patients.5 Tomporowski showed that submaximal executive aerobic exercise performed for periods up to 60 minutes facilitates specific aspects of information processing.6 Recently, Budde et al indicated that 10 minutes bilateral coordinative exercise has positive effects on attentional performance in adolescents.7Performance of the whole body should be considered as an important part of treatment whereas postural control is the base of movement and function.
8 Nowadays it has been shown that coordination of postural control may be affected in CLBP patients.8-10 Tsao and Hodges showed immediate improvements in feedforward postural adjustments of the transversus abdominis (TrA) muscle following a single session of isolated voluntary contractions training.11Despite the relationship between CLBP and postural balance, until now, according to our knowledge, no study has assessed the influence of concise supervised stability training (CSST) on postural balance in patients with CLBP. However, the aim of this study was to examine the effects of CSST on postural control of CLBP population.
METHODOLOGY
Subjects:
Thirty-eight subjects with CLBP were randomly assigned to one of two groups: CSST group (n=20, age=25/94 ± 5/7 years old, height =174/84± 7/83cm, and mass=76/42±9/5 kg) and electrotherapy (E) group (n=18,age =28/11±6/21 years old, height =175/11± 7/45 cm, and mass = 72/08 ± 11/98 kg). All patients had pain more than three month ago that was not specific and was better with rest and exaggerated with activity. Subjects with LBP were excluded if they had radicular pain, disc herniation, spinal stenosis, serious spinal complications, presence of any neurological signs, previous spinal surgery, systemic infection, balance or cardiovascular disorders, history of any surgery in the three months prior to testing, uncorrected vision problems, severe musculoskeletal deformity, injury to the lower extremity or taking medication one week prior to testing session. Each subject provided written informed consent in accordance with institutional human-subjects review-board policy.Instrumentation: To assess balance and neuromuscular control, this study used a commercially available balance device, the BBS (Biodex Balance Systems, NY, USA), which consists of a movable platform that is interfaced with computer software to serve as an objective assessment of balance. The measures of postural stability include the overall (OA), the anterior/posterior (AP), and the medial/lateral (ML) stability indices (SI). Also limit of stability was recorded as time to complete (TC) and functional performance (FP) of the individuals.
10Testing Procedures: Bilateral and unilateral stance ability was assessed between eight (most stable) and level three (more unstable) stability level with the BBS over a period of 15 seconds before and after treatment.
At first, subjects were given an overview of the testing procedure, removed their footwear from both feet, and stood on both legs on the BBS’s locked platform.
12 They were instructed to place arms across the chest and look at the quadrant and zones on the LCD screen. Then the platform was unlocked and participants adjusted the position of the supporting foot to maintain platform stability. Testing was initiated as the platform was released for a 15-sec trial and participants were asked to maintain an upright standing position on their feet while the stability level was between 6 and 3.10During single leg standing, the subjects stood on their dominant foot over the approximate center of the BBS platform. The unsupported leg was in a comfortable knee-flexed position. The stability level was between 8 and 4 in this position. All dynamic stability parameters were recorded in four situations: Double Leg Eyes Open (DLEO), Double Leg Eyes Closed (DLEC), Single Leg Eyes Open (SLEO), Single leg Eyes Closed (SLEC).Thus, limit of stability variables were recorded in DLEO position only.
10,12All CLBP patients performed the treatment program during 10 days consecutively under physical therapist supervision. The treatment program in the E group included: Ultrasound (1 MG, Continuous, 5 min), TENS (2 canal, 90 -110 Hz, 15 min), InfraRed (15 min). But the program in the CSST group includes:
*
Explaining the importance of stability exercises in CLBP.13*
Isolating muscular functions emphasizing Tr A and Multifidus by an expert physiotherapist using palpation and pressure biofeedback.14*
Training tonic cocontractions of Tr A and Multifidus during single limb movements and then cross limb movements in different positions. Finally, the patients walked on treadmill with controlled speed and time (15 min).13-15
Statistical Analysis: Chi-square and Independent t-test was used to compare qualitative and quantitative data between CSST group and E group pre-test. Balance scores in each group pre and post test were analyzed using 2-tailed paired observation t test. An level of 0.05 was set for the analyses.
RESULTS
Table-I summarizes the CLBP demographics of the patients.
The results indicated that qualitative and quantitative variables were not
significant in both groups before treatment (p>0/05). (Table-I,I
I)
The OSI and APSI showed significant decrease in DLEC and SLEO situations after stability training. MLSI demonstrated significant decrease in DLEO and DLEC situations. Also TC and FP indicates significant differences pre and post stability training. All measures in SLEC position didn’t show significant differences pre-post stability training. In contrast, about E group only APSI and MLSI in DLEC position and FP were significant statistically after treatment. (Table-III)
Discussion
Previous studies have indicated a high reliability in balance test indices measured by using BBS (OSI, APSI, and MLSI) patients with LBP.
10 The results of this study showed that CSST was effective in improving postural balance and limit of stability in CLBP patients. Postural control is affected by vestibular, visual, somatosensory and central nervous system.8 Any disturbance in postural control after pain or injury may decrease body control and lead to more abnormalities. So far, in many studies postural disturbance were reported after CLBP.8-10,15,16Feedforward postural mechanism has been improved immediately after one session of isolated and voluntary contractions of Tr A. However, these type of training interventions may have immediate effects on postural control.
11Lumbosacral and lower extremity joints as a part of body proprioceptive system can influence postural control.
17 In addition, Tr A and multifidus muscles are full of proprioceptive receptors that have important role in neuromuscular control of lumbar region.18,19 CSST may retrain these muscles and improve neuromuscular and postural control. These findings are in agreement and disagreement with other studies.20-22Nadler et al found that muscle imbalance in hip abductors is highly associated with LBP occurrence in female athletes.
23 Karimi et al showed significant difference in MLSI and no significant difference in APSI stability indices between healthy group and LBP patients because of hip abductor weakness in patients with LBP.10 However, training of all muscles of lumbo-pelvic-hip may change postural strategies and improving the role of hip strategy in balance control.22There is a positive association between temporal action of local muscles and quality of training.
11,24 Several studies about quality of treatment has shown that precision and supervision in training isolated muscles is as important as frequency of training that may alter feedforward mechanism of muscles.11 This may be explained how CSST can affect postural control. Finally, present study should be further examined using a larger sample as well as a control group that can be symptomatic or asymptomatic.CONCLUSIONS
According to findings of the present study CSST may improve muscles cocontractions and postural control. However, it should be emphasized as a clinical choice of treatment in CLBP patients. Finally, further studies are needed to explore the effects of CSST in CLBP patients.
REFERENCES
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21. Hubely-Kozey CL, Vezina J. Muscle activation during exercises to improve trunk stability in men with low back pain. Archives Physc Med Rehabili 2002;83:1100-8.
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