The Effect of Core Stabilization Exercises Using a Sling on Pain and Muscle Strength of Patientswith Chronic Low Back Pain

Efficacy of specific exercises in general population with non-specific low back pain: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Localized exercises are employed to activate, train, or restore the function of particular muscles and they are usually considered as part of treating individuals suffering low back pain. So, this systematic review and meta-analysis aimed to assess the efficacy of specific exercises in general population with non-specific low back pain (LBP).

METHODS

We conducted electronic searches in MEDLINE/PubMed, Scopus, Web of Science (WoS), and Google scholar from January 1990 to June 2021. Initially, 47,740 records were identified. Following the removal of duplicates, 32,138 records were left. After reviewing titles and abstracts, 262 papers were chosen for thorough assessment. Among these, 208 studies were excluded, resulting in 54 trials meeting the inclusion criteria for this study. Additionally, 46 of these trials were randomized controlled trials and were further evaluated for the meta-analysis. We included trials investigating the effectiveness of exercise therapy, including isometric activation of deep trunk muscles, strengthening exercises, stabilization exercises, stretching exercises, and proprioceptive neuromuscular facilitation exercises (PNF) in LBP patients. The primary outcome was pain intensity, measured using tools such as the visual analogue scale (VAS) and numeric pain rating scale (NPRS). The secondary outcome was disability, assessed through instruments such as the Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI). The quality of the eligible studies was assessed using the Verhagen tool, and the level of evidence was evaluated using the GRADE approach.

RESULTS

Based on the Verhagen tool, 46 trials (85.2%) were categorized as having low methodological quality, while 8 studies (14.8%) were considered to have medium methodological quality. The meta-analysis indicated a small efficacy in favor of isometric activation of deep trunk muscles (-0.37, 95% CI: -0.88 to 0.13), a moderate efficacy in favor of stabilization exercises (-0.53, 95% CI: -1.13 to 0.08), and a large efficacy in favor of PNF exercises (-0.91, 95% CI: -1.62 to -0.2) for reducing pain intensity as assessed by VAS or NPRS tools. Moreover, the meta-analysis revealed a moderate efficacy for isometric activation of deep trunk muscles (-0.61, CI: -1.02 to -0.19), and a large efficacy for PNF exercises (-1.26, 95% CI: -1.81 to -0.72) in improving disability, assessed using RMDQ or ODI questionnaires. The level of certainty in the evidence, as determined by the GRADE approach, was very low to low.

CONCLUSION

These findings emphasize the importance of incorporating localized therapeutic exercises as a fundamental aspect of managing non-specific LBP. Clinicians should consider utilizing localized therapeutic exercise tailored to individual patient needs. Furthermore, further research investigating optimal exercise therapy, optimal dose of the exercises, durations, and long-term adherence is warranted to enhance the precision and efficacy of exercise-based interventions for non-specific LBP.

Exercise intervention for patients with chronic low back pain: a systematic review and network meta-analysis

Purpose

Chronic low back pain (CLBP) is an aging and public health issue that is a leading cause of disability worldwide and has a significant economic impact on a global scale. Treatments for CLBP are varied, and there is currently no study with high-quality evidence to show which treatment works best. Exercise therapy has the characteristics of minor harm, low cost, and convenient implementation. It has become a mainstream treatment method in clinics for chronic low back pain. However, there is insufficient evidence on which specific exercise regimen is more effective for chronic non-specific low back pain. This network meta-analysis aimed to evaluate the effects of different exercise therapies on chronic low back pain and provide a reference for exercise regimens in CLBP patients.

Methods

We searched PubMed, EMBASE, Cochrane Library, and Web of Science from inception to 10 May 2022. Inclusion and exclusion criteria were used for selection. We collected information from studies to compare the effects of 20 exercise interventions on patients with chronic low back pain.

Results

This study included 75 randomized controlled trials (RCTs) with 5,254 participants. Network meta-analysis results showed that tai chi [standardized mean difference (SMD), -2.11; 95% CI, -3.62 to -0.61], yoga (SMD, -1.76; 95% CI -2.72 to -0.81), Pilates exercise (SMD, -1.52; 95% CI, -2.68, to -0.36), and sling exercise (SMD, -1.19; 95% CI, -2.07 to -0.30) showed a better pain improvement than conventional rehabilitation. Tai chi (SMD, -2.42; 95% CI, -3.81 to -1.03) and yoga (SMD, -2.07; 95% CI, -2.80 to -1.34) showed a better pain improvement than no intervention provided. Yoga (SMD, -1.72; 95% CI, -2.91 to -0.53) and core or stabilization exercises (SMD, -1.04; 95% CI, -1.80 to -0.28) showed a better physical function improvement than conventional rehabilitation. Yoga (SMD, -1.81; 95% CI, -2.78 to -0.83) and core or stabilization exercises (SMD, -1.13; 95% CI, -1.66 to -0.59) showed a better physical function improvement than no intervention provided.

Conclusion

Compared with conventional rehabilitation and no intervention provided, tai chi, toga, Pilates exercise, sling exercise, motor control exercise, and core or stabilization exercises significantly improved CLBP in patients. Compared with conventional rehabilitation and no intervention provided, yoga and core or stabilization exercises were statistically significant in improving physical function in patients with CLBP. Due to the limitations of the quality and quantity of the included studies, it is difficult to make a definitive recommendation before more large-scale and high-quality RCTs are conducted.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Efficacy of Core Stability in Non-Specific Chronic Low Back Pain

(1) Background: Management of chronic low back pain (cLBP) is often multidisciplinary, involving a combination of treatments, including therapeutic exercises. Core stability exercises aim to improve pain and disability in cLBP increasing spinal stability, neuromuscular control, and preventing shear force that causes injury to the lumbar spine. The purpose of this study was to review the available evidence about the effectiveness in reducing pain and improving disability of core stability exercises for non-specific cLBP. (2) Methods: We perform a systematic research on common Medline databases: PubMed, Pedro, and Cochrane Library. Search results were limited to articles written in English and published between January 2005 and November 2020.The search provided a total of 420 articles. Forty-nine articles met the inclusion criteria and 371 articles were excluded. (3) Results: Core stability provides great therapeutic effects in patients with non-specific chronic low back pain reducing pain intensity, functional disability, and improving quality of life, core muscle activation, and thickness. Evidences suggest that core stability is more effective than rest or no/minimal intervention and combination with other types of exercise for cLBP have shown grater efficacy. (4) Conclusion: Core stability could be proposed in a comprehensive approach in cLBP, the combination with other modalities of therapeutic exercise should be promoted. Patient compliance is crucial to determine the efficacy of the intervention.

Efficacy and safety of thread embedding acupuncture combined with acupuncture for chronic low back pain: A randomized, controlled, assessor-blinded, multicenter clinical trial

BACKGROUND

Low back pain is a very common disease. Many patients with chronic low back pain (CLBP) have been treated by complementary and alternative medicine such as acupuncture (AT) treatment. A type of AT, thread embedding acupuncture (TEA), consists of a thread that can continually stimulate at the AT points and has mechanical and chemical effects. Although TEA was widely used in clinical practice, there was little evidence of its efficacy and safety for CLBP.

METHODS

This clinical trial was randomized, controlled, assessor-blinded, two-armed, parallel, and conducted in multiple centers. Four Korean medical institutions recruited 38 outpatients with CLBP. The participants were randomly allocated to a treatment group (TEA combined with AT) or a control group (only AT) in a 1:1 ratio. All participants received conventional AT twice a week for 8 weeks (16 sessions) at 15 AT points (GV3 and bilateral BL23, BL24, BL25, BL26, BL40, BL60, and EX-B5) and the treatment group participants additionally received TEA once a week for 8 weeks (8 sessions) on 10 AT points in the multifidus, spinal erector, and lumbar quadrate muscles. The primary outcome measure of this study was the change of visual analog scale (VAS) from baseline (0 week) to the end of intervention (8 weeks). Secondary outcome measures included clinically relevant improvement (minimal clinically important difference) and 3% to 50% decrease on VAS, disability level (Korean version of Roland and Morris disability questionnaire), quality of life (Korean version of European quality of life 5dimension), global assessment (patient global impression of change), economic analysis, credibility test, and safety assessment.

RESULTS

The treatment group showed a significant reduction in VAS scores when compared with the control group (-33.7 ± 25.1 vs -15.6 ± 17.0, P = .013). As for the secondary outcome measures, the treatment group showed significant difference in 50% decrease on VAS and patient global impression of change. There was no serious adverse event associated with TEA and AT.

CONCLUSION

This clinical trial documents the efficacy and safety of TEA combined with AT for the management of CLBP.

Dynamics of Changes in Isometric Strength and Muscle Imbalance in the Treatment of Women with Low back Pain

The aim of the study was to evaluate the dynamics of isometric changes in strength and muscular lumbar-pelvic imbalances in the treatment of women with low back pain. Forty-one women, nineteen in the study group (A) and twenty-two in the control group (B), participated in the study. Magnetic resonance imaging (MRI) was performed to assess the degree of degenerative changes in the lumbar spine. The diagnosis of isometric muscle strength and their imbalances was performed with the Tergumed 700 device. After six weeks of therapy in the study group (A), there was a significant improvement in the strength of all the examined muscle groups. However, in the control group (B), significant improvement occurred only in the strength of the lumbar flexor muscles and the flexor muscles on the left side. Furthermore, there was a significant intensification of the imbalance of left flexor muscle strength compared to right flexor strength in group B. Significant differences in favour of the study group (A) concerned the strength of the rotator muscles to the left, the strength of the extensor muscles of the lumbar spine, the strength of the flexors of the lumbar spine to the right, and the balance of the strength of the lumbar spine flexors to the left compared to the strength of the flexor muscles to the right. Therapy with the Tergumed 700 system leads to an increase in the muscle strength of the lumbar and pelvic complex, compensating for its imbalance, bringing beneficial effects in the treatment of low back pain.

Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis

Objective

Examine the effectiveness of specific modes of exercise training in non-specific chronic low back pain (NSCLBP).

Design

Network meta-analysis (NMA).

Data sources

MEDLINE, CINAHL, SPORTDiscus, EMBASE, CENTRAL.

Eligibility criteria

Exercise training randomised controlled/clinical trials in adults with NSCLBP.

Results

Among 9543 records, 89 studies (patients=5578) were eligible for qualitative synthesis and 70 (pain), 63 (physical function), 16 (mental health) and 4 (trunk muscle strength) for NMA. The NMA consistency model revealed that the following exercise training modalities had the highest probability (surface under the cumulative ranking (SUCRA)) of being best when compared with true control: Pilates for pain (SUCRA=100%; pooled standardised mean difference (95% CI): −1.86 (–2.54 to –1.19)), resistance (SUCRA=80%; −1.14 (–1.71 to –0.56)) and stabilisation/motor control (SUCRA=80%; −1.13 (–1.53 to –0.74)) for physical function and resistance (SUCRA=80%; −1.26 (–2.10 to –0.41)) and aerobic (SUCRA=80%; −1.18 (–2.20 to –0.15)) for mental health. True control was most likely (SUCRA≤10%) to be the worst treatment for all outcomes, followed by therapist hands-off control for pain (SUCRA=10%; 0.09 (–0.71 to 0.89)) and physical function (SUCRA=20%; −0.31 (–0.94 to 0.32)) and therapist hands-on control for mental health (SUCRA=20%; −0.31 (–1.31 to 0.70)). Stretching and McKenzie exercise effect sizes did not differ to true control for pain or function (p>0.095; SUCRA<40%). NMA was not possible for trunk muscle endurance or analgesic medication. The quality of the synthesised evidence was low according to Grading of Recommendations Assessment, Development and Evaluation criteria.

Summary/conclusion

There is low quality evidence that Pilates, stabilisation/motor control, resistance training and aerobic exercise training are the most effective treatments, pending outcome of interest, for adults with NSCLBP. Exercise training may also be more effective than therapist hands-on treatment. Heterogeneity among studies and the fact that there are few studies with low risk of bias are both limitations.

Effects of Sling Exercise on Flexibility, Balance Ability, Body Form, and Pain in Patients With Chronic Low Back Pain

PURPOSE

The aim of this study was to investigate the effects of sling exercise on pain, balance, flexibility, and body form in patients with chronic low back pain (LBP).

DESIGN

The pretest-posttest control group design.

METHODS

Thirty participants with chronic lumbar pain were divided into three groups (Sling only, Sling + Swing stick flexible bar, and Sling + Ball cushion) and exercised for 12 weeks.

FINDINGS

All types of sling exercises provided significant positive effects on pain scale, body balance, flexibility, and body form. In particular, the sling exercise with swing stick flexible bar or ball cushion was more effective on body form, flexibility, and balance than a sling alone.

CONCLUSIONS

In conclusion, sling exercises over a period of 12 weeks had positive effects on flexibility, balance, pain, and body form in patients with chronic lumbar pain.

CLINICAL RELEVANCE

This study has generated effects of sling exercise, which will assist nursing practitioners in prescribing the beneficial physical rehabilitation for patients with chronic LBP.

Effects of 12-week lumbar stabilization exercise and sling exercise on lumbosacral region angle, lumbar muscle strength, and pain scale of patients with chronic low back pain

[Purpose] The purpose of this study is to investigate the effects of lumbar stabilization exercise and sling exercise on lumbosacral region angle, lumbar muscle strength, pain scale of patients with chronic low back pain. [Subjects and Methods] The subjects of this study were 29 chronic low back pain patient women who were selected among participants in exercise class at K Region Health Promotion Center in South Korea and were randomly assigned to the lumbar stabilization exercise group (n=10), sling exercise group (n=10), and the control group (n=9). Both lumbar stabilization and sling exercise programs were executed for 60 minutes, three times a week, for 12 weeks. Before and after exercise we measured lumbosacral region angle (lumbar lordosis angle, lumbosacral angle, sacral inclination angle), lumbar muscle strength, and pain scale in all subjects. Two-way analysis of variance was conducted to analyze experimental data. In order to analyze the interaction effect, we conducted paired t-test before and after treatment. [Results] Lumbar stabilization exercise group and sling exercises group did not affect lumbar lordosis angle, lumbosacral angle and sacral inclination angle. Whereas the lumbar flexion muscle strength and lumbar extension muscle strength significantly increased in the lumbar stabilization exercise group and sling exercise group. The flexibility increased in the lumbar stabilization exercise group and sling exercise group. The pain scale decreased in the lumbar stabilization exercise group and sling exercise group. [Conclusion] Both lumbar stabilization exercise and sling exercises are useful therapeutic approaches to chronic back pain.

An analysis on muscle tone and stiffness during sling exercise on static prone position

[Purpose] The purpose of this study was to examine changes in the muscle tone and stiffness of the lumbar region while individuals adopted the static prone position using sling suspension. [Subjects and Methods] The subjects were 30 healthy women in their 20s. The muscle tone and stiffness of the upper and lower lumbar regions of the sling suspension group and a control group were measured using myotonmetory as they maintained the static prone positon. [Results] The sling suspension group showed statistically significant declines in the muscle tone and stiffness of the upper lumbar region 5–10 min after adopting the initial prone position. They also showed statistically significant declines in the muscle tone and stiffness of the lower lumbar region immediately after being suspended in the slings and a statistically significant decline in the muscle tone of the lower lumbar region 5–10 min after adopting the initial prone position during which the sling suspension was applied. In contrast, the muscle tone and stiffness of the lumbar region of the control group increased while maintaining the static prone position. [Conclusion] The static prone position performed on a treatment table using sling suspension can be an effective intervention for reducing the muscle tone and stiffness of the lumbar region.

Improvements in tissue blood flow and lumbopelvic stability after lumbopelvic core stabilization training in patients with chronic non-specific low back pain

[Purpose] This study investigated the effects of lumbopelvic stabilization training on tissue blood flow changes in the lumbopelvic region and lumbopelvic stability compared to placebo treatment and controlled intervention among patients with chronic non-specific low back pain. [Subjects and Methods] A total of 25 participants (7 males, 18 females; mean age, 33.3 ± 14.4 years) participated in this within-subject, repeated-measures, double-blind, placebo-controlled comparison trial. The participants randomly underwent three types of interventions that included lumbopelvic stabilization training, placebo treatment, and controlled intervention with 48 hours between sessions. Lumbopelvic stability and tissue blood flow were measured using a pressure biofeedback device and a laser Doppler flow meter before and after the interventions. [Results] The repeated-measures analysis of variance results demonstrated a significant increase in tissue blood flow over the lumbopelvic region tissues for post- versus pre-lumbopelvic stabilization training and compared to placebo and control interventions. A significant increase in lumbopelvic stability before and after lumbopelvic stabilization training was noted, as well as upon comparison to placebo and control interventions. [Conclusion] The current study supports an increase in tissue blood flow in the lumbopelvic region and improved lumbopelvic stability after core training among patients with chronic non-specific low back pain.

Motor control exercise for acute non-specific low back pain

BACKGROUND

Motor control exercise (MCE) is used by healthcare professionals worldwide as a common treatment for low back pain (LBP). However, the effectiveness of this intervention for acute LBP remains unclear.

OBJECTIVES

To evaluate the effectiveness of MCE for patients with acute non-specific LBP.

SEARCH METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), four other databases and two trial registers from their inception to April 2015, tracked citations and searched reference lists. We placed no limitations on language nor on publication status.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) examining the effectiveness of MCE for patients with acute non-specific LBP. We considered trials comparing MCE versus no treatment, versus another type of treatment or added as a supplement to other interventions. Primary outcomes were pain intensity and disability. Secondary outcomes were function, quality of life and recurrence.

DATA COLLECTION AND ANALYSIS

Two review authors screened for potentially eligible studies, assessed risk of bias and extracted data. A third independent review author resolved disagreements. We examined MCE in the following comparisons: (1) MCE versus spinal manipulative therapy; (2) MCE versus other exercises; and (3) MCE as a supplement to medical management. We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the quality of evidence. For missing or unclear information, we contacted study authors. We considered the following follow-up intervals: short term (less than three months after randomisation); intermediate term (at least three months but within 12 months after randomisation); and long term (12 months or longer after randomisation).

MAIN RESULTS

We included three trials in this review (n = 197 participants). Study sample sizes ranged from 33 to 123 participants. Low-quality evidence indicates no clinically important differences between MCE and spinal manipulative therapy for pain at short term and for disability at short term and long term. Low-quality evidence also suggests no clinically important differences between MCE and other forms of exercise for pain at short or intermediate term and for disability at intermediate term or long term follow-up. Moderate-quality evidence shows no clinically important differences between MCE and other forms of exercise for disability at short term follow-up. Finally, very low-quality evidence indicates that addition of MCE to medical management does not provide clinically important improvement for pain or disability at short term follow-up. For recurrence at one year, very low-quality evidence suggests that MCE and medical management decrease the risk of recurrence by 64% compared with medical management alone.

AUTHORS' CONCLUSIONS

We identified only three small trials that also evaluated different comparisons; therefore, no firm conclusions can be drawn on the effectiveness of MCE for acute LBP. Evidence of very low to moderate quality indicates that MCE showed no benefit over spinal manipulative therapy, other forms of exercise or medical treatment in decreasing pain and disability among patients with acute and subacute low back pain. Whether MCE can prevent recurrences of LBP remains uncertain.

Motor control exercise for chronic non-specific low-back pain

BACKGROUND

Non-specific low back pain (LBP) is a common condition. It is reported to be a major health and socioeconomic problem associated with work absenteeism, disability and high costs for patients and society. Exercise is a modestly effective treatment for chronic LBP. However, current evidence suggests that no single form of exercise is superior to another. Among the most commonly used exercise interventions is motor control exercise (MCE). MCE intervention focuses on the activation of the deep trunk muscles and targets the restoration of control and co-ordination of these muscles, progressing to more complex and functional tasks integrating the activation of deep and global trunk muscles. While there are previous systematic reviews of the effectiveness of MCE, recently published trials justify an updated systematic review.

OBJECTIVES

To evaluate the effectiveness of MCE in patients with chronic non-specific LBP.

SEARCH METHODS

We conducted electronic searches in CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers from their inception up to April 2015. We also performed citation tracking and searched the reference lists of reviews and eligible trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that examined the effectiveness of MCE in patients with chronic non-specific LBP. We included trials comparing MCE with no treatment, another treatment or that added MCE as a supplement to other interventions. Primary outcomes were pain intensity and disability. We considered function, quality of life, return to work or recurrence as secondary outcomes. All outcomes must have been measured with a valid and reliable instrument.

DATA COLLECTION AND ANALYSIS

Two independent review authors screened the search results, assessed risk of bias and extracted the data. A third independent review author resolved any disagreement. We assessed risk of bias using the Cochrane Back and Neck (CBN) Review Group expanded 12-item criteria (Furlan 2009). We extracted mean scores, standard deviations and sample sizes from the included trials, and if this information was not provided we calculated or estimated them using methods recommended in the Cochrane Handbook. We also contacted the authors of the trials for any missing or unclear information. We considered the following time points: short-term (less than three months after randomisation); intermediate (at least three months but less than 12 months after randomisation); and long-term (12 months or more after randomisation) follow-up. We assessed heterogeneity by visual inspection of the forest plots, and by calculating the Chi(2) test and the I(2) statistic. We combined results in a meta-analysis expressed as mean difference (MD) and 95% confidence interval (CI). We assessed the overall quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 29 trials (n = 2431) in this review. The study sample sizes ranged from 20 to 323 participants. We considered a total of 76.6% of the included trials to have a low risk of bias, representing 86% of all participants. There is low to high quality evidence that MCE is not clinically more effective than other exercises for all follow-up periods and outcomes tested. When compared with minimal intervention, there is low to moderate quality evidence that MCE is effective for improving pain at short, intermediate and long-term follow-up with medium effect sizes (long-term, MD -12.97; 95% CI -18.51 to -7.42). There was also a clinically important difference for the outcomes function and global impression of recovery compared with minimal intervention. There is moderate to high quality evidence that there is no clinically important difference between MCE and manual therapy for all follow-up periods and outcomes tested. Finally, there is very low to low quality evidence that MCE is clinically more effective than exercise and electrophysical agents (EPA) for pain, disability, global impression of recovery and quality of life with medium to large effect sizes (pain at short term, MD -30.18; 95% CI -35.32 to -25.05). Minor or no adverse events were reported in the included trials.

AUTHORS' CONCLUSIONS

There is very low to moderate quality evidence that MCE has a clinically important effect compared with a minimal intervention for chronic low back pain. There is very low to low quality evidence that MCE has a clinically important effect compared with exercise plus EPA. There is moderate to high quality evidence that MCE provides similar outcomes to manual therapies and low to moderate quality evidence that it provides similar outcomes to other forms of exercises. Given the evidence that MCE is not superior to other forms of exercise, the choice of exercise for chronic LBP should probably depend on patient or therapist preferences, therapist training, costs and safety.

Comparison of physical function according to the lumbar movement method of stabilizing a patient with chronic low back pain

[Purpose] The purpose of this study was to examine the changes caused by lumbar stabilization exercises in chronic low back pain patients. [Subjects and Methods] Swiss ball exercise regimen group and sling exercise regimen group exercised for 30 minutes a day, 5 days a week, for 12 weeks. The control group was to continue performing their usual daily living activities. [Results] We obtained significant results in both the Swiss ball and sling exercise groups, but not in the control group. The best effect was obtained in the sling exercise group. [Conclusion] The Oswestry Low Back Pain Disability Index and visual pain scale scores of the patients with low back pain decreased in both the Swiss ball exercise group and the sling exercise group, and these patients experienced an increase in waist isometric muscular strength after 12 weeks of exercise compared with those doing no exercise (the control group).

Specific rehabilitation exercise for the treatment of patients with chronic low back pain

[Purpose] To evaluate the efficacy of our special rehabilitation method for patients with low back pain (LBP). [Subjects and Methods] All participants (n=33) received at least five individual 30-minute therapy sessions per week using the INFINITY method^® and six group therapy sessions per week in a gymnasium and swimming pool, each lasting 30 minutes and including the INFINITY method^®. The treatment lasted between four to seven weeks. Plantar function using a graphic method (computer plantography), graphical quantification of postural control during static standing (posturography), and pain were measured and evaluated before and after rehabilitation therapy. The INFINITY method^® is a special rehabilitation method for patients with musculoskeletal problems. The method focuses on stabilization and strengthening of the trunk, dorsal and abdominal muscles, including the deep stabilization system which is closely linked with diaphragmatic breathing. It teaches the central nervous system to control muscles more precisely. [Results] Plantar functions, postural control in the upright stance and pain of LBP patients were significantly improved by 4−7 weeks of rehabilitation treatment with the INFINITY method^®. There were significant differences in all measured dependent variables of the patients between before and after treatment. [Conclusion] Rehabilitation therapy with the INFINITY method^® positively influences body stabilization and pain in patients with problems of the lumbar spine. This method presents a new improved approach (with enhanced effect) to rehabilitation therapy for LBP patients.

Effects of flexi-bar and non-flexi-bar exercises on trunk muscles activity in different postures in healthy adults

[Purpose] The purpose of this study was to assess the effects of flexi-bar exercises and non-flexi-bar exercises on trunk muscle activity in different postures in healthy adults. [Subjects] Twenty healthy right-hand dominant adults (10 males and 10 females) were selected for this study. None of the participants had experienced any orthopedic problems in the spine or in the upper and lower extremities in the previous six months. [Methods] The subjects were instructed to adopt three exercise postures: posture 1, quadruped; posture 2, side-bridge; and posture 3, standing. Surface electromyography of selected trunk muscles was normalized to maximum voluntary isometric contraction. [Results] The external oblique, internal oblique, and erector spinae muscle activity showed significant differences between flexi-bar exercises and non-flexi-bar exercises. [Conclusion] The results of this study suggest that flexi-bar exercises are useful in the activation of trunk muscles.

Effect of evidence-based trunk stability exercises on the thickness of the trunk muscles

[Purpose] This study was conducted to investigate the effect of four spine stability exercises on the thickness of the internal and external oblique abdominal muscles, the transverses abdominis, and the multifidus muscles. [Subjects and Methods] Forty healthy adults were enrolled and randomly allocated to four groups. Ten participants performed bridge exercises (BE) while lying on their back; 10 others performed the same exercises with their right legs up (BERL); another 10 performed the same exercises on their side (SBE); and the remaining 10 performed them in a quadruped position with left arm and right leg lifts (QLARL). The participants performed the exercises three times a week for five weeks. The thicknesses of the muscles before and after the interventions were measured using ultrasound. [Results] The results show that the normal bridge exercise significantly thickened the TrA; BERL, the LM; QLARL, the IO; and SBE, the EO and the IO. [Conclusion] All four spine stability exercises were effective. The normal bridge exercise and BERL selectively strengthened the local muscles at the early stage of the treatment. We consider SBE and QLARL should be used in the later stages of treatments because they strengthen both the local and global muscles.

An update of stabilisation exercises for low back pain: a systematic review with meta-analysis

Background

Non-specific low back pain (NSLBP) is a large and costly problem. It has a lifetime prevalence of 80% and results in high levels of healthcare cost. It is a major cause for long term sickness amongst the workforce and is associated with high levels of fear avoidance and kinesiophobia. Stabilisation (or ‘core stability’) exercises have been suggested to reduce symptoms of pain and disability and form an effective treatment. Despite it being the most commonly used form of physiotherapy treatment within the UK there is a lack of positive evidence to support its use. The aims of this systematic review update is to investigate the effectiveness of stabilisation exercises for the treatment of NSLBP, and compare any effectiveness to other forms of exercise.

Methods

A systematic review published in 2008 was updated with a search of PubMed, CINAHL, AMED, Pedro and The Cochrane Library, October 2006 to October 2013. Two authors independently selected studies, and two authors independently extracted the data. Methodological quality was evaluated using the PEDro scale. Meta-analysis was carried out when appropriate.

Results

29 studies were included: 22 studies (n = 2,258) provided post treatment effect on pain and 24 studies (n = 2,359) provided post treatment effect on disability. Pain and disability scores were transformed to a 0 to 100 scale. Meta-analysis showed significant benefit for stabilisation exercises versus any alternative treatment or control for long term pain and disability with mean difference of -6.39 (95% CI -10.14 to -2.65) and -3.92 (95% CI -7.25 to -0.59) respectively. The difference between groups was clinically insignificant. When compared with alternative forms of exercise, there was no statistical or clinically significant difference. Mean difference for pain was -3.06 (95% CI -6.74 to 0.63) and disability -1.89 (95% CI -5.10 to 1.33).

Conclusion

There is strong evidence stabilisation exercises are not more effective than any other form of active exercise in the long term. The low levels of heterogeneity and large number of high methodological quality of available studies, at long term follow-up, strengthen our current findings, and further research is unlikely to considerably alter this conclusion.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-416) contains supplementary material, which is available to authorized users.

Effectiveness of sling exercise for chronic low back pain: a systematic review

[Purpose] This study investigated effects of sling exercise for patients with chronic low back pain. [Methods] We reviewed all relevant papers indexed in PubMed, SCOPUS, and the Cochrane Registered Trials. Eligible trials were randomized controlled trials that compared sling exercise with any type of treatment. We extracted data on muscle thickness, muscle activation, pain, and disability, and assessed the methodological quality of the data. Seven studies met our inclusion criteria. [Results] When sling exercise had an impact on activation of the trunk muscles, increasing the trunk muscle thickness, and the reduction in pain and disability had been assessed shortly after the final exercise session, it was more effective than general exercise at activating trunk muscles, but not more effective at increasing trunk muscle thickness and improving pain and disability than general exercise. [Conclusion] As sling therapy studies are based on a small number of trials, we cannot draw conclusions about the therapeutic effects of sling exercise. When segmental stabilizing exercise and individually designed programs are added to sling exercise, it increases the effectiveness of sling exercise at improving low back pain. This should be the focus of future studies.

Sling exercise for chronic low back pain: a systematic review and meta-analysis

Background

Trials on sling exercise (SE), commonly performed to manage chronic low back pain (LBP), yield conflicting results. This study aimed to review the effects of SE on chronic LBP.

Methods

The randomized controlled trials comparing SE with other treatments or no treatment, published up to August 2013, were identified by electronic searches. Primary outcomes were pain, function, and return to work. The weighted mean difference (WMD) and 95% confidence interval (CI) were calculated, using a random-effects model.

Results

Risk of bias was rated as high in 9 included trials, where some important quality components such as blinding were absent and sample sizes were generally small. We found no clinically relevant differences in pain or function between SE and other forms of exercise, traditional Chinese medical therapy, or in addition to acupuncture. Based on two trials, SE was more effective than thermomagnetic therapy at reducing pain (short-term: WMD –13.90, 95% CI –22.19 to –5.62; long-term: WMD –26.20, 95% CI –31.32 to –21.08) and improving function (short-term: WMD –10.54, 95% CI –14.32 to –6.75; long-term: WMD –25.75, 95% CI –30.79 to –20.71). In one trial we found statistically significant differences between SE and physical agents combined with drug therapy (meloxicam combined with eperisone hydrochloride) but of borderline clinical relevance for pain (short-term: WMD –15.00, 95% CI –19.64 to −10.36) and function (short-term: WMD −10.00; 95% CI −13.70 to −6.30). There was substantial heterogeneity among the two trials comparing SE and thermomagnetic therapy; both these trials and the trial comparing SE with physical agents combined with drug therapy had serious methodological limitations.

Interpretation

Based on limited evidence from 2 trials, SE was more effective for LBP than thermomagnetic therapy. Clinically relevant differences in effects between SE and other forms of exercise, physical agents combined with drug therapy, traditional Chinese medical therapy, or in addition to acupuncture could not be found. More high-quality randomized trials on the topic are warranted.

Effects of sling exercise therapy on trunk muscle activation and balance in chronic hemiplegic patients

Weakening of trunk muscles in stroke patients hinders functional ability, safety and balance. To confirm whether strengthening trunk muscles could facilitate rehabilitation of stroke patients, we investigated the effectiveness of sling exercise therapy (SET) using closed kinetic chain exercises to activate trunk muscles and improve balance in stroke patients. [Subjects and Methods] Twenty stroke patients with chronic hemiplegia were equally divided into 2 groups, a SET group and a control group that performed regular exercises on a mat with the assistance of a table. Patients in both groups exercised for 30 min, three times per week for 4 weeks. Trunk muscle activity was measured using surface electromyography, whereas balance was measured using the Berg Balance Scale, Frailty and Injuries Cooperative Studies of Intervention Technique, Timed Up & Go test, and BioRescue before and after the 4-week experimental period. [Results] Trunk muscle activity and balance before and after intervention in both groups were significantly different. However, no significant differences were observed between the 2 groups. [Conclusion] Although SET was not more effective than regular exercise, significant improvement was observed before and after SET. Therefore, SET can be considered effective in strengthening trunk muscles in stroke patients with chronic hemiplegia.