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New Study - March 4, 2005 10:30:00 AM
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OaksPT
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So is this going to affect how you treat, or is the study done well enough to be considered valid?
I'll post my opinion after I digest the article.
Scott
Research Report
Trunk Muscle Stabilization Training Plus General Exercise Versus General Exercise Only: Randomized Controlled Trial of Patients With Recurrent Low Back Pain
George A Koumantakis, Paul J Watson, and Jacqueline A Oldham
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Background and Purpose. The purpose of this randomized controlled trial was to examine the usefulness of the addition of specific stabilization exercises to a general back and abdominal muscle exercise approach for patients with subacute or chronic nonspecific back pain by comparing a specific muscle stabilization-enhanced general exercise approach with a general exercise-only approach. Subjects. Fifty-five patients with recurrent, nonspecific back pain (stabilization-enhanced exercise group: n=29, general exercise-only group: n=26) and no clinical signs suggesting spinal instability were recruited. Methods. Both groups received an 8-week exercise intervention and written advice (The Back Book). Outcome was based on self-reported pain (Short-Form McGill Pain Questionnaire), disability (Roland-Morris Disability Questionnaire), and cognitive status (Pain Self-Efficacy Questionnaire, Tampa Scale of Kinesiophobia, Pain Locus of Control Scale) measured immediately before and after intervention and 3 months after the end of the intervention period. Results. Outcome measures for both groups improved. Furthermore, self-reported disability improved more in the general exercise-only group immediately after intervention but not at the 3-month follow-up. There were generally no differences between the 2 exercise approaches for any of the other outcomes. Discussion and Conclusion. A general exercise program reduced disability in the short term to a greater extent than a stabilization-enhanced exercise approach in patients with recurrent nonspecific low back pain. Stabilization exercises do not appear to provide additional benefit to patients with subacute or chronic low back pain who have no clinical signs suggesting the presence of spinal instability. [Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain. Phys Ther. 2005;85:209-225.]
Key Words: Exercise, Low back pain
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Scott Oaks PT,DPT
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Re: New Study - March 4, 2005 11:40:00 AM
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SJBird55
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I just read that... still need to think about the article. I wonder if the future is heading down the path of a subcategory of patients that will benefit from the stabilization approach? Meaning... classification of patients.
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Re: New Study - March 4, 2005 3:27:00 PM
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nari
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I think the teaching of stabilisation movements is highly variable, and it would be interesting to see how they were taught in the study. For instance, many teach pelvic tilt first, before trying to recruit TA et al. According to the researchers- not on, if we are to call it core stability. If it is just getting pelvic musculature in general going- it is still interesting that standard abdo/long muscle work is about equal in outcome.
Nari
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Re: New Study - March 4, 2005 4:00:00 PM
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ericm
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These findings are similiar to what I have experienced clinically.
The comments by Anthony Delitto in the introduction to the same volume of Physical Therapy deserve some consideration with respect to this study.
http://www.ptjournal.org/Mar2005/Mar05_EdNote.cfm
eric
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Re: New Study - March 4, 2005 9:44:00 PM
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Randy Dixon
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I liked that article.
I think the problem with the study, or perhaps not, is that the patients were not tested for dysfunction in the muscles being specifically trained.(As far as I know, I haven't read the whole study). What would be the point of specifically training the TrA, for example, if it is functioning normally. In fact it is easy to see how making conscious control of it can alter normal reflexive control.
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Re: New Study - March 5, 2005 1:35:00 AM
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Andrew M. Ball PT PhD
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I agree, as I read the article, I found that many of the "general exercises" were core stability exercises too - - - begging the question "Are lumbar stabilization exercises more or less effective than core stabilization exercises?"
I suspect that most PT's would respond, "Stab is stab, so what the heck's the difference?"
It would have been more academic, and clinically relevant, to have actually tested the question that the title of the article implied . . . are stab exercises more effective than a program of say, Treadmill training, UBE/LBE, aquatic jogging, and reclined bike. This SOUNDS like what was tested in the study, but this wasn't what was tested.
In my opinion, a study with an inappropriate title.
Drew
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Dr. Andrew M. Ball, PT, DPT, Ph.D.
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Re: New Study - March 5, 2005 3:23:00 AM
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SJBird55
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From a clinical, time perspective - the one approach is more time intensive with a ton of therapist feedback (both verbal and manual). The real specific, fine tuning type of approach.
The general exercise group really did seem to focus more on either the abdominals or the back extensors. General was interpreted by the researchers to probably mean general trunk strengthening. And, I do believe that you have to take into consideration where the authors live... these guys are in Greece and the United Kingdom (just a bit of cultural sensitivity before judging because we really don't have a well-defined set of terminology). From my interpretation of these exercises, there really wasn't any "core strengthening" because pelvic position didn't appear to be mentioned.
I really don't understand the time thing... the class duration was 45-60 minutes so what's up with mentioning 180 minutes and 99 minutes? I'm not sure the relevance of converting the actual time in performing the activity to some number based on another study dealing with % activation of muscles during the activity... whatever though.
I'm not great with statistics, but to me there was a big difference in pre-treatment pain between the groups in Table 2. All the other numbers looked pretty equal. It was interesting that pain control didn't seem to change much, but there was a trend toward increasing pain responsibility, a reduction of fear of movement and increase in self-efficacy beliefs. Both groups seemed to have a low grade amount of disabilty after. What I don't understand is why on the McGill both groups are pretty similar, but then on the VAS there is a decent difference between the two groups pretreatment. And the general exercise group does have a bit more fear of movement pretreatment, but it isn't a huge difference in my mind. That's kind of interesting.
I thought the researchers did a great job in capturing the psychosocial aspects that seem to be a current topic. And, I guess, it also seems fitting that with patients in chronic pain, regular general trunk strengthening exercises do achieve comparable results. Again, though, patients weren't put into any particular category except as "chronic." What if patients were categorized a bit more specifically? Would the results prove to be the same?
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Re: New Study - March 6, 2005 2:14:00 AM
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PTupdate.com
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Randy,
You state "What would be the point of specifically training the TrA, for example, if it is functioning normally" How would we define "normally", under what life circumstances does this "normal" suffice?
Would the function and strength of the TA needed to satisfy a desk jockey be the same for an athlete, even if recreational? Does "5/5" necessarily mean we don't strengthen it any more?
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: New Study - March 6, 2005 11:06:00 PM
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Randy Dixon
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A real short answer, then I'll answer more later.
The reasoning behind specifically training the TrA in LBP is that there has been a correlation between LBP and dysfunctional motor patterns of that muscle. It doesn't occur in every LBP and I don't think causality has been established, that is which causes which. It doesn't seem to be a matter of a strength deficit, therefore if it is firing normally then it is normal. Functional tests, and specific tests, can determine this.
As far as differences between sedentary and athletic populations, there may be differences in absolute strength of the TrA, or not, but not relative to the other stabilizing muscles. Well, there may be, but to keep it short I don't think they are relevant as to whether "specific" exercises should be applied. Should we strengthen it more? Probably, but in concert and in coordination with the other muscles.
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Re: New Study - March 7, 2005 4:28:00 AM
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OaksPT
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Agree with Drew/Nari completely,
The general exercise group(the specific program for each group was listed in the journal appendix)appeared to be a higher level of truncal stabilization, the stabilization group did not use a progressive stabilization protocol as indicated by one of their references(Paul Hodges), none of the initial training of the TA/Multifidus was done in a supine/prone position, it was started in a weight-bearing position. SJ, I agree that general exercise can mean many things, kind of reminds me of a Physiatrist that used to refer to me, he would dictate no strengthening , which in his mind meant no aerobic activity, caused a lot of head butting between the two of us.
Scott
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Scott Oaks PT,DPT
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Re: New Study - March 8, 2005 4:46:00 AM
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JLS_PT_OCS
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Seems like more evidence leaning toward that classification approach.
Good points have been made about just what core stabilization is -- and it is sweeping the fitness and conditioning world as well. VERY few fitness people are talking TrAbd or Multifidus and rather more about global trunk muscle activity - not bad or wrong, just different.
I agree with SJ about some of the between-group differences.
But I do think this study lends credence to the thought that not every patient with back pain needs the kind of intensive one on one care about muscle function that in my mind characterizes lumbar stabilization.
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: New Study - March 8, 2005 11:00:00 AM
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pablo w
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I haven't read the whole article, will have to access it when it comes to the hospital library.
The classification of patients labelled with non-specific low back pain is something that is brought up regularly by people researching segmental stabilisation. What Peter O'Sullivan, for example, has said is that there is a subgroup of patients with chronic non-specific low back pain who are more likely to benefit from a muscle retraining approach. I never got the impression that treating every chronic low back patient with the same approach is advocated. Where there are clinical signs from examination and findings in the history consistent with a segmental instability and impaired load transfer, the approach works. So yes, clssification is important. Do we manipulate everyone with back pain, for example? No, but we now have a useful prediction rule that helps determine who will benefit from it. The same applies to a segmental stabilisation approach. No I don't have a study to prove it, but we can look at exclusion criteria from studies, as it tells us a lot about who we may not be able to apply the findings to.
There is debate as to what stabilisation means. At the recent World Congress on Low Back and Pelvic Pain, in Melbourne, Australia, Stuart McGill and Paul Hodges (among other world-renowned researchers) presneted different sides of the argument. As Stuart McGill said, "show me the patient", meaning that every patient is different, while there may be patterns. Peter O'Sullivan presented findings of patients having directional movement preferneces in the direction that makes their symptoms worse. The patient's presentation has to be taken into account.
Clinically this is what I have seen. Not every patient needs or will benefit from specific focused retraining of transversus abdominus and multifidus. The research is done using real-time ultrasound feedback, which I persoanally don't have access to. Can I generalise that I will obtain the same results without it? Maybe these muscles improve in their function with a general approach, but I am not aware of any studies looking at this. It may not even be that important, as long as function improves and symptoms decreas. I don't have a great way of determining if specific muscle function did improve.
Now, if the findings of this research are taken to mean that specific exercises are no better than general conditioning exercises, and that an individualised program isn't necessary to achieve positive outcomes, maybe we will lose a lot of professional ground to exercise trainers. And if it can be shown that this will achieve results similar to what physiotherapists achieve, then rightly so. It is already happening.
Pablo
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Re: New Study - March 8, 2005 1:13:00 PM
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Jon Newman
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Hi Pablo,
I asked in a different thread about the use of US when getting a person to perform TrA exercises as it seems to be standard practice in research circles. How important do you feel this is?
Also,
You stated, "And if it can be shown that this will achieve results similar to what physiotherapists achieve, then rightly so. It is already happening."
I interpret similar results to mean that not only are physiotherapists lousy at treating chronic pain but so is everyone else.
jon
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Re: New Study - March 8, 2005 6:09:00 PM
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pablo w
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Hi Jon,
On the second question, I think you are right, no profession seems to be the best at treating chronic pain (but I'll limit that to non-specific low back pain). So I guess until we can come up with credible research that shows unequivocally that a specific approach is better than another, we can't get too upset about losing a bit of turf. The approach that has been shown to be effective is exercise. We don't own that. Another approach is Cognitive Behavioural Therapy, and we don't own that either. But we can use exercise in a CBT framework.
We have not yet had consistent evidence that physiotherapists treat chronic low back pain with more success than other professions.
I haven't had the chance to use an ultrasound machine so I don't have an opinion on the importance of this based on experience. But a segmntal stabilisation approach has worked well for me with some patients with chronic low back pain, but not all. I suspect it is related to patient selection. I don't think that answers your question, does it? My brain is full and I'm trying to stop it dribbling out.
I think we are a long way from answering the question of how best to treat chronic non-specific low back pain, but there are lots of promising leads. I have a suspicion that they all lead in the same direction, but depending on where one starts from the path will look different. I think the linking theme has to be understanding pain mechanisms to integrate these into the picture. More of this is happening, so maybe all the threads are converging. I hope so, so that someone can explain it to me!
Pablo
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Re: New Study - March 8, 2005 9:44:00 PM
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nari
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No one profession has any advantage in treating chronic pain; we are all in the same boat travelling on the same ocean with dodgy GPS and sonar.
If physiotherapists can gain an edge through our research and knowledge of functional anatomy, so much the better, but time is starting to run out if we want that edge...competition is getting tougher by the year/month...
Pablo, I seriously thought I had invented the phrase "my brain is full"and thought I was quite clever!! I'm dismayed that someone else has 'stolen' it!! ;)
Nari
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Re: New Study - March 8, 2005 10:20:00 PM
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pablo w
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I knew I wasn't creative enough to invent that. I must have picked it up somewhere! :)
Pablo
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Re: New Study - March 8, 2005 10:32:00 PM
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nari
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It's not patented!!!
Nari
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Re: New Study - May 5, 2005 6:10:00 PM
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jbeneciuk
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Randy:
It doesn't seem to be a matter of a strength deficit, therefore if it is firing normally then it is normal. Functional tests, and specific tests, can determine this.
What specific tests and functional tests were you referring to ?
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Re: New Study - May 6, 2005 9:07:00 AM
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JLS_PT_OCS
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I think determining the "proper" or "normal" function is difficult.
With TrAbd and Multifidus, I have seen some encouraging results with real time diagnostic ultrasound biofeedback, but the studies are ongoing.
A colleague of mine, Deydre Teyhen, is a PT doing a lot of work in this area. Very smart lady. So be on the look out for further studies using ultrasound.
I guess I determine core "function" with my hands and ability of patient to do an activity or position without pain.
If I let pain be the guide and teach them how to problem-solve the solution to a movement or function problem with the pelvic strength and control we teach them, they do quite well.
I think overall, my approach for most folks has been to to progress at first with general stability exercises, and save the more labor-intensive local approach (a la australian approach) for those with lumbar fusions, who fail to improve with general approach, or patients who my spider sense tells me need the more detailed feedback and instruction.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: New Study - May 6, 2005 9:23:00 AM
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jbeneciuk
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Jason:
I meant to place that in quotes...still figuring how to work this thing out??? I wanted to know what clinical tests that Randy was referring to a few threads back ??
Jbeneciuk
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