EFFECTS OF STABILIZATION EXERCISE ON PAIN, CROSS-SECTIONAL AREA AND MUSCLE THICKNESS OF LUMBAR MULTIFIDUS IN PATIENTS WITH CHRONIC LOW BACK PAIN.

CHAPTER ONE

INTRODUCTION

 

                   1.1       INTRODUCTION

Low back pain (LBP) is a highly prevalent problem and one of the main causes of disability in the society. Despite its high prevalence, source of pain is not established in majority of cases (Macedo et al., 2009; Freeman et al., 2010).  Low back pain is the most common complaint seen by physical therapists and it is always the symptoms most often associated with the use of physiotherapy modalities (Coste et al., 1991). It has been estimated that 80% – 90% of people will suffer from LBP at some time in their lifetime (Bakhtiary et al., 2005).  The aetiology of low back pain is diverse; many causes have been related to weakness or injury of the soft tissues in the lumbar area (O‟Sullivan, 2000). The low back is susceptible to injury because it supports most of the body weight (Odebiyi et al., 2007). People with LBP and associated disability usually improve rapidly within weeks, nonetheless pain and disability are usually ongoing and recurrences are common (Pengel et al., 2003).

 

It has been reported that despite the large number of pathological conditions that can give rise to LBP, 85% of these are without pathoanatomical/radiological abnormalities (Dankaerts et al., 2006).  It is the non-specific LBP population which often develops into a chronic fluctuating problem with intermittent flares (Burton et al., 2004). Skeletal muscles play an important role in the pathology of low back disorders. It is known clinically that excessive motion beyond the normal physiological limits, sometimes referred to as spinal instability, may result in chronic low back pain (Hodge and Richardson, 1996).

Available evidence suggests that spinal muscles provide stability and muscle recruitment patterns significantly affect loading on the intervertebral joints (Van Dien et al., 2003). The stability of the spine is determined by the osseoligamentous armour that encapsulates the spine (Panjabi, 1992). The complex loading patterns associated with activities of daily living, act on these structures and if unprotected, can expose spinal vulnerability, predisposing to musculoskeletal injuries, such as LBP (Renkawitz et al., 2006).

 

The growing awareness of CLBP as a major clinical problem has promoted increased interest and research into this continuing epidemic (Cairns et al., 2000). Epidemiological research has focused primarily on the local stability system, which acts as a „corset like‟ structure to tighten the waist, when the spine is in a loaded position (Hides et al., 2001). The correct alignment required to stabilize and accommodate movements depends on adequate strength and endurance on abdominal musculature (Hodges and Richardson, 1997). It is the activation of the dynamic spinal support system that is exposed and which provides the basis for the concept of

stabilization training (Hides et al., 2001).

 

Hodges et al. (2003) reported on the anatomical, biomechanical and neurophysiological characteristics of Transversus abdominis (TrA) and Lumbar multifidus (LM), which are important components of the local stability system. Electromyographic (EMG) studies revealed that the LM along with TrA are the only muscles active during all trunk movement (Cresswell et al., 1994). Transversus abdominis is active in a nondirectional-specific feed forward manner in preparation for the perturbation of the spine from arm movements.

 

The Electromyography (EMG) analysis shows that the onset of activity of the muscles of the abdominal wall in response to upper and lower limb movements indicated that the timing of onset of TrA was delayed in patients with CLBP, compared with individuals who have never experienced back pain (Hodges and Richardson, 1995).

 

Ultrasound imaging of LM muscle is of increasing interest to physiotherapists, both for clinical and research purposes. Ultrasound imaging has provided accurate assessment of muscle wasting in various muscles, clinically the application is two folds: as an objective assessment tool for detecting abnormalities, and monitoring changes during recovery (Hides et al., 1996), and for visual feedback during reeducation of muscle contraction (Hides et al., 1997). Measurement of muscle size using ultrasound has provided accurate assessment of muscle wasting in various muscles (Stokes et al., 1997). In a recent study Ultrasound measurement of LM muscle has been reported to be a potentially valuable, fast and easy way to evaluate muscle size at different levels of lumbar vertebrae in clinical settings (Larrie-Baghal, 2012).

 

The technique was also useful in demonstrating that LM size does not recover when pain subsides unless it undergoes specific exercises (Hides et al., 1996). Biomechanical models suggest that all muscles with intervertebral attachments are better suited for intersegmental stability provision (LM, TrA), as opposed to the larger trunk muscles (erector spinae, rectus abdominis), which are dedicated to movement generation (Bergmark, 1989). Inadequate activation of the local stabilizing trunk muscles may lead to instability of the lumbar spine (Panjabi, 1992). This evidence indicated that a programme for the TrA and LM is required for specific lumbar segmental stabilization training for muscle dysfunction in individuals with a history of lower back problems

(Jull et al., 1995). In a study by Kasai (2006) it was concluded that stabilization exercise has significant long term effect on CLBP in the reduction of pain and improvement in functional ability with low recurrence rate.

 

Basically stabilization exercise is aimed at protecting and supporting the spinal segment from re-injury by reestablishing and enhancing muscle control to compensate for any loss of muscle action caused by injury or degenerative changes (Richardson et al., 1999).  A study by Gatti et al. (2011) also reported that stabilization exercise was found to be more effective in reducing disability in patients with CLBP. However the number of studies related to the use of stabilization exercise in the treatment of NCLBP and ultrasound scanning in the assessment of cross-sectional area and muscle thickness of lumbar multifidus is currently not in existence in Nigeria; hence this study was thus designed to determine the effects of stabilization exercise on pain, cross-sectional area and muscle thickness of lumbar multifidus in patient with CLBP.

EFFECTS OF STABILIZATION EXERCISE ON PAIN, CROSS-SECTIONAL AREA AND MUSCLE THICKNESS OF LUMBAR MULTIFIDUS IN PATIENTS WITH CHRONIC LOW BACK PAIN.

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