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Research Review By Dr. Paul Bruno©

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Date Posted:

November 2014

Study Title:

The use of “stabilization exercises” to affect neuromuscular control in the lumbopelvic region: a narrative review

Authors:

Bruno P

Author's Affiliations:

Assistant Professor and CCRF Research Chair in Neuromusculoskeletal Health, Faculty of Kinesiology and Health Studies, University of Regina, Canada.

Publication Information:

Journal of the Canadian Chiropractic Association 2014; 58(2): 119-130.

Background Information:

It is well accepted that the neuromuscular control of the lumbopelvic region is an important factor in generating and maintaining spinal stability, and models have been proposed that describe mechanisms by which altered neuromuscular control strategies can lead to impaired spinal stability during functional activities. Over the years, several “stabilization exercise” programs have been proposed as being potentially useful in restoring optimal neuromuscular control. In general, these programs focus on having a patient perform functional movements whilst selectively targeting the transversus abdominis and multifidus muscles (“abdominal hollow”) (1), or whilst attempting to contract all abdominal and lumbopelvic musculature (“abdominal brace”) (2).

Current evidence generally suggests that exercise programs incorporating the “abdominal hollow” are more effective in reducing pain and disability than no treatment, regular medical treatment, and general exercise (3-9). However, there are currently no published trials that have directly compared the effects of exercise programs incorporating the “abdominal hollow” with those incorporating the “abdominal brace”.

One important consideration that is currently the focus of much attention in the literature is the need to develop clinical tools that can identify sub-groups of patients with low back pain who are more likely to respond to specific treatments. To date, there have only been a handful of published studies investigating the effects of stabilization exercise programs in sub-groups of patients deemed to be more likely to respond to such programs (10-12). One of the primary hindrances in conducting such studies is the current lack of reliable and valid clinical protocols to identify such sub-groups. Two protocols that have been described in the literature, and which have some degree of evidential support for their clinical use, are presented and discussed in this narrative review.

Summary:

Protocol 1: Treatment-Based Classification System (13)

Proposed criteria to identify patients more likely to respond to stabilization exercise (Note: the number of criteria that must be present to determine inclusion in this sub-group is not specified):
  • History of frequent recurrent episodes of LBP precipitated by minimal perturbations
  • History of alternating sides of a lateral shift deformity (i.e. antalgic posture)
  • History of frequent spinal manipulation with short-term relief
  • History of trauma, pregnancy, or use of oral contraceptives
  • Pain relief with immobilization (e.g. external support, abdominal bracing)
  • Clinical signs of generalized ligamentous laxity
  • Clinical signs of “segmental instability” (e.g. presence of aberrant movement during lumbar range of motion testing, positive posterior shear test)
Evidential support for the system:
  • Two studies have demonstrated moderate inter-rater reliability of classification assignment (14-15).
  • One study provides preliminary evidence regarding the construct validity of the classification system (16).
  • Two studies have demonstrated that patients who receive treatment matched to sub-group classification (i.e. spinal manipulation, stabilization exercise, directional preference exercise) had a significantly greater improvement in clinical outcomes post-intervention and at a 1-year follow-up compared to patients who did not receive matched treatment (17-18).
Current limitations of the system:
  • The literature regarding this system is generally restricted to its use with acute low back pain patients.
  • The type of stabilization exercise to prescribe to identified patients is not specified.
Protocol 2: Clinical Prediction Rule (19)

Proposed criteria to identify patients more likely to respond to stabilization exercise:
  • Age < 40 years
  • Average straight leg raise > 91°
  • Presence of aberrant movement during lumbar range of motion testing
  • Positive prone instability test
Evidential support for the system:
  • The best rule for predicting treatment success (i.e. ≥ 50% reduction in disability score) following a stabilization exercise program (“abdominal brace”) is the presence of ≥ 3/4 of the criteria (+LR: 4.0) (19).
  • One study provides limited preliminary evidence regarding the construct validity of the prediction rule (20).
  • One study demonstrated that patients identified using the rule who performed a stabilization exercise program (“abdominal brace” and “abdominal hollow”) had a significantly greater improvement in clinical outcomes post-intervention and at a 3-month follow-up compared to identified patients who performed routine exercise (12).
Current limitations of the system:
  • Has not undergone full validation or impact analysis testing.

Clinical Application & Conclusions:

This narrative review highlights the ongoing debate in the literature regarding the use of “stabilization exercise” as a treatment for low back pain. The two clinical protocols described in the review have some degree of evidential support for their use in clinical practice. However, clinicians need to be aware of the limitations in the current evidence base for each protocol in order to apply them more appropriately and judiciously with their patients.

Study Methods:

This is a narrative (non-systematic) review of the published peer-reviewed literature.

Study Strengths / Weaknesses:

A relatively thorough literature search was performed to form the basis for this review. However, as with all narrative reviews, there may have been selection bias regarding the literature included and described in the review. Another limitation of this review is that a formal assessment of the quality and risk of bias for the included studies was not performed.

Additional References:

  1. Richardson C, Jull G, Hodges P, Hides J. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. Scientific Basis and Clinical Approach. Edinburge, Churchill Livingstone, 1999.
  2. McGill S. Low Back Disorders: Evidence-Based Prevention and Rehabilitation. Champaign: Human Kinetics, 2002.
  3. Ferreira P, Ferreira M, Maher C et al. Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Aust J Physiother 2006; 52: 79-88.
  4. Hauggaard A, Persson A. Specific spinal stabilisation exercises in patients with low back pain – a systematic review. Phys Ther Rev 2007; 12: 233-48.
  5. Macedo L, Maher C, Latimer J, McAuley J. Motor control exercise for persistent, non-specific low back pain: a systematic review. Phys Ther 2009; 89: 9-25.
  6. Rackwitz B, de Bie R, Ewert T, Stucki G. Segmental stabilizing exercises and low back pain. What is the evidence? A systematic review of randomized controlled trials. Clin Rehabil 2006; 20: 553-67.
  7. Standaert C, Weinstein S, Rumpeltes J. Evidence-informed management of chronic low back pain with lumbar stabilization exercises. Spine J 2008; 8: 114-20.
  8. Byström M, Rasmussen-Barr E, Grooten W. Motor control exercises reduces pain and disability in chronic and recurrent low back pain. A meta-analysis. Spine 2013; 38: E350-8.
  9. Wang X, Zheng J, Yu Z et al. A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PLoS One 2012; 7: e52082.
  10. Fersum K, Dankaerts W, O’Sullivan P et al. Integration of subclassification strategies in randomised controlled trials evaluating manual therapy treatment and exercise therapy for non-specific chronic low back pain: a systematic review. Br J Sports Med 2010; 44: 1054-62.
  11. Kent P, Mjøsund H, Petersen D. Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review. BMC Med 2010; 8: 22.
  12. Javadian Y, Behtash H, Akbari M et al. The effects of stabilization exercises on pain and disability of patients with lumbar segmental instability. J Back Musculoskelet Rehabil 2012; 25: 149-55.
  13. Delitto A, Erhard R, Bowling R. A treatment-based approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther 1995; 75: 470-89.
  14. Fritz J, Brennan G, Clifford S et al. An examination of the reliability of a classification algorithm for subgrouping patients with low back pain. Spine 2006; 31: 77-82.
  15. Fritz J, George S. The use of a classifcation approach to identify subgroups of patients with acute low back pain. Interrater reliability and short-term treatment outcomes. Spine 2000; 25: 106-14.
  16. George S, Delitto A. Clinical examination variables discriminate among treatment-based classification groups: a study of construct validity in patients with acute low back pain. Phys Ther 2005; 85: 306-14.
  17. Brennan G, Fritz J, Hunter S et al. Identifying subgroups of patients with acute/subacute “nonspecific” low back pain. Results of a randomized clinical trial. Spine 2006; 31: 623-31.
  18. Fritz J, Delitto A, Erhard R. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. A randomized clinical trial. Spine 2003; 28: 1363-72.
  19. Hicks G, Fritz J, Delitto A, McGill S. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil 2005; 86: 1753-62.
  20. Teyhan D, Flynn T, Childs J, Abraham L. Arthrokinematics in a subgroup of patients likely to benefit from a lumbar stabilization exercise program. Phys Ther 2007; 87: 3131-25.

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