Research Review by Dr. Shawn Thistle©

Date:

Aug. 2006

Study Title:

Specific stabilization exercise for spinal and pelvic pain: A systematic review

Authors:

Ferriera PH et al.

Publication Information:

Australian Journal of Physiotherapy 2006; 52: 79-88.

Summary:

Spinal pain is very common, and has been a frequent topic in my Research Reviews over the years. The estimated lifetime prevalence for cervical (neck) pain is 35-40%, 11-15% for thoracic (mid-back) pain, 60-80% for lumbar (low back) pain, and 15% for pelvic pain. Despite our best efforts clinically and with advanced imaging, the exact cause of most cases of spinal pain remains elusive.

In the early 1990s, Panjabi proposed a mechanism for the development and recurrence of spinal pain. His model focused on spinal stability, which assumes that three subsystems are responsible for the biomechanical stability of the spine - the articular (or passive), muscular (or active), and neural subsystems.

This theory was expanded to include the pelvic joints in the late 1990s (by Vleeming et al.), while other groups were beginning to discover the importance of deep spinal muscles in low back pain patients (the Queensland, Australia physiotherapy group - Jull, Hodges, Richardson, Hides etc.), and developing biomechanical models of the spine which would revolutionize spinal rehabilitation (McGill and colleagues at the University of Waterloo).

Collectively, this work has generated numerous advances in low-tech spinal rehabilitation that has changed the way we approach and treat spinal pain conditions. Stabilization exercise now forms a cornerstone of spinal treatment being administered successfully by many professions.

The aim of this study was to conduct a systematic review of the literature investigating the efficacy of stabilization exercise for spinal and pelvic pain. Randomized clinical trial were included if they met the following inclusion criteria:
  • participants had to be adults (> 18 years old) with pain in the cervical, thoracic, low back, or pelvic area
  • symptoms could be referred to the arms or legs
  • studies had to mention explicitly that at least on group received specific stabilization exercise - described as activating, training, or restoring the function of specific muscles of the spine or pelvis
  • stabilization exercise could be applied in isolation or with other therapies
  • at least one of the following outcomes had to be reported: disability, pain, return to work, number of episodes, global perceived effect, or health-related quality of life
All relevant and customary databases were searched, yielding 194 studies, 13 of which met inclusion criteria and were included in the review. The authors provide a study-by-study breakdown, from which the following relevant findings and trends were observed:
  • overall, there is some evidence that specific stabilization exercise produces modest beneficial effects for people with spinal and pelvic pain
  • stabilization exercise was, in general, superior to no treatment, or treatments such as usual care and education
  • the effects of stabilization exercise did not appear to be any greater than effects of spinal manipulation of conventional physiotherapy (but all are considered beneficial)
  • specific stabilization exercise was not effective in reducing pain or disability in acute low back pain (however, there is some evidence that it can reduce recurrence after an episode of acute low back pain)
  • specific stabilization exercise is beneficial in the management of chronic low back pain
  • single trials show promise for stabilization exercise in the treatment of cervicogenic headache, neck pain, and pelvic pain

Conclusions & Practical Application:

Overall, this review indicates that specific stabilization exercise is useful in the treatment of many types of spinal pain.

A few points mentioned above deserve further discussion. First, the fact that stabilization exercise seemed ineffective for acute low back pain shouldn't be a surprise. Those of us who see acute low backs know that these patients respond best to pain relieving interventions like spinal manipulation, acupuncture, electrotherapy, ice etc. Once pain is alleviated, then a stabilization program can begin.

In my experience, a patient who is in pain has little if any interest in properly activating and rehabilitating deep stabilizing muscle function! This observation leads to another point that stabilization exercise seems beneficial in the management of chronic low back pain. Normally these patients have recurrent episodes of back pain that must be managed acutely, and rehabilitated to prevent or reduce chronicity. This seems to be where the stabilization approach fits best according to the current level of evidence.

The final point is that (as always) more quality trials are needed to clarify the role of stabilization in low back pain, and continue to build the evidence base for neck and pelvic pain conditions.

A primary goal of all manual medicine professionals should be to reduce recurrence of spinal pain (does "treat the cause" ring a bell here?). Becoming familiar with the implementation of spinal stabilizing exercise can be a valuable tool in your practice, and your patients will appreciate it. Now that the clinical research is beginning to validate the earlier theoretical work, this approach looks like it will become a mainstay in manual medicine.

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