Introduction
Chronic lumbalgy is one of the most common forms of chronic pain, a common cause of disability and increased healthcare costs to society. It is estimated that it affects 60% to 80% of middle-aged people at some point in their lives. Chronic lumbalgy significantly reduces working capacity and is associated with difficulties in recruitment and retention in the workplace [9, pp. 32-38].
A number of studieshave proven that the application of a functional program in patients with chronic lumbalgyresults in a significant improvement of muscle power and cardiovascular functions, and increase psychological, psychic, and emotional endurance, which leads to improved professional activities and reduced absences from work [5, 12, 2, 6].
Given the social importance of this disease,for the first time in Bulgaria,there was carried out a prospective study of pain intensity and extensional features of the trunk muscles before and after the application of a kinesitherapeutic program of special exercises at home in patients with chronic lumbalgy.
Objective of the study
The objective of this study is to take into account the effect of a kinesitherapeutic program of special exercises for treatment of pain intensity and endurance of the extensor trunk muscles in patients with chronic lumbalgy.
Patients and Methods:
The study is representative, prospective, with test-retest design and tracking with filling out questionnaires at the beginning and end of the observation (12 months). It was carried out with the participation of a representative sample of 110 patients with chronic lumbalgy, distributed equally into two treatment groups (experimental and control) of uniform age and gender. The selection of patients was done according to their appearance in the consulting room of the physiotherapy diagnosis and counseling center in Stambolijski by involving all those who met the inclusion criteria. They were each diagnosed and were undergoingtherapy at the time,having been referred to the centerby a general practitioner after consultation with a neurologist.
All procedures related to the study were performed in accordance with the guidelines of good clinical practices. Prior to procedures, each patient was familiarized with the design of the study and signed an informed consent form.
135 consecutive patients with chronic lumbalgy were initially screened, 25 of which were not included in the survey due to non-compliance with the inclusion criteria. Of 110 patients included in the final stage of the study, a total of 51 patients dropped out (22 of the experimental group due to a temporary improvement or social commitments and 29 in the control group due to lack of motivation).
Patient information was obtained by taking a history and focused review of available medical records of the therapist and neurologist. The experimental group was trained to perform special exercises 3 times a week at home, and participants in the control group followed the recommendations of a physician for medical treatment. Patients’ follow-up lasted for a year. At the beginning and end of the study,there was applied Biering-Sorensen test.
The isometric Biering-Sorensen test is the only clinically validated tool for testing the strength of the lumbar trunk extensors, wherein a chair is used for exercises while the subject keeps the trunk in a horizontal position against gravity in a single contraction. The test involves measuring the time for which a person can hold their body in a horizontal position with fixed lower limbs to a Roman chair. The test is used in many studies in its original form or in different variants [1, pp. 106-119]. Gruther et al. (2009) showed its excellent accuracy in the absence of effects on retention of patients and recommended it for rehabilitation of patients with chronic lumbalgy [7, p. 613-619].
The kinesitherapeutic program applied in patients with chronic lumbalgy in the experimental group included five types of training:
- Training for lumbar stability: elevation of the pelvis to maintain neutral position, axial withdrawal during co-contraction, maintaining co-contraction with elevation of one foot and abduction of the upper limb.
- Training for mobility: supplying in flexion position, suppling in extensional position, abductor muscle active tension, adductor muscle active tension, active tension of the ischiocrural muscle group.
- Flexor workout: exercise for strengthening the abdominal muscles from side leg positions, co-contraction trainingfor the anterior oblique system involving the anterior abdominal fascia, dynamic strength training m.obliquus abdominis externus and m.obliquus abdominis internus.
- Extensors workout: exercises for extension of the spine from aproneposition with hands support andholding for 30 sec. in extensional position; co-contraction for strength of m.gluteus maximus and m.latissimus dorsi.
- Training for sensory-motor reprogramming: exercises for thetrunk rotators, exercises for upper limb flexion and extension of homolateral lower limbs fromside leg position on a Swiss-ball, exercises to maintain the neutral position by moving the Swiss-ball on the wall.
Monitoring and evaluation of the results of kinesitherapeutic program was carried out by an experienced physiotherapist.
The collected primary information was checked, encoded, and entered into a computer database for statistical analysis. Data were processed using SPSS13.0. Results for quantitative variables were expressed as mean ± SE (standard error) and results for qualitative variables as percentages.
Results
Table 1 shows the characteristics of the individuals in the two groups in terms of age, gender, pre-existing risk factors for chronic lumbalgy. The described risk factors include: strenuous physical activity, repetitivemotion with rotations of the body, spinal column burdening in upright and seated position, being overweight.
Table 1.
Age, gender and presence of risk factors in patients from the experimental and control groups at the beginning and end of the study
|
Indicator |
ExperimentalGroup
|
Control Group |
||
| At the beginning of study | At the end
of study |
At the beginning of study | At the end
of study |
|
| Mean age (yr.)
(mean ± SE) |
43.31±1.11 |
44.24±1.35 |
43.90 ± 0.87 |
44.57 ± 0.55 |
| Gender /N (p%)/
— male — female |
26 (47.27%) 29 (52.73%) |
11 (39.39%) 20 (60.61%) |
24 (43.63%) 31 (56.37%) |
8 (30.76%) 18 (69.24%) |
| Risk factors
— yes — no |
33(60.00%) 22 (40.00%) |
19 ( 57.57% ) 14 (42.43%) |
32(58.18 %) 33 (41.82%) |
15 (57.69%) 11 (42.31%) |
At the beginning of the study there were ascertained no significant differences between the participants in the experimental and control groups in terms of mean age P > 0.05 (u = 0.41), gender P > 0.05 (χ2 = 0.15) and present risk factors, P > 0.05 (χ2 = 0.04). No correlation was found between the participants’ gender and the presence of risk factors P > 0.05 (χ2 = 3.51) as well as between age and the presence of risk factors P> 0.05 (χ2 = 2.81).
There was ascertained no statistically significant difference in the experimental group between the Biering-Sorensen test results at the beginning and end of the study P> 0.05 (u = 0.86). However, these resultsshow a certain positive effect in the reduction of complaints. Likewise, the control group test results show no statistically significant difference between the beginning and end of the study P> 0.05 (u = 1.42). However, they lackthe positive effect of the kinesitherapeutic program described in the experimental group. No statistically significant difference was also found between either group at the end of the study P> 0.05 (u = 0.77) — Table 2.
Table 2.
Comparison of Biering-Sorensen test results from the experimental and control groups at the beginning and end of the study
| Biering—Sorensen
test results |
Groups | N | mean ± SE | u | P |
| At the beginning of study
of |
Experimental | 55 | 88.13±2.49 | 0.86 | >0.05 |
| Control | 55 | 83.04±3.58 | |||
| At the end of study | Experimental | 33 | 93.15±3.73 | 0.77 | >0.05 |
| Control | 26 | 88.08±5.39 |
The results obtained from the Biering-Sorensen tests in the experimental group at the beginning and end of the study are closely dependent on the intensity of the pain, the presence of risk factors, age and gender of the subjects studied.
A comparison by gender with the meanBiering-Sorensen test results in the experimental group showed that women endure longer periods at both the beginning and end of the study — Table 3.
Table 3.
Comparison of the mean Biering-Sorensen test results by gender from the experimental group at the beginning and end of the study
| Biering—Sorensen
test results |
Gender | N | Mean ± SE | F/u | P |
| At the beginning of study | Male | 26 | 82.54±3.26 | F = 2.20 | <0.05 |
| Female | 29 | 93.14±3.52 | |||
| At the end of study | Male | 13 | 83.00±5.12 | u = 2.41 | <0.05 |
| Female | 20 | 99.75±4.71 |
The comparison by age with the Biering-Sorensen mean test resultsin the experimental group demonstrated that patients over 50 years of age had a much lower resistance at both the beginning and end of the study P <0.01 (r = -0.34) — Table 4.
Table 4.
Comparison of the mean Biering-Sorensen test results by age from the experimental group at the beginning and end of the study
| Biering—Sorensen
test results |
Age | N | Mean ± SE
|
F | P |
| At the beginning
of study |
Up to 39 yr. | 20 | 92.00 ± 3.60 |
4.61 |
< 0.01 |
| 40-49 yr. | 18 | 93.78 ± 4.65 | |||
| Over 50 yr. | 17 | 77.59 ± 3.85 | |||
| At the end of study | Up to 39 yr. | 9 | 98.11 ± 7.33 |
3.67
|
< 0.05 |
| 40-49 yr. | 12 | 101.67 ± 5.94 | |||
| Over 50 yr. | 12 | 80.92 ± 5.00 |
The comparison of the presence of risk factors for chronic lumbalgy with the Biering-Sorensen mean test results in the experimental group showed thatin the presence of risk factors patients endured less time at the beginning and end of the study P < 0.001 (r = — 0:46) — Table 5.
Table 5.
Comparison of the mean Biering-Sorensen test results by the presence of risk factors from the experimental group at the beginning and end of the study
| Biering—Sorensen test results | Risk factors | N | Mean ± SE | t/u | P |
| At the beginning of study | No | 22 | 97.73 ± 3.83 | t = 3.46 | < 0.01 |
| Yes | 33 | 81.73 ± 2.78 | |||
| At the end of study | No | 17 | 103.12 ± 4.66 | u = 3.10 | < 0.01 |
| Yes | 16 | 82.56 ± 4.71 |
Pain intensity influenced the Biering-Sorensen test results of the patients in the experimental group at the beginning and end of the study, while patients with severe pain had reduced enduranceof the trunk extensors P <0.001 (r = -0.87) — Table 6.
Table 6.
Biering-Sorensen test results of patients from the experimental group at the beginning and end of study according to pain intensity by VAS
| Biering—Sorensen test results | Pain intensity (VAS) | N | Mean ± SE | t/u | P |
| At the beginning of study | 0-4 | 29 | 105.45±4.35
|
6.51 | < 0.0001
|
| 5-7 | 26 | 72.42±2.61 | |||
| At the end of study | 0-4 | 25 | 99.96 ±3.92
|
3.86 | < 0.001 |
| 5-7 | 8 | 71.88±3.60 |
Discussion
The purpose of this study is to take into account the effect of a kinesitherapeutic program of special exercises for treatment of pain intensity and endurance of the extensor trunk muscles in patients with chronic lumbalgy.
The significant reduction of endurance and strength of lumbar extensors in patients with chronic lumbalgy compared to healthy people motivated our choice of the Biering-Sorensen test for assessing the endurance of spinal muscles in our study participants [4, pp. 39–46].
The comparison of Biering-Sorensen test results in the experimental group at the beginning and end of the study showed that at the end of the study the percentage of participants who may holdover 101 sec increased (from 40% to 42.42%). The improvement of extensional features of the spine in the experimental group was due to the applied training of the paravertebral muscles, including stabilization workouts in pairs through isometric exercises. In the literature we found confirmation of our conclusion in Danneels et al. (2001), who demonstrated through a scanning visualization, that in patients with chronic lumbalgy, atrophy mm.multifidi responds well to the application of stabilization workouts in pairs with isometric exercises for 10 weeks [3, pp. 186-191].
Olivier (2004) found that dynamic exercises with progressive loading increase muscle volume with (15%) in case training is performed with this frequency [10, pp.73-87].
Kankaanpää et al. (1998) showed that the fatigue of the lumbar paraspinal musculature during the Biering-Sorensen test was influenced by the individual characteristics of the subject [8, pp. 253–260].
In chronic degenerative pathologies of the spinewe observe the formationof abnormalities in muscle fibers mm.multifidi (selective atrophy of type 2 fibers, and abnormalities in the internal structure of the fiber type 1) [13, pp. 253–260]. Rissanenet al. (1995) examined the effects of intensive rehabilitation program on the trunk and knee extensor muscles respectively in patients with chronic lumbalgy and found that males of type 1 fibers retain their dimensions unchanged, while those of type 2 increased them by 11% for m. multifidus and 8% for m. vastuslateralis of m.quadriceps femoris; women increased these sizesby 11% for both muscles. Therefore, because of better expressed structural changes in its dorsal muscles,the strength of extension of the female trunk greatly increases [11, pp.333-40].
Conclusion: The application of specific exercises in patients with chronic lumbalgy proved extremely useful in view of the obtained information, so as to effectively recover aspects of motor control. The reported positive effect of the kinesitherapeutic program consists improvement of extensional features of the trunk muscles. Non-implementation of such a program is associated with worsening of the functional status of patients. Our results may motivate the introduction and implementation of the described kinesitherapeutic program in the clinical practice in Bulgaria to improve the quality of life and reduce disability in people with chronic lumbalgy.
References
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- Schaafsma FG., Whelan K., van der Beek AJ., van der Es-Lambeek LC., Ojajärvi A., Verbeek JH. Réadaptation physique dans le cadre d’une stratégie de retour au travail pour réduire les congés de maladie chez les travailleurs souffrant de dorsalgies. Centre Cochrane Français 2013, e-pub. DOI: 10.1002/14651858.CD001822.pub3.
- 13.Sullivan MJ., Stanish W., Waite H., Sullivan M., Tripp DA. Catastrophizing, pain, and disability in patients with soft-tissue injuries. Spine 1998, 77(3), 253–26[schema type=»book» name=»DYNAMIC MONITORING OF THE EFFECT OF SPECIAL KINESITHERAPEUTIC PROGRAM ON ENDURANCE OF EXTENSOR TRUNKMUSCLES IN PATIENTS WITH CHRONIC LUMBALGY» author=»Becheva Maria Vakrilova, VitevaEkaterina» publisher=»БАСАРАНОВИЧ ЕКАТЕРИНА» pubdate=»2017-04-03″ edition=»ЕВРАЗИЙСКИЙ СОЮЗ УЧЕНЫХ_30.04.2015_04(13)» ebook=»yes» ]