# Exercise as it relates to Disease/Stabilisation Exercise for those with Chronic Low Back Pain

This fact sheet relates to the article Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain With Radiologic Diagnosis of Spondylolysis or Spondylolisthesis (1997) by O'Sullivan, Phyty, Twomey and Allison.

## What is the background to this research?

Low back pain is a common condition affecting approximately 12% of the global population. Two specific conditions that can contribute to chronic low back pain and lumbar instability are spondylolysis and spondylolisthesis, and these conditions are the focus of this research article. Spondylolysis is a condition common in the lower spine, where a bony defect or fracture is found in a spinal vertebrae in a region called the pars interarticularis. Spondylolisthesis, on the other hand, is a condition in which the intervertebral discs give way in the lower spine, and one of the vertebrae slips forward.

### Lumbar Instability

Lumbar instability refers to an increased level of movement between the bones of the lumbar spine. Lumbar stability is influenced by changes in any of the three subsystems that comprise it, described in the table below.
| Subsystem | Characteristics | Anatomical Structures Included |
| Passive | Can't contract | Vertebrae, ligaments, intervertebral discs |
| Active | Can contract | Spinal muscles, tendons |
| Neural | Controls contraction | Nerves, brain, spinal cord |

### Context of the Research

As low back pain is so globally prevalent, research regarding management strategies for the condition are needed. Before this study, treatment options including general abdominal exercises, stretching, orthotic bracing, pelvic tilting exercises had been suggested, however few research trials had been conducted to determine how effective these are. At the time, new research had suggested that specific training of the stabilising muscles of the lumbar spine (transversus abdominis, internal oblique and lumbar multifidus) decreased pain and disability those with low back pain. From this research, O'Sullivan and his colleagues expanded on this idea, examining the effectiveness of specific training of the spinal muscles in those with spondylolysis or spondylolisthesis.

## Where is the research from?

This study was conducted in Perth, Australia, and was lead by a Physiotherapist named Peter O'Sullivan, an internationally renowned musculoskeletal Physiotherapist. O'Sullivan has published multiple studies mostly relating to the lumbar spine, including research on chronic low back pain and activation patterns of the lumbar musculature.

## What kind of research was this?

This study is a randomised-controlled trial. Randomised-controlled trials randomly assign the study participants into two groups, one group that will receive an experimental intervention and one group that will receive a standard intervention or no intervention. All participants were assessed at the start and end of the study by an independent assessor (not related to the study), and this helps the results stay free of bias. This study is rated as level II evidence according to the NHMRC criteria, the second most trustworthy study design behind a systematic review.

## What did the research involve?

Forty-two participants completed this study, with 21 people in the exercise group, and 21 people in the control group. The characteristics of the participants are detailed in the table below.
| Inclusion Criteria | Exclusion Criteria | Withdrawal Criteria |
| Age 16-49 | Clinical presentation not attributable to spondylolysis or spondylolisthesis | Withdrawn consent |
| Low back pain symptoms >3 months | Diagnosed psychologic illness | Showed a lack of cooperation and motivation to carry out the intervention |
| No sign of easing symptoms | Difficulty understanding English | Persistent exacerbation of their symptoms |
| Radiologic diagnosis of isthmica spondylolysis or spondylolisthesis by CT scan | Undergone previous spinal surgery | |
| | Diagnosed inflammatory joint disease | |
| | Displayed overt neurologic signs | |
Before testing all participants completed a short form McGill pain questionnaire, an Oswestry disability questionnaire and participated in electromyography of abdominal muscle activation patterns and lumbar spine and hip range of motion testing. The study then ran over a 10 week period, with the exercise group attending weekly physiotherapy sessions focusing on specific contraction of the deep abdominal muscles. These exercises were completed daily, progressed (as able) and then incorporated into functional activities. The control group underwent treatment by their medical practitioner only across the 10 week period. For these people this included performing general exercise like swimming or walking. The assessment measures described above were then taken after the 10 weeks, as well as at 3, 6 and 30 months after the study.

## What were the basic results?

After the 10 week period the exercise group had a significant reduction in low back pain intensity, pain descriptor scores and functional disability compared to controls. The exercise group also showed significant increases in sagittal plane hip range of motion, but no change in lumbar spine range of motion. The reduction in pain intensity and functional disability was maintained up until the 30 month follow up, and reduced pain descriptor scores were maintained up to the 6 month follow up.

### How did the Researchers Interpret the Results

The results were not overstated, and the information was presented in an unbiased manner. The researchers found that the results supported their hypothesis that training the deep core muscles can reduce pain and disability in those with chronic spondylolysis or spondylolisthesis. On a deeper level they also believed that lumbar stability can be improved even if the 'passive subsystem' is compromised, by training the 'active subsystem' to compensate. By training the deep muscles of the core, intersegmental stability is improved, leading to a suspected increase in overall dynamic stability.

## What conclusions should be taken away from this research?

The main finding that can be taken away from this study is that specific training of the deep core muscles significantly reduces pain and disability associated with lumbar instability from spondylolysis or spondylolisthesis. It also shows that specific training is more effective for these conditions than general exercise such as gym work, walking or swimming. Importantly, this study demonstrates that the exercises are proven effective even 30 months after the study, showing their validity in the long term. Furthermore, this study shows that lumbar instability symptoms can be managed with exercise, by strengthening the active subsystem to compensate for the compromised passive subsystem.
Since this research was published, further studies have shown that specific exercises are more effective in treating low back pain than medical management in conjunction with normal activity. A systematic review regarding exercises for low back pain also found that specific stabilisation exercise programs are more effective than other interventions for reducing pain. In terms of spondylolisthesis, there is currently no widely accepted non-operative management protocol, however activity modification, physiotherapy and specific core strengthening are still stated as being major components of treatment. The original study conducted by O'Sullivan and his colleagues is still recognised in low back pain research today, and their results are still accepted as effective ways to treat low back pain and lumbar instability.

## What are the implications of this research?

This evidence of a valid conservative management option for both spondylolysis and spondylolisthesis may translate to a lower need for surgery in these populations. It also gives those suffering with chronic low back pain a valid way to reduce their pain and improve their function, which could lead to reduced sick days and increased participation in life activities in the long term. This research should also change the way medical practitioners go about treating chronic low back pain patients, focusing on specific exercises with feedback rather than general exercise.

## Further Information

Further information about the subject matter from this research can be found at the links below:
1. Spondylolysis: http://physioworks.com.au/injuries-conditions-1/spondylolysis-pars-stress-fracture
2. Spondylolysis: http://www.spine-health.com/conditions/spondylolisthesis/degenerative-spondylolisthesis
3. Exercise and Chronic Low Back Pain (a view in 2015): http://cre.sagepub.com/content/29/12/1155.short
4. Australian Government Run Website Regarding Low Back Pain (including service finder): https://www.healthdirect.gov.au/what-causes-back-pain

## References

* 1 2 3 4 5 6 7 8 O'Sullivan, P. B., Phyty, G. D. M., Twomey, L. T., & Allison, G. T. (1997). Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine, 22(24), 2959-2967.
* ↑ Hoy, D., Bain, C., Williams, G., March, L., Brooks, P., Blyth, F., ... & Buchbinder, R. (2012). A systematic review of the global prevalence of low back pain. Arthritis & Rheumatism, 64(6), 2028-2037.
* ↑ Panjabi, M. M. (1992). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord, 5(4), 383-389; discussion 397.
* ↑ Richardson, C. A., & Jull, G. A. (1995). Muscle control–pain control. What exercises would you prescribe?. Manual therapy, 1(1), 2-10.
* ↑ Coleman, K., Norris, S., Weston, A., Grimmer-Somers, K., Hillier, S., Merlin, T., & Tooher, R. (2005). NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC.
* ↑ Hides, J. A., Jull, G. A., & Richardson, C. A. (2001). Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine, 26(11), e243-e248.
* ↑ Searle, A., Spink, M., Ho, A., & Chuter, V. (2015). Exercise interventions for the treatment of chronic low back pain: A systematic review and meta-analysis of randomised controlled trials. Clinical rehabilitation, 29(12), 1155-1167.
* ↑ Zavatsky, J. M., Briski, D. C., & Frisch, R. (2015). Non-surgical Management of Spondylolisthesis in Adults. In Spondylolisthesis (pp. 129-136). Springer US.