# Exercise as it relates to Disease/The efficacy of cross-sectional lumbar strengthening in spinal stabilization for pain reduction and disability in patients with degenerative disc disease

This is a critical assessment of the original article "Effects of Spinal Stabilization Exercise on the Cross-sectional Areas of the Lumbar Multifidus and Psoas Major Muscles, Pain Intensity, and Lumbar Muscle Strength of Patients with Degenerative Disc Disease" Seongho Kim, PhD, PT, Hyungguen Kim, MSC, PT, Jaeyeop Chung, MSc, OT, J. Phys. Ther. Sci. 26: 579–582, 2014

## What is the background to this research?

Degenerative disc disease is characterised by acute, subacute, and chronic lower back pain, which can often cause radiating pain in the surrounding areas and down the leg/s. Progression of disc degeneration drastically accelerates the eradication of surrounding cartilage, compresses disc height/s, atrophies deep intrinsic muscles and inaugurates spinal instability.
Lower back pain can arise from soft tissue damage and muscle weakening, resulting in restricted spinal movement due to decreased flexibility, contraction speed and muscular endurance.
Lower back pain (LBP) is one of the most common diseases within modern society, occurring in ~80% of the population. Quick fixes often include anti-inflammatories, pain suppressant medications, steroidal injections and surgery. These options are expensive, intrusive and present with dangerous side effects.
The following research paper addresses spinal stabilisation for patients suffering with 'degenerative disc disease' for the promotion of safe, non-invasive, cost-effective and easily-administered management of symptoms, due to the high prevalence of reoccurring 'flare-ups'.

## Where is the research from?

This study was carried-out in the Republic of Korea and published in the Journal of Physical Therapy Science. Its execution was orchestrated by Dr. Seongho Kim, (Department of Physical Therapy). His experience is recognised internationally, having contributed to publications across a diverse field of studies. Other authors involved include Hyungguen Kim (Rusk Hospital, Department of Physical Therapy) and Jaeyeop Chung (Inje University, Department of Rehabilitation Science). The study has no conflicts of interest from organisations and/or sponsors.

## What kind of research was this?

The research was conducted utilising a Cross-Sectional, Interventional design; consisting of a pre-test and post-test.
The use of questionnaires was administered to determine subjective results of pain levels via the visual analogue scale (VAS) and lumbar function via the Oswestry Disability Index (ODI). CENTAUR 3D Spatial Rotation Device (BFMC, Germany) was used to capture Paraspinal Muscular Strength at four angles (0°, 90°, 180°, -90°)
The ODI is deemed highly reliable with no differentiation amongst studies. Data proposes VAS to have sufficiently high reliability. The CTT Centaur equally shows good test-retest reliability.

## What did the research involve?

Thirty-three people were enrolled; 14 males and 19 females, aged 25 - 68. Participants were outpatients of W Hospital, Seoul from November 2011 to October 2012, diagnosed with Degenerative Disc Disease at the L4 and L5. Inclusion criteria required participants to have presented with symptoms for over a twenty-week period, with the absence of radiating leg pain.
Under the direction of a supervisor, participants undertook the following activities twice a week;
* Warm-Up: (10 minute) Fixed bicycle ride
* Main: (25-30 minute) Exercises including a mat and/or ball within CENTAUR 3D SRD.
* Cool-Down: (10 minutes) Stretching; quadriceps, psoas major, quadratus lumborm and calf
* Loading progression (% of Max Intensity): Weeks 1-4: 30–40% & Weeks 5-8: 40–50%
Limitations included a small sample size and absent control group of alternative therapeutic approaches. The study was confined to the strict inclusion/exclusion criteria mentioned above.

## What were the basic results?

The main findings are presented in the tables below. Data obtained from this research included those of associated pain levels via VAS, levels of disability via ODI and paraspinal muscular strength measured via the C3D SRD at 4 angles. Results were obtained pre and post the commencement of the 8-week spinal stabilisation program for comparison.
Table 1. Clinical variables :
| Parameter | Pre-Test | Post-test |
| VAS | 6.12±1.24 | 2.43±1.14 |
| ODI | 20.18±7.14 | 8.81±5.73 |
| $_{VAS,visualanaloguescale;ODI,OswestryDisabilityIndex*p-value<0.05,pairedt-test}$ |||
Table 2. CSA of the multifidus and psoas major (mm2) :
| Parameter | Pre-Test | Post-test |
| CSA Right Multifidus | 386.1±77.8 | 411.9±94.3 |
| CSA Left Multifidus | 386.1±78.3 | 410.6±91.1 |
| CSA Right Psoas | 893.0±311.5 | 929.0±335.6 |
| CSA Left Psoas | 872.5±334.0 | 907.9±343.8 |
| $_{RM,Rightmultifidus;LM,Leftmultifidus;RP,Rightpsoas;LP,Leftpsoas}$ $_{*p-value<0.05,pairedt-test}$ |||
Table 3. Paraspinal muscle strength (Nm) :
| Parameter | Pre-Test | Post-test |
| Centaur 0° | 72.8±21.1 | 78.4±19.0 |
| Centaur 90° | 68.9±17.7 | 77.3±17.7 |
| Centaur 180° | 42.7±11.5 | 57.3±15.7 |
| Centaur -90° | 69.3±19.8 | 78.2±17.0 |
| $_{0°,erectorspinae,multifidus;180°,rectusabdominisandinternal/externaloblique;}$ $_{90°,rightinternalobilique;−90°,leftintrenaloblique}$ $_{*p-value<0.05,pairedt-test}$ |||
Data was interpreted positively, where an increase in muscular size and width correlates positively to a reduction in muscular atrophy, increased spinal stability and an improvement in both perceived pain and disability. Researchers placed a large emphasis on the significance of improvement, this is justified.

## What conclusions can we take from this research?

Muscle strengthening positively influences spinal stabilisation by providing support and protection of the spinal structures. The correlation between stabilisation, improved function and pain reduction is evident and promotes quality of life.
Stretching is an imperative part in the maintenance of spinal mobility, in conjunction with pain reduction and promotion of function.
It is established that LBP is multi dimensional and impacted by a variety of variables. Therefore, it is evident that more research needs to be conducted into the potential benefits of alternative therapies and/or a combination of therapies on a control group.

## Practical advice

A few considerations need to be taken around some of the potential implications including, but not limited to, time constraints, motivation, consistency, patience, education, confidence, nature of disease and lifestyle factors.
This disease is sensitive in nature and easy to aggravate. Caution should be exercised when prescribing and programming, including specificity of exercises, loading, volume and rate of progression. Level of education is crucial in the proper execution of movement patterns and understanding of pain responses, including what is an acceptable pain threshold.
The risk/reward pay-off should not be overlooked, with spinal stabilisation presenting as a healthier, more cost-effective alternative to current methods and procedures. This includes the prescription of anti-inflammatories, pain relief medications, steroidal injections and surgeries. This method promotes self reliance and the management of realistic expectations.

## Further information/resources

For those wishing to further their understanding Degenerative Disc Disease the following readings may be of interest.
Physical Therapy Guide to Degenerative Disk Disease
Controlling Degenerative Disc Disease Pain: Three Things You Can Do
Exercise and Physical Therapy for Disc Disease Treatment and Pain Management
Pain Management Techniques for Degenerative Disc Disease
The evidence for an alternative to spinal fusion surgery
For a more in depth understanding providing a deeper insight include:
Pathophysiology of Degenerative Disc Disease.
Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain

## References

* ↑ Adams, M. and Roughley, P., 2006. What is Intervertebral Disc Degeneration, and What Causes It?. Spine, 31(18), pp.2151-2161.
* ↑ Barker, K., Shamley, D. and Jackson, D., 2004. Changes in the Cross-Sectional Area of Multifidus and Psoas in Patients With Unilateral Back Pain. Spine, 29(22), pp.E515-E519.
* ↑ Hides, J., Richardson, C. and Jull, G., 1996. Multifidus Muscle Recovery Is Not Automatic After Resolution of Acute, First-Episode Low Back Pain. Spine, 21(23), pp.2763-2769.
* ↑ Rasmussen-Barr, E., Nilsson-Wikmar, L. and Arvidsson, I., 2003. Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain. Manual Therapy, 8(4), pp.233-241.
* ↑ Longdom Publishing, 2021. Seongho Kim. [online] Longdom Group SA. Available at: <https://www.longdom.org/author-profile/seongho-kim-95835> [Accessed September 2021].
* ↑ Holm I, Friis A, Storheim K, Brox JI. Measuring self-reported functional status and pain in patients with chronic low back pain by postal questionnaires: a reliability study. Spine (Phila Pa 1976). 2003 Apr 15;28(8):828-33. PMID: 12698128.
* ↑ Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med. 2001 Dec;8(12):1153-7. doi: 10.1111/j.1553-2712.2001.tb01132.x. PMID: 11733293.
* ↑ Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med. 2001 Dec;8(12):1153-7. doi: 10.1111/j.1553-2712.2001.tb01132.x. PMID: 11733293.
* ↑ Mst. Rabea Begum et al. Validity and Reliability of visual Analogue Scale (VAS) for Pain Measurement. Journal of Medical Case Reports and Reviews 2:11, Page No: 394-402 (2019)
* ↑ Pfeifle, C., Edel, M., Schleifenbaum, S., Kühnapfel, A. and Heyde, C., 2020. The reliability of a restraint sensor system for the computer-supported detection of spinal stabilizing muscle deficiencies. BMC Musculoskeletal Disorders, [online] 21(1). Available at: <https://bmcmusculoskeletdisord.biomedcentral.com/track/pdf/10.1186/s12891-020-03597-4.pdf> [Accessed September 2021].