LUMBAR MULTIFIDUS MUSCLES FUNCTION AMONG PATIENTS WITH LOW BACK PAIN: VIRTUAL REALITY VERSUS STABILIZATION EXERCISES.
Condition: Low Back Pain; Low Back Pain, Mechanical
MeSH terms: Back Pain; Low Back Pain
Study type: Interventional

Summary: 
      Abstract:

      Background: The multifidus muscle, the most medially located back muscle and the largest
      muscle that spans the lumbosacral junction serves to provide dynamic stability to the spinal
      column. Virtual reality and core stabilization exercises are commonly used for balance
      training in musculoskeletal conditions. The knowledge regarding the effective implementation
      of these training protocols in patients suffering from chronic low back pain (LBP) is
      insufficient.

      Objective: The purpose of the present study is to investigate the efficacy of virtual reality
      versus stabilization exercises on lumbar multifidus muscle function among patients with low
      back pain.

      Design: Randomized, double-blinded controlled study. Participants: Sixty LBP participants
      will be divided into three groups in a 1:1:1 ratio, 20 in each group (control group,
      stabilizing exercises, and virtual reality rehabilitation system). All three groups received
      training three days per week throughout the Six-week treatment session.

      Outcome measures: Evaluation of pain by the visual analog scale (VAS), Level of functional
      impairments by Oswestry Disability Index and Accuracy of lumbar repositioning measurement by
      Biodex system will be measured at baseline and after Six weeks.
    

Detailed description: 
      Introduction:

      Low back pain (LBP) is still a significant concern for the public. Health concerns in
      affluent nations despite advances in our understanding of spinal illnesses. The issue is
      significant because of its socioeconomic and psychological implications and the shortcomings
      of many suggested preventive or cure measures (Almazrou et al., 2020; Schmidt et al., 2020).
      Up to 75% of people will experience low back discomfort at some point with some extent of
      functional difficulties (De Souza et al., 2019).

      With its distinct stabilizing function, the multifidus muscle, which spans the lumbosacral
      junction and is situated medially in the back, gives the spinal column dynamic stability
      (Zwambag et al., 2019). It is crucial to remember that people with low back pain may have a
      multifidus muscle problem, which includes critical structural alterations such as atrophy and
      the replacement of muscular tissue with fatty infiltrates (Shahidi et al., 2017). A lack of
      proprioception and abnormal recruitment patterns are two further motor control deficiencies
      noted (Chua et al., 2022; Shahidi et al., 2023).

      Several studies have linked Multifidus muscle atrophy to LBP in both acute and chronic stages
      (Maas et al., 2018). This muscle loss is not due to atrophy from lack of usage; multifidus
      activity is reflexively inhibited (Masse-Alarie et al., 2016a). Atrophy of the spinal muscles
      can lead to instability and recurrent back problems (Massé-Alarie et al., 2016b). Appropriate
      lumbosacral position sensing depends on the multifidus muscles' muscle spindles. Lower back
      pain (LBP) sufferers typically have a less accurate and exact sense of their position than
      healthy individuals. Multifidus muscle atrophy may result in muscle spindle dysfunction,
      which can limit muscle spindle input and impair segmental stability and spinal proprioception
      (Crawford et al., 2019; Gabel et al., 2021).

      Computer technology, virtual reality (VR), employs sensory feedback to provide users with an
      experience that mimics real-life activities and events. People can improve their motor
      abilities in a fashion that mimics the real world by using a three-dimensional virtual
      environment (Park et al., 2019). Virtual reality systems are well known for their distinctive
      qualities of interactivity and immersion. Utilizing several sense channels, such as sight,
      hearing, and touch, requires interaction. The degree of interaction with the virtual
      environment, on the other hand, is related to immersion (Coburn et al., 2017; Papadopoulos et
      al., 2021). To influence the cognitive processes involved in motor control, one needs a sense
      of "degree of presence," or awareness of one's existence in a certain scenario. Virtual
      reality technology makes the development of interactive training regimens that target various
      muscles, joints, coordinated movements, or the complete body easier (Levac et al., 2019;
      Tieri et al., 2018). There is currently a dearth of research on how VR affects the function
      of the multifidus muscles in people with LBP.

      Even though much research has been done, the best course of action for treating persistent
      LBP and the value of different physical therapy are still debatable. A various physical
      therapy methods for treating LBP have also been conducted without the superior of one
      technique on the others (Ahmed, Maharaj, et al., 2021; Ahmed, Nadasan, et al., 2021; Mohamed
      Kamel et al., 2019).

      This study compares the effects of lumbar stabilizing exercises and virtual reality on the
      multifidus muscle's cross-sectional area, the lumbar spine's ability to accurately realign
      pain levels, and functional limitations in people with chronic lower back pain.

      Methods.

      Design of the trial

      Using a computer random table method, the study divided the participants evenly among the
      three groups in a 1:1:1 ratio. The research will be randomized, controlled, and
      double-blinded. There will be 60 participants, 20 in each of the three groups (control group,
      stabilizing exercises, and virtual reality rehabilitation system). The Physical Therapy
      Department at the University of Hail in Saudi Arabia selected study participants from the
      Hail University Clinics. The research underwent approval from the Departmental Scientific
      Ethics Committee. Additionally, it adhered to the comprehensive reporting standards of the
      unified standards for reporting trials (CONSORT), ensuring full transparency. A physical
      therapist from the department evaluated to determine participant eligibility.

      Participants:

      Participants had to provide their consent and sign an informed consent form authorized by an
      ethics committee to be eligible for the study. The selection criteria comprised those between
      the ages of 30 and 50 who had been dealing with persistent lower back pain for more than
      three months and who graded their pain on a visual analog scale (VAS) as being between four
      and eight. A person will be not considered eligible for the study if they had severe
      musculoskeletal, neural, somatic, or psychiatric disorders, will be recovering from spinal
      surgery, will be abusing alcohol or drugs, will be taking part in other weight and
      balance-training programs, had deformities or other soft tissue injuries or bone fractures.

      Patient participation:

      Through a study information form, the researchers sent the 60 patients who will be initially
      chosen thorough instructions and information regarding the trial's goals, design,
      intervention techniques, outcome metrics, length, and potential risks and benefits.

      Interventions:

      With The Ethics Committee's Approval, the VRG, STG, and control groups will undergo four-week
      rehabilitation programs. A physiotherapist with five years of expertise and a good skill set
      completed the recovery process. The study excluded ten people who chose not to participate,
      eleven with joint problems, four who applied for surgery, and seven who reported significant
      pain (VAS score greater than 8).

      Participants in the study utilized a device that encouraged balance exercises to strengthen
      their core muscles and increase their stability. They will be given one-on-one instructions
      while seated on how to use the virtual reality game (VRG). The participants' balance will be
      tested in this position, which also helped them become accustomed to the game's rules.

      A shooting game will be present in the recent study. The game will be played on a display
      screen while participants sat on a virtual platform. Following the signs, they moved their
      trunks forward, backward, and left to right to control the game. Participants will be urged
      to move their spines as much as possible while staying within their discomfort thresholds.
      The actions in the game will be rated, and as they progressed in complexity, They have become
      increasingly challenging.

      Measures of results

      The outcome measures will be assessed at baseline and again Six weeks later.

        1. Evaluation of pain:

           The visual analog scale (VAS) is a 10 cm line with 0 representing no pain and 10
           representing the worst pain. It will be used to ask patients to rate how much pain they
           perceived. They will be told to draw a mark on the line where their level of pain will
           be.

        2. Level of functional impairments

           To assess functional disability, we employed the Oswestry Disability Index. Ten
           multiple-choice questions about back discomfort and everyday activities are included.
           Each question has six potential answers and a maximum score of 5. Based on a few chosen
           statements, the ultimate score is determined.

           Score overall: (5 questions answill bed) x 100%.

           The degree of disability is determined using a scale from 0 to 50. The score reflects
           the severity of the condition, with higher scores indicating more profound impairment.
           Scores between 20% and 40% indicate significant disability, whereas those between 0 and
           20% suggest mild disability. Scores between 40% and 60% indicate severe disability, and
           those between 60% and 80% indicate crippling disability. Lastly, an 80% to 100% score
           denotes bed rest for the patient (Fairbank & Pynsent, 2000; Monticone et al., 2012).

        3. Accuracy of lumbar repositioning measurement

      Knee blocks, leg pads, thigh straps, pelvic brace, lumbar pad, and force application straps
      will be used to position the person in the Biodex system. The head will be supported on a
      flexible rest while straps restrained the torso. The spinal range of motion created a neutral
      spinal posture at 30 degrees lumbar flexion. We asked participants to bend their backs as far
      as possible to determine the range of motion. For consistency, the dynamometer will be
      adjusted at zero degrees. Participants will be instructed to recall and replicate a 30°
      position in a practice trial. We ran this test thrice and calculated the mean deviation each
      time (Wilson & Granata, 2003).

      Statistic evaluation

      We used Levene's test to measure the participant's demographics to confirm the study's
      consistency. We showed the mean and standard deviation for the outcome data. We used SPSS
      software to conduct repeated measures and one-way ANOVA tests to determine significant
      changes within groups, with a statistical significance level of P 0.05. (IBM SPSS Statistics,
      V 23).
    

Intervention name(s): VIRTUAL REALITY
Intervention type(s): Device
Intervention description(s): LUMBAR MULTIFIDUS MUSCLES FUNCTION AMONG PATIENTS WITH LOW BACK PAIN: VIRTUAL REALITY VERSUS STABILIZATION EXERCISES.
Other intervention name(s): STABILIZATION EXERCISES
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized, double-blinded controlled study.
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Pain