PNF vs Pilates Exercises in Patients With CLBP
Condition: Low Back Pain
MeSH terms: Low Back Pain
Study type: Interventional

Summary: 
      Low back pain (LBP) is a common health problem that affects people all over the world and is
      a leading cause of disability, affecting work performance and overall health. In patients
      with low back pain, spinal movements are restricted, endurance decreases, flexor, and
      extensor muscle strength weaken, and aerobic capacity is impaired. Exercise is an essential
      component in the therapy of many musculoskeletal issues and chronic disorders. In the
      literature, studies using Pilates exercises and PNF exercises in patients with CLBP have
      demonstrated that both treatments have some beneficial effects in terms of reducing pain and
      disability, as well as improving the functional level and quality of life. Studies in the
      literature showed that both methods are among the treatment methods frequently used in the
      clinic, but it is difficult to provide sufficient information about which method is more
      effective. Therefore, the aim of this study is to examine the effects of PNF and Pilates
      exercises on pain, body image, fear-avoidance beliefs, core stability, disability, and
      balance functions in individuals with CLBP.
    

Detailed description: 
      Low back pain (LBP) is a common health problem that affects people all over the world and is
      a leading cause of disability, affecting work performance and overall health. Chronic LBP
      (CLBP) is defined as a problem that develops due to mechanical or non-mechanical causes and
      is characterized by pain, movement, and antalgic posture in the gluteal region and spine,
      limiting physical activity. In patients with low back pain, spinal movements are restricted,
      endurance decreases, flexor, and extensor muscle strength weaken, and aerobic capacity is
      impaired. It has been found that in patients with CLBP, pain creates fear of movement and
      avoidance belief, leading to inadequacy in physical functionality and a decrease in quality
      of life. Exercise is an essential component in the therapy of many musculoskeletal issues and
      chronic disorders. Exercise therapy addresses aims such as pain relief, relaxing,
      strengthening weak muscles, extending shortened muscles, minimizing mechanical stress on
      spinal structures, correcting posture, enhancing endurance, and quickly returning to work.

      The Pilates Method is a mind-body approach to therapeutic exercises that promotes movement
      stability and control. Pilates focuses on body posture alignment, which includes proper head,
      shoulder, and pelvic girdle adjustment in a neutral position while preserving spine
      curvatures, as well as the axial position of the lower limbs and symmetrical weight-bearing
      of the feet in standing position. Back pain inhibits various motions of the lumbar spine and
      pelvis, and this condition weakens the stabilizer muscles, which can lead to CLBP. In the
      rehabilitation of patients with back pain, the stabilizer muscles are emphasized in order to
      decrease pain and improve muscular endurance and strength. The Pilates method utilizes
      principles of various accepted rehabilitation methods that have scientific support for LBP,
      including core strengthening. This is important since core weakness has been increasingly
      recognized as a biomechanical deficit in patients with LBP. The systematic review study by
      Wells et al (2014) indicates that Pilates exercise results in statistically significant
      improvements in pain and functional ability in the short term compared to usual care and
      physical activity in people with CLBP. Another recent systematic review by Barros et al.
      (2020), on the other hand, shows that the Pilates exercise program in moderate-to-high
      quality RCTs for the treatment of lower back pain is still insufficient.

      Proprioceptive neuromuscular facilitation (PNF) is based on facilitating the responses of
      neuromuscular mechanisms by stimulating proprioceptors which aim to increase muscle strength,
      improve active movement ability, increase muscle endurance, and improve stabilization at the
      point where the technique is applied within the movement pattern. A systematic review and
      meta-analysis by Tong et al. (2014), identified that compared to controls, patients with low
      back pain have poorer lumbar proprioception. Furthermore, Meier et al. (2019) stated that
      back pain-induced disturbed or diminished proprioceptive signaling likely plays a key role in
      causing long-term alterations in the top-down regulation of the motor system via motor and
      sensory cortex remodeling. Individuals with chronic LBP showed lower acuity for detecting
      changes in trunk position and demonstrated significantly higher trunk repositioning errors
      during flexion of the back compared with pain-free individuals. Nijs et al. (2012), suggested
      that the presence of increased proprioceptive prediction errors might originate from
      reduced/disrupted proprioceptive input, probably triggered by nociceptive input. Therefore,
      the underlying physiological mechanisms of the PNF techniques such as autogenic inhibition,
      reciprocal inhibition, stress relaxation, and the gate control theory may influence the
      competition between the proprioceptive and nociceptive inputs, resulting in pain reduction
      and improved joint control. Furthermore, it has been found that PNF training can increase
      trunk muscular flexibility, strength, and endurance, providing support for the application of
      PNF training in functional improvement. Pourahmadi et al. (2020) stated in their systematic
      review and meta-analysis study that there was a low quality of evidence and a weak level of
      recommendation that PNF training had good benefits on back pain and disability in LBP
      patients and suggested further high-quality randomized clinical trials regarding long-term
      effects of PNF training.

      In the literature, studies using Pilates exercises and PNF exercises in patients with CLBP
      have demonstrated that both treatments have some beneficial effects in terms of reducing pain
      and disability, as well as improving the functional level and quality of life. Studies in the
      literature showed that both methods are among the treatment methods frequently used in the
      clinic, but it is difficult to provide sufficient information about which method is more
      effective. Therefore, the aim of this study is to examine the effects of PNF and Pilates
      exercises on pain, body image, fear-avoidance beliefs, core stability, disability, and
      balance functions in individuals with CLBP.
    

Intervention name(s): Pilates exercise; PNF exercise
Intervention type(s): Other; Other
Intervention description(s): All participants will be given a basic introduction to the Pilates-based exercises and will be taught how to activate the core muscles, which entails isometric contraction of the transverses abdominis, pelvic floor, and multifidus muscles while exhaling during diaphragmatic breathing, before beginning the exercise program. The Pilates exercise program will consist of floor exercises on a mat, including the following exercises: one-leg kick, single leg stretch, shoulder bridge, the hundred, one leg circle, and swimming. All exercises progressed at three degrees of difficulty: basic, intermediate, and advanced. Depending on the patient's tolerance, each exercise will be done for 8-10 repetitions. The treatment plan included a five-minute warm-up, twenty minutes of exercise, and a five-minute cool-down.; The PNF techniques utilized in the PNF exercise group will include a combination of isotonics, rhythmic stabilization, and repeated stretch. The exercises which will be performed are; (1) Trunk rotation in sitting position (1a) Chopping to the left and right and (1b) Lifting to the left and right, (2) Rolling activity (2a) Resistance to pelvic anterior patterns 2(b) Resistance to posterior patterns, 2(c) Combination of scapula and pelvis, 2(d) Combination of scapula and pelvis (i.e. asymmetrical exercise for trunk extension: the scapula moves in posterior elevation, the pelvis in posterior depression) and (3) Bridging activity (3a) Stabilize the pelvis in its neutral position, 3(b) Bridging lower trunk rotation and, 3(c) Bridging on two legs in the supine position.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized controlled study
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: CLBP; Pilates exercise; Proprioceptive Neuromuscular Facilitation; Pyschological functions; Physical functions