Proprioceptive, Calisthenic, and Kinesthetic Exercises for Chronic Low Back Pain

Numerous studies have emphasized the debilitating effects of chronic low back pain (CLBP), which persists for over 12 weeks and impacts approximately 20% of the global population. The etiology of CLBP encompasses various factors, such as sedentary lifestyles, diminished muscle strength, poor neuromuscular control of deep trunk muscles, and compromised proprioception, all contributing to lumbar spine strain. These factors result in limitations in essential daily activities, significantly diminishing the overall quality of life. Continued exploration in this field is essential to furthering our understanding of managing chronic low back pain. Investigating alternative treatment approaches, such as proprioceptive, calisthenic, and kinesthetic exercises, contributes to expanding the range of solutions available for addressing this issue. Embracing a diverse array of interventions not only proves beneficial but also holds promise in providing long-term advantages for enhancing patients' overall well-being. Therefore, this study aims to comprehensively investigate the combined effects of proprioceptive, kinesthetic, and calisthenic exercises, alongside core stabilization exercises, in alleviating chronic low back pain and their potential to enhance range of motion and diminish functional disability in individuals with CLBP in Lahore, Pakistan.

The research will adopt a Randomized Controlled Trial design. Upon approval of the synopsis, ethical clearance would be taken, and necessary permissions from Riphah Rehab Training and Research Centre, Lahore, and the Physiotherapy Department of the National Hospital, Lahore. The study duration will span 4 weeks, involving a sample size of 38 participants, with 19 individuals allocated to both the control and intervention groups. Data collection will utilize a structured proforma, following the acquisition of participants' consent and permissions from the respective study settings. In Group A (control), participants will undergo core stabilization exercises and heat therapy. Group B (intervention) will engage in proprioceptive, calisthenic, and kinesthetic exercises, coupled with core stabilization exercises and heat therapy. The sampling technique employed will be a non-probability sampling method. The tools for outcome measurement will include the Numeric Pain Rating Scale (NPRS) for pain assessment, an inclinometer to measure lumbar Range of Motion (ROM), and the Modified Oswestry Disability Index (Urdu Version) for evaluating disability. Randomization will be performed using computer-generated software. The study design will be single-blinded, with the assessor kept uninformed. Pretest data will be gathered at 0 weeks, with posttest data collected at 4 weeks. For intergroup analysis, if the data follows a normal distribution, the parametric Independent t-test will be utilized, enabling the calculation of mean, standard deviation, and p-values. Alternatively, if the data does not display a normal distribution, the non-parametric Mann-Whitney test will be employed, allowing the calculation of median, interquartile ranges, and p-values.

Chronic low back pain (CLBP) is a debilitating musculoskeletal condition primarily involving the lumbar spine, sacrum, and the surrounding soft tissue structures often resulting in the potential for pain radiating to the lower extremities (1) (2). It is characterized by prolonged pain lasting more than 12 weeks, impacting around 20% of the worldwide population (3, 4) (5). CLBP significantly impacts the quality of life affecting activities fundamental to daily living (6). Low back pain (LBP) seems to influence approximately 60% to 80% of adults in their lifespan, and almost 10% of these individuals eventually progress towards CLBP (7). The precise underlying cause of CLBP remains unknown in nearly 85% of cases. However, sedentary living habits, reduced muscle strength, poor neuromuscular control of deep trunk muscles, and proprioception are considered some of the risk factors for CLBP, contributing to strain of the lumbar spine, and leading to functional limitations. (7) (8) (9).

The patient's motivation and active participation are of utmost importance for the exercise rehabilitation program, decreasing pain and improving functional activities (2) (10). Commonly adopted exercises like extension and flexion-focused routines as well as other conservative management including spinal manipulative therapy, pain neuroscience education (PNE) and acupuncture alleviate pain and disability related to LBP (10) (4). However, the outcomes are limited and may not target the central issue of impaired lumbar joint sense, a significant factor in LBP (10) (4).

Core stabilizing exercises are a standard treatment method for CLBP (10) (8). The exercises involve combined activation and conditioning of the pelvic floor and deep core muscles, attaching to the thoracolumbar fascia (8) (10) (11). This connection results in reinforcing the lumbar spine, increasing stability and neuromuscular control through elevated abdominal pressure, and reducing stress on the lumbar vertebrae (10) (8) (11). These core stabilizing exercises also help in decreasing pain and stability, further optimizing proprioception, postural alignment, and stability in patients with LBP (9) (12). The outcome of one of the studies conducted by O'Sullivan on patients with CLBP showed that the pain intensity decreased and functional disability improved in patients in receipt of Transverse Abdominis and Multifidus muscle training for 10 weeks (3).

Proprioception refers to the body's remarkable ability to perceive and sense joint and body movements, commonly known as kinesthetic, while also perceiving the position of the body or its segments within space (13) (14). This ability contributes significantly to muscle awareness and posture, as it involves accumulating information from the surrounding environment and relaying it to the central nervous system (15) (14) (16). Reduction in proprioception can cause neuromuscular dysfunction, leading to tense, imbalanced muscular activation and compromised postural alignment (17). Consequently, prioritizing the maintenance of proprioception and improving neuromuscular function becomes crucial for engaging in daily activities without experiencing LBP (16) (14). Exercises targeting proprioception would comprise balance training, incorporating other components of balance such as the vestibular system, base of support, and center of gravity, which stimulates sensory receptors, increasing the perception of joint position and movement (16) (14). Kinesthetic exercises are essential in motor control and prediction of proprioceptive responses (18) (19). Calisthenic exercises are a series of repetitive movements that create numerous muscle contractions that can be isotonic or isometric. These type of exercises utilizes the body's weight to enhance muscular strength, endurance, flexibility, proprioception, balance, and coordination, deemed superior when compared to other exercise programs.

Chronic low back pain stands as a prevalent musculoskeletal condition worldwide, leading to significant functional limitations and disability. This presents a complex issue within both healthcare infrastructures and socioeconomic frameworks, necessitating focused attention and effective solutions. While alternative treatment methods exist, ongoing research in this area would facilitate the development of additional solutions for managing low back pain, enhancing the patient's plan of care. A diverse range of interventions prove beneficial, ultimately offering long-term advantages for patients' well-being.

Eligibility Criteria:
Inclusion Criteria:

* Minimum 3 months or above LBP
* Moderate pain (NPRS: 3-7)
* Disability score of 19% or greater as evident from the modified Oswestry Disability Questionnaire (MODQ)

Exclusion Criteria:

* History of inflammatory joint diseases e.g. rheumatoid arthritis, gouty arthritis, psoriatic arthritis, and ankylosing spondylitis
* History of neurological deficit e.g. paresthesia, sensory loss, radiculopathy, myelopathy
* History of surgery related to spine, lower extremities, metal implants on lower extremities
* History of any mental illness
* Subjects on medication e.g. antidepressants, corticosteroids, and anti-inflammatory medications
* Other conditions include peripheral vascular diseases, recent fractures including lower limb or spine, osteoporosis, spine or other joint deformities, brain injuries, neuromuscular disorders, and respiratory diseases
* Pregnancy