Effectiveness of Perturbation Training in Nonspecific Low Back Pain

Study Overview
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Brief Summary
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Nonspecific low back pain is defined as low back pain that cannot be associated with a specific identified pathology. Many methods such as patient education, medical treatment, physical modalities, exercise, manual therapy, massage, traction and cognitive behavioral therapy are used in the treatment of nonspecific low back pain. Spinal stabilization exercises, which are among the therapeutic exercises, aim to improve and improve muscle control to compensate for any loss of muscle movement caused by degenerative changes or injury. Perturbation training, which is among the neuromuscular exercises, is an intervention that aims to improve the control of rapid balance reactions and involves repetitive postural distortions. In perturbation training, the surface is moved in multiple directions with different forces and moments. The aim of this exercise is to develop the stabilization response that will be created by stresses applied from different directions. It is believed that the number of motor units participating in contraction and proprioceptive input will increase with perturbation exercise. Although the number of studies on low back pain is quite limited, it has been stated that applications that provide perturbation can reduce the incidence of low back pain and provide improvement in neuromuscular control of spinal stability. In the light of these data, in our study, we aimed to investigate the effects of perturbation training in addition to the exercise program on pain, disability, trunk muscle endurance, functionality, fear avoidance beliefs and quality of life parameters in people with nonspecific low back pain.

Detailed Description
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Nonspecific low back pain is defined as low back pain that cannot be associated with a specific identified pathology. Many methods such as patient education, medical treatment, physical modalities, exercise, manual therapy, massage, traction and cognitive behavioral therapy are used in the treatment of nonspecific low back pain. In current guidelines, it has been reported that patient education and therapeutic exercises are treatment methods with a high level of evidence. Spinal stabilization exercises, which are among the therapeutic exercises, aim to improve and improve muscle control to compensate for any loss of muscle movement caused by degenerative changes or injury. With stabilization exercises, deep muscles are activated while excessive activity of superficial muscles is reduced. Thus, correcting muscle abnormalities and ensuring the correct function of the muscles supports the spine. Perturbation training, which is among the neuromuscular exercises, is an intervention that aims to improve the control of rapid balance reactions and involves repetitive postural distortions. In perturbation training, the surface is moved in multiple directions with different forces and moments. The aim of this exercise is to develop the stabilization response that will be created by stresses applied from different directions. It is believed that the number of motor units participating in contraction and proprioceptive input will increase with perturbation exercise. Previous studies have shown that the effects of perturbation training were mostly investigated in geriatric and neurological patient groups. However, current studies show that perturbation training is also applied to some orthopedic problems such as anterior cruciate ligament injury, shoulder pain, ankle instability and makes positive contributions to the healing process. Although the number of studies on low back pain is quite limited, it has been stated that applications that provide perturbation can reduce the incidence of low back pain and provide improvement in neuromuscular control of spinal stability. In the light of these data, in our study, we aimed to investigate the effects of perturbation training in addition to the exercise program on pain, disability, trunk muscle endurance, functionality, fear avoidance beliefs and quality of life parameters in people with nonspecific low back pain.

Official Title
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Effectiveness of Perturbation Training in Nonspecific Low Back Pain

Conditions
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Low Back Pain

Intervention / Treatment
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* Other: Perturbation training
* Other: Exercise


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Nonspecific low back pain persisting for at least 3 months Pain intensity at least 3 on VAS Ability to perceive verbal and written Turkish instructions Having signed the voluntary consent form Exclusion Criteria: History of spinal surgery/trauma Low back cpain associated with other pathologies (Rheumatic diseases, malignancy, MS) Having herniation at the level of sequestration and extrusion Instability conditions such as spondylolysis and spondylolisthesis Use of painkillers and antidepressants Pregnancy Obesity (BMI≥30kg/m²) Orthopedic problems and chronic diseases that may prevent exercises FTR/steroid injection application within the last 3 months

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 50 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Perturbation Group<br>Exercise program with progressive perturbation conditions | Other: Perturbation training<br>* The exercise program will be applied 2 days/week for 8 weeks, with the addition of progressive perturbation conditions.<br>|
| Active Comparator: Exercise Group<br>Exercise program | Other: Exercise<br>* The exercise program will be applied 2 days/week for 8 weeks.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Trunk extensor endurance test | Individuals are asked to hang their trunks from the bed starting from the spina iliaca anterior superior and cross both arms on the shoulders. The legs are fixed by the practitioner over the gastrocnemius muscle. The test is started when the individuals maintain the horizontal position and the time they maintain the position is recorded in seconds. | At baseline and after 8 weeks of intervention | 
| Trunk flexor endurance test | The participant is positioned by the tester with the knees and hips at 90 degrees, the body at 60 degrees, the hands in a crossed position on both shoulders, and the soles of the feet firmly on the ground. The time this position can be maintained is recorded in seconds. | At baseline and after 8 weeks of intervention | 
| Bilater side bridge endurance test | For the left lateral plank test, the participants' feet are placed on top of each other, the right arm is perpendicular to the ground, the elbow is on the mat, the left arm is at chest level, and the left hand is on the right shoulder. When the individual is ready, he is asked to lift his hips with support from his elbows and feet. As soon as the test position is taken in which the shoulders, hips and feet are in the same direction, the time is started by the researcher. The period ends when the individual cannot maintain the position and body swings forward and backward. | At baseline and after 8 weeks of intervention | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pain intensity | The pain felt by the participants at rest, during activity and at night will be questioned with the 0-10 cm Visual Analogue Scale (VAS). On VAS, 0 means no pain and 10 means worst pain ever felt. | At baseline and after 8 weeks of intervention | 
| Disability | The disability levels of the participants will be evaluated with the 'Oswestry Disability Index (ODS)'. The survey contains 10 questions on 10 topics with 6 options. The increase in the total score is proportional to the increase in activity limitation. | At baseline and after 8 weeks of intervention | 
| Timed Up and Go Test | The 3-meter area in front of the chair is determined. The patient is asked to get up from the chair, walk this distance and sit down again. The elapsed time gives the result of the test and the time is recorded in seconds. The test is performed twice with a 1-minute interval and the average time is taken. | At baseline and after 8 weeks of intervention | 
| Fear Avoidance Beliefs Questionnaire | The first part of the survey, which consists of 16 questions and 2 parts, includes physical activity and the second part includes beliefs about work. | At baseline and after 8 weeks of intervention | 
| Health-related quality-of-life | Individuals' health-related quality of life will be evaluated with Short Form-12/SF-12. With SF-12, two subscores are obtained: physical component summary (PBS) and mental component summary (MBS). While the FBÖ-12 score is obtained from the sub-dimensions of general health, physical functionality, physical role and body pain, the MBÖ-12 score is obtained from the social functionality, emotional role, mental health and energy sub-dimensions. Both FBÖ-12 and MBÖ-12 scores range from 0 to 100, with a higher score representing better health. | At baseline and after 8 weeks of intervention | 
| Patient Satisfaction | Patient satisfaction with the treatment will be evaluated with the Global Rating of Change scale. Participants will be asked to rate their condition compared to baseline after an 8-week intervention period, indicating whether they had significantly improved, slightly improved, remained unchanged, slightly deteriorated, or significantly worsened in this study. | After 8 weeks of intervention | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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low back pain, nonspecific low back pain