Not Just Strength but Also Neuromuscular Exercise and Counseling Decreases Low Back Pain.

Neuromuscular exercise and counseling decrease absenteeism due to low back pain in young conscripts: a randomized, population-based primary prevention study.   Spine (Phila Pa 1976). 2013 Mar 1;38(5):375-84.   Suni JH, Taanila H, Mattila VM, Ohrankämmen O, Vuorinen P, Pihlajamäki H, Parkkari J.

 

Abstract
STUDY DESIGN:
Controlled intervention with group randomization.
OBJECTIVE:
To investigate the effectiveness of a 6-month neuromuscular exercise and counseling program for reducing the incidence of low back pain (LBP) and disability in young conscripts, with a healthy back at the beginning of their compulsory military service.
SUMMARY OF BACKGROUND DATA:
Basic military training is physically demanding on the back and requires adequate physical fitness. LBP causes significant morbidity and absence from military service.
METHODS:
Participants were conscripts of 4 successive age cohorts (n = 1409). In the prestudy year, before adoption of the intervention, 2 successive cohorts of conscripts of 4 companies (n = 719) were followed prospectively for 6 months to study the baseline incidence of different categories of LBP. In the intervention year, conscripts (n = 690) of 2 new cohorts of the same companies (intervention group: antitank, engineer;control group: signal, mortar) were followed for 6 months. The intervention program aimed to improve conscripts’ control of their lumbar neutral zoneand specifically to avoid full lumbar flexion in all daily tasks.
RESULTS:
Total number and incidence of off-duty days due to LBP were significantly decreased in the intervention companies compared with controls (adjusted hazard ratio = 0.42, 95% confidence interval = 0.18-0.94, P = 0.035). The number of LBP cases, number of health clinic visits due to LBP, and number of the most severe cases showed a similar decreasing trend but without statistical significance.
CONCLUSION:
These findings provide evidence that exercise and education to improve control of the lumbar neutral zone have a prophylactic effect on LPB-related off-duty service days in the military environment when implemented as part of military service among young healthy men.

My comments:

This is a really good paper. Generally when you read a paper regarding spine stabilization and motor control exercises it describes patients performing abdominal hollowing and trying to isolate their transverse abdominus muscles and multifidus, which is a concept that has been disproven but is still pervasive in some physical therapy practices and still persists as a goal even in newer published research. This study, however, gets it right by teaching exercises directed at increasing core and LE endurance while maintaining a neutral spine, combined with counseling on the importance of doing the same during both static and dynamic activities. The exercises were all reasonably light, so I would not expect them to increase strength much in the subject population but would expect them to primarily improve motor control and awareness and ability to maintain a neutral spine during activities. The result was a 58% decrease in off duty days due to low back pain. Full text with a number of photos of slides of the intervention is available here.

Worth talking about is that this study decreased pain by a different mechanism than some other research I have discussed where the researchers focused almost solely on increasing strength, which also worked to some degree.  The combination of the two approaches, in addition to using EMS rather than TENS of the core musculature, goes a long way towards explaining the success of my own physical therapy program for low back pain.  Over the years I started with the strength approach with reasonably good results. Later, I learned about and integrated more motor learning with education regarding a neutral spine and postural awareness, which improved my outcomes significantly. Later still with the addition of the EMS, the more long-term benefits of exercise and counseling came with substantially shorter-term relief.  The best part is that it all works together with each component helping the others.  Strength from exercise and EMS makes maintaining a neutral spine easier; maintaining a neutral spine, EMS, and increased strength itself decrease pain making the patient better able to tolerate strengthening exercise.  Yin and Yang I guess, and there is always more to learn.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

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