Mannion Sprott
Fakultäten » Medizinische Fakultät » Rheumaklinik und Institut für physikalische Medizin » PD Dr. Anne Mannion » Mannion Sprott
Completed research project
| Title / Titel | Chronic low back pain and spine stabilisation exercises. | ||||
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| Abstract (PDF, 14 KB) | |||||
| Summary / Zusammenfassung | Summary of results Background Exercise therapy is one of the few evidence-based treatments for non-specific cLBP, although it does not elicit a positive response in all patients. The reasons for the widely varying individual responses are not known, although many believe that it is the result of an inappropriate, “one-sizefits-all” approach to treatment; it is argued that, instead, specific types of exercise should be prescribed for specific patients, determined on the basis of their individual LBP history, signs, symptoms, and functional disturbances. Nonetheless, identifying “the right treatment for the right patient” is far from easy. Dysfunction in the activation of the deep-lying trunk muscles, measured using intramuscular electromyography (EMG), is one disturbance that has been observed in connection with LBP; it is believed to pose a threat to segmental stability and hence predispose to continuing/future episodes of pain. As such, "spine stabilisation exercises", aimed at restoring deep trunk muscle motor control, have become a popular concept in physiotherapy. However, there are still many “unknowns” in relation to both the extent and nature of the proposed dysfunction and the mechanism of action of the specific exercise treatment. Since intramuscular EMG is invasive, a prerequisite for the in depth investigation of these phenomena is the availability of a reliable, accurate and sensitive means for assessing deep trunk muscle function. The objectives of our study were to develop such a method, based on M-mode ultrasound and tissue velocity information from tissue Doppler imaging (TDI), and use it to examine the trunk muscle function of patients with cLBP compared with healthy controls and compared with themselves after a physiotherapy programme of spine stabilisation exercises. Methods Development and validity of the non-invasive ultrasound method. Fourteen healthy subjects made rapid arm movements, in standing, in response to a visual signal indicating the required movement direction. Recordings were made of medial deltoid (MD) surface EMG, and of fine-wire intramuscular EMG and TDI tissue-velocity changes of the contralateral transversus abdominis (TrA), obliquus internus (OI) and obliquus externus (OE) (=the lateral abdominal muscles). Muscle onsets of activity were determined by blinded visual analysis of EMG and TDI data. TDI could not distinguish between the relative activation of the three muscles, so in subsequent analyses only the onset of the earliest abdominal muscle activity was used. The latter occurred <50ms after the onset of medial deltoid EMG (i.e. was feedforward) and correlated significantly with the corresponding EMG-onsets (r=0.47, p<0.0001). The mean difference between methods was 20ms, and was likely explained by electromechanical delay; limits of agreement were wide (-40 to +80ms) but no greater than those typical of repeated measurements using either technique. TDI yielded reliable and valid measures of the earliest onset of feedforward activity within the lateral abdominal muscle group. Main results Evaluation of lateral abdominal muscle function in cLBP . In 50 patients with cLBP and 50 matched, pain-free controls, the ability to preferentially activate and increase the thickness of the TrA during an “abdominal hollowing” exercise was examined using M-mode ultrasound; the feedforward activity of the lateral abdominal muscle group during rapid arm movements was also assessed, using the new TDI technique. Patients self-rated their pain and disability in everyday activities. In both groups, feed-forward activity of the lateral abdominal muscles (<50 ms after MD activation) was recorded during arm movements in all directions. There was a tendency for the onset of the earliest abdominal muscle activity to be slightly earlier in the cLBP group than in the control group, reaching significance for left arm movements (p=0.015). There was no significant relationship between the muscle onsets (mean over all directions and sides) and pain or self-rated disability. The mean TrA contraction ratio (i.e., thickness of the muscle during contraction divided by the thickness at rest) during abdominal hollowing was significantly lower in the cLBP patients than in the controls (p=0.02), although the difference was not great (1.35 ± 0.14 vs 1.44 ± 0.23 respectively). The TrA contraction ratio showed a low but significant negative correlation with selfrated disability (Roland Morris (RM) score) (r=-0.40, p=0.004), i.e., higher disability was associated with a lesser ability to activate the TrA. Effect of a programme of spine stabilization exercises on lateral abdominal muscle function, pain and disability in patients with cLBP. 32/37 (86%) patients completed a 9-week physiotherapy programme of spine stabilization exercises (PT-SS). The RM disability score showed a moderate, significant decrease after treatment (from 8.9 ± 4.7 to 6.7 ± 4.3), as did average pain intensity (from 4.7 ± 1.7 to 3.5 ± 2.3) (each p<0.01). The mean TrA contraction ratio increased significantly from 1.34 ± 0.12 to 1.41 ± 0.17 (p=0.04) and improvements were seen in various functional tests simulating everyday activities (p<0.05). However, on an individual level the functional changes bore little relationship to the corresponding changes in pain or disability. There was no significant response to therapy in the onset of the earliest lateral abdominal muscle activity during rapid arm movements (p=0.53). Implications and practice In contrast to popular belief in physiotherapy practice, the voluntary activation of the TrA has only a minor role, and the anticipatory (feedforward) activity of the lateral abdominal muscles appears to have no role in cLBP, as far as distinguishing between patients and controls, correlating with self-rated pain and disability, responding to specific exercise therapy, and explaining treatment effects are concerned. There is evidence from RCTs for the effectiveness of spine stabiliation exercises as a treatment for cLBP (regardless of their mechanism of action), and our studies hence provide no grounds to discourage their continued use. However, the underlying physiological rationale certainly requires further investigation. The M-mode ultrasound TDI tool developed in the present study could be used to further investigate the phenomenon in large groups of cLBP patients undergoing treatment. |
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| Publications / Publikationen | 1) Mannion AF, Pulkovski N, Gubler D, Gorelick M, O'Riordan D, Loupas T, Schenk P, Gerber H, Sprott H (2008) Muscle thickness changes during abdominal hollowing: an assessment of between-day measurement error in controls and patients with chronic low back pain. Eur Spine J. 17(4):494-501.2) Mannion AF, Pulkovski N, Schenk P, Hodges PW, Gerber H, Loupas T, Gorelick M, Sprott H (2008) A new method for the non-invasive determination of abdominal muscle feedforward activity based on tissue velocity information from tissue Doppler imaging. J Appl Physiol. 104(4):1192-2013) Pulkovski N, Schenk P, Maffiuletti N, Mannion AF (2008) Tissue Doppler imaging for detecting onset of muscle activity. Muscle Nerve. 37(5):638-494) Mannion AF, Pulkovski N, Toma V, Sprott H (2008) Abdominal muscle size and symmetry at rest and during abdominal hollowing exercises in healthy control subjects. J Anat. 213 (2): 173-1825) Mannion AF, Pulkovski N, Helbling D, Sprott H (2008) The influence of adherence with therapy on clinical outcome after a spine stabilisation exercise program in patients with chronic non-specific low back pain. International Society for the Study of the Lumbar Spine (Spine Week), Geneva, Switzerland, 26.5.08-31.5.086) Mannion AF, Pulkovski N, Schenk P, Hodges PW, Gerber H, Gorelick M, Sprott H (2008) “Direction-dependent” feed-forward activation of transversus abdominis during rapid arm movements challenges its unique role in spine stabilisation. International Society for the Study of the Lumbar Spine (Spine Week), Geneva, Switzerland, 26.5.08-31.5.087) Sprott H, Pulkovski N, Toma V, Mannion AF. (2008) Abdominal muscle size and symmetry at rest and during abdominal hollowing exercises in healthy control subjects. International Association for the Study of Pain, 12th World Congress on Pain, Glasgow, UK, 17-22.8.2008.8) Mannion AF, Helbling D, Pulkovski N, Sprott H (2009) Spinal segmental stabilisation exercises for chronic low back pain: programme adherence and its influence on clinical outcome.Eur Spine J. 18(12):1881-919) Meyer K, Tschopp A, Sprott H, Mannion AF (2009) The association between catastrophizing and self-rated pain and disability in patients with chronic low back pain. J Rehab Med 41(8):620-510) Mannion AF, Caporaso F, Pulkovski N, Sprott H (2010) Goal attainment scaling as a measure of treatment success after physiotherapy for chronic low back pain. Rheumatology (Oxford). 2010 Sep;49(9):1734-8.11) Gubler D, Mannion AF, Schenk P, Gorelick M, Helbling D, Gerber H, Toma V, Sprott H. Ultrasound Tissue Doppler Imaging Reveals No Delay in Abdominal Muscle Feed-Forward Activity During Rapid Arm Movements in Patients With Chronic Low Back Pain. Spine 2010 Jul 15;35(16):1506-1312) Mannion AF, Pulkovski N, Caporaso F and Sprott H. Are changes in pain and disability after a programme of "spine stabilisation exercises" contingent upon improvements in the voluntary activation of transversus abdominis? International Society for the Study of the Lumbar Spine, Auckland, New Zealand, 14-17.04.201013) Pulkovski N, Mannion AF, Caporaso F and Sprott H. Transversus abdominis contraction ratio during abdominal hollowing: a valid tool to identify patients with chronic low back pain? International Society for the Study of the Lumbar Spine, Auckland, New Zealand, 14-17.04.201014) Pulkovski N, Mannion AF, Caporaso F, Toma V, Gubler D, Helbling D, Sprott H.Ultrasound assessment of transversus abdominis muscle contraction ratio during abdominal hollowing: a useful tool to distinguish between patients with chronic low back pain and healthy controls? Eur Spine J. 2011 Mar 31. [Epub ahead of print] | ||||
| Project leadership and contacts / Projektleitung und Kontakte |
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| Funding source(s) / Unterstützt durch |
SNF (Programm NFP) NFP53, grant for implementation of findings of study 405340-104787 |
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| Duration of Project / Projektdauer | Dec 2008 to Dec 2011 |