PT Critically Appraised Topics
 

Document Type

Critically Appraised Topic

Publication Date

2011

Clinical Scenario

At this facility, I have seen several patients with chronic LBP who have a core stabilization exercise program incorporated into their rehabilitation program. There are two physical therapists at the clinic, and one tends to start with segmental or local stabilization exercises involving learning to fire the deep core stabilizer muscles such as transversus abdominis (TA) and multifidus before progressing to global core stabilization. The other therapist usually goes straight to incorporating a global stabilization exercise program involving kinetic chains and muscular slings, and works on the larger core stabilizer muscles such as rectus abdominis, internal and external obliques, and erector spinae. I would like to know if there is a difference in outcomes between starting with segmental stabilization, or going straight to global stabilization without first teaching segmental stabilization for patients with chronic LBP not due to instability. Other interventions in a typical session include joint mobilizations and lower extremity strengthening exercises especially of the hip musculature.

Clinical Question

Is segmental stabilization more effective in reducing long term pain and improving long term functional outcomes than global stabilization for patients with chronic LBP?

Clinical Bottom Line

Based on the results of the studies by Koumantakis et. al (2005) and Cairns et. al (2006), general exercise including global core stabilization with or without the addition of specific segmental core stabilization were both effective in decreasing pain as measured by the VAS and improving overall function as measured by the RMDQ in the long term (3 to 12 months after discharge). However, there is no statistical significance in results to show that one treatment is any more effective than the other in improving long term function and pain. This suggests that there is no added long term benefit to using segmental spinal stabilization exercises for patients with nonspecific chronic LBP. The main threats to internal validity in both studies are the lack of blinding of therapists and subjects, a large study loss of 30%, differences in VAS B scores (pain over last week) at baseline in the study by Koumantakis et. al (2005) and the lack of detailed protocol for general exercises in the conventional PT group in the study by Cairns et. al (2006). The first and last threats are minor, and the other two are moderate but were accounted for in the statistics with an intention to treat analysis and an ANCOVA. The main cost is time and financial cost of treatment, but the treatment is within reason to be covered by insurance. The results from both studies show that the addition of specific core stabilization exercises is not any more effective than conventional PT and general exercise including global core stabilization, but both are effective treatments in reducing pain and improving function. Thus, I would recommend that the clinician use discretion in determining whether to include specific segmental core stabilization in addition to conventional treatment including global core stabilization for patients with nonspecific chronic LBP on a case by case basis.

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