Overall Clinical Bottom Line: After a thorough examination of ten articles, we conclude that the addition of spinal stabilization exercises (SSEs) to a conventional physical therapy program (modalities, traction, manual therapy, and general exercises to increase strength and range of motion) clinically improved pain and function in patients with clinical sacroiliac/lumbar spinal instability (CSI). SSEs did not provide additional, clinically significant, reduction in pain or disability versus conventional physical therapy in patients without evidence of CSI. The majority of the population with general low back pain (LBP) and sacroiliac joint (SIJ) pain may not present with radiological evidence of CSI. We can use the clinical prediction rule proposed by Hicks et al., 2005 to assist in identifying patients that may have CSI and will likely benefit from SSEs more than with conventional physical therapy alone. Because the costs of SSEs were minimal, and there was no documented harm caused by the exercises in any of the ten articles, our clinical decision is to include a SSE program in addition to conventional physical therapy in treating patients with insidious onset lumbar and/or sacroiliac pain with CSI.
Clinical Scenario: There are various physical therapy treatments for patients with LBP and SI dysfunction including: modalities, manual therapy, and therapeutic exercise. The term “therapeutic exercise” encompasses a broad range of exercises aimed at gaining range of motion, centralizing symptoms, and increasing strength and stability. It remains a general term used to describe multiple interventions. General abdominal strengthening has commonly been used to treat and prevent episodes of LBP. In recent years, specific stabilization exercises (SSEs) have been proposed as intervention for treating patients with LBP and SIJ dysfunction. These exercises involve isometric contraction of the transverse abdominis (TvA) and multifidii musculature in low load positions with progression to functional movements. For many patients, the ability to voluntarily isolate and contract TvA and multifidus is more difficult than general abdominal contractions and learning and performing SSEs can be a frustrating process. While in vitro studies have provided the biomechanical basis for prescribing SSEs, we are interested in their clinical efficacy to reduce pain and restore function. Clinical Question: Are spinal stabilization exercises more effective in decreasing pain and disability compared to conventional physical therapy alone in patients with nonspecific, insidious onset low back and sacroiliac pain?
Clinical PICO: Population: Male and female adults with nonspecific, idiopathic low back or sacroiliac pain of insidious onset Intervention: Specific spinal stabilization exercises in addition to conventional physical therapy Comparison: Conventional physical therapy Outcomes: Disability (reported by Oswestry Disability Questionnaire, Roland Morris Disability Questionnaire, patient-specific measures using 11-point numeric rating scale (NRS-11)) and pain (reported by NRS-11 or Visual Analog Scale)
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