Non-specific low back pain (NSLBP) is a major cause of long-term sickness and has estimated costs of £624 million per annum for UK employers and £1 billion for health services (Department of Health, 2000; Maniadakis & Gray, 2000; Savigny et.al., 2009). Stabilisation exercises (also known as core stability exercises) are thought to be effective at reducing pain and disability and are a popular treatment choice for back pain in the UK.
This treatment is defined as facilitation of deep muscles of the spine (primarily transverses abdominus or multifidus) at a low level, integrated into exercise and progressing into functional activity. I was keen to explore this further and found this systematic review whose objective was to evaluate the current evidence for the benefit of stabilisation exercises for low back pain.
Here’s what they did
A recent systematic review concluded that stabilisation exercises may be beneficial compared to no treatment but are unlikely to produce better outcomes than any type of exercise. This review was updated searching PubMed, CINAHL, AMED, Pedro and The Cochrane Library between 2006 to 2013 and produced an additional 19 (from a potential 2,076) further relevant articles. Methodological quality was evaluated using the PEDro scale and the review followed PRISMA recommendations.
Here’s what they found
Twenty nine studies were included in analysis (10 from previous review).
Twenty two studies (n = 2,258) reported the post treatment effect of stabilisation exercises on pain. Although there was significant benefit of stabilisation exercises for low back pain in the short (-7.93 (95% CI -11.74 to -4.12), medium (-6.10 (95% CI -10.54 to – 1.65)) and long term (-6.39 (95% CI -10.14 to -2.65)), when compared with any alternative treatments or control, the difference between groups was clinically insignificant.
Twenty four studies (n = 2,359) reported the post treatment effect of stabilisation exercises on disability. Although there is significant benefit of stabilisation exercises for low back pain in the short (-3.61 (95% -6.53 to -0.70) and long term (-3.92 (95% CI -7.25 to -0.59)) when compared to alternative treatments or control, there was no difference statistically or clinically.
The authors concluded
The overall results of the meta-analysis indicate a trend favouring this intervention, which is not regarded as clinically significant, when compared with any alternative treatment or control.
Given the low levels of heterogeneity and the large number of high methodological quality studies the authors were confident that further research is unlikely to alter their conclusion.
Тhe use of stabilisation exercises as a sole treatment choice for NSLBP has to be questioned
The Musculoskeletal Elf’s view
In 2013 Nijs et.al., challenged the role of core stability in NSLBP rehabilitation, suggesting it could encourage unhelpful beliefs on pain and movement.
In the 2008 review the majority of the studies favouring stabilisation exercises combined these with some other form of treatment, implying that the package of care was effective rather than stabilisation exercises alone.
In this updated review the majority of the studies used stabilisation exercises as sole treatment, which allowed analysis of this intervention in isolation. Five studies advocated one to one instruction where therapists dedicated between 6 to 10 hours per patient. With mounting pressures on the resources of time, capacity and funding, the use of stabilisation exercises as a sole treatment choice for NSLBP has to be questioned.
What do you think?
- When treating people with NSLBP do you instruct solely on core stability exercises? Are you surprised at the study findings?
- When treating people with NSLBP do you address core stability at all?
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Links
Smith, B. E., Littlewood, C., & May, S. (2014). An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC musculoskeletal disorders, 15(1), 416[Abstract]
Department of Health. (2000). The NHS plan: A plan for investment, a plan for reform.
Liddle, S. D., Baxter, G. D., & Gracey, J. H. (2009). Physiotherapists’ use of advice and exercise for the management of chronic low back pain: a national survey. Manual therapy, 14(2), 189-196 [Abstract]
Maniadakis, N., & Gray, A. (2000). The economic burden of back pain in the UK. Pain, 84(1), 95-103[Abstract]
Nijs, J., Roussel, N., van Wilgen, C. P., Köke, A., & Smeets, R. (2013). Thinking beyond muscles and joints: therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Manual therapy, 18(2), 96-102 [Abstract]
Savigny, P., Watson, P., & Underwood, M. (2009). Early management of persistent non-specific low back pain: summary of NICE guidance. BMJ, 338.
Stabilisation exercises for low back pain http://t.co/ixrQXrNu47
Stabilisation exercises for low back pain – The Musculoskeletal Elf http://t.co/Oz2CmtwcKW
I do not see any perspective from the patient, ie how well are the interventions acceptd, how much support does the patient continue in their own care between physio intervention. Can you divide those patients who are motivated to follow instructions etc. and those who do not?
Hi Ethne. I would suggest that the very interesting question of motivation could be posed of any exercise/ self management strategy advised by physiotherapists. This was not, however, what the review was investigating. Many of the papers advocated a prescribed home program
Very interesting findings and, as with most physiotherapy interventions, it is seldom only one modality which has an impact, rather a package including education, advice, exercise prescription etc and this seems to back this up. There are so many variables including psychological impact, motivation and rapport and belief in the physiotherapist and the physiotherapist’s level of experience and expertise that it is difficult to isolate results to a single intervention, regardless of what that intervention is.
This is a great summary of evidence for the physiotherapy lead Pilates classes that we run in Edinburgh (although the classes don’t focus only on core stability but breathing, stretches, functional movement ect as well). Pilates based classes are a more realistic form of management rather than the 1:1 physio sessions, however only if the person enjoys attended a class with that style of exercise.