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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 699–707 DOI 10.3233/BMR-140572 IOS Press

Efficacy of core muscle strengthening exercise in chronic low back pain patients Tarun Kumara , Suraj Kumarb,∗ , Md. Nezamuddinc and V.P. Sharmad a

Department of Physiotherapy, NIOH, Kolkata, India Department of Physiotherapy, Paramedical Vigyan Mahavidyalaya, UPRIMS&R, Saifai, Etawah, Uttar Pradesh, India c Department of Physiotherapy, NIOH, Kolkata, India d Department of PMR, CSM Medical University, Lucknow, India b

Abstract. BACKGROUND AND OBJECTIVES: Low back pain is a common health problem in human being and about 5 to 15% will develop chronic low back pain (CLBP). The clinical findings of CLBP suggest that lumbar mobility is decreased and recruitment order of core muscles is altered. In literature, there is no data about the effect of core muscles strengthening in the chronicity (short duration, long duration) of CLBP. This study evaluated the effect of core muscle strengthening intervention on chronicity of chronic low back pain. METHOD: Thirty patients were recruited from the outpatient department of the National Institute for the Orthopaedically Handicapped. These 30 patients divided into two groups: A and B on the basis of duration of low back pain. Group-A patients complain about pain duration for more than twelve months and Group B complains about pain duration from three to twelve months. Both the groups were received same intervention for six weeks. Assessment was done pre intervention and post intervention after six weeks for both the groups. RESULTS: The result described both the groups showed improvement in all the outcome measures including pain as well as in function using Numerical pain rating scale, Oswestry Disability Index, Sorensen test, Gluteus Maximus Strength, Activation of transversus abdominis and Modified-Modified Schober’s Test. The improvement was statistically non-significant with inter groups and significant within group. CONCLUSION: This study concludes that core muscle strengthening exercise along with lumbar flexibility and gluteus maximus strengthening is an effective rehabilitation technique for all chronic low back pain patients irrespective of duration (less than one year and more than one year) of their pain. Keywords: Chronic low back pain, pressure biofeedback unit, core muscle strengthening, lumbar flexibility, Gluteus maximus strengthening

1. Introduction Low back pain (LBP) is a common health problem in all developed countries and is most commonly treated in primary healthcare setting. There is a lifetime prevalence of 35–40% for cervical pain, 11–15% ∗ Corresponding author: Suraj Kumar, Department of Physiotherapy, Uttar Pradesh Rural Institute of Medical Sciences and Research, Paramedical Vigyan Mahavidyalaya, Saifai, Etawah, UP – 206301, India. Tel.: +91 7830337168; E-mail: [email protected].

for thoracic pain 60–70% for lumbar pain, and 15% for pelvic pain [1,2] and the recurrence rate of low back pain is 80% [3]. It is estimated that 80–90% of patients recover within 6 weeks, regardless of treatment. However, 5–15% will develop chronic low back pain (CLBP) [4]. The “core” has been described as a muscular box with the abdominals in the front, paraspinals and gluteals in the back, the diaphragm as the roof, and the pelvic floor and hip girdle musculature as the bottom [5]. Bergmark [6] divided the trunk muscles into

c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00 

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T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients

two groups – a local and a global system of muscles engaged in the equilibrium of the lumbar spine. The local system consists of muscles with insertion or origin (or both) at lumbar vertebrae, whereas the global system consists of muscles with origin on the pelvis and insertions on the thoracic cage. The anatomical, biomechanical and physiological features muscles may be categorized into two groups, stabilizers and mobilizers. The structural and functional characteristics of the two muscle categories make the stabilizers better equipped for postural holding with an ‘anti-gravity’ function. The mobilizers are better set up for rapid ballistic movements and are often referred to as ‘task muscles’. In the case of the abdominal muscles, the rectus abdominis and lateral fibres of external oblique may be considered as the prime movers (mobilizers) of trunk flexion, and erector spinae is trunk extensor while the internal oblique, multifidus and transversusabdominis are the major stabilizers of trunk movement in general [7]. Further categorization may be made into primary and secondary stabilizers. The primary stabilizers are those muscles which cannot create significant joint movements, such as the lumbar multifidus (LM) and transversus abdominis (TrA). These muscles act only to stabilize the lumbar spine. The secondary stabilizers, such as the internal oblique, medial fibres of external oblique and quadratus lumborum have excellent stabilizing capacity, but may also move joints of spine. Taking this categorization further, mobilizers could be termed ‘tertiary stabilizers’ in that they primarily move the joint, but can stabilize in times of extreme need, an example being muscle spasm in the presence of pain. In this situation, however, stability has moved on to become rigidity and does not allow normal movement patterns [8]. The activity of the gluteus maximus muscle is reduced in patients with CLBP [9–12]. Chronic low back pain (CLBP) is a complex condition which is mainly associated with back (multifidus) [13–19], abdominal (transversusabdominis) [12, 16–19] and hip (gluteus maximus) [9–11] muscles dysfunction along with reduced lumbar flexibility [8]. Transversus abdominis directly attached to the thoracolumbar fascia (TLF), the weakness of this muscles decrease the shear strain of the TLF. The function of TLF is to increase the intra-abdominal pressure (IAP). Increase IAP may contribute to both unloading and stabilization of the lumbar spine [28] so that, in weakness of TrA the IAP decreases and lumbar spines becomes unstable and produced loading on lumbar spines. Thus core muscle stabilization training [4,14,16,19– 21,24,25,56] is recommended for treatment of CLBP.

Richardson et al [42] divided the core muscle strengthening in to three stages on the principles of ‘segmental stabilization exercises model’. This was on the basis of motor relearning principle, these exercises stages are first Local segmental control then Close chain segmental control and finally Open chain segmental control and progression into function. The purpose of study was to find out the effect of core muscle strengthening, lumbar flexibility and gluteus maximus strengthening in patients with chronic lowback pain using pain and function using Numerical pain rating scale, lumbar flexibility, Oswestry Disability Index, Sorensen test, Gluteus Maximus Strength, Activation of transversus abdominis and ModifiedModified Schober’s Test, between long duration CLBP (more than one year) and short duration CLBP (less than one year). We hypothesise that the shot duration CLBP group would improve faster than the long duration CLBP.

2. Methods 2.1. Subjects A total 30 patients of non-specific CLBP of both gender, were aged 20–40, with pain felt between T12 and inferior Gluteal fold with numerical pain rating scores between 3 to 6 and no neurological deficits were included from the National Institute for the Orthopaedically Handicapped (NIOH), B.T. Road, Bon-Hooghly, Kolkata, India. In this study, 30 patients were divided into two groups on the basis of duration of LBP. Patients in Group-A had pain for more than 12 months and in Group-B had pain between 3 and 12 months. Those subjects who had history of any lumbar spine surgery, infection, vascular problem, history of spinal exercises at least 12 weeks before the onset of study, receiving steroid injection within previous 3 months and pregnancy, non-mechanical LBP (no relief with bed rest), with systemic disorder and history of malignancy were excluded. They were also excluded if they had LBP less than three month. The study was approved by the Institutional Ethical committee (Review letter no.: IEC/1610/R&D/08/NIOH/458). Informed consent was obtained from all patients before included in the study. 2.2. Approach Using ‘stratified sampling’, two groups were formed on the basis of duration of pain. The outcome measures

T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients

were pain intensity, functional ability, back endurance, lumbar flexibility, TrA and Gluteus Maximus strength. The baseline data recorded on day 0 (zero) and follow up after 6 weeks. All of these were assessed by same test procedure. Test and retest of each group were conducted in the same place and at same time of the day. 2.3. Procedure All subjects were treated by the same physiotherapist with the same intensity and capacity on alternate (3 days/week) for 6 weeks. The duration of each individual treatment was depending on stages of treatment protocol. The treatment protocol included warm up, flexibility and core muscle strengthening exercises. Ten minute warm-up by bicycle or normal walk, flexibility exercises included knee to chest in supine, catcamel, trunk side flexion in standing, trunk rotation in crook lying. The exercises of core muscle strengthening in stage (1) comprised of local segmental control and activation of TrA with the help of pressure biofeedback. In stage (2) exercises included close chain segmental control, upper quadrant close chain exercise, trunk forward lean and weight bearing (closed chain) exercise in flexed posture. In stage (3), the regimen consisted of open chain segmental control, lower limb activity maintaining lumbar spine stable using PBU as feedback. Gluteus maximus strengthening first consisted of corrected recruitment order and then strengthening by single limb squat and single limb dead lift. The subjects were not allowed to take any other treatment and medication during the treatment. 2.4. Outcome variable The level of pain intensity was assessed by numerical pain rating scale (NPRS) that is a 10 points scale. The functional ability was assessed according to Oswestry Disability Index, back endurance by Sorensen test (trunk holding time), lumbar flexibility by Modified-Modified Schober’s test, Gluteus Maximus strength by Jamar Hydraulic Hand Dynamometer and activation of Transversus abdominis with pressure biofeedback unit. The measuring details of variables in brief are summarized as follows. 2.4.1. Numerical pain rating scale (NPRS) [32,33] This is the 10 point scale with 0 representing No Pain, 1–3 representing Mild Pain (nagging, annoying, interfering little with ADLs), 4–6 representing Mod-

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erate Pain (interferes significantly with ADLs), 7–10 representing Severe Pain (disabling; unable to perform ADLs). The subject’s been asked to make a mark and selected the number that best represents his/her intensity of pain experienced on the same day [57]. 2.4.2. Oswestry Disability Index [35] The Oswestry Disability Index (also known as the Oswestry Low Back Pain Disability Questionnaire) is an extremely important tool that researchers and disability evaluators use to measure a patient’s permanent functional disability. The test is considered the ‘gold standard’ of low back functional outcome tools. This scale contain question related to functional activities of pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life and travelling. For the understanding of ODI to the local population it translated into local language (Bengali). Interpretation of scale are 0% to 20% for minimal disability, 21% to 40% for moderate disability, 41 % to 60 % for severe disability 61% to 80 % for crippled and 81 % to 100 %. Bed-bound. 2.4.3. Sorensen test [36] Biering-Sorenson described this method of testing isometric back endurance; it measures how long (to a maximum of 240 seconds) the subject can keep the unsupported trunk (from the upper border of the iliac crest) horizontal while prone on an examination table. During the test, the buttocks and legs are fixed to the table by 3 wide canvas straps and the arms are folded across the chest. The subject is asked to maintain the horizontal position until he or she can no longer control the posture or has no more tolerance for the procedure or until symptoms of fatigue are reached. 2.4.4. Pressure biofeedback unit [37] The pressure biofeedback unit consists of an inelastic, three-section air-filled bag, which is inflated to fill the space between the target body area and a firm surface, and a pressure dial for monitoring the pressure in the bag for feedback on position The bag is inflated to an appropriate level for the purpose and the pressure recorded. Quite simply, movement of the body part off the bag results in a decrease in pressure, while movement of the body part onto the bag results in an increase in pressure. Pressure change uses as a diagnostic and therapeutic uses.

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T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients Table 1 Compare the Demographic data at base line

Age (Mean ± SD) Height (Mean ± SD) Weight (Mean ± SD) BMI (Mean ± SD)

Group-1

Group-2

30.47 ± 7.16 161.13 ± 10.18 62.80 ± 12.23 24.20 ± 3.85

33.2667 ± 5.30 164.47 ± 6.11 65 ± 7.121 24.00 ± 2.39

2.4.5. Modified-Modified Schober’s test [31] Modified-Modified Schober’s test to measures the flexibility of lumbar spine. Patient standing with cervical, thoracic and lumbar spine in 0 degrees of lateral flexion and rotation. Stabilize the pelvic to prevent anterior tilting. Ask the patient to bend forward as far as possible while keeping the knee straight. The therapist stands behind the patient and identifies the posterior superior iliac spines (PSISs) by marking the PSISs with his or her thumbs. Make an ink mark on the midline of the lumbar spines horizontal to the PSIS. Make another mark 15 cm superior just above the midline of the PSIS. Align the tape measure between the two skin marks, with zero at the inferior skin mark and 15 cm at the superior skin mark. Keep the tape measure firmly against the patient’s skin while the patient bends forward. When the patient has bent forward, the new distance between the superior and inferior skin markings is measured with the patient positioned in full lumbar flexion. Flexion range of motion is the difference between the initial length between skin markings (15 cm) and the length measured in full forward flexion. 2.4.6. Jamar Hydraulic Hand Dynamometer(JHHD) [30] The gluteus maximus strength was measured by using Jamar Hydraulic Hand dynamometer [12,30]. The readings were taken at baseline and at the end of intervention. Patient lie prone head on the hands, tested knee flexed to 90 degree and hip laterally rotated, placed the JHHD on femur at 10 cm from lateral joint line of knee. Measurement of maximum voluntarily isometric contraction of hip extension was taken. 2.4.7. Statistical analysis A pre-test post-test experimental group design was used for the study. The baseline values for all dependent variables of pain, lumbar flexibility, back endurance, contraction of TrA, strength of gluteus maximus and function outcome were taken on day 0 (designated as NPRS-0, MMS-0, SOR-0, PBU-0, JHHD-0 and ODI-0 respectively).The final readings were taken at the end of 6 weeks (designated as NPRS-1, MMS-1,

Independent t-test t P 1.201 0.240 1.087 0.286 0.602 0.552 0.171 0.866

Table 2 Shown the baseline reading (0 days) and post- test reading (6 weeks). Figure represent graphical presentation of improvement of each of six variables score in both groups S.NO NPRS PBU JHHD Rt. JHHD Lt MMS SORENSEN ODI

Group-1 Pre-5.67 ± 0.488 Post-0.47 ± 0.516 Pre-0.80 ± 1.012 Post-6.67 ± 0.967 Pre-25.60 ± 5.501 Post-27.47 ± 5.343 Pre-22.27 ± 5.007 Post-24.73 ± 5.007 Pre-4.73 ± 1.438 Post-7.80 ± 0.775 Pre-31.93 ± 12.686 Post-133.93 ± 18.234 Pre-54.20 ± 14.610 Post-6.80 ± 6.270

Group-2 Pre 5.67 ± 1.047 Post-1.047 ± 0.594 Pre 1.07 ± 1.077 Post-6.53 ± 1.187 Pre 24.60 ± 4.102 Post-27.67 ± 4.435 Pre 22.67 ± 3.904 Post-25.87 ± 4.533 Pre 5.33 ± 1.113 Post-7.93 ± 0.799 Pre 40.67 ± 24.394 Post-139.20 ± 19.943 Pre 51.47 ± 16.552 Post-8.13 ± 6.679

SOR-1, PBU-1, JHHD-1 and ODI-1).Statistical analysis IBM SPSS statistical 20, MS EXCEL and MS Office 97–2003 during the analysis of study. A two-tailed probability (P) value between 0.05 (P < 0.05) and 0.01 were considered statistically significant; P < 0.01 as highly significant and P > 0.05 had no significance (ns). Paired t test was applied for comparison of NPRS, MMS, SOR, PBU, JHHD and ODI within the groups (inter-group) and independent t-test between groups (intra-group). All dependent variables were compared between baseline and the value at end of 6 weeks. 3. Results 3.1. Distribution of subjects The values of Age, Height, Weight and BMI indicates that there was no statistically significant difference between Group A and B at baseline. The registered ‘p’ values of Age, Height, Weight and BMI was 0.240, 0.286, 0.552 and 0.866 respectively. These show that both groups were homogenous and the baselines were comparable (Table 1). 3.2. Outcome measures The pre and post outcome measures data were sum-

T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients 9

Post Value

Pre Value

8

6.67

7 5 5.67

6

7.93

7.8 6.53

5.67

5.33

4.7 73

5 4 3 2 1

1.047

0.47

0

NPRS Gp-1

1.07

0.8 PBU Gp--1

NPRS Gp-2

PBU Gp-2

MMS Gp-2

MMS Gp-1

Fig. 1. Graphical presentation of improvement of each of six variables score in both groups. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BMR-140572) 160

Prtee value

140

Posst value

139.2

133.93

120 100 80 54.2

60 40

25.66 27.47

24.6 27.67

22.2724.73

20

22.67 24.6

51.47

40.67

. 31.91

8.13

6.8

2 pIG 0D

IG p1 0D

-2 EN NS

RE SO

SO

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NS

ES

ES

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-1

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1 D

pD HH

HH

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Fig. 2. Graphical presentation of improvement of each of six variables score in both groups. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BMR-140572)

marised in Table 2 and also shown graphically in Figs 1 and 2. The ‘student t-test’ showed p < 0.05 for intra group (pre and post) in both groups; this p value showed it was significant. ‘Paired t-test’ showed p > 0.05 for inter groups (compare group-A to group-B); this p value showed non-significant results.

4. Discussion The goals of rehabilitation include restoring function, pain free full range of motion, and achieving full muscle strength and endurance. This paper discusses the rehabilitation of CLBP with the application of core muscle strengthening special focus on transversus abdominis and lumbar multifidus muscles. The aim of study was to find out the effect of core muscle strengthening, lumbar flexibility and gluteus maximus strengthening in patients with chronic low back pain using pain and function using numerical pain rating scale, lumber flexibility, Oswestry Disability Index, Sorensen test, Gluteus Maximus Strength, Activation of transversus abdominis and Modified-Modified

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Schober’s Test, between long duration CLBP and short duration CLBP. The limitation of our study includes very short follow-up, limited sample size and lack of measurement of lateral flexion, extension and rotation ROM of spine. However, patients were included on a very strict inclusion criteria and objective assessment of the outcome parameters. Franca et al. [20] showed the effect of segmental stabilization of core muscle on CLBP pain, which decreased 99% on visual analogue scale. They explained that the improvement could be due to the fact that this technique addressed two muscles (primary stabilizers) that get affected in low back pain. Hodges [22] and Morris et al. [40] concluded from their study that contraction of TrA develops Intra Abdominal Pressure (IAP) within the abdominal cavity by coordinated action of diaphragm, transversusabdominis and pelvic floor muscle that serves as a pressurized balloon attempting to separate the diaphragm and pelvic floor. This creates distraction of the lumbar spine that decreases the compressive load on it. Liebenson [39] stated that Multifidus is a primary inter-segmental stabilizer of the spine. It has a short reaction time due to its location near the centre of rotation of the vertebrae. Increased lordosis is a sign of a poor hip extension movement pattern. Decreased activation of the multifidus, especially Type-2 fibres atrophy [17,41] has been found in chronic LBP and was improved with stabilization training and restoration of function. Vogt et al. [11] concluded that Gluteus maximus producing stability to the SI Joint is provided by compression thus creating a self-bracing mechanism. There is very little movement at the SI joint which is important for the primary function of load transfer from the trunk to legs. If excess movement occurs at the joint, a positional change may occur between the ilium and sacrum thus compromising the L5-S1 intervertebral joints and disc, SI joint and pubic symphysis could lead to SI joint dysfunction and low back pain. Due to its proximal attachment on to the sacro-tuberous ligament, gluteus maximus is thought to cause tightening of the ligament, giving dynamic joint stability and thereby reducing mobility [40]. Asfour et al. [43] supported that the increased strength is associated with biofeedback was a result of both motor unit firing rate and recruitment patterns. Thus after intervention the recruitment order of muscles were corrected and the compressive load from spine decreased, consequently producing stabilization of spine which might be the reason for reduced pain and symptoms.

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T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients

Akuthota et al. [36] concluded that adequate muscle length and flexibility are necessary for proper joint function and efficiency of movement. The restriction of mobility thus increases load on the spine [44]. The “cat and camel” exercise proves to be a way to achieve spinal segmental and pelvic accessory motion [45]. Rainville et al. [28] concluded that stretching exercises can be used to eliminate impaired flexibility and restore normal trunk range of motion. In order to be successful, however, stretching must be performed at the patient’s physiological end range and therefore within the range of motion that may induce back discomfort. The reason for improvement in lumbar flexibility could be due to the exercises that were included in this study. The cat-camel exercises reduced spinal viscosity (internal resistance and friction) and floss the nerve roots at the outlet of each lumbar level [54], and other flexibility exercises were knee to chest, trunk rotation in crook lying and side flexion in standing, all these exercises created a stretch in the lumbar muscles, which could be a reason for improving the flexibility. Connective tissue deformation (stretch) occurs to different degrees at different intensities of force. It requires breaking of collagen bonds and realignment of the fibres for there to be permanent elongation or increased flexibility. Healing and adaptive remodelling capabilities allow the tissue to respond to repetitive and sustained loads if time is allowed between bouts. This is important for increasing both flexibility and tensile strength of the tissue [55]. The findings of the present study is in accordance with the above stated researches that the increased flexibility could be due to restoration of mobility which was disturbed in chronic low back pain. Thus after intervention the mobility of lumbar spine were improved and the proprioceptive feedback of muscle from joint increased, for good balance between flexibility and stability. The contraction of transversusabdominis is essential for the stabilization of lumbar spine. Hodge [22] in his study on efficacy of TrA training suggested that several points should be considered when training this muscle. According to him it is the principle abdominal muscle affected in low back pain and should be trained separately from the other trunk muscles. Hence, in this study activation of Transversus abdominis was one of the important components for rehabilitation of patient with chronic low back pain. The findings of the present study is in concordance with the above stated researches that the increased activation of TrA could be due to isolated activation of

TrA by PBU and the co-activation of these with multifidus, further increased activation of TrA. Hides et al. (2011) [18] concluded that the ability to contract multifidus was related to the ability to contract TrA with the odds of a good contraction of multifidus being 4.5 times higher for patients who had a good contraction of TrA. A poor ability to contract multifidus was related to poor TrA contraction. The reason for improvement could be that Gluteus maximus strengthening exercises incorporated into intervention in this study corrected the recruitment order [12] and strengthening [27] of gluteus maximus. Kankaanpaa et al. [9] demonstrated increased fatigability of the gluteus maximus in individuals with CLBP. Leinonen et al. [10] also demonstrated the gluteus maximus to be more easily fatigued in those with nonspecific CLBP, but noted improvement in the latency of firing in the gluteus maximus after rehabilitation. Patients who suffer from low back pain often avoid painful movements and subsequently have reduced activity of gluteus maximus and decreased muscle endurance through disuse. Low back pain has been associated with changes in the hip extensor recruitment pattern and disturbed lumbo-pelvic rhythm, both to which the gluteus maximus muscle contributes [10, 11]. Sakamoto et al. [12] concluded by EMG study that with hip extension and 90 degree knee flexion and hip lateral rotation, the gluteus maximus is recruited maximally and inhibition of other hip and knee muscles muscle occurs. The result of this study concludes that there was significant improvement in the gluteus Maximus strength following recruitment and strengthening exercises which was showed objectively by the JHHD and this in effect had a role in improving the patient symptoms. The percentage mean of trunk holding time in this study after intervention was 138.13 sec in group -A and 139.07 sec. in group-B. The range of different studies on trunk holding time in non-symptomatic individual is around 77.8 sec to 171.5 sec [50]. The Sorensen test involves all muscle of trunk not only paraspinal (multifidus) but also for hip extensor muscle. BieringSorensen [51] reported that a position-holding time less than 176sec predicted low back pain during next year in males, whereas a time greater than 198 sec predicted absence of low back pain. Luoto et al. [50] had shown that a time less than 58 sec was associated with a three times increase in the risk of low back pain, as compared to a time greater than 104 sec. In this study the value of Sorensen test after intervention lies in the range in which the chance of LBP

T. Kumar et al. / Efficacy of core muscle strengthening exercise in chronic low back pain patients

and its recurrence would be less. It might be due to strengthening of multifidusand gluteus maximus [50] during the intervention which is an important muscle in back endurance. This has been supported by an EMG study done by Ng et al. [51] in which they concluded that during the Sorensen test, the multifidus demonstrates more EMG activity. In the first phase of core muscle strengthening exercise protocol of the present study multifidus was strengthened. The improvement in function can be attributed to reduction in pain, improvement flexibility of lumbar spine, improved back endurance and activation of TrA and strength of gluteus maximus. The Correction of recruitment order of core muscle (primary stabilizer) and gluteus maximus by core muscle stabilization, flexibility and gluteus maximus exercises in both groups. With the reduction in pain perception, improvement in back endurance and gluteus maximus strength subjects noted increased ability to perform their daily activity on ODI index which include component like pain intensity, personal care, lifting, walking, sitting and travelling. Balance between flexibility and stability of lumbar spine prevent low back pain [53]. The results of the present study were consistent with the study done by Franca et al. [20] who have given the effect of segmental stabilization of core muscle on CLBP functional disability which decreased to 90%. Venu Akuthota et al. [26] study showed decreased pain and disability because of improved core stability [24]. This study showed insignificant results (p  0.05) in all outcome measure between the group analyses. In chronic low back pain the weakness of core muscle (local and global) is not the root cause but the disturbed recruitment order of core and gluteus maximus, and decrease the flexibility of lumbar spine are the main problem. After six weeks of intervention, there might be correction in the recruitment order of these muscles and significant improvement in lumbar mobility. Cholewicki et al. [29] small increase in the level of activity of the muscles of the local system could prevent spinal instability. The flexibility and endurance also depends on the other factors like age, gender, weight, lumbar lordosis etc. [50] but it was not analysed in present study. The study done by Kumar et al. [56] also supported our study which concludes that DMST (dynamic muscular stabilization technique) intervention is an effective rehabilitation technique for all CLBP patient irrespective of duration (chronicity) of their pain.

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5. Conclusion This study concluded that core muscle strengthening exercise along with lumbar flexibility and gluteus maximus strengthening is an effective rehabilitation technique for all chronic low back pain patients irrespective of duration (chronicity) of their pain.

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