Three variables were measured before and after the intervention for each participant including: 1- Disability and Pain 2- Trunk muscle activation patterns Electromyographic Ratios. The last 1 sec of EMG signal while subjects were in the proper test condition was ignored and previous 3 sec were selected and averaged for analysis.
To assess the reliability of the EMG signals, 12 healthy subjects were tested two times in the same manner as the patients. EMG signal acquisition was conducted in 5 positions in two different conditions challenging trunk stability:. They wore a harness having a hook for applying a torque to the trunk by a rope Fig.
Subjects were placed on the apparatus in two positions. Their trunk were pulled in forward and backward directions [Forward Fig. They were instructed to hold a 4. To assess trunk muscle activation patterns and imbalance in participants performing the tasks, two types of ratio were calculated including:.
Imbalance ratios: Using analysis similar to Oddsson and DeLuca [ 10 ], to assess imbalance in trunk muscles three types of ratio were calculated:. The RMS signals from pair of those five muscles were used. Then, using the following procedure Eq. To show the difference in percent between the right and left sides, the obtained ratio was multiplied by It is possible to make comparison between right- and left-sided differences in EMG signals by these ratios [ 10 ].
Using the procedure which is shown in the eqs. For example, uncompensated imbalance extensor ratio was calculated by averaging absolute ratio values for longissimus dorsi and iliocostalis muscles. Muscle 1, 2 and muscle n are muscles that have been defined in a muscle group A, B or C and n is the number of muscles in the group. The uncompensated imbalance ratio is an index showing the total muscular imbalances regardless of either to right or left, whereas the compensated imbalance shows the direction of the local segmental imbalances.
Therefore a positive value indicates that right is larger than left and a negative value shows the opposite. Also in compensated imbalance ratios, there may be cancellation between the different muscles within each subject so they represent the residual imbalance. In order to avoid cancellation of values of compensated imbalances with opposite signs, absolute values of the compensated imbalances were used.
So the number of ratios calculated for five positions reduced to one mean value. The normality of the data was confirmed using the K—S test. Independent t-test and Chi-square test were used to examine differences between the two study groups in demographic characteristics and baseline values of disability level, pain intensity and EMG ratios. Within-group changes before and after the study were assessed by paired t-test.
The intra-class correlation coefficient ICC and standard error of measurements SEM were used to assess the relative and absolute reliability of EMG signals, respectively. Different phases of the trial are presented in the Fig.
In our study, we had ten dropouts out of 56 participants fulfilling inclusion criteria and 46 participants remained 22 participants in CSE and 24 in GE group.
The mean values for antagonist coactivation, compensated and uncompensated RMS imbalance ratios are shown in Table 3. The mean TotC ratio showed a significant decrease in GE group mean difference, 0. The current study compared trunk muscles coactivation and imbalance patterns between two groups of patients with chronic non-specific LBP enrolled in two types of exercise program.
At the end of the study, antagonist coactivation did not reduced in either groups. Sixteen sessions of training in both groups shifted compensated ratios residual unequal muscular activity after cancelation of directionality ExtC, FlxC and TotC to negative, indicating change in muscle imbalance to the left side.
The only significant change was TotC for the general exercise group. In a survey on the literature, no study was found on comparison between core stability and general exercises regarding recruitment pattern and activation imbalance. Trunk muscle imbalance in LBP compared with healthy subjects has been reported in some studies [ 10 , 21 ] though other studies [ 22 ] have failed to show differences in muscle activity between these two groups.
We measured EMG for global and not local muscles, and decrease in antagonist coactivation in GE group could be attributed to the change from static to dynamic spinal control whereas this change has not occurred in CSE group which is claimed [ 23 ] to cause enhancement in spinal stability specifically. Regarding imbalance in trunk muscles, Oddsson and Carlo [ 10 ] found similar levels of uncompensated imbalance in LBP patients and healthy control participants whereas they found that high compensated RMS imbalance, i.
The concept of uncompensated and compensated EMG-based imbalance parameters has been introduced to show how contralateral muscles in the trunk are contracted during a sustained isometric contraction in a symmetrical task [ 10 ].
These ratios show how much load each side shares and how much work the muscles of each side do. In a similar designed work, Reeves and Cholewicki [ 24 ] had different results of equal activation imbalance between two sides for athletes with a history of low back injury and healthy athletes.
They believed the differences between the studies could stem from the populations being used. For example, the LBP sufferers, unlike the athlete population, may show more pain avoidance behaviour which could cause lesser muscle activity.
The fact that the force developed by a muscle is partly proportional to the amplitude of the EMG signal [ 25 ] is the physiological rationale for the interpretation of these ratios.
Uncompensated imbalances show that contralateral muscle groups do not activate equally, whereas the compensated imbalances indicate the residual unequal muscular activity after cancelation of directionality right-left of these imbalances. So, for each participant, a positive compensated imbalance means that values for the right side are greater than those for the left side, and vice versa for a negative value. If the uncompensated imbalance is equal to the compensated imbalance, the imbalance at all muscles will be in the same direction.
When the compensated imbalance is smaller than the uncompensated imbalance, then some positive and negative values have been canceled by each other, i. All compensated ratios in either groups decreased, indicating imbalance shift to the left side, though the only significant change was that for the TotC ratio in GE.
Therefore, both training programs made the imbalance change more or less, to the left side. This difference in imbalance direction at the baseline could be attributed either to the distribution of alterations in muscle activity around the location of pain or to the random chance for side dominancy, in the case of random allocation of participants in groups.
The net finding is that both exercises made or kept imbalance to the left. Though we have not asked the participants their dominant side, as most people including our subjects are right-handed [ 26 ], this change may be attributed to hand dominance, especially since our training was symmetric. Some authors [ 27 , 28 ] have pointed out that dominant to non-dominant strength imbalances are normal to some extent.
In a study of neuromuscular imbalance in tennis players with low back pain [ 29 ], nearly all right-handed athletes showed significant lower muscle activity on the left side of erector spinae, and left-handed players showed lower activity on the right side. In our study, the reverse non-dominant to dominant side imbalance after the intervention may be related to the effects of exercise programs for low back pain that have changed the direction of imbalance.
However, it remains unclear why the muscle imbalance really shifted to the left side due to either exercises. Future studies are recommended to investigate why the muscle imbalance shifted to the left side after the exercise programs. In spite of the general decrease in uncompensated ratios unless FlxUn , since these changes are not significant, it could not be concluded that either exercises decreased muscle imbalance, though their trends are toward imbalance reduction.
Unlike coactivation and imbalance ratios, improvement in clinical outcomes pain and disability index occurred in both groups without significant difference between them. It could be interpreted that both exercises made useful effects on clinical symptoms regardless of whether they made change on muscle activation patterns. However, this question remains unanswered whether changing trunk muscle activation affects pain and other clinical features.
However, the findings of this study could be used in motor control studies which investigate the behaviour of trunk muscles of patients suffering from LBP after a course of therapeutic exercise. The main limitations of this study are the lack of a true control group in the design and performance and lack of blindness for the treating physiotherapist due to the nature of the interventions.
Having a control group in the future studies would be useful. In the article by Garcia, difference offour points in Disability in the MK group was observed. Katherinne Moura Franco did not find differences between active interferential current prior to exercise of pilates and placebo compared to outcomes evaluated with Roland-Morris Disability Questionnaire in patients with nonspecific CLBP.
Gisela C Mijamoto noted a disability improvement in modified pilates group, but these differences were no longer statistically significant at 6 months. Jamil Natour found that pilates exercises in addition to NSAIDs were found favorable with regard to functional capacity. In the article by David Cruz Diaz, results showed that only the group of pilates plus physiotherapy standard improved in fear of falling, functional mobility and balance after treatment.
U Albert Anand observed that pain and disability appeared much improved in the modified pilates group. In the article of Nikolaos Kofotolis et al, the results showed that pilates participants reported greater improvements in disability and an effectiveness maintenance of 3 months.
The article by Henry Wajswelner showed how the individual pilates program produced similar beneficial effects in disability and pain scores when compared to nonspecific exercises.
Above all, there are many studies that link CLBP and depression or other aspects that are intimately correlated to pain perception. On the other hand, Marshall et al emphasize on the psychosocial components of pain for complementing and improving the response to physical activity interventions and confirming the fear-avoidance model used to explain the relationship between pain and disability.
The research by Maurcio Antonio da Luz Jr. Katherinne Moura Franco did not find any difference between pilates with or without interferential current. Gisela C Mijamoto examined the efficacy of modified pilates exercises; improvements were also observed in overall impression of recovery in the pilates group measured with Global Perceived Effect Scale and Tampa Scale. In the article by David Cruz Diaz, results showed that only the pilates group with addition of physiotherapy standard improved in fear of falling.
In the article of David Cruz Diazonly, the group of pilates with addition of standard physiotherapy improved in the fear of falling. The effects were maintained for 3 months after the end of the program. We analyzed the article by Henry Wajswelner where results showed how the individual pilates program produced similar function and QoL improvement compared to patients treated with standard exercises.
For Paul WM Marshall, both groups trunk exercises and Pedal pilates performed sessions three times a week for 8 weeks. Similar reductions in pain perception were observed in both groups at each point of time during follow-up. Till date, based on what we know from literature, this is the first recent study that has tried to compare various postural methods. Of course, it must be taken into account as already mentioned, that ours is a narrative review that has not allowed us to statistically weigh the present studies in literature, but only to highlight the state of literature regarding this field.
However, in clinical practice, the results of this study could be useful to clarify which approach is most appropriate in the management of chronic back pain considering the different therapeutic and beneficial effects of the methods discussed.
We conclude that all the analyzed techniques have proved their efficacy with respect to the CG, but it is difficult to affirm the superiority of one approach as compared to another; they are more or less equivalent in reducing pain, reducing disability and improving the QoL.
These research studies concluded about a non-resolution of CLBP in the untreated group, that the natural history of progression of untreated lumbar chronic pain is to remain so with peaks of recurrences and a floating but unresolved pain. We can generally observe that the pilates, the MK method, the Feldenkrais method and BS improve the pain and are more efficient than just a generic, pharmacological or instrumental approach. We can also observe the same results in reducing disability and improving all psychological aspects we mentioned related to CLBP.
Even GPR, in three articles, has shown very good results in follow-ups at 6 months and up to 1 year. Concerning PNF techniques, further investigations are needed in order to confirm their efficacy although results of reported studies are promising because of their multiple effects. Finally, as can be observed in the mentioned studies, BS technique has shown good results in patient education and improving QoL and in managing pain.
We think that further scientific research is needed to strengthen the efficacy of the different techniques and to support an evidence-based approach to CLBP. National Center for Biotechnology Information , U. Journal List J Pain Res v. J Pain Res. Published online Dec Author information Copyright and License information Disclaimer. Filippo Neri Hospital, Rome, Italy. This work is published and licensed by Dove Medical Press Limited.
By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. This article has been cited by other articles in PMC. Abstract Chronic low back represents one of the major causes of disability worldwide. Introduction Chronic low back pain CLBP is defined as a pain that persists for more than 3 months, or longer than the expected healing period; it represents one of the most common and costly musculoskeletal problems in modern society.
Materials and methods A narrative review of the literature was performed using the following search engines: PubMed, Cochrane, Pedro and Scopus. Open in a separate window. Figure 1. Flow diagram showing study selection. Results In total, 26 articles satisfied the inclusion criteria and were considered in the review: 14 articles on the pilates approach, six articles treating the MK method, three articles about GPR, one article concerning the Feldenkrais technique.
Table 1 Summary of articles comparing different patient samples, interventions and outcomes for the treatment of CLBP. In the following 4 weeks, 40 minutes of pilates were added.
Discussion We have found no article about the Alexander method in the last 5 years. Disability and function Disability is another main topic of most articles examined; it is most often measured with Roland-Morris Disability Questionnaire and Oswestry Disability Index, and sometimes also with Waddell Disability Index and Patient-Specific Functional Scale.
Conclusion Till date, based on what we know from literature, this is the first recent study that has tried to compare various postural methods. Footnotes Disclosure The authors report no conflicts of interest in this work. References 1. Last AR, Hulbert K. Chronic low back pain: evaluation and management.
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Summary of background data: Delayed onset in abdominal muscles has been associated with LBP. Low load exercises to volitionally activate the transversus abdominis were introduced to restore trunk muscle activation deficits.
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