Stabilisation exercises for low back pain: a systematic review

I was recently in a forum for dancers where I suggested that there were no specific exercises that were particularly helpful for low back pain – horrors! Someone said ‘You mean the doctor might as well have said to go home and pick your nose as do even Pilates’, to which I sighed…not exactly what I meant.

So I was really pleased to see this systematic review of stabilization exercises for low back pain by Stephen May and Ros Johnson.

I think I mentioned a few posts ago that I’ve seen fads come and fads go, and one of the most recent ones is ‘core stability’, along with using a swiss ball, and doing loads of abdominal exercises. This review summarises 18 trials that met the selection criteria:

• randomized clinical trials,
• in English,
• full publications,
• adults with low back pain,
• one group with specific stabilization exercises as the primary intervention, and
• outcome measures included pain/function.

Studies were scored using PEDro, and because of heterogeneity of interventions, control groups, follow-up duration, outcome measures and study population, meta-analysis was not carried out. A large number of possible studies were excluded because they did not meet the PEDro criteria.

 

And the results? Overall, there was little evidence to support the use of stabilization exercises for acute low back pain, some evidence for their use in chronic low back pain, but mainly when the control condition was no treatment rather than any other active treatment.

What this means is that with the evidence in its current state, it’s not possible to recommend using stabilization exercises over any other form of active intervention such as maintaining activity levels, general strengthening, manual therapy and ‘general exercise’.

This is particularly the case for acute low back pain, with some suggestion that in some cases (possibly identified through clinical examination of ‘instability’) chronic low back pain may respond to stabilization. The problem is that clinical assessment of ‘instability’ is subject to poor interrater reliability, apart from the prone instability test, and the authors of this paper state ‘there are no completely valid and reliable methods for detecting at baseline those who might respond to stabilization exercises’.

I keep hearing from physiotherapists, occupational therapists, oh and even medical practitioners ‘if we were only to use evidence-based treatments, we wouldn’t be able to use anything’. It is a problem – except, if we take the example of acute low back pain, we know that the majority of people recover all by themselves in around 6 weeks to 3 months.

We also know that the majority of people having trouble recovering are those with psychosocial yellow flags – particularly fear of moving. My thoughts are that

• if we can provide effective support to help people to move again despite pain,
• reduce the talk of ‘instability’ or ‘pathology’ in order to demedicalise this very common but incredibly painful condition, and
• teach all health care providers just what ‘reassurance’ consists of,

we might reduce the amount of unnecessary suffering and long-term disability that I see when working in chronic pain management.

The problem is, there is very little training for health care providers in this thing called ‘reassurance’, and while the theory of ‘supporting people to move again’ seems simple, it is actually quite hard to do because it means thinking psychologically. For physiotherapists and indeed anyone who likes ‘hands-on’ therapy, it’s incredibly difficult to sit firmly on those hands and watch as someone starts moving on their own.

Where do we need more research?

Yes, loads more research on treatments that follow quality guidelines as outlined in this article – double blind, randomized, good control groups, clear specification of the treatment components so that replication can occur, long term follow up (oh yeah, that means funding…), and publication of negative results…

 

But we also need to know more about the things that people with acute conditions find reassuring (or not). What something thinks when they have a physical examination and hear ‘instability’, what they believe is going on when the health practitioner prods and taps and says ‘hmmmmm’. We need to know this, so we can train health care providers in the practicalities of ‘reassurance’, so that people with acute low back pain don’t feel like they’ve been given a brush-off.

This is qualitative, exploratory, observational, clinically-relevant research. It’s also within the grasp of clinicians in everyday practice.

How about it?

 

May S, Johnson R. Stabilisation exercises for low back pain: a systematic review, Physiotherapy (2008), doi:10.1016/j.physio.2007.08.010