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Three Part Question

In [patients presenting with low back pain] is [a core stability programme more effective than conventional exercise based therapy] at [decreasing pain, increasing mobility and returning to play].

Clinical Scenario

A 24 year old male presents with chronic low back pain. Investigations have ruled out any serious disc, joint or bony pathology. Current opinion advocates core stability as the ‘go to’ treatment for this non-specific pain scenario. You wonder if it would be more effective than a conventional exercise programme?

Search Strategy

MEDLINE (1966-05/2015), CINAHL (1982-05/2015), AMED (1985 – 05/2015) and SPORTDiscus (1830 – 05/2015) and EMBASE (1996 – 05/2015) databases were searched using the OVID interface using the following strategy:

1. Low Back Pain
2. Discogenic
3. Low Back Strain
4. 1 or 2 or 3
5. Core stability
6. Core stabilisation
7. 5 or 6
8. Lumbopelvic control
9. Lumbar pelvic dysfunction
10. Lumbopelvic stabilisation
11. 8 or 9 or 10
12. 4 AND 7 AND 11

The Cochrane Library was also searched using the strategy: low back pain AND exercise



All searches were limited to human AND English language.

Search Outcome

Six papers were found which were relevant to the three part question. One of which (Inani and Selkar 2013) was found to be included in one of the systematic reviews and the other was a meta analysis in 2012 (Wand et al) which was superceded by a subsequent meta analysis in 2014 (Smith et al). The four remaining papers were subsequently analysed. There were also 2 Cochrane systematic reviews on LBP and exercise but these were not relevant to the 3 part Q.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Aluko et al. 2012 UK	33 participants with acute NSLBP Group 1 = Regular exercise & core stability 2 males 15 female 35.8 (SD 9.1) Group 2 = group 1 + specific stabilising exercise 3 males 13 females age 36.2 SD 9.8)	Level 1b RCT	1. Pain VAS	1. NSS	Both groups did core stability type exercises Small sample size and risk of type II statistical error
			2. Roland Morriss Disability Questionnaire (RMDQ)	2.NSS
			3. Lumbar Motion Monitor	3.NSS
Stuber et al 2014 Canada	5 studies 2 RCTs 84 participants	Systematic review Level 1a	1. Back pain and disability	1. No meta analysis	Search criteria only in English language Large Heterogeneity Quality of literature overall was deemed low by authors
			2. Function and global health	2.No meta analysis
Smith et al 2014 UK	29 studies included 2,359 participants A discrepancy in the number of participants is because the number is taken from articles found with the paper. - it doesn't include any taken from May & Johnson (2008). To save time the reader was referred to this original review.	Systematic review Level 1a	1.Pain VAS	1.meta analysis showed significant benefit for stabilisation exercises versus any alternative treatment or control for long term pain	Search criteria only in English language.
			2.RMDQ	2.Difference between groups was clinically insignificant
			3.Patient specific functional scale	3.when compared with alternative forms of exercise no statistical or clinical significance was found between that or core stability exercises
			4.Oswestry disability index (ODI)	4. 1 study showed Group 1 had significantly greater re-injury with 7 athletes (70%) P=0.005. 1 athlete in Group 2 (7.7%). The other no data available.
			5.Quality of life health survey	The other no data available.
			6.Numerical rating scale for pain	The other no data available.
You et al. 2014 South Korea	40 participants with low back pain 20 experimental mean 50.3 years (SD 9.3) and 20 control 51.3 years (SD 7). men n=19 women n=21	Level 1b RCT	1. ODI	1 P<0.001	No intention to treat analysis.
			2. RMDQ	2. P<0.001
			3. VAS	3. NSS
			4. PDI	4. P<0.001
			5.Pain rating scale	5. P<0.011
			6.‘Core stability test’	6. P<0.001

Comment(s)

There is no conclusive evidence that stabilisation exercises are more effective for low back pain than any other form of active exercise in the short and long term. Core stabilisation exercises need not be the ‘go to’ treatment for low back pain.

Editor Comment

NSLBP, non specific low back pain; NSS, not statistically significant; PDI, pain disability index; RCT, randomised controlled trial; VAS, visual analogue scale.

Clinical Bottom Line

The perception that a core stability rehab programme will improve low back pain has not yet been proven.

References

1. Aluko A, DeSouza L, Peacock J. The effect of core stability exercise on variations in acceleration of trunk movement, pain, and disability during an episode of acute non-specific low back pain: a pilo J. Manipulative Physiol Ther 2013; 36: 497-504. e3
2. Stuber KJ, brunoi P, Sajko S, Hayden JA. Core stability exercises for low back pain in athletes: a systematic review of the literature. Clin J Sports med 2014; 24(60: 448-456)
3. Smith BE, Littlewood,C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis BMC Musculoskeletal Disorders 2014; 15: 416
4. You JH, Kim SY, Oh DW, Chon SC. The effects of a novel core stabilisation technique on managing patients with chronic low back pain: a randomised controlled, experimenter blinded study Clin Rehab. 2014 28(5): 460-469
5. May S, Johnson R . Stabilisation exercises for low back pain: a systematic review. Physiotherapy 2008;94:179–89.
6. Inani SB, Selkar SP . Effect of core stabilization exercises versus conventional exercises on pain and functional status in patients with non-specific low back pain: a randomized clinical trial. J Back Musculoskelet Rehabil 2013;26:37–43
7. Wang XQ, Zheng JJ, Yu ZW, et al . A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PLoS One 2012;7:e52082.